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Covering: up to 2022Tricyclic bridgehead carbon centers (TBCCs) are a synthetically challenging substructure found in many complex natural products. Here we review the syntheses of ten representative families of TBCC-containing isolates, with the goal of outlining the strategies and tactics used to install these centers, including a discussion of the evolution of the successful synthetic design. We provide a summary of common strategies to inform future synthetic endeavors.
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Produtos Biológicos , Produtos Biológicos/química , CarbonoRESUMO
We describe a stereocontrolled synthesis of 3, the fully glycosylated monomeric unit of the dimeric cytotoxic bacterial metabolite (-)-lomaiviticin A (2). A novel strategy involving convergent, site- and stereoselective coupling of the ß,γ-unsaturated ketone 6 and the naphthyl bromide 7 (92%, 15:1 diastereomeric ratio (dr)), followed by radical-based annulation and silyl ether cleavage, provided the tetracycle 5 (57% overall), which contains the carbon skeleton of the aglycon of 3. The ß-linked 2,4,6-trideoxy-4-aminoglycoside l-pyrrolosamine was installed in 73% yield and with 15:1 ß:α selectivity using a modified Koenigs-Knorr glycosylation. The diazo substituent was introduced via direct diazo transfer to an electron-rich benzoindene (4 â 27). The α-linked 2,6-dideoxyglycoside l-oleandrose was introduced by gold-catalyzed activation of an o-alkynyl glycosylbenzoate (75%, >20:1 α:ß selectivity). A carefully orchestrated endgame sequence then provided efficient access to 3. Cell viability studies indicated that monomer 3 is not cytotoxic at concentrations up to 1 µM, providing conclusive evidence that the dimeric structure of (-)-lomaiviticin A (2) is required for cytotoxic effects. The preparation of 3 provides a foundation to complete the synthesis of (-)-lomaiviticin A (2) itself.
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Antineoplásicos , Fluorenos , Fluorenos/química , Glicosilação , Estrutura MolecularRESUMO
INTRODUCTION: As exposed regions of the body, the head and neck are at increased risk of burn injury. The cosmetic and functional importance of these anatomical regions means that burns can result in substantial morbidity and mortality. Our objective was to characterize predictive factors for surgery and discharge condition in patients with head and neck burns internationally. METHODS: We conducted an epidemiological study of all head and neck burns in 14 countries reported in the World Health Organization Global Burn Registry. Multivariate regression was used to identify variables predictive of surgical treatment and discharge condition. RESULTS: We identified 1014 patients who sustained head and neck burns; the majority were adults (60%). Both adults and children admitted to hospital with head and neck burn injuries were less likely to be treated surgically in lower-middle-income countries (LMIC) than in higher-income countries (P < 0.001). Increasing age and greater total surface body area (TBSA) were significant predictors of surgical intervention in children with head and neck burn injuries (P < 0.001). Total surface body area, associated injuries, ocular burns, female sex, and LMIC residency were all significant predictors of mortality in adult patients with head and neck burns (P < 0.050). Conversely, TBSA was the only variable that independently increased the risk of death in children with head and neck burns (P < 0.001). CONCLUSIONS: Certain groups are at increased risk of an adverse outcome after admission with a head and neck burn injury. Given the reduced incidence of surgical intervention and the elevated mortality risk in LMICs, global health initiatives should be targeted to these countries.
