Impact of the Affordable Care Act on Disparities in Access to and Outcomes After Coronary Artery Bypass Grafting.

OBJECTIVES: The aim of this study was to examine the effect of implementation of the Affordable Care Act's Medicaid expansion on access to and outcomes after coronary artery bypass grafting (CABG) surgery. METHODS: Retrospective observational study utilizing the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2011 to 2016. The southern region of the USA was used as a control and the western region as the implementation group. Univariate regression models and interrupted time series models were created to evaluate and assess the impact of the Affordable Care Act's Medicaid expansion on mortality after CABG with respect to patient race. RESULTS: From 2011 to 2016, a total of 117,819 isolated CABG operations were identified in the specified regions using the HCUP NIS. Of these, 89,918 were performed in the southern region, and the remainder were performed in the western region. The proportion of African American patients with Medicaid increased significantly in the western region after the ACA Medicaid expansion, from 13.1 to 17.6%, p = 0.034. There was no significant increase seen in the number of African American patients with Medicaid in the southern region. We found that overall, Black patients had higher mortality after CABG as compared to white patients (OR 1.15, p = 0.02); however, when broken down by region we found higher mortality among African American patients in the southern region only, with no statistically significant difference in mortality between white and Black patients in the western region. CONCLUSIONS: Implementation of the Affordable Care Act increased access to Medicaid among Black Americans but did not necessarily decrease the disparity in access to CABG or mortality after CABG between Black and white patients. When it comes to racial disparities in mortality after CABG, there are significant regional and geographic variations which have not been previously described. This finding has important implications for the development of policy and other strategies that aim to reduce these disparities.

Preoperative Anemia as a Risk Factor for Postoperative Outcomes in Patients Undergoing Lung Transplantation.

OBJECTIVES: The aim of this study was to evaluate the effect of preoperative anemia on early postoperative outcomes in a population of patients undergoing lung transplantation. DESIGN: Single-center retrospective study of lung transplantation recipients between April 2013 and June 2018. The primary outcome was hospital length of stay. SETTING: Ronald Reagan UCLA Medical Center, Los Angeles, CA, a tertiary academic medical center. PARTICIPANTS: Patients presenting from home for lung transplantation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 435 patients underwent lung transplantation during the study period. After exclusion, 342 were included in the analysis. The prevalence of preoperative anemia was 54% (n = 183); however, only 11% of anemic patients received treatment for anemia before transplantation. Multivariate regression analysis indicated that lower hemoglobin levels were associated with longer hospital lengths of stay (p = 0.049). Preoperative anemia also was independently associated with an increased risk for redo surgery for bleeding (odds ratio 4.89; p = 0.007). No association between preoperative anemia and any of the other postoperative outcomes examined was found. CONCLUSIONS: Preoperative anemia in patients undergoing lung transplantation is undertreated and independently associated with an increased risk for redo surgery for bleeding. Additional studies regarding reasons for this association and effect of treatment are necessary to improve outcomes.