Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 162
Filtrar
1.
J Am Med Dir Assoc ; : 105149, 2024 Jul 12.
Artigo em Inglês | MEDLINE | ID: mdl-39009064

RESUMO

OBJECTIVE: To review evidence on post-acute care (PAC) use and disparities related to race and ethnicity and rurality in the United States over the past 2 decades among individuals who underwent major joint replacement (MJR). DESIGN: Systematic review. SETTING AND PARTICIPANTS: We included studies that examined US PAC trends and racial and ethnic and/or urban vs rural differences among individuals who are ≥18 years with hospitalization after MJR. METHODS: We searched large academic databases (PubMed, CINAHL, Embase, Web of Science, and Scopus) for peer-reviewed, English language articles from January 1, 2000, and January 26, 2022. RESULTS: Seventeen studies were reviewed. Studies (n = 16) consistently demonstrated that discharges post-MJR to skilled nursing facilities (SNFs) or nursing homes (NHs) decreased over time, whereas evidence on discharges to inpatient rehab facilities (IRFs), home health care (HHC), and home without HHC services were mixed. Most studies (n = 12) found that racial and ethnic minority individuals, especially Black individuals, were more frequently discharged to PAC institutions than White individuals. Demographic factors (ie, age, sex, comorbidities) and marital status were not only independently associated with discharges to institutional PAC, but also among racial and ethnic minority individuals. Only one study found urban-rural differences in PAC use, indicating that urban-dwelling individuals were more often discharged to both SNF/NH and HHC than their rural counterparts. CONCLUSIONS AND IMPLICATIONS: Despite declines in institutional PAC use post-MJR over time, racial and minority individuals continue to experience higher rates of institutional PAC discharges compared with White individuals. To address these disparities, policymakers should consider measures that target multimorbidity and the lack of social and structural support among socially vulnerable individuals. Policymakers should also consider initiatives that address the economic and structural barriers experienced in rural areas by expanding access to telehealth and through improved care coordination.

2.
JAMA Netw Open ; 7(5): e249312, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38696169

RESUMO

Importance: Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs). Objective: To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents. Design, Setting, and Participants: This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022. Exposure: Race and ethnicity of NH residents. Main Outcomes and Measures: Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate. Results: Of 2 098 385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39 873 (1.9%) were Asian, 229 112 (10.9%) were Black or African American, 99 304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1 713 670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1 355 143 (64.6%) were female; 128 997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]). Conclusions and Relevance: In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.


Assuntos
Hospitalização , Casas de Saúde , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etnologia , Estudos Transversais , Hospitalização/estatística & dados numéricos , Casas de Saúde/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Estados Unidos/epidemiologia , População Branca/estatística & dados numéricos , Brancos , Hispânico ou Latino , Indígena Americano ou Nativo do Alasca , Asiático , Negro ou Afro-Americano , Havaiano Nativo ou Outro Ilhéu do Pacífico , Grupos Raciais
4.
Anesthesiology ; 141(1): 116-130, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38526387

RESUMO

BACKGROUND: The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19. METHODS: Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. RESULTS: Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. CONCLUSIONS: Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.


Assuntos
COVID-19 , Oxigenação por Membrana Extracorpórea , Disparidades em Assistência à Saúde , Medicaid , Medicare , Humanos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , COVID-19/terapia , Masculino , Feminino , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Disparidades em Assistência à Saúde/estatística & dados numéricos , Idoso , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Adulto , Mortalidade Hospitalar , Alta do Paciente/estatística & dados numéricos , Resultado do Tratamento
7.
J Am Geriatr Soc ; 72(4): 1070-1078, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38241196