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Hospitalização , Hospitais , Adulto , Superfície Corporal , Criança , Feminino , Humanos , Incidência , Tempo de Internação , Sistema de Registros , Estudos RetrospectivosRESUMO
OBJECTIVE: To characterize the economic hardship for uninsured patients admitted for trauma using catastrophic health expenditure (CHE) risk. BACKGROUND: Medical debts are the greatest cause of bankruptcies in the United States. Injuries are often unpredictable, expensive to treat, and disproportionally affect uninsured patients. Current measures of economic hardship are insufficient and exclude those at greatest risk. METHODS: We performed a retrospective review, using data from the 2007-2011 Nationwide Inpatient Samples of all uninsured nonelderly adults (18-64 yrs) admitted with primary diagnoses of trauma. We used US Census data to estimate annual postsubsistence income and inhospital charges for trauma-related admission. Our primary outcome measure was catastrophic health expenditure risk, defined as any charges ≥40% of annual postsubsistence income. RESULTS: Our sample represented 579,683 admissions for uninsured nonelderly adults over the 5-year study period. Median estimated annual income was $40,867 (interquartile range: $21,286-$71.733). Median inpatient charges were $27,420 (interquartile range: $15,196-$49,694). Overall, 70.8% (95% posterior confidence interval: 70.7%-71.1%) of patients were at risk for CHE. The risk of CHE was similar across most demographic subgroups. The greatest risk, however, was concentrated among patients from low-income communities (77.5% among patients in the lowest community income quartile) and among patients with severe injuries (81.8% among those with ISS ≥ 16). CONCLUSIONS: Over 7 in 10 uninsured patients admitted for trauma are at risk of catastrophic health expenditures. This analysis is the first application of CHE to a US trauma population and will be an important measure to evaluate the effectiveness of health care and coverage strategies to improve financial risk protection.
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Gastos em Saúde , Hospitalização/economia , Pessoas sem Cobertura de Seguro de Saúde , Pobreza , Ferimentos e Lesões/economia , Adolescente , Adulto , Efeitos Psicossociais da Doença , Preços Hospitalares , Humanos , Renda , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos , Ferimentos e Lesões/terapia , Adulto JovemRESUMO
We report the first reductive coupling of unactivated alkenes with N-methoxy pyridazinium, imidazolium, quinolinium, and isoquinolinium salts under hydrogen atom transfer (HAT) conditions, and an expanded scope for the coupling of alkenes with N-methoxy pyridinium salts. N-Methoxy pyridazinium, imidazolium, quinolinium, and isoquinolinium salts are accessible in 1-2 steps from the commercial arenes or arene N-oxides (25-99%). N-Methoxy imidazolium salts are accessible in three steps from commercial amines (50-85%). In total 36 discrete methoxyheteroarenium salts bearing electron-donating, electron-withdrawing, alkyl, aryl, halogen, and haloalkyl substituents were prepared (several in multigram quantities) and coupled with 38 different alkenes. The transformations proceed under neutral conditions at ambient temperature, provide monoalkylation products exclusively, and form a single alkene addition regioisomer. Preparatively useful and complementary site selectivities in the addition of secondary and tertiary radicals to pyidinium salts are documented: harder secondary radicals favor C-2 addition (2->10:1), while softer tertiary radicals favor bond formation to C-4 (4.7->29:1). A diene possessing a 1,2-disubstituted and 2,2-disubstituted alkene undergoes hydropyridylation at the latter exclusively (61%) suggesting useful site selectivities can be obtained in polyene substrates. The methoxypyridinium salts can also be employed in dehydrogenative arylation, borono-Minisci, and tandem arylation processes. Mechanistic studies support the involvement of a radical process.
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OBJECTIVES: The aims of this study were to assess for changes in uninsured rates among trauma patients at age 64 versus 65 years and whether there are associated changes in post-discharge rehabilitation; determine whether changes are driven by rehabilitation provided at home, skilled nursing facilities (SNFs), or acute inpatient facilities; and determine whether changes vary among stratified subgroups of trauma-related "best-practice" factors. SUMMARY BACKGROUND DATA: Rehabilitation is an important component of high-quality trauma systems with access heavily influenced by insurance status. In the wake of policy changes affecting insurance coverage, it remains unknown the extent to which insurance changes associate with variations in rehabilitation access/use among otherwise similar patients. METHODS: Regression discontinuity models were used to assess for changes in insurance status and rehabilitation at age 64 versus 65 years among adults ages 54 to 75 years (±10 years age-related Medicare eligibility). Data were extracted from the 2007-2012 National Trauma Data Bank. RESULTS: A total of 305,198 patients were included; 40.1% were discharged to rehabilitation. Medicare eligibility was associated with an abrupt 6.4 (95% confidence interval: 5.8-7.0) percentage-point decline in uninsured and a 9.6 (95% confidence interval: 6.5-12.6) percentage-point increase in rehabilitation at age 64 versus 65 years, enabling an additional 1-in-10 patients to access rehabilitation. Differences were driven by SNF use and were greatest among patients with less-severe clinical presentations. Restriction based on Medicare-payment eligibility to patients with length of stay ≥3days (SNF requirement) and ≥1 "presumptive diagnosis codes" (inpatient facilities' 60% rule) demonstrated abrupt gains in both SNF and inpatient care. CONCLUSIONS: The results reveal the magnitude of changes in access to rehabilitation associated with changes in insurance coverage at age 65 years. Use of quasiexperimental models enabled meaningful consideration of health-policy change.
