Hospital Presumptive Eligibility Emergency Medicaid Programs: An Opportunity for Continuous Insurance Coverage?

BACKGROUND: Lack of health insurance is a public health crisis, leading to foregone care and financial strain. Hospital Presumptive Eligibility (HPE) is a hospital-based emergency Medicaid program that provides temporary (up to 60 d) coverage, with the goal that hospitals will assist patients in applying for ongoing Medicaid coverage. It is unclear whether HPE is associated with successful longer-term Medicaid enrollment. OBJECTIVE: To characterize Medicaid enrollment 6 months after initiation of HPE and determine sociodemographic, clinical, and geographic factors associated with Medicaid enrollment. DESIGN: This was a cohort study of all HPE approved inpatients in California, using claims data from the California Department of Healthcare Services. SETTING: The study was conducted across all HPE-participating hospitals within California between January 1, 2016 and December 31, 2017. PARTICIPANTS: We studied California adult hospitalized inpatients, who were uninsured at the time of hospitalization and approved for HPE emergency Medicaid. Using multivariable logistic regression models, we compared HPE-approved patients who enrolled in Medicaid by 6 months versus those who did not. EXPOSURES: HPE emergency Medicaid approval at the time of hospitalization. MAIN OUTCOMES AND MEASURES: The primary outcome was full-scope Medicaid enrollment by 6 months after the hospital's presumptive eligibility approval. RESULTS: Among 71,335 inpatient HPE recipients, a total of 45,817 (64.2%) enrolled in Medicaid by 6 months. There was variability in Medicaid enrollment across counties in California (33%-100%). In adjusted analyses, Spanish-preferred-language patients were less likely to enrollin Medicaid (aOR 0.77, P<0.001). Surgical intervention (aOR 1.10, P<0.001) and discharge to another inpatient facility or a long-term care facility increased the odds of Medicaid enrollment (vs. routine discharge home: aOR 2.24 and aOR 1.96, P<0.001). CONCLUSION: California patients who enroll in HPE often enroll in Medicaid coverage by 6 months, particularly among patients requiring surgical intervention, repeated health care visits, and ongoing access to care. Future opportunities include prospective evaluation of HPE recipients to understand the impact that Medicaid enrollment has on health care utilization and financial solvency.

Statistical Methods to Examine Racial and Ethnic Disparities in the Surgical Literature: A Review and Recommendations for Improvement.

OBJECTIVE: We characterized the quality of statistical methods for studies of racial and ethnic disparities in the surgical-relevant literature during 2021-2022. BACKGROUND: Hundreds of scientific papers are published each year describing racial and ethnic disparities in surgical access, quality, and outcomes. The content and design quality of this literature has never been systematically reviewed. METHODS: We searched for 2021-2022 studies focused on describing racial and/or ethnic disparities in surgical or perioperative access, process quality, or outcomes. Identified studies were characterized in terms of three methodological criteria: 1) adjustment for variables related to both race/ethnicity and outcomes, including social determinants of health (SDOH); 2) accounting for clustering of patients within hospitals or other subunits ("providers") and; 3) distinguishing within- and between-provider effects. RESULTS: We identified 224 papers describing racial and/or ethnic differences. Of the 38 single institution studies, 24 (63.2%) adjusted for at least one SDOH variable. Of the 186 multisite studies, 113 (60.8%) adjusted for at least one SDOH variable, and 43 (23.1%) accounted for clustering of patients within providers using appropriate statistical methods. Only 10 (5.4%) of multi-institution studies made efforts to examine how much of overall disparities were driven by within versus between provider effects. CONCLUSIONS: Most recently published papers on racial and ethnic disparities in the surgical literature do not meet these important statistical design criteria and therefore may risk inaccuracy in the estimation of group differences in surgical access, quality, and outcomes. The most potent leverage points for these improvements are changes to journal publication guidelines and policies.

Impact of a coaching program on resident perceptions of communication confidence and feedback quality.