RESUMO

BACKGROUND: Nursing home (NH) residents' vulnerability to COVID-19 underscores the importance of infection preventionists (IPs) within NHs. Our study aimed to determine whether training and credentialing of NH IPs were associated with resident COVID-19 deaths. METHODS: This retrospective observational study utilized data from the Centers for Disease Control and Prevention's National Healthcare Safety Network NH COVID-19 Module and USAFacts, from May 2020 to February 2021, linked to a 2018 national NH survey. We categorized IP personnel training and credentialing into four groups: (1) LPN without training; (2) RN/advanced clinician without training; (3) LPN with training; and (4) RN/advanced clinician with training. Multivariable linear regression models of facility-level weekly deaths per 1000 residents as a function of facility characteristics, and county-level COVID-19 burden (i.e., weekly cases or deaths per 10,000 population) were estimated. RESULTS: Our study included 857 NHs (weighted n = 14,840) across 489 counties and 50 states. Most NHs had over 100 beds, were for profit, part of chain organizations, and located in urban areas. Approximately 53% of NH IPs had infection control training and 82% were RNs/advanced clinicians. Compared with NHs employing IPs who were LPNs without training, NHs employing IPs who were RNs/advanced clinicians without training had lower weekly COVID-19 death rates (-1.04 deaths per 1000 residents; 95% CI -1.90, -0.18), and NHs employing IPs who were LPNs with training had lower COVID-19 death rates (-1.09 deaths per 1000 residents; 95% CI -2.07, -0.11) in adjusted models. CONCLUSIONS: NHs with LPN IPs without training in infection control had higher death rates than NHs with LPN IPs with training in infection control, or NHs with RN/advanced clinicians in the IP role, regardless of IP training. IP training of RN/advanced clinician IPs was not associated with death rates. These findings suggest that efforts to standardize and improve IP training may be warranted.


Assuntos
COVID-19 , Humanos , Estados Unidos/epidemiologia , Casas de Saúde , Instituições de Cuidados Especializados de Enfermagem , Controle de Infecções , Credenciamento
8.
J Am Heart Assoc ; 12(19): e031221, 2023 10 03.
Artigo em Inglês | MEDLINE | ID: mdl-37750574

RESUMO

Background COVID-19 stressed hospitals and may have disproportionately affected the stroke outcomes and treatment of Black and Hispanic individuals. Methods and Results This retrospective study used 100% Medicare Provider Analysis and Review file data from between 2016 and 2020. We used interrupted time series analyses to examine whether the COVID-19 pandemic exacerbated disparities in stroke outcomes and reperfusion therapy. Among 1 142 560 hospitalizations for acute ischemic strokes, 90 912 (8.0%) were Hispanic individuals; 162 752 (14.2%) were non-Hispanic Black individuals; and 888 896 (77.8%) were non-Hispanic White individuals. The adjusted odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51 [95% CI, 1.34-1.69]; P<0.001), whereas the rates of nonhome discharges decreased by 11% (aOR, 0.89 [95% CI, 0.82-0.96]; P=0.003) for patients hospitalized during weeks when the hospital's proportion of patients with COVID-19 was >30%. The overall rates of motor deficits (P=0.25) did not increase, and the rates of reperfusion therapy did not decrease as the weekly COVID-19 burden increased. Black patients had lower 30-day mortality (aOR, 0.70 [95% CI, 0.69-0.72]; P<0.001) but higher rates of motor deficits (aOR, 1.14 [95% CI, 1.12-1.16]; P<0.001) than White individuals. Hispanic patients had lower 30-day mortality and similar rates of motor deficits compared with White individuals. There was no differential increase in adverse outcomes or reduction in reperfusion therapy among Black and Hispanic individuals compared with White individuals as the weekly COVID-19 burden increased. Conclusions This national study of Medicare patients found no evidence that the hospital COVID-19 burden exacerbated disparities in treatment and outcomes for Black and Hispanic individuals admitted with an acute ischemic stroke.


Assuntos
COVID-19 , AVC Isquêmico , Acidente Vascular Cerebral , Idoso , Humanos , Negro ou Afro-Americano , COVID-19/terapia , Medicare , Pandemias , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Resultado do Tratamento , Estados Unidos/epidemiologia , Hispânico ou Latino , Brancos
9.
JAMA Netw Open ; 6(8): e2330327, 2023 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-37624599