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Definição da Elegibilidade , Custos de Cuidados de Saúde , Medicare/economia , Centros de Reabilitação/economia , Ferimentos e Lesões/reabilitação , Adulto , Fatores Etários , Idoso , Bases de Dados Factuais , Feminino , Humanos , Incidência , Escala de Gravidade do Ferimento , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Avaliação das Necessidades , Avaliação de Resultados em Cuidados de Saúde , Alta do Paciente/economia , Alta do Paciente/estatística & dados numéricos , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/estatística & dados numéricos , Centros de Reabilitação/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Estados Unidos , Ferimentos e Lesões/cirurgiaRESUMO
OBJECTIVE: To compare incremental costs associated with complications of elective colectomy using nationally representative data among patients undergoing laparoscopic/open resections for the 4 most frequent diagnoses. SUMMARY BACKGROUND DATA: Rising healthcare costs have led to increasing focus on the need to achieve a better understanding of the association between costs and quality. Among elective colectomies, a focus of surgical quality-improvement initiatives, interpretable evidence to support existing approaches is lacking. METHODS: The 2009 to 2011 Nationwide Inpatient Sample (NIS) data were queried for adult (≥18 years) patients undergoing elective colectomy. Patients with primary diagnoses for colon cancer, diverticular disease, benign colonic neoplasm, and ulcerative colitis/regional enteritis were included. Based on system-based complications considered relevant to long-term treatment of elective colectomy, stratified differences in risk-adjusted incremental hospital costs and complications probabilities were compared. RESULTS: A total of 68,462 patients were included, weighted to represent 337,887 patients nationwide. A total of 16.4% experienced complications. Annual risk-adjusted incremental costs amounted to >$150 million. Magnitudes of complication prevalences/costs varied by primary diagnosis, operative technique, and complication group. Infectious complications contributed the most ($55 million), followed by gastrointestinal ($53 million), pulmonary ($22 million), and cardiovascular ($11 million) complications. Total annual costs for elective colectomies amounted to >$1.7 billion: 11.3% was due to complications [1.9% due to current Centers for Medicare and Medicaid Services (CMS) complications]. CONCLUSIONS: The results highlight a need to consider the varied/broad impact of complications, offering a stratified paradigm for priority setting in surgery. As we move forward in the development of novel/adaptation of existing interventions, it will be essential to weigh the cost of complications in an evidence-based way.