BACKGROUND: While communication is an essential skill for providing effective medical care, it is infrequently taught or directly assessed, limiting targeted feedback and behavior change. We sought to evaluate the impact of a multi-departmental longitudinal residency communication coaching program. We hypothesized that program implementation would result in improved confidence in residents' communication skills and higher-quality faculty feedback. METHODS: The program was implemented over a 3-year period (2019-2022) for surgery and neurology residents at a single institution. Trained faculty coaches met with assigned residents for coaching sessions. Each session included an observed clinical encounter, self-reflection, feedback, and goal setting. Eligible residents completed baseline and follow-up surveys regarding their perceptions of feedback and communication. Quantitative responses were analyzed using paired t-tests; qualitative responses were analyzed using content analysis. RESULTS: The baseline and follow-up survey response rates were 90.0% (126/140) and 50.5% (46/91), respectively. In a paired analysis of 40 respondents, residents reported greater confidence in their ability to communicate with patients (inpatient: 3.7 vs. 4.3, p < 0.001; outpatient: 3.5 vs. 4.2, p < 0.001), self-reflect (3.3 vs. 4.3, p < 0.001), and set goals (3.6 vs. 4.3, p < 0.001), as measured on a 5-point scale. Residents also reported greater usefulness of faculty feedback (3.3 vs. 4.2, p = 0.001). The content analysis revealed helpful elements of the program, challenges, and opportunities for improvement. Receiving mentorship, among others, was indicated as a core program strength, whereas solving session coordination and scheduling issues, as well as lowering the coach-resident ratio, were suggested as some of the improvement areas. CONCLUSIONS: These findings suggest that direct observation of communication in clinical encounters by trained faculty coaches can facilitate long-term trainee growth across multiple core competencies. Future studies should evaluate the impact on patient outcomes and workplace-based assessments.

Disparities in Access, Quality, and Clinical Outcome for Latino Californians with Colon Cancer.

OBJECTIVE: To compare access, quality, and clinical outcomes between Latino and non-Latino White Californians with colon cancer. SUMMARY BACKGROUND DATA: Racial and ethnic disparities in cancer care remain understudied, particularly among patients who identify as Latino. Exploring potential mechanisms, including differential utilization of high-volume hospitals, is an essential first step to designing evidence-based policy solutions. METHODS: We identified all adults diagnosed with colon cancer between January 1, 2010 and December 31, 2020 from a statewide cancer registry linked to hospital administrative records. We compared survival, access (stage at diagnosis, receipt of surgical care, treatment at a high-volume hospital), and quality of care (receipt of adjuvant chemotherapy, adequacy of lymph node resection) between patients who identified as Latino and as non-Latino White. RESULTS: 75,543 patients met inclusion criteria, including 16,071 patients who identified as Latino (21.3%). Latino patients were significantly less likely to undergo definitive surgical resection (marginal difference [MD] -0.72 percentage points, 95% CI -1.19,-0.26), have an operation in a timely fashion (MD -3.24 percentage points, 95% CI -4.16,-2.32), or have an adequate lymphadenectomy (MD -2.85 percentage points, 95% CI -3.59,-2.12) even after adjustment for clinical and sociodemographic factors. Latino patients treated at high-volume hospitals were significantly less likely to die and more likely to meet access and quality metrics. CONCLUSIONS: Latino colon cancer patients experienced delays, segregation, and lower receipt of recommended care. Hospital-level colectomy volume appears to be strongly associated with access, quality, and survival--especially for patients who identify as Latino--suggesting that directing at-risk cancer patients to high-volume hospitals may improve health equity.

The value of national accreditation program for rectal cancer: A survey of accredited programs and programs seeking accreditation.

BACKGROUND: Significant variation in rectal cancer care has been demonstrated in the United States. The National Accreditation Program for Rectal Cancer was established in 2017 to improve the quality of rectal cancer care through standardization and emphasis on a multidisciplinary approach. The aim of this study was to understand the perceived value and barriers to achieving the National Accreditation Program for Rectal Cancer accreditation. METHODS: An electronic survey was developed, piloted, and distributed to rectal cancer programs that had already achieved or were interested in pursuing the National Accreditation Program for Rectal Cancer accreditation. The survey contained 40 questions with a combination of Likert scale, multiple choice, and open-ended questions to provide comments. This was a mixed methods study; descriptive statistics were used to analyze the quantitative data, and thematic analysis was used to analyze the qualitative data. RESULTS: A total of 85 rectal cancer programs were sent the survey (22 accredited, 63 interested). Responses were received from 14 accredited programs and 41 interested programs. Most respondents were program directors (31%) and program coordinators (40%). The highest-ranked responses regarding the value of the National Accreditation Program for Rectal Cancer accreditation included "improved quality and culture of rectal cancer care," "enhanced program organization and coordination," and "challenges our program to provide optimal, high-quality care." The most frequently cited barriers to the National Accreditation Program for Rectal Cancer accreditation were cost and lack of personnel. CONCLUSION: Our survey found significant perceived value in the National Accreditation Program for Rectal Cancer accreditation. Adhering to standards and a multidisciplinary approach to rectal cancer care are critical components of a high-quality care rectal cancer program.

