Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study.

BACKGROUND: Anesthesiologists' contribution to perioperative healthcare disparities remains unclear because patient and surgeon preferences can influence care choices. Postoperative nausea and vomiting is a patient- centered outcome measure and a main driver of unplanned admissions. Antiemetic administration is under the sole domain of anesthesiologists. In a U.S. sample, Medicaid insured versus commercially insured patients and those with lower versus higher median income had reduced antiemetic administration, but not all risk factors were controlled for. This study examined whether a patient's race is associated with perioperative antiemetic administration and hypothesized that Black versus White race is associated with reduced receipt of antiemetics. METHODS: An analysis was performed of 2004 to 2018 Multicenter Perioperative Outcomes Group data. The primary outcome of interest was administration of either ondansetron or dexamethasone; secondary outcomes were administration of each drug individually or both drugs together. The confounder-adjusted analysis included relevant patient demographics (Apfel postoperative nausea and vomiting risk factors: sex, smoking history, postoperative nausea and vomiting or motion sickness history, and postoperative opioid use; as well as age) and included institutions as random effects. RESULTS: The Multicenter Perioperative Outcomes Group data contained 5.1 million anesthetic cases from 39 institutions located in the United States and The Netherlands. Multivariable regression demonstrates that Black patients were less likely to receive antiemetic administration with either ondansetron or dexamethasone than White patients (290,208 of 496,456 [58.5%] vs. 2.24 million of 3.49 million [64.1%]; adjusted odds ratio, 0.82; 95% CI, 0.81 to 0.82; P < 0.001). Black as compared to White patients were less likely to receive any dexamethasone (140,642 of 496,456 [28.3%] vs. 1.29 million of 3.49 million [37.0%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.78; P < 0.001), any ondansetron (262,086 of 496,456 [52.8%] vs. 1.96 million of 3.49 million [56.1%]; adjusted odds ratio, 0.84; 95% CI, 0.84 to 0.85; P < 0.001), and dexamethasone and ondansetron together (112,520 of 496,456 [22.7%] vs. 1.0 million of 3.49 million [28.9%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.79; P < 0.001). CONCLUSIONS: In a perioperative registry data set, Black versus White patient race was associated with less antiemetic administration, after controlling for all accepted postoperative nausea and vomiting risk factors.

Sex Differences in In-Hospital Mortality After Open Cardiac Valve Surgery.

BACKGROUND: Cardiac valvular disease affects millions of people worldwide and is a major cause of morbidity and mortality. Female patients have been shown to experience inferior clinical outcomes after nonvalvular cardiac surgery, but recent data are limited regarding open valve surgical cohorts. The primary objective of our study was to assess whether female sex is associated with increased in-hospital mortality after open cardiac valve operations. METHODS: Utilizing the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), we conducted a retrospective cohort study of patients who underwent open cardiac valve surgery from 2007 to 2018 in Washington, Maryland, Kentucky, and Florida; from 2007 to 2011 in California; and from 2007 to 2016 in New York. The primary objective of this study was to estimate the confounder-adjusted association between sex and in-hospital mortality (as recorded and coded by SID HCUP) after open cardiac valve surgery. We used multilevel multivariable models to account for potential confounders, including intrahospital practice patterns. RESULTS: A total of 272,954 patients (108,443 women; 39.73% of sample population with mean age of 67.6 ± 14.3 years) were included in our analysis. The overall mortality rates were 3.8% for male patients and 5.1% for female patients. The confounder-adjusted odds ratio (OR) for in-hospital mortality for female patients compared to male patients was 1.41 (95% confidence interval [CI], 1.35-1.47; P < .001). When stratifying by surgical type, female patients were also at increased odds of in-hospital mortality ( P < .001) in populations undergoing aortic valve replacement (adjusted OR [aOR], 1.38; 95% CI, 1.25-1.52); multiple valve surgery (aOR, 1.38; 95% CI, 1.22-1.57); mitral valve replacement (aOR, 1.22; 95% CI, 1.12 - 1.34); and valve surgery with coronary artery bypass grafting (aOR, 1.64; 95% CI, 1.54 - 1.74; all P < .001). Female patients did not have increased odds of in-hospital mortality in populations undergoing mitral valve repair (aOR, 1.26; 95% CI, 0.98 - 1.64; P = .075); aortic valve repair (aOR, 0.87; 95% CI, 0.67 - 1.14; P = .32); or any other single valve repair (aOR, 1.10; 95% CI, 0.82 - 1.46; P = .53). CONCLUSIONS: We found an association between female patients and increased confounder-adjusted odds of in-hospital mortality after open cardiac valve surgery. More research is needed to better understand and categorize these important outcome differences. Future research should include observational analysis containing granular and complete patient- and surgery-specific data.