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Colectomia/efeitos adversos , Doenças do Colo/cirurgia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Custos de Cuidados de Saúde , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/economia , Adolescente , Adulto , Idoso , Colectomia/economia , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Prioridades em Saúde , Hospitalização , Humanos , Laparoscopia/economia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act allowed young adults to remain on their parents' health insurance plans until age 26 years. Although the provision improved coverage and survey-reported access to care, little is known regarding its impact on timely access for acute conditions. This study aims to assess changes in insurance coverage and perforation rates among young adults with acute appendicitis-an established metric for population-level health care access-after the DCP. METHODS: The National Inpatient Sample and difference-in-differences linear regression were used to assess prepolicy/postpolicy changes for policy-eligible young adults (aged 19-25 y) compared with a slightly older, policy-ineligible comparator group (aged 26-34 y). RESULTS: After adjustment for covariates, 19-25 year olds experienced a 3.6-percentage point decline in the uninsured rate after the DCP (baseline 22.5%), compared with 26-34 year olds (P<0.001). This coincided with a 1.4-percentage point relative decline in perforated appendix rate for 19-25 year olds (baseline 17.5%), compared with 26-34 year olds (P=0.023). All subgroups showed significant reductions in uninsured rates; however, statistically significant reductions in perforation rates were limited to racial/ethnic minorities, patients from lower-income communities, and patients presenting to urban teaching hospitals. CONCLUSIONS: Reductions in uninsured rates among young adults after the DCP were associated with significant reductions in perforated appendix rates relative to a comparator group, suggesting that insurance expansion could lead to fewer delays in seeking and accessing care for acute conditions. Greater relative declines in perforation rates among the most at-risk subpopulations hold important implications for the use of coverage expansion to mitigate existing disparities in access to care.
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Apendicite/economia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act , Adulto , Fatores Etários , Feminino , Humanos , Cobertura do Seguro/legislação & jurisprudência , Modelos Lineares , Masculino , Pessoas sem Cobertura de Seguro de Saúde/legislação & jurisprudência , Adulto JovemRESUMO
Background: Pectoralis major muscle/myocutaneous flaps (PMMFs) are commonly used in reconstructive surgery, but may result in shoulder disability on the donor side. A systematic review evaluating this morbidity could be beneficial for guiding patients and providers considering this procedure. Methods: In October 2022, a systematic review of studies evaluating quantitative/qualitative measures of functional morbidity after PMMF was conducted. The results were categorized into PMMF's effect on range of motion (ROM), strength, and ability to complete shoulder-related activities/quality of life. Results: Eleven studies were included for analysis, which analyzed standard PMMF and two PMMF variants that spared portions of the muscle. Three of five studies demonstrated reduced shoulder ROM for standard PMMF versus controls lasting at least 4 months after head and neck reconstruction. Two of five studies, including two prospective studies demonstrated reduced shoulder strength for standard PMMF versus controls lasting at least 3 months after surgery. Five of nine studies found significant impairment in the ability to conduct shoulder-related activities, including work, up to one year postoperatively for standard PMMF versus controls. Muscle-sparing PMMF variants exhibited more promising outcomes in some categories. Conclusion: Standard PMMF results in prolonged reductions in shoulder ROM and strength, which may impair patients in shoulder-related activities. Other reconstructive options should be considered in patients who frequently participate in such activities. For patients requiring PMMF, muscle-sparing PMMF variants should be considered as alternatives to the standard PMMF.