A Qualitative Study of Emergency Medicaid Programs From the Perspective of Hospital Stakeholders.

INTRODUCTION: Uninsured patients often have poor clinical outcomes associated with lower access to care. Hospital Presumptive Eligibility (HPE) provides up to 60-d emergency Medicaid coverage for uninsured, low-income patients. After obtaining 60-d HPE, patients must file for ongoing Medicaid to sustain coverage; however, navigating HPE approval is complex. We conducted a qualitative study to understand (1) stakeholder perspectives on the application process and workflow and (2) facilitators and barriers to HPE approval to understand process improvement opportunities. MATERIAL AND METHODS: We conducted semi-structured interviews between September-December 2021 with key stakeholders (social workers, financial counselors, case managers, and private third-party vendor representatives) involved in HPE coverage determination, screening, approval, and Medicaid sustainment at our institution. We performed a team-based thematic analysis to elicit factors influencing HPE screening and approval, and recommendations for process improvement. RESULTS: Study participants described the HPE application and Medicaid approval processes. Patient-level barriers included information disclosure and immigration status, inability to contact patients or next-of-kin, and knowledge gaps about insurance acquisition and sustainment. System-level barriers included technical challenges with the state HPE application portal, inadequate staffing for patient screening, and short emergency department stays that limited opportunities to initiate HPE. Stakeholders proposed improvements in education, patient outreach, and logistics. CONCLUSIONS: This qualitative study reveals the process of HPE approval and outlines barriers within HPE and Medicaid processing from the perspective of direct hospital stakeholders. We identified opportunities at the patient, hospital, and policy levels that could improve successful HPE application and approval rates.

SCAN for Abuse: Electronic Health Record-Based Universal Child Abuse Screening.

BACKGROUND: Identification of physical abuse at the point of care without a systematic approach remains inherently subjective and prone to judgement error. This study examines the implementation of an electronic health record (EHR)-based universal child injury screen (CIS) to improve detection rates of child abuse. METHODS: CIS was implemented in the EHR admission documentation for all patients age 5 or younger at a single medical center, with the following questions. 1) "Is this patient an injured/trauma patient?" 2) "If this is a trauma/injured patient, where did the injury occur?" A "Yes" response to Question 1 would alert a team of child abuse pediatricians and social workers to determine if a patient required formal child abuse clinical evaluation. Patients who received positive CIS responses, formal child abuse work-up, and/or reports to Child Protective Services (CPS) were reviewed for analysis. CPS rates from historical controls (2017-2018) were compared to post-implementation rates (2019-2021). RESULTS: Between 2019 and 2021, 14,150 patients were screened with CIS. 286 (2.0 %) patients screened received positive CIS responses. 166 (58.0 %) of these patients with positive CIS responses would not have otherwise been identified for child abuse evaluation by their treating teams. 18 (10.8 %) of the patients identified by the CIS and not by the treating team were later reported to CPS. Facility CPS reporting rates for physical abuse were 1.2 per 1000 admitted children age 5 or younger (pre-intervention) versus 4.2 per 1000 (post-intervention). CONCLUSIONS: Introduction of CIS led to increased detection suspected child abuse among children age 5 or younger. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Study of Diagnostic Test.

Do hospital-based emergency Medicaid programs benefit trauma centers? A mixed-methods analysis.

INTRODUCTION: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization, which can offset patient costs of care, increase access to postdischarge resources, and provide a path to sustain coverage through Medicaid. Less is known about the implications of HPE programs on trauma centers (TCs). We aimed to describe the association with HPE and hospital Medicaid reimbursement and characterize incentives for HPE participation among hospitals and TCs. We hypothesized that there would be financial, operational, and mission-based incentives. METHODS: We performed a convergent mixed methods study of HPE hospitals in California (including all verified TCs). We analyzed Annual Financial Disclosure Reports from California's Department of Health Care Access and Information (2005-2021). Our primary outcome was Medicaid net revenue. We also conducted thematic analysis of semistructured interviews with hospital stakeholders to understand incentives for HPE participation (n = 8). RESULTS: Among 367 California hospitals analyzed, 285 (77.7%) participate in HPE, 77 (21%) of which are TCs. As of early 2015, 100% of TCs had elected to enroll in HPE. There is a significant positive association between HPE participation and net Medicaid revenue. The highest Medicaid revenues are in HPE level I and level II TCs. Controlling for changes associated with the Affordable Care Act, HPE enrollment is associated with increased net patient Medicaid revenue ( b = 6.74, p < 0.001) and decreased uncompensated care costs ( b = -2.22, p < 0.05). Stakeholder interviewees' explanatory incentives for HPE participation included reduction of hospital bad debt, improved patient satisfaction, and community benefit in access to care. CONCLUSION: Hospital Presumptive Eligibility programs not only are a promising pathway for long-term insurance coverage for trauma patients but also play a role in TC viability. Future interventions will target streamlining the HPE Medicaid enrollment process to reduce resource burden on participating hospitals and ensure ongoing patient engagement in the program. LEVEL OF EVIDENCE: Economic And Value Based Evaluations; Level II.