Patient care in rapid-expansion intensive care units during the COVID-19 pandemic crisis.

BACKGROUND: The coronavirus-2019 (COVID-19) pandemic highlighted the unfortunate reality that many hospitals have insufficient intensive care unit (ICU) capacity to meet massive, unanticipated increases in demand. To drastically increase ICU capacity, NewYork-Presbyterian/Weill Cornell Medical Center modified its existing operating rooms and post-anaesthesia care units during the initial expansion phase to accommodate the surge of critically ill patients. METHODS: This retrospective chart review examined patient care in non-standard Expansion ICUs as compared to standard ICUs. We compared clinical data between the two settings to determine whether the expeditious development and deployment of critical care resources during an evolving medical crisis could provide appropriate care. RESULTS: Sixty-six patients were admitted to Expansion ICUs from March 1st to April 30th, 2020 and 343 were admitted to standard ICUs. Most patients were male (70%), White (30%), 45-64 years old (35%), non-smokers (73%), had hypertension (58%), and were hospitalized for a median of 40 days. For patients that died, there was no difference in treatment management, but the Expansion cohort had a higher median ICU length of stay (q = 0.037) and ventilatory length (q = 0.015). The cohorts had similar rates of discharge to home, but the Expansion ICU cohort had higher rates of discharge to a rehabilitation facility and overall lower mortality. CONCLUSIONS: We found no significantly worse outcomes for the Expansion ICU cohort compared to the standard ICU cohort at our institution during the COVID-19 pandemic, which demonstrates the feasibility of providing safe and effective care for patients in an Expansion ICU.

Disparities in Obstetric Readmissions: A Multistate Analysis, 2007-2014.

OBJECTIVE: Hospital readmissions are generally higher among racial-ethnic minorities and patients of lower socioeconomic status. However, this has not been widely studied in obstetrics. The aim of the study is to determine 30-day postpartum readmission rates by patient-level social determinants of health: race ethnicity, primary insurance payer, and median income, independently and as effect modifiers. STUDY DESIGN: Using state inpatient databases from the health care cost and utilization project from 2007 to 2014, we queried all deliveries. To produce accurate estimates of the effects of parturients' social determinants of health on readmission odds while controlling for confounders, generalized linear mixed models (GLMMs) were used. Additional models were generated with interaction terms to highlight any associations and their effect on the outcome. Adjusted odds ratios (aOR) with 95% confidence intervals are reported. RESULTS: There were 5,129,867 deliveries with 79,260 (1.5%) 30-day readmissions. Of these, 947 (1.2%) were missing race ethnicity. Black and Hispanic patients were more likely to be readmitted within 30 days of delivery, as compared with White patients (p < 0.001 and p < 0.05, respectively). Patients with government insurance were more likely to be readmitted than those with private insurance (p < 0.001). Patients living in the second quartile of median income were also more likely to be readmitted than those living in other quartiles (p < 0.05). Using GLMMs, we observed that Black patients with Medicare were significantly more likely to get readmitted as compared with White patients with private insurance (aOR 2.78, 95% CI 2.50-3.09, p < 0.001). Similarly, Black patients living in the fourth (richest) quartile of median income were more likely to get readmitted, even when compared with White patients living in the first (poorest) quartile of median income (aOR 1.48, 95% CI 1.40-1.57, p < 0.001). CONCLUSION: Significant racial-ethnic disparities in obstetric readmissions were observed, particularly in Black patients with government insurance and even in Black patients living in the richest quartile of median income. KEY POINTS: · Using generalized linear mixed models, we observed significant interactions.. · Government-insured Black patients were 2.78X more likely to be readmitted.. · The wealthiest Black patients were still 1.48X more likely to be readmitted..