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OBJECTIVE: Comparative effectiveness research has mostly been focused on comparison of treatment techniques. The goal of the present study was to extend the research to physician specialty. BACKGROUND: Both surgeons and interventionalists (cardiologists and radiologists) are involved in endovascular repairs (EVAR) of aortic aneurysms, with different residency education, operative experience, preoperative assessment and patient selection, and postoperative continuity of care. METHODS: Retrospective analysis was performed using the Nationwide Inpatient Sample from 1998 to 2009. Patients undergoing EVAR for abdominal aortic aneurysm were identified with International Classification of Diseases, Ninth Revision, procedure code 39.71. Using physician identifiers available in the database, surgeons were identified by case experience in the same calendar year with elective open AAA repairs, arteriovenous fistula repairs, or carotid endarderectomy. Multivariate analysis adjusted for physician volume, AAA ruptured status, patient demographic and comorbidities, and hospital characteristics. RESULTS: A total of 28,094 EVARs were analyzed. Unadjusted mortality rates, length of stay, and total hospital charges were significantly higher for patients treated by interventionalists than those by surgeons (all Ps < 0.001). This difference persisted on multivariate analysis, where interventionalists were associated with increased likelihood of mortality (odds ratio = 1.39; 95% confidence interval, 1.04-1.89), longer length of stay (1.32 days; 95% confidence interval, 1.03-1.62), and higher total hospital charges ($19,312; 95% confidence interval, 16,471-22,153). CONCLUSIONS: Physician specialty is associated with patient outcomes. Surgeons are associated with improved outcomes, with lower mortality, shorter length of stay, and lower charges for EVAR cases, when compared with interventionalists. This finding has significant implications for future comparative effectiveness research and potential policy changes in patient referrals or physician admitting privileges.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Cardiologia , Procedimentos Endovasculares , Radiologia Intervencionista , Especialização , Especialidades Cirúrgicas , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/economia , Implante de Prótese Vascular/métodos , Implante de Prótese Vascular/mortalidade , Pesquisa Comparativa da Efetividade , Bases de Dados Factuais , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/mortalidade , Feminino , Preços Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Resultado do Tratamento , Estados UnidosRESUMO
In this work, we report the development and experimental validation of a coupled statistical thermodynamic model allowing prediction of the structural transitions executed by a novel DNA nanodevice, for quantitative operational design. The efficiency of target structure formation by this nanodevice, implemented with a bistable DNA molecule designed to transform between three distinct structures, is modeled by coupling the isolated equilibrium models for the individual structures. A peculiar behavior is predicted for this nanodevice, which forms the target structure within a limited temperature range by sensing thermal variations. The predicted thermal response is then validated via fluorescence measurements to quantitatively assess whether the nanodevice performs as designed. Agreement between predictions and experiment was substantial, with a 0.95 correlation for overall curve shape over a wide temperature range, from 30 C to 90 C. The obtained accuracy, which is comparable to that of conventional melting behavior prediction for DNA duplexes in isolation, ensures the applicability of the coupled model for illustrating general DNA reaction systems involving competitive duplex formation. Finally, tuning of the nanodevice using the current model towards design of a thermal band pass filter to control chemical circuits, as a novel function of DNA nanodevices is proposed.
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DNA/química , Modelos Estatísticos , Nanoestruturas/química , Termodinâmica , Transferência Ressonante de Energia de Fluorescência , Conformação de Ácido NucleicoRESUMO
(-)-Lomaiviticin A is a complex C 2-symmetric bacterial metabolite comprising two diazotetrahydrobenzo[b]fluorene (diazofluorene) residues and four 2,6-dideoxy glycosides, α-l-oleandrose and N,N-dimethyl-ß-l-pyrrolosamine. The two halves of lomaiviticin A are linked by a single carbon-carbon bond oriented syn with respect to the oleandrose residues. While many advances toward the synthesis of lomaiviticin A have been reported, including synthesis of the aglycon, a route to the bis(cyclohexenone) core bearing any of the carbohydrate residues has not been disclosed. Here we describe a short route to a core structure of lomaiviticin A bearing two α-l-oleandrose residues. The synthetic route features a Stille coupling to form the conjoining carbon-carbon bond of the target and a double reductive transposition to establish the correct stereochemistry at this bond. Two synthetic routes were developed to elaborate the reductive transposition product to the bis(cyclohexenone) target. The more efficient pathway features an interrupted Barton vinyl iodide synthesis followed by oxidative elimination of iodide to efficiently establish the enone functionalities in the target. The bis(cyclohexenone) product may find use in a synthesis of lomaiviticin A itself.
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BACKGROUND: Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies. METHODS: We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation. RESULTS: Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%). CONCLUSIONS: A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.