Transforming the Future of Surgeon-Scientists.

OBJECTIVE: To create a blueprint for surgical department leaders, academic institutions, and funding agencies to optimally support surgeon-scientists. BACKGROUND: Scientific contributions by surgeons have been transformative across many medical disciplines. Surgeon-scientists provide a distinct approach and mindset toward key scientific questions. However, lack of institutional support, pressure for increased clinical productivity, and growing administrative burden are major challenges for the surgeon-scientist, as is the time-consuming nature of surgical training and practice. METHODS: An American Surgical Association Research Sustainability Task Force was created to outline a blueprint for sustainable science in surgery. Leaders from top NIH-sponsored departments of surgery engaged in video and in-person meetings between January and April 2023. A strength, weakness, opportunities, threats analysis was performed, and workgroups focused on the roles of surgeons, the department and institutions, and funding agencies. RESULTS: Taskforce recommendations: (1) SURGEONS: Growth mindset : identifying research focus, long-term planning, patience/tenacity, team science, collaborations with disparate experts; Skill set : align skills and research, fill critical skill gaps, develop team leadership skills; DEPARTMENT OF SURGERY (DOS): (2) MENTORSHIP: Chair : mentor-mentee matching/regular meetings/accountability, review of junior faculty progress, mentorship training requirement, recognition of mentorship (eg, relative value unit equivalent, awards; Mentor: dedicated time, relevant scientific expertise, extramural funding, experience and/or trained as mentor, trusted advisor; Mentee : enthusiastic/eager, proactive, open to feedback, clear about goals; (3) FINANCIAL SUSTAINABILITY: diversification of research portfolio, identification of matching funding sources, departmental resource awards (eg, T-/P-grants), leveraging of institutional resources, negotiation of formalized/formulaic funds flow investment from academic medical center toward science, philanthropy; (4) STRUCTURAL/STRATEGIC SUPPORT: Structural: grants administrative support, biostats/bioinformatics support, clinical trial and research support, regulatory support, shared departmental laboratory space/equipment; Strategic: hiring diverse surgeon-scientist/scientists faculty across DOS, strategic faculty retention/ recruitment, philanthropy, career development support, progress tracking, grant writing support, DOS-wide research meetings, regular DOS strategic research planning; (5) COMMUNITY AND CULTURE: Community: right mix of faculty, connection surgeon with broad scientific community; Culture: building research infrastructure, financial support for research, projecting importance of research (awards, grand rounds, shoutouts); (6) THE ROLE OF INSTITUTIONS: Foundation: research space co-location, flexible start-up packages, courses/mock study section, awards, diverse institutional mentorship teams; Nurture: institutional infrastructure, funding (eg, endowed chairs), promotion friendly toward surgeon-scientists, surgeon-scientists in institutional leadership positions; Expectations: RVU target relief, salary gap funding, competitive starting salaries, longitudinal salary strategy; (7) THE ROLE OF FUNDING AGENCIES: change surgeon research training paradigm, offer alternate awards to K-awards, increasing salary cap to reflect market reality, time extension for surgeon early-stage investigator status, surgeon representation on study section, focused award strategies for professional societies/foundations. CONCLUSIONS: Authentic recommitment from surgeon leaders with intentional and ambitious actions from institutions, corporations, funders, and society is essential in order to reap the essential benefits of surgeon-scientists toward advancements of science.

Standardization of Colon Resection for Cancer: An Overview of the American College of Surgeons Commission on Cancer Standard 5.6.

The purpose of this editorial is to review the American College of Surgeons Commission on Cancer Standard 5.6, which pertains to curative intent colon resections performed for cancer. We first provide a broad overview of the Operative Standard, followed by the underlying rationale, technical components, and documentation requirements.

