Early Treatment at a Referral Center Improves Outcomes for Patients with Acute Vascular Disease.

BACKGROUND: Patients with acute vascular disease frequently need specialized management that may require transfer to a vascular referral center. Although transfer may be medically necessary, it can delay definitive care and is an indicator of incorrect triage to the initial hospital. Regionalization of acute vascular care could improve patient triage and subsequent outcomes. To evaluate the potential benefit from regionalization, we analyzed outcomes of patients treated for acute vascular disease at vascular referral centers. METHODS: Using a statewide database capturing all inpatient admissions in Maryland during 2013-2015, patients undergoing noncardiac vascular procedures on an acute basis were identified. Patients admitted to a vascular referral center were stratified by admission status as direct or transfer. The primary outcome was inpatient mortality, and the secondary outcome was resource use. Patient groups were compared by univariable analyses, and the effect of admission status on mortality was assessed by multivariable logistic regression. RESULTS: Of 4,873 patients with acute vascular disease managed at vascular referral centers, 2,713 (56%) were admitted directly, whereas 2,160 (44%) were transferred. Transfers to referral centers accounted for 71% of all interhospital transfers. The transfer-group patients were older, had more comorbidities, and higher illness severities. Patients who were transferred had higher mortality (14% vs. 9%, P < 0.0001), longer hospital lengths of stay, greater critical care-resource utilization, and higher costs. After adjusting for demographics, comorbidities, and illness severity, transfer status was independently associated with higher inpatient mortality. CONCLUSIONS: Primary treatment at a referral center is independently associated with improved outcomes for patients with acute vascular disease. Direct admission or earlier triage to a specialty center may improve patient and system outcomes and could be facilitated by standardization and regionalization of complex acute vascular care.

Impact of COVID-19 on gynecologic and obstetrical services at two large health systems.

BACKGROUND: The COVID-19 pandemic disrupted medical care in the US, leading to a significant drop in utilization of some types of health services. We sought to quantify how the pandemic influenced obstetrics and gynecology care at two large health care organizations. MATERIALS AND METHODS: Comparing 2020 to 2019, we quantified changes to obstetrics and gynecology care at two large health care organizations in the United States, Allegheny Health Network (in western Pennsylvania) and Johns Hopkins University (in Maryland). The analysis considered the numbers of surgical encounters, in-person visits, and telemedicine visits. For each system, we quantified temporal changes in surgical volume, in-person and telemedicine visits, and financial impact related to professional fee revenues. We used segmented regression to evaluate longitudinal effects. RESULTS: At both institutions, the volume of care was similar in the first few months of 2020 compared to 2019 but dropped precipitously in March 2020. From April to June 2020, surgical volumes were 67% of the same period in 2019 at Allegheny Health and 48% of the same period in 2019 at Johns Hopkins. During that same interval, televisits accounted for approximately 21% of all ambulatory care at both institutions. Although surgical and ambulatory volumes recovered in the second half of 2020, annual surgical volumes in 2020 were significantly lower than 2019 at both institutions (p<0.05) and 2020 ambulatory volumes remained significantly lower at Johns Hopkins (p = .0006). Overall, revenues in 2020 were 91% of 2019 revenues for both institutions. CONCLUSIONS: Obstetrical and gynecologic ambulatory visits and gynecologic surgeries were sharply reduced during the COVID-19 pandemic. Although care volumes returned to 2019 levels in late 2020, we observed an overall reduction in the volume of care provided and a 9% reduction in professional revenue for both institutions.