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Cirurgia Bariátrica/economia , Cobertura do Seguro , Seguro Saúde , Obesidade Mórbida/cirurgia , Adolescente , Adulto , Fatores Etários , Idoso , Cirurgia Bariátrica/estatística & dados numéricos , Comorbidade , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Política de Saúde/economia , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/organização & administração , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/organização & administração , Seguro Saúde/estatística & dados numéricos , Masculino , Programas Obrigatórios/economia , Programas Obrigatórios/organização & administração , Programas Obrigatórios/estatística & dados numéricos , Pessoa de Meia-Idade , Obesidade Mórbida/economia , Obesidade Mórbida/epidemiologia , Obesidade Infantil/economia , Obesidade Infantil/epidemiologia , Obesidade Infantil/cirurgia , Reoperação/economia , Reoperação/estatística & dados numéricos , Inquéritos e Questionários , Estados Unidos/epidemiologia , Redução de Peso , Programas de Redução de Peso/economia , Programas de Redução de Peso/organização & administração , Programas de Redução de Peso/estatística & dados numéricos , Adulto JovemRESUMO
In this work, a detailed coupled equilibrium model is presented for predicting the ensemble average probability of hybridization error per chip-hybridized input strand, providing the first ensemble average method for estimating postannealing microarray/TAT system error rates. Following a detailed presentation of the model and implementation via the software package NucleicPark, under a mismatched statistical zipper model of duplex formation, error response is simulated for both mean-energy and randomly encoded TAT systems versus temperature and input concentration. Limiting expressions and simulated model behavior indicate the occurrence of a transition in hybridization error response, from a logarithmically convex function of temperature for excess inputs (high-error behavior), to a monotonic, log-linear function of temperature for dilute inputs (low-error behavior), a novel result unpredicted by uncoupled equilibrium models. Model scaling behavior for random encodings is investigated versus system size and strand-length. Application of the model to TAT system design is also undertaken, via the in silico evolution of a high-fidelity 100-strand TAT system, with an error response improved by nine standard deviations over the performance of the mean random encoding.
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Algoritmos , Artefatos , Etiquetas de Sequências Expressas , Hibridização In Situ/métodos , Modelos Genéticos , Análise de Sequência com Séries de Oligonucleotídeos/métodos , Simulação por Computador , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: The Affordable Care Act has the potential to significantly affect access to care for previously uninsured patients in need of emergency general surgical care. Our objective was to determine the relationship between insurance status and disease complexity at presentation among a national sample of emergency general surgical patients. METHODS: Data from the National Emergency Department Sample from 2006-2009 were queried to identify all patients aged 18-64 years old admitted through the emergency department with a primary diagnosis of appendicitis, diverticulitis, inguinal hernia, or bowel obstruction. Primary outcome of complex presentation was defined as also presenting with generalized peritonitis, intra-abdominal abscess, perforated bowel, intestinal gangrene, or other disease-specific measures of complexity. We used multivariable logistic regression to determine the independent association between insurance status and complex presentation. Models accounted for patient- and hospital-level covariates. Counterfactual models were used to estimate the risk of complex presentation attributable to lack of insurance. RESULTS: A total of 1,373,659 patients were included, with an overall uninsured rate of 12.3%. Uninsured patients had significantly higher, unadjusted rates of complex presentation, and uninsured payer status was independently associated with complex presentation (odds ratio 1.38, 95% confidence interval: 1.34-1.42). Counterfactual models suggest that having insurance would result in a 22.37% (95% confidence interval: 22.35-22.39%) relative decline in risk of complex emergency general surgical presentation among the uninsured population. CONCLUSION: Insurance status is independently associated with severity of disease at presentation among emergency general surgical conditions nationally. In light of recently reaffirmed Affordable Care Act insurance expansion provisions, these results anticipate increased timely access to operative care for newly insured patients and a corresponding decline in complex, emergency general surgical presentations.