Association of High-Deductible Health Plans and Time to Surgery for Breast and Colon Cancer.

BACKGROUND: High-deductible health plans (HDHPs) have been shown to delay timing of breast and colon cancer screening, although the relationship to the timing of cancer surgery is unknown. The objective of this study was to characterize timing of surgery for breast and colon cancer patients undergoing cancer operations following routine screening. STUDY DESIGN: Data from the IBM MarketScan Commercial Claims Database from 2007 to 2016 were queried to identify patients who underwent screening mammogram and/or colonoscopy. The calendar quarters of screening and surgery were analyzed with ordinal logistic regression. The time from screening to surgery (time to surgery, TTS) was evaluated using a Cox proportional hazard function. RESULTS: Among 32,562,751 patients who had screening mammograms, 0.7% underwent breast cancer surgery within the following year. Among 9,325,238 patients who had screening colonoscopies, 0.9% were followed by colon cancer surgery within a year. The odds of screening (OR 1.146 for mammogram, 1.272 for colonoscopy; p < 0.001) and surgery (OR 1.120 for breast surgery, 1.219 for colon surgery; p < 0.001) increased each quarter for HDHPs compared to low-deductible health plans. Enrollment in an HDHP was not associated with a difference in TTS. Screening in Q3 or Q4 was associated with shorter TTS compared to screening in Q1 (hazard ratio 1.061 and 1.046, respectively; p < 0.001). CONCLUSIONS: HDHPs were associated with delays in screening and surgery. However, HDHPs were not associated with delays in TTS. Interventions to improve cancer care outcomes in the HDHP population should concentrate on reducing barriers to timely screening.

Disparities in Preoperative Goals of Care Documentation in Veterans.

Importance: Preoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk. Objective: To assess the association of race, ethnicity, and other factors, including history of mental health disability, with disparities in preoperative goals of care documentation among veterans. Design, Setting, and Participants: This retrospective cross-sectional study assessed data from the Veterans Healthcare Administration (VHA) of 229 737 veterans who underwent surgical procedures between January 1, 2017, and October 18, 2022. Exposures: Patient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors. Main Outcomes and Measures: Preoperative life-sustaining treatment (LST) note documentation or no LST note documentation within 30 days prior to or on day of surgery. The standardized mean differences were calculated to assess the magnitude of differences between groups. Odds ratios (ORs) and 95% CIs were estimated with logistic regression. Results: In this study, 13 408 patients (5.8%) completed preoperative LST from 229 737 VHA patients (209 123 [91.0%] male; 20 614 [9.0%] female; mean [SD] age, 65.5 [11.9] years) who received surgery. Compared with patients who did complete preoperative LST, patients tended to complete preoperative documentation less often if they were female (19 914 [9.2%] vs 700 [5.2%]), Black individuals (42 571 [19.7%] vs 2416 [18.0%]), Hispanic individuals (11 793 [5.5%] vs 631 [4.7%]), or from rural areas (75 637 [35.0%] vs 4273 [31.9%]); had a history of mental health disability (65 974 [30.5%] vs 4053 [30.2%]); or were seen at lowest-complexity (ie, level 3) facilities (7849 [3.6%] vs 78 [0.6%]). Over time, despite the COVID-19 pandemic, patients undergoing surgical procedures completed preoperative LST increasingly more often. Covariate-adjusted estimates of preoperative LST completion demonstrated that patients of racial or ethnic minority background (Black patients: OR, 0.79; 95% CI, 0.77-0.80; P <.001; patients selecting other race: OR, 0.78; 95% CI, 0.74-0.81; P <.001; Hispanic patients: OR, 0.78; 95% CI, 0.76-0.81; P <.001) and patients from rural regions (OR, 0.91; 95% CI, 0.90-0.93; P <.001) had lower likelihoods of completing LST compared with patients who were White or non-Hispanic and patients from urban areas. Patients with any mental health disability history also had lower likelihood of completing preoperative LST than those without a history (OR, 0.93; 95% CI, 0.92-0.94; P = .001). Conclusions and Relevance: In this cross-sectional study, disparities in documentation rates within a VHA cohort persisted based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume, high-complexity facilities.

Contextual Determinants of Time to Surgery for Patients With Hip Fracture.

Importance: Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions. Objective: To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals. Design, Setting, and Participants: This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022. Main Outcomes and Measures: Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds). Results: A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work. Conclusions and Relevance: In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.

Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans.