RESUMO

Importance: The COVID-19 pandemic disrupted usual care for emergent conditions, such as acute myocardial infarction (AMI). Understanding whether Black and Hispanic individuals experiencing AMI had greater increases in poor outcomes compared with White individuals during the pandemic has important equity implications. Objective: To investigate whether the COVID-19 pandemic was associated with increased disparities in treatment and outcomes among Medicare patients hospitalized with AMI. Design, Setting, and Participants: This cross-sectional study used Medicare data for patients hospitalized with AMI between January 2016 and November 2020. Patients were categorized as Hispanic, non-Hispanic Black, and non-Hispanic White. The association between race and ethnicity and outcomes as a function of the proportion of hospitalized patients with COVID-19 was evaluated using interrupted time series. Data were analyzed from October 2022 to June 2023. Exposure: The main exposure was a hospital's proportion of hospitalized patients with COVID-19 on a weekly basis as a proxy for care disruption during the pandemic. Main Outcomes and Measures: Revascularization, 30-day mortality, 30-day readmission, and nonhome discharges. Results: A total of 1 319 273 admissions for AMI (579 817 females [44.0%]; 122 972 Black [9.3%], 117 668 Hispanic [8.9%], and 1 078 633 White [81.8%]; mean [SD] age, 77 [8.4] years) were included. For patients with non-ST segment elevation MI (NSTEMI) overall, the adjusted odds of mortality and nonhome discharges increased by 51% (adjusted odds ratio [aOR], 1.51; 95% CI, 1.29-1.76; P < .001) and 32% (aOR, 1.32; 95% CI, 1.15-1.52; P < .001), respectively, and the odds of revascularization decreased by 27% (aOR, 0.73; 95% CI, 0.64-0.83; P < .001) among patients hospitalized during weeks with a high hospital COVID-19 burden (>30%) vs patients hospitalized prior to the pandemic. Black individuals with NSTEMI experienced a clinically insignificant 7% greater increase in the odds of mortality (aOR, 1.07; 95% CI, 1.00-1.15; P = .04) for each 10% increase in the COVID-19 hospital burden but no increases in readmissions or nonhome discharges or reductions in revascularization rates compared with White individuals. There were no differential increases in adverse outcomes among Hispanic compared with White patients with NSTEMI based on hospital COVID-19 burden. Increases in hospital COVID-19 burden were not associated with changes in outcomes or the use of revascularization in STEMI overall or by racial or ethnic group. Conclusions and Relevance: This study found that while hospital COVID-19 burden was associated with worse treatment and outcomes for NSTEMI, race and ethnicity-associated inequities did not increase significantly during the pandemic. These findings suggest the need for additional efforts to mitigate outcomes associated with the COVID-19 pandemic for patients admitted with AMI when the hospital COVID-19 burden is substantially increased.


Assuntos
COVID-19 , Infarto do Miocárdio , Infarto do Miocárdio sem Supradesnível do Segmento ST , Estados Unidos/epidemiologia , Feminino , Humanos , Idoso , Pandemias , COVID-19/epidemiologia , Estudos Transversais , Medicare , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Resultado do Tratamento
11.
J Cardiothorac Vasc Anesth ; 37(8): 1449-1455, 2023 08.
Artigo em Inglês | MEDLINE | ID: mdl-37127521

RESUMO

OBJECTIVES: The aim was to characterize hospitalization costs, charges, and lengths of hospital stay for COVID-19 patients treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO) in the United States during 2020. Secondarily, differences in hospitalization costs, charges, and lengths of hospital stay were explored based on hospital-level factors. DESIGN: Retrospective cohort study. SETTING: Multiple hospitals in the United States. PARTICIPANTS: Adult patients with COVID-19 who were on VV ECMO in 2020 and had data in the national inpatient sample. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics and baseline comorbidities were recorded for patients. Primary study outcomes were hospitalization costs, charges, and lengths of hospital stay. Study outcomes were compared after stratification by hospital region, bed size, and for-profit status. The median hospitalization cost for the 3,315-patient weighted cohort was $200,300 ($99,623, $338,062). Median hospitalization charges were $870,513 ($438,228, $1,553,157), and the median length of hospital stay was 30 days (17, 46). Survival to discharge was 54.4% for all patients in the cohort. Median hospitalization cost differed by region (p = 0.01), bed size (p < 0.001), and for-profit status (p = 0.02). Median hospitalization charges also differed by region (p = 0.04), bed size (p = 0.002), and for-profit status (p < 0.001). Length of hospital stay differed by region (p = 0.03) and bed size (p < 0.001), but not for-profit status (p = 0.40). Hospitalization costs were the lowest, and charges were highest in private-for-profit hospitals. Large hospitals also had higher costs, charges, and hospital stay lengths than small hospitals. CONCLUSIONS: In this retrospective cohort study, hospitalization costs and charges for patients with COVID-19 on VV ECMO were found to be substantial but similar to what has been reported previously for patients without COVID-19 on VV ECMO. Significant variation was observed in costs, charges, and lengths of hospital stay based on hospital-level factors.