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Cirurgia Geral/economia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Segurança do Paciente , Adulto , Bases de Dados Factuais , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/economia , Feminino , Cirurgia Geral/métodos , Acessibilidade aos Serviços de Saúde/economia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Patient Protection and Affordable Care Act/economia , Estudos Retrospectivos , Medição de Risco , Fatores Socioeconômicos , Estados Unidos , Adulto JovemRESUMO
IMPORTANCE: Emergency general surgery (EGS) represents 11% of surgical admissions and 50% of surgical mortality in the United States. However, there is currently no established definition of the EGS procedures. OBJECTIVE: To define a set of procedures accounting for at least 80% of the national burden of operative EGS. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was conducted using data from the 2008-2011 National Inpatient Sample. Adults (age, ≥18 years) with primary EGS diagnoses consistent with the American Association for the Surgery of Trauma definition, admitted urgently or emergently, who underwent an operative procedure within 2 days of admission were included in the analyses. Procedures were ranked to account for national mortality and complication burden. Among ranked procedures, contributions to total EGS frequency, mortality, and hospital costs were assessed. The data query and analysis were performed between November 15, 2015, and February 16, 2016. MAIN OUTCOMES AND MEASURES: Overall procedure frequency, in-hospital mortality, major complications, and inpatient costs calculated per 3-digit International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. RESULTS: The study identified 421â¯476 patient encounters associated with operative EGS, weighted to represent 2.1 million nationally over the 4-year study period. The overall mortality rate was 1.23% (95% CI, 1.18%-1.28%), the complication rate was 15.0% (95% CI, 14.6%-15.3%), and mean cost per admission was $13â¯241 (95% CI, $12â¯957-$13â¯525). After ranking the 35 procedure groups by contribution to EGS mortality and morbidity burden, a final set of 7 operative EGS procedures were identified, which collectively accounted for 80.0% of procedures, 80.3% of deaths, 78.9% of complications, and 80.2% of inpatient costs nationwide. These 7 procedures included partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy. CONCLUSIONS AND RELEVANCE: Only 7 procedures account for most admissions, deaths, complications, and inpatient costs attributable to the 512â¯079 EGS procedures performed in the United States each year. National quality benchmarks and cost reduction efforts should focus on these common, complicated, and costly EGS procedures.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Emergências , Cirurgia Geral/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Complicações Pós-Operatórias/epidemiologia , Apendicectomia/efeitos adversos , Apendicectomia/mortalidade , Apendicectomia/estatística & dados numéricos , Colecistectomia/efeitos adversos , Colecistectomia/mortalidade , Colecistectomia/estatística & dados numéricos , Colectomia/efeitos adversos , Colectomia/mortalidade , Colectomia/estatística & dados numéricos , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Emergências/economia , Cirurgia Geral/economia , Humanos , Intestino Delgado/cirurgia , Úlcera Péptica/cirurgia , Peritônio/cirurgia , Estudos Retrospectivos , Aderências Teciduais/cirurgia , Estados Unidos/epidemiologiaRESUMO
Health care disparities (differential access, care, and outcomes owing to factors such as race/ethnicity) are widely established. Compared with other groups, African American individuals have an increased mortality risk across multiple surgical procedures. Gender, sexual orientation, age, and geographic disparities are also well documented. Further research is needed to mitigate these inequities. To do so, the American College of Surgeons and the National Institutes of Health-National Institute of Minority Health and Disparities convened a research summit to develop a national surgical disparities research agenda and funding priorities. Sixty leading researchers and clinicians gathered in May 2015 for a 2-day summit. First, literature on surgical disparities was presented within 5 themes: (1) clinician, (2) patient, (3) systemic/access, (4) clinical quality, and (5) postoperative care and rehabilitation-related factors. These themes were identified via an exhaustive preconference literature review and guided the summit and its interactive consensus-building exercises. After individual thematic presentations, attendees contributed research priorities for each theme. Suggestions were collated, refined, and prioritized during the latter half of the summit. Breakout sessions yielded 3 to 5 top research priorities by theme. Overall priorities, regardless of theme, included improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. The National Institutes of Health and American College of Surgeons Summit on Surgical Disparities Research succeeded in identifying a comprehensive research agenda. Future research and funding priorities should prioritize patients' care perspectives, workforce diversification and training, and systematic evaluation of health technologies to reduce surgical disparities.