Enhanced Recovery after Surgery for Cesarean Delivery: A Quality Improvement Initiative.

OBJECTIVE: Enhanced recovery after surgery (ERAS) was developed as a way to standardize clinical care pathways and communication across multidisciplinary teams to improve patient recovery and reduce hospital length of stay (LOS). Our objective was to implement an ERAS protocol for cesarean delivery (ERAS-CD) and evaluate its efficacy in reducing LOS. STUDY DESIGN: An ERAS-CD program was implemented at our institution in October 2018. Patients undergoing scheduled and unscheduled CD were maintained on an ERAS pathway of care, which included preoperative hydration, standardized intraoperative protocols, and postoperative analgesic regimens as well as early feeding, urinary catheter removal, and ambulation. We compared LOS after delivery (calculated from time of delivery to discharge), readmission rates, health care disparities and postoperative opioid prescribing practices before (October 2017-September 2018) and after (November 2018-October 2019) ERAS implementation. We excluded any outliers, defined as a LOS >25 days. Continuous data are expressed as mean ± standard deviation. Student's t-test and Chi-square were used for statistical comparison with p <0.05 considered statistically significant. RESULTS: There were 1,729 patients who had a CD in the pre-ERAS group with a mean LOS after delivery of 3.32 ± 6.19 days. In the post-ERAS group, 1,753 women underwent CD with a mean LOS after delivery of 2.85 ± 5.79 days, a statistically significant difference from the pre-ERAS group (p <0.001). There was no difference in readmission rates between pre- and post-ERAS implementation groups (1.9 vs. 2.2%, p = 0.53). There was a reduction in health care disparities in postoperative LOS, when stratifying by race-ethnicity, and a reduction in opioid prescribing practices after the implementation of the program. CONCLUSION: With the implementation of an ERAS-CD program, we achieved a reduced LOS, without increasing readmission rates, and saw a reduction in health care disparities and opioid dispensing. A shorter LOS could offer an enhanced patient experience, as well as improved and equitable perioperative outcomes. KEY POINTS: · ERAS-CD is associated with a reduction in postoperative hospital length of stay.. · A reduction in health care disparities by race-ethnicity was observed with the implementation of ERAS-CD.. · A reduction in opioid dispensing was observed with the implementation of ERAS-CD..

Obstetric and perinatal racial and ethnic disparities.

PURPOSE OF REVIEW: Healthcare disparities are health differences that adversely affect disadvantaged populations. In the United States, research shows that women of color, in particular Black and Hispanic women and their offspring, experience disproportionately higher mortality, severe maternal morbidity, and neonatal morbidity and mortality. This review highlights recent population health sciences and comparative effectiveness research that discuss racial and ethnic disparities in maternal and perinatal outcomes. RECENT FINDINGS: Epidemiological research confirms the presence of maternal and neonatal disparities in national and multistate database analysis. These disparities are associated with geographical variations, hospital characteristics and practice patterns, and patient demographics and comorbidities. Proposed solutions include expanded perinatal insurance coverage, increased maternal healthcare public funding, and quality improvement initiatives/efforts that promote healthcare protocols and practice standardization. SUMMARY: Obstetrical healthcare disparities are persistent, prevalent, and complex and are associated with systemic racism and social determinants of health. Some of the excess disparity gap can be explained through community-, hospital-, provider-, and patient-level factors. Providers and healthcare organizations should be mindful of these disparities and strive to promote healthcare justice and patient equity. Several solutions provide promise in closing this gap, but much effort remains.

Hospital Safety-Net Burden Is Associated With Increased Inpatient Mortality and Perioperative Complications After Colectomy.