Assuntos
COVID-19 , Oxigenação por Membrana Extracorpórea , Adulto , Humanos , Estados Unidos/epidemiologia , Tempo de Internação , Estudos de Coortes , Estudos Retrospectivos , COVID-19/terapia , Hospitalização
12.
Ann Surg ; 277(2): 246-251, 2023 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-36448909

RESUMO

OBJECTIVE: To assess the association between low preoperative serum creatinine and postoperative outcomes. BACKGROUND: The association between low creatinine and poor surgical outcomes is not well understood. METHODS: We identified patients with creatinine in the 7 days preceding nonemergent inpatient surgery in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2020. Multivariable logistic regression was used to examine the association between creatinine and 30-day mortality and major complications. RESULTS: Of 1,809,576 patients, 27.8% of males and 23.5% of females had low preoperative serum creatinine, 14.6% experienced complications, and 1.2% died. For males, compared with the reference creatinine of 0.85 to 1.04, those with serum creatinine ≤0.44 had 55% increased odds of mortality [ adjusted odds ratio (aOR), 1.55; 95% CI, 1.29-1.86] and 82% increased odds of major complications (aOR, 1.82; 95% CI, 1.69-1.97). Similarly, for females, compared with the reference range of 0.65 to 0.84, those with serum creatinine ≤0.44 had 49% increased odds of mortality (aOR, 1.49; 95% CI, 1.32-1.67) and 76% increased odds of major complications (aOR, 1.76; 95% CI, 1.70-1.83). These associations persisted for the total cohort, among those with mildly low albumin, and for those with creatinine values measured 8 to 30 days preoperatively. CONCLUSIONS: A low preoperative creatinine is common and associated with poor outcomes after nonemergent inpatient surgery. A low creatinine may help identify high-risk patients who may benefit from further evaluation and optimization.


Assuntos
Pacientes Internados , Complicações Pós-Operatórias , Masculino , Feminino , Humanos , Creatinina , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Estudos Retrospectivos
13.
JAMA Netw Open ; 5(12): e2247968, 2022 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-36542380

RESUMO

Importance: Whether people from racial and ethnic minority groups experience disparities in access to minimally invasive mitral valve surgery (MIMVS) is not known. Objective: To investigate racial and ethnic disparities in the utilization of MIMVS. Design, Setting, and Participants: This cross-sectional study used data from the Society of Thoracic Surgeons Database for patients who underwent mitral valve surgery between 2014 and 2019. Statistical analysis was performed from January 24 to August 11, 2022. Exposures: Patients were categorized as non-Hispanic White, non-Hispanic Black, and Hispanic individuals. Main Outcomes and Measures: The association between MIMVS (vs full sternotomy) and race and ethnicity were evaluated using logistic regression. Results: Among the 103 753 patients undergoing mitral valve surgery (mean [SD] age, 62 [13] years; 47 886 female individuals [46.2%]), 10 404 (10.0%) were non-Hispanic Black individuals, 89 013 (85.8%) were non-Hispanic White individuals, and 4336 (4.2%) were Hispanic individuals. Non-Hispanic Black individuals were more likely to have Medicaid insurance (odds ratio [OR], 2.21; 95% CI, 1.64-2.98; P < .001) and to receive care from a low-volume surgeon (OR, 4.45; 95% CI, 4.01-4.93; P < .001) compared with non-Hispanic White individuals. Non-Hispanic Black individuals were less likely to undergo MIMVS (OR, 0.65; 95% CI, 0.58-0.73; P < .001), whereas Hispanic individuals were not less likely to undergo MIMVS compared with non-Hispanic White individuals (OR, 1.08; 95% CI, 0.67-1.75; P = .74). Patients with commercial insurance had 2.35-fold higher odds of undergoing MIMVS (OR, 2.35; 95% CI, 2.06-2.68; P < .001) than those with Medicaid insurance. Patients operated by very-high volume surgeons (300 or more cases) had 20.7-fold higher odds (OR, 20.70; 95% CI, 12.7-33.9; P < .001) of undergoing MIMVS compared with patients treated by low-volume surgeons (less than 20 cases). After adjusting for patient risk, non-Hispanic Black individuals were still less likely to undergo MIMVS (adjusted OR [aOR], 0.88; 95% CI, 0.78-0.99; P = .04) and were more likely to die or experience a major complication (aOR, 1.25; 95% CI, 1.16-1.35; P < .001) compared with non-Hispanic White individuals. Conclusions and Relevance: In this cross-sectional study, non-Hispanic Black patients were less likely to undergo MIMVS and more likely to die or experience a major complication than non-Hispanic White patients. These findings suggest that efforts to reduce inequity in cardiovascular medicine may need to include increasing access to private insurance and high-volume surgeons.