Assuntos
Pesquisa Biomédica , Disparidades em Assistência à Saúde , National Institutes of Health (U.S.) , Qualidade da Assistência à Saúde , Sociedades Médicas , Procedimentos Cirúrgicos Operatórios , Competência Cultural , Acessibilidade aos Serviços de Saúde , Disparidades em Assistência à Saúde/etnologia , Humanos , Relações Médico-Paciente , Cuidados Pós-Operatórios , Padrões de Prática Médica , Fatores Socioeconômicos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/reabilitação , Estados UnidosRESUMO
High disease burden and inadequate resources have formed the basis for advocacy to improve surgical care in low- and middle-income countries (LMICs). Current measures are heavily focused on availability of resources rather than impact and fail to fully describe how surgery can be more integrated into health systems. We propose a new monitoring and evaluation framework of surgical care in LMICs to integrate surgical diseases into broader health system considerations and track efforts toward improved population health. Although more discussion is required, we seek to broaden the dialogue of how to improve surgical care in LMICs through this comprehensive framework.
Assuntos
Países em Desenvolvimento , Procedimentos Cirúrgicos Operatórios/métodos , Alocação de Recursos para a Atenção à Saúde , Humanos , Avaliação de Programas e Projetos de Saúde , Integração de SistemasRESUMO
BACKGROUND: Hospital readmissions are an increasing focus of health care policy. This study explores the association between 30-day readmissions and 30-day mortality for surgical procedures. STUDY DESIGN: California longitudinal statewide data from 1995 to 2009 were analyzed for 7 complex procedures: abdominal aortic aneurysm repair, aortic valve replacement, bariatric surgery, coronary artery bypass grafting, esophagectomy, pancreatectomy, and percutaneous coronary intervention. Hospitals were categorized based on observed-to-expected (O/E) ratios for 30-day mortality and 30-day readmissions. Hospitals were considered "high" or "low" outliers if the 95% confidence intervals of their O/E ratios excluded 1 and "expected" if they included 1. Hospitals that were outliers in at least 1 metric were classified as "discordant" if their readmission and mortality rates were not both "high" or both "low," and "poorly discordant" in the particular scenario of high mortality with "expected" or "low" readmission rates. RESULTS: A total of 1,090,071 patients and 299 hospitals were analyzed for 7 procedures, representing a total of 1,150 clinical encounters. The overall 30-day mortality was 3.79% and the 30-day readmission was 12.69%. Of the total, 729 (63.3%) had "expected" O/E ratios for both outcomes. Among outliers, 358 (85.0%) were "discordant" and 100 (23.8%) were "poorly discordant." CONCLUSIONS: Hospital readmission rate alone is a limited measure of quality given the poor correlation between hospital readmission and mortality rates. In this study, 85% of hospital outliers were "discordant" for readmission and mortality. Furthermore, almost a quarter of these discordant hospitals had "expected" or "low" readmission but "high" mortality rates. Quality metrics that focus exclusively on readmission rates overlook these discrepancies.
Assuntos
Hospitais/normas , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Garantia da Qualidade dos Cuidados de Saúde/métodos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , California , Bases de Dados Factuais , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Surgical care is increasingly recognised as an important component of global health delivery. However, there are still major gaps in knowledge related to access to surgical care in low-income countries. In this study, we compare distances travelled by surgical patients with patients seeking other medical services at a first-level hospital in rural Mozambique. METHODS: Data were collected on all inpatients at Hospital Rural de Chókwè in rural Mozambique between 20 June 2012 and 3 August 2012. Euclidean distances travelled by surgical versus non-surgical patients using coordinates of each patient's city of residence were compared. Data were analysed using ArcGIS 10 and STATA. RESULTS: In total, 500 patients were included. Almost one-half (47.6%) lived in the city where the hospital is based. By hospital ward, the majority (62.0%) of maternity patients came from within the hospital's city compared with only 35.2% of surgical patients. The average distance travelled was longest for surgical patients (42 km) compared with an average of 17 km for patients on all other wards. CONCLUSIONS: Patients seeking surgical care at this first-level hospital travel farther than patients seeking other services. While other patients may have access to at community clinics, surgical patients depend more heavily on the services available at first-level hospitals.