CONTEXT: Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively. OBJECTIVES: To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons. METHODS: We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8). RESULTS: Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care. CONCLUSION: The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.

Disparities in the Timing of Preoperative Hemodialysis Among Patients With End-Stage Kidney Disease.

This cohort study evaluates the association of patient characteristics with the interval between hemodialysis and surgery among patients with end-stage kidney disease.

Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial.

Importance: Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations. Objective: To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers. Design, Setting, and Participants: From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients. Intervention: Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation. Main Outcomes and Measures: The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed. Results: In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99). Conclusions and Relevance: To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers. Trial Registration: ClinicalTrials.gov Identifier: NCT03611309.

Decision Making and Cost in Healthcare: The Patient Perspective.

Unsustainable spending and unsatisfactory outcomes have prompted a reanalysis of healthcare policy towards value. Several strategies have been proposed as part of this effort including cost sharing plans to shift costs to patients and gain-sharing models to shift risk to health systems. The patient perspective is rarely elicited in policy formation despite efforts to increase patient-centered care. We conducted a prospective study of 118 patients presenting to hand clinic to assess patient perspective of who should constrain treatment options (patient, physician, insurance company, hospital) and be responsible for costs in scenarios of clinical equipoise. We found that patients believed that insurance companies and hospitals should not constrain which treatment options are available to a patient and that physicians and patients should together influence the availability of treatment options. Patients were willing to cost share with insurance companies when choosing more expensive treatments or in the setting of non-life-threatening diseases. In addressing rising healthcare costs, patient perspectives can inform policies designed to increase value. Asking patients to cost share when choosing a more expensive treatment option in the setting of clinical equipoise could be a strategy for health systems to increase value. Level of Evidence: III (Journal of Surgical Orthopaedic Advances 32(1):023-027, 2023).

Financial Toxicity and Its Association With Health-Related Quality of Life Among Partners of Colorectal Cancer Survivors.

Importance: Partners of colorectal cancer (CRC) survivors play a critical role in diagnosis, treatment, and survivorship. While financial toxicity (FT) is well documented among patients with CRC, little is known about long-term FT and its association with health-related quality of life (HRQoL) among their partners. Objective: To understand long-term FT and its association with HRQoL among partners of CRC survivors. Design, Setting, and Participants: This survey study incorporating a mixed-methods design consisted of a mailed dyadic survey with closed- and open-ended responses. In 2019 and 2020, we surveyed survivors who were 1 to 5 years from a stage III CRC diagnosis and included a separate survey for their partners. Patients were recruited from a rural community oncology practice in Montana, an academic cancer center in Michigan, and the Georgia Cancer Registry. Data analysis was performed from February 2022 to January 2023. Exposures: Three components of FT, including financial burden, debt, and financial worry. Main Outcomes and Measures: Financial burden was assessed with the Personal Financial Burden scale, whereas debt and financial worry were each assessed with a single survey item. We measured HRQoL using the PROMIS-29+2 Profile, version 2.1. We used multivariable regression analysis to assess associations of FT with individual domains of HRQoL. We used thematic analysis to explore partner perspectives on FT, and we merged quantitative and qualitative findings to explain the association between FT and HRQoL. Results: Of the 986 patients eligible for this study, 501 (50.8%) returned surveys. A total of 428 patients (85.4%) reported having a partner, and 311 partners (72.6%) returned surveys. Four partner surveys were returned without a corresponding patient survey, resulting in a total of 307 patient-partner dyads for this analysis. Among the 307 partners, 166 (56.1%) were aged younger than 65 years (mean [SD] age, 63.7 [11.1] years), 189 (62.6%) were women, and 263 (85.7%) were White. Most partners (209 [68.1%]) reported adverse financial outcomes. High financial burden was associated with worse HRQoL in the pain interference domain (mean [SE] score, -0.08 [0.04]; P = .03). Debt was associated with worse HRQoL in the sleep disturbance domain (-0.32 [0.15]; P = .03). High financial worry was associated with worse HRQoL in the social functioning (mean [SE] score, -0.37 [0.13]; P = .005), fatigue (-0.33 [0.15]; P = .03), and pain interference (-0.33 [0.14]; P = .02) domains. Qualitative findings revealed that in addition to systems-level factors, individual-level behavioral factors were associated with partner financial outcomes and HRQoL. Conclusions and Relevance: This survey study found that partners of CRC survivors experienced long-term FT that was associated with worse HRQoL. Multilevel interventions for both patients and partners are needed to address factors at individual and systemic levels and incorporate behavioral approaches.