Assuntos
Etnicidade , Valva Mitral , Estados Unidos , Humanos , Feminino , Pessoa de Meia-Idade , Estudos Transversais , Valva Mitral/cirurgia , Grupos Minoritários , Hispânico ou Latino
14.
Anesthesiology ; 137(6): 661-663, 2022 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-36413784
15.
JAMA Health Forum ; 3(2): e215111, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-35977279

RESUMO

Importance: Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare's mandatory bundled payment reform-the Comprehensive Care for Joint Replacement (CJR) model-was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. Objective: To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. Design Setting and Participants: This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. Results: The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, -0.13 to -0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, -0.12 to -0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, -0.08 to 0.09; P = .88). No statistically significant changes in knee replacement rates were noted for beneficiaries with ADRD compared with those without ADRD with CJR implementation (percentage point difference: -0.03, 95% CI, -0.09 to 0.02; P = .27). Conclusions and Relevance: In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.


Assuntos
Doença de Alzheimer , Artrite , Artroplastia de Quadril , Idoso , Doença de Alzheimer/cirurgia , Estudos de Coortes , Feminino , Humanos , Masculino , Medicare , Estados Unidos
16.
Anesth Analg ; 135(3): 558-566, 2022 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-35977365

RESUMO

BACKGROUND: Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure in the world and up to one-third of patients are transfused red blood cells (RBCs). RBC transfusion may increase the risk for health care-associated infection (HAI) after CABG, but previous studies have shown conflicting results and many did not establish exposure temporality. Our objective was to explore whether intraoperative RBC transfusion is associated with increased odds of postoperative HAI. We hypothesized that intraoperative RBC transfusion would be associated with increased odds of postoperative HAI. METHODS: We performed an observational cohort study of isolated CABG patients in the Society of Thoracic Surgeons adult cardiac surgery database from July 1, 2017, to June 30, 2019. The exposure was intraoperative RBC transfusion modeled as 0, 1, 2, 3, or 4+ units. The authors focused on intraoperative RBC transfusion as a risk factor, because it has a definite temporal relationship before postoperative HAI. The study's primary outcome was a composite HAI variable that included sepsis, pneumonia, and surgical site infection (both deep and superficial). Mixed-effects modeling, which controlled for hospital as a clustering variable, was used to explore the relationship between intraoperative RBC transfusion and postoperative HAI. RESULTS: Among 362,954 CABG patients from 1076 hospitals included in our analysis, 59,578 patients (16.4%) received intraoperative RBCs and 116,186 (32.0%) received either intraoperative or postoperative RBCs. Risk-adjusted odds ratios for HAI in patients who received 1, 2, 3, and 4+ intraoperative RBCs were 1.11 (95% confidence interval [CI], 1.03-1.20; P = .005), 1.13 (95% CI, 1.05-1.21; P = .001), 1.15 (95% CI, 1.04-1.27; P = .008), and 1.14 (95% CI, 1.02-1.27; P = .02) compared to patients who received no RBCs. CONCLUSIONS: Intraoperative RBC transfusion is associated with a small increase in odds of HAI in CABG patients. Future studies should explore whether reductions in RBC transfusion can also reduce HAIs.


Assuntos
Cirurgiões , Cirurgia Torácica , Adulto , Transfusão de Sangue , Ponte de Artéria Coronária/efeitos adversos , Transfusão de Eritrócitos/efeitos adversos , Transfusão de Eritrócitos/métodos , Humanos , Estudos Retrospectivos
17.
JAMA Netw Open ; 5(7): e2222360, 2022 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-35849395

RESUMO

Importance: The COVID-19 pandemic caused significant disruptions in surgical care. Whether these disruptions disproportionately impacted economically disadvantaged individuals is unknown. Objective: To evaluate the association between the COVID-19 pandemic and mortality after major surgery among patients with Medicaid insurance or without insurance compared with patients with commercial insurance. Design, Setting, and Participants: This cross-sectional study used data from the Vizient Clinical Database for patients who underwent major surgery at hospitals in the US between January 1, 2018, and May 31, 2020. Exposures: The hospital proportion of patients with COVID-19 during the first wave of COVID-19 cases between March 1 and May 31, 2020, stratified as low (≤5.0%), medium (5.1%-10.0%), high (10.1%-25.0%), and very high (>25.0%). Main Outcomes and Measures: The main outcome was inpatient mortality. The association between mortality after surgery and payer status as a function of the proportion of hospitalized patients with COVID-19 was evaluated with a quasi-experimental triple-difference approach using logistic regression. Results: Among 2 950 147 adults undergoing inpatient surgery (1 550 752 female [52.6%]) at 677 hospitals, the primary payer was Medicare (1 427 791 [48.4%]), followed by commercial insurance (1 000 068 [33.9%]), Medicaid (321 600 [10.9%]), other payer (140 959 [4.8%]), and no insurance (59 729 [2.0%]). Mortality rates increased more for patients undergoing surgery during the first wave of the pandemic in hospitals with a high COVID-19 burden (adjusted odds ratio [AOR], 1.13; 95% CI, 1.03-1.24; P = .01) and a very high COVID-19 burden (AOR, 1.38; 95% CI, 1.24-1.53; P < .001) compared with patients in hospitals with a low COVID-19 burden. Overall, patients with Medicaid had 29% higher odds of death (AOR, 1.29; 95% CI, 1.22-1.36; P < .001) and patients without insurance had 75% higher odds of death (AOR, 1.75; 95% CI, 1.55-1.98; P < .001) compared with patients with commercial insurance. However, mortality rates for surgical patients with Medicaid insurance (AOR, 1.03; 95% CI, 0.82-1.30; P = .79) or without insurance (AOR, 0.85; 95% CI, 0.47-1.54; P = .60) did not increase more than for patients with commercial insurance in hospitals with a high COVID-19 burden compared with hospitals with a low COVID-19 burden. These findings were similar in hospitals with very high COVID-19 burdens. Conclusions and Relevance: In this cross-sectional study, the first wave of the COVID-19 pandemic was associated with a higher risk of mortality after surgery in hospitals with more than 25.0% of patients with COVID-19. However, the pandemic was not associated with greater increases in mortality among patients with no insurance or patients with Medicaid compared with patients with commercial insurance in hospitals with a very high COVID-19 burden.


Assuntos
COVID-19 , Medicare , Adulto , Idoso , Estudos Transversais , Feminino , Humanos , Medicaid , Pandemias , Estados Unidos/epidemiologia
18.
JAMA Surg ; 157(8): e222236, 2022 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-35767247

RESUMO

Importance: Perioperative strokes are a major cause of death and disability. There is limited information on which to base decisions for how long to delay elective nonneurologic, noncardiac surgery in patients with a history of stroke. Objective: To examine whether an association exists between the time elapsed since an ischemic stroke and the risk of recurrent stroke in older patients undergoing elective nonneurologic, noncardiac surgery. Design, Setting, and Participants: This cohort study used data from the 100% Medicare Provider Analysis and Review files, including the Master Beneficiary Summary File, between 2011 and 2018 and included elective nonneurologic, noncardiac surgeries in patients 66 years or older. Patients were excluded if they had more than 1 procedure during a 30-day period, were transferred from another hospital or facility, were missing information on race and ethnicity, were admitted in December 2018, or had tracheostomies or gastrostomies. Data were analyzed May 7 to October 23, 2021. Exposures: Time interval between a previous hospital admission for acute ischemic stroke and surgery. Main Outcomes and Measures: Acute ischemic stroke during the index surgical admission or rehospitalization for stroke within 30 days of surgery, 30-day all-cause mortality, composite of stroke and mortality, and discharge to a nursing home or skilled nursing facility. Multivariable logistic regression models were used to estimate adjusted odds ratios (AORs) to quantify the association between outcome and time since ischemic stroke. Results: The final cohort included 5 841 539 patients who underwent elective nonneurologic, noncardiac surgeries (mean [SD] age, 74.1 [6.1] years; 3 371 329 [57.7%] women), of which 54 033 (0.9%) had a previous stroke. Patients with a stroke within 30 days before surgery had higher adjusted odds of perioperative stroke (AOR, 8.02; 95% CI, 6.37-10.10; P < .001) compared with patients without a previous stroke. The adjusted odds of stroke were not significantly different at an interval of 61 to 90 days between previous stroke and surgery (AOR, 5.01; 95% CI, 4.00-6.29; P < .001) compared with 181 to 360 days (AOR, 4.76; 95% CI, 4.26-5.32; P < .001). The adjusted odds of 30-day all-cause mortality were higher in patients who underwent surgery within 30 days of a previous stroke (AOR, 2.51; 95% CI, 1.99-3.16; P < .001) compared with those without a history of stroke, and the AOR decreased to 1.49 (95% CI, 1.15-1.92; P < .001) at 61 to 90 days from previous stroke to surgery but did not decline significantly, even after an interval of 360 or more days. Conclusions and Relevance: The findings of this cohort study suggest that, among patients undergoing nonneurologic, noncardiac surgery, the risk of stroke and death leveled off when more than 90 days elapsed between a previous stroke and elective surgery. These findings suggest that the recent scientific statement by the American Heart Association to delay elective nonneurologic, noncardiac surgery for at least 6 months after a recent stroke may be too conservative.


Assuntos
AVC Isquêmico , Acidente Vascular Cerebral , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Medicare , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Estados Unidos/epidemiologia
19.
JAMA Netw Open ; 5(5): e2213527, 2022 05 02.
Artigo em Inglês | MEDLINE | ID: mdl-35604684

RESUMO

Importance: Racial minority groups account for 70% of excess deaths not related to COVID-19. Understanding the association of the Centers for Medicare & Medicaid Services' (CMS's) moratorium delaying nonessential operations with racial disparities will help shape future pandemic responses. Objective: To evaluate the association of the CMS's moratorium on elective operations during the first wave of the COVID-19 pandemic among Black individuals, Asian individuals, and individuals of other races compared with White individuals. Design, Setting, and Participants: This cross-sectional study assessed a 719-hospital retrospective cohort of 3 470 905 adult inpatient hospitalizations for major surgery between January 1, 2018, and October 31, 2020. Exposure: The first wave of COVID-19 infections between March 1, 2020, and May 31, 2020. Main Outcomes and Measures: The main outcome was the association between changes in monthly elective surgical case volumes and the first wave of COVID-19 infections as a function of patient race, evaluated using negative binomial regression analysis. Results: Among 3 470 905 adults (1 823 816 female [52.5%]) with inpatient hospitalizations for major surgery, 70 752 (2.0%) were Asian, 453 428 (13.1%) were Black, 2 696 929 (77.7%) were White, and 249 796 (7.2%) were individuals of other races. The number of monthly elective cases during the first wave was 49% (incident rate ratio [IRR], 0.49; 95% CI, 0.486-0.492; P < .001) compared with the baseline period. The relative reduction in unadjusted elective surgery cases for Black (unadjusted IRR, 0.99; 95% CI, 0.97-1.01; P = .36), Asian (unadjusted IRR, 1.08; 95% CI, 1.03-1.14; P = .001), and other race individuals (unadjusted IRR, 0.97; 95% CI, 0.95-1.00; P = .05) during the surge period compared with the baseline period was very close to the change in cases for White individuals. After adjustment for age, sex, comorbidities, and surgical procedure, there was still no evidence that the first wave of the pandemic was associated with disparities in access to elective surgery. Conclusions and Relevance: In this cross-sectional study, the CMS's moratorium on nonessential operations was associated with a 51% reduction in elective operations. It was not associated with greater reductions in operations for racial minority individuals than for White individuals. This evidence suggests that the early response to the pandemic did not increase disparities in access to surgical care.


Assuntos
COVID-19 , Adulto , Idoso , COVID-19/epidemiologia , Estudos Transversais , Feminino , Humanos , Medicare , Pandemias , Estudos Retrospectivos , SARS-CoV-2 , Estados Unidos/epidemiologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...