BACKGROUND: Colectomies are common yet costly, with high surgical-site infection rates. Safety-net hospitals (SNHs) carry a large proportion of uninsured or Medicaid-insured patients, which has been associated with poorer surgical outcomes. Few studies have examined the effect of safety-net burden (SNB) status on colectomy outcomes. We aimed to quantify the independent effects of hospital SNB and surgical site infection (SSI) status on colectomy outcomes, as well as the interaction effect between SSIs and SNB. METHODS: We used the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky. We included 459,568 colectomies (2009 to 2014) for analysis, excluding patients age <18 y and rectal cases. The primary and secondary outcomes were inpatient mortality and complications, respectively. RESULTS: Adjusting for patient, procedure, and hospital factors, colectomy patients were more likely to die in-hospital at high-burden SNHs (adjusted OR [aOR]: 1.38, 95% confidence interval [CI]: 1.25-1.51, P < 0.001), compared with low SNB hospitals and to experience perioperative complications (aOR: 1.12, 95% CI: 1.04-1.20, P < 0.01). Colectomy patients with SSIs also had greater odds of in-hospital mortality (aOR: 1.92, 95% CI: 1.83-2.02, P < 0.001) and complications (aOR: 3.65, 95% CI: 3.55-3.75, P < 0.001) compared with those without infections. Patients treated at SNHs who developed a SSI were even more likely to have an additional perioperative complication (aOR: 4.33, 95% CI: 3.98-4.71, P < 0.001). CONCLUSIONS: Our study demonstrated that colectomy patients at SNHs have poorer outcomes, and for patients with SSIs, this disparity was even more pronounced in the likelihood for a complication. SNB should be recognized as a significant hospital-level factor affecting colectomy outcomes, with SSIs as an important quality metric.

Segmented lateral dyke growth in a rifting event at Bárðarbunga volcanic system, Iceland.

Crust at many divergent plate boundaries forms primarily by the injection of vertical sheet-like dykes, some tens of kilometres long. Previous models of rifting events indicate either lateral dyke growth away from a feeding source, with propagation rates decreasing as the dyke lengthens, or magma flowing vertically into dykes from an underlying source, with the role of topography on the evolution of lateral dykes not clear. Here we show how a recent segmented dyke intrusion in the Bárðarbunga volcanic system grew laterally for more than 45 kilometres at a variable rate, with topography influencing the direction of propagation. Barriers at the ends of each segment were overcome by the build-up of pressure in the dyke end; then a new segment formed and dyke lengthening temporarily peaked. The dyke evolution, which occurred primarily over 14 days, was revealed by propagating seismicity, ground deformation mapped by Global Positioning System (GPS), interferometric analysis of satellite radar images (InSAR), and graben formation. The strike of the dyke segments varies from an initially radial direction away from the Bárðarbunga caldera, towards alignment with that expected from regional stress at the distal end. A model minimizing the combined strain and gravitational potential energy explains the propagation path. Dyke opening and seismicity focused at the most distal segment at any given time, and were simultaneous with magma source deflation and slow collapse at the Bárðarbunga caldera, accompanied by a series of magnitude M > 5 earthquakes. Dyke growth was slowed down by an effusive fissure eruption near the end of the dyke. Lateral dyke growth with segment barrier breaking by pressure build-up in the dyke distal end explains how focused upwelling of magma under central volcanoes is effectively redistributed over long distances to create new upper crust at divergent plate boundaries.

To Swan or Not to Swan: Indications, Alternatives, and Future Directions.

The pulmonary artery catheter (PAC) has revolutionized bedside assessment of preload, afterload, and contractility using measured pulmonary capillary wedge pressure, calculated systemic vascular resistance, and estimated cardiac output. It is placed percutaneously by a flow-directed balloon-tipped technique through the venous system and the right heart to the pulmonary artery. Interest in the hemodynamic variables obtained from PACs paved the way for the development of numerous less-invasive hemodynamic monitors over the past 3 decades. These devices estimate cardiac output using concepts such as pulse contour and pressure analysis, transpulmonary thermodilution, carbon dioxide rebreathing, impedance plethysmography, Doppler ultrasonography, and echocardiography