Hispanic/Latino Ethnicity and Loss of Post-Surgery Independent Living: A Retrospective Cohort Study from a Bronx Hospital Network.

BACKGROUND: Black race is associated with postoperative adverse discharge to a nursing facility, but the effects of Hispanic/Latino ethnicity are unclear. We explored the Hispanic paradox, described as improved health outcomes among Hispanic/Latino patients on postoperative adverse discharge to nursing facility. METHODS: A total of 93,356 adults who underwent surgery and were admitted from home to Montefiore Medical Center in the Bronx, New York, between January 2016 and June 2021 were included. The association between self-identified Hispanic/Latino ethnicity and the primary outcome, postoperative adverse discharge to a nursing home or skilled nursing facility, was investigated. Interaction analysis was used to examine the impact of socioeconomic status, determined by estimated median household income and insurance status, on the primary association. Mixed-effects models were used to evaluate the proportion of variance attributed to the patient's residential area defined by zip code and self-identified ethnicity. RESULTS: Approximately 45.9% (42,832) of patients identified as Hispanic/Latino ethnicity and 9.7% (9074) patients experienced postoperative adverse discharge. Hispanic/Latino ethnicity was associated with lower risk of adverse discharge (relative risk [RRadj] 0.88; 95% confidence interval [CI], 00.82-0.94; P < .001), indicating a Hispanic Paradox. This effect was modified by the patient's socioeconomic status (P-for-interaction <.001). Among patients with a high socioeconomic status, the Hispanic paradox was abolished (RRadj 1.10; 95% CI, 11.00-1.20; P = .035). Furthermore, within patients of low socioeconomic status, Hispanic/Latino ethnicity was associated with a higher likelihood of postoperative discharge home with health services compared to non-Hispanic/Latino patients (RRadj 1.06; 95% CI, 11.01-1.12; P = .017). CONCLUSIONS: Hispanic/Latino ethnicity is a protective factor for postoperative adverse discharge, but this association is modified by socioeconomic status. Future studies should focus on postoperative discharge disposition and socioeconomic barriers in patients with Hispanic/Latino ethnicity.

An Analysis of the Cost-Effectiveness of Spinal Versus General Anesthesia for Lumbar Spine Surgery in Various Hospital Settings.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To determine the relative cost-effectiveness of spinal anesthesia and general anesthesia for lumbar laminectomy and microdiscectomy surgery performed in an academic versus private practice hospital setting. METHODS: The authors retrospectively reviewed charts of 188 consecutive patients who underwent lumbar laminectomy or microdiscectomy by a single surgeon from 2012 to 2016 at either an academic or a private practice hospital setting. Intraoperative and postoperative outcomes were recorded and direct variable costs were calculated. RESULTS: At the academic institution, the direct cost of a lumbar laminectomy or microdiscectomy surgery under general anesthesia was determined to be 9.93% greater than with spinal anesthesia (P = .040). The greatest difference was seen with operating room costs, in which general anesthesia was associated with 18.74% greater costs than spinal anesthesia (P = .016). There was no significant difference in cost at the private practice hospital setting. CONCLUSIONS: We conclude that use of spinal anesthesia for lumbar laminectomy leads to less operating room, postanesthesia care unit, and anesthesia times, lower levels of postoperative pain, and no increased rate of other complications compared with general anesthesia at an academic institution as compared to a private practice setting. Spinal anesthesia is 9.93% less expensive than general anesthesia, indicating substantial cost-saving potential. With no sacrifice of patient outcomes and the added benefit of less pain and recovery time, Spinal anesthesia represents a more cost-effective alternative to general anesthesia in lumbar spine surgery in the academic hospital setting.

The role of accountable care organizations in delivering value.

The goal of Accountable Care Organizations is to improve patient outcomes while maximizing the value of the services provided. This will be achieved through the use of performance and quality measures that facilitate efficient, cost-effective, evidence-based care. By creating a network connecting primary care physicians, specialists, rehabilitation facilities and hospitals, patient care should be maximized while at the same time delivering appropriate value for those services provided. The Medicare Shared Savings Program will financially reward ACOs that meet performance standards while at the same time lowering costs. The orthopaedic surgeon can only benefit by understanding how to participate in and negotiate the complexities of these organizations.