Screening for Social Risk Factors in the ICU During the Pandemic.

Due to limitations in data collected through electronic health records, the social risk factors (SRFs) that predate severe illness and restrict access to critical care services are poorly understood. OBJECTIVES: This study explored the feasibility and utility of directly eliciting SRFs in the ICU by implementing a screening program. DESIGN SETTING AND PARTICIPANTS: Five hundred sixty-six critically ill patients at the medical ICU of Robert Wood Johnson University Hospital from July 1, 2019, to September 31, 2021, were interviewed for SRFs using an adapted version of the American Academy of Family Physicians' Social Needs Screening Tool. MAIN OUTCOMES AND MEASURES: For each SRFs, we compared basic demographic factors, proxies of socioeconomic status, and severity score between those with and without the SRFs through chi-square tests and Wilcoxon rank-sum tests. Furthermore, we determined the prevalence of SRFs overall, before, and during the COVID-19 pandemic. RESULTS: Of critically ill patients, 39.58% reported at least one SRF. Age, zip-code matched median household income, and insurance type differed depending on the SRFs. Notably, patients with SRFs were admitted with a lower average severity score, indicating reduced risk in mortality. Since March 2020, the prevalence of SRFs in the ICU overall fell from 54.47% to 35.44%. Conversely, the proportion of patients unable to afford healthcare increased statistically significantly from 7.32% to 18.06%. CONCLUSIONS AND RELEVANCE: Screening for SRFs in the ICU detected the presence of disproportionally low-risk patients whose access to critical care services became restricted throughout the pandemic.

Medicaid Reimbursement for Common Spine Procedures: Are Compensation Rates Consistent?

STUDY DESIGN: Health Services Research. OBJECTIVE: The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery. SUMMARY OF BACKGROUND DATA: The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively. METHODS: MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement. RESULTS: The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR. CONCLUSION: Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care. LEVEL OF EVIDENCE: 4.

Preinjury Patient Characteristics and Postinjury Neurological Status Are Associated With Mortality Following Spinal Cord Injury.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study investigates the association between spinal cord injuries (SCI) and post-injury mortality. SUMMARY OF BACKGROUND DATA: SCIs) are severe conditions treated in the acute trauma setting. Owing to neurological deficits, unstable spinal columns, and associated injuries, these patients often have complex inpatient hospitalizations with significant morbidity and mortality. It is assumed that a high rate of postinjury mortality would follow such severe injuries; however, the effect of SCI and its treatment on predictors of longevity remain largely unknown. METHODS: Patients seen at a regional referral center for SCI were reviewed from a prospectively maintained database. Four hundred and twenty-six patients with SCI and varying degrees of injury between 2004 and 2009 were collected. Injury characteristics, including injury severity score, level of SCI, and type of SCI were retrieved. To determine independent predictors of 5-year mortality, a logistic regression using patient and injury characteristics at the time of presentation was performed. RESULTS: Average age was 47.4 years (range: 14-95), and 74.5% (318/426) were male. Half of the cohort sustained low-energy mechanisms of injury (220/426; 52.4%). The 30-day, 90-day, 1-year, 2-year, and 5-year mortality rates in the SCI cohort were 6.6% (28/426), 9.2% (39/426), 12.0% (51/426), 15.0% (64/426), and 17.8%, respectively (76/426). Logistic regression demonstrated that increasing age (B = 1.06, P < 0.001), increasing ICU length-of-stay (B = 1.06; P = 0.002), decreased motor score at presentation (B = 0.98; P = 0.004), and lack of surgical intervention (B = 0.38; P < 0.001) were independent predictors of mortality at 5 years. CONCLUSION: There is substantial mortality associated with SCI. A significant proportion of the mortalities occurred acutely after injury. Mortality was associated with neurological deficit and severity of injury, as well as with preinjury patient characteristics. To combat this high rate of death, efforts are needed to address the concomitant disease processes associated with neurological deficits. LEVEL OF EVIDENCE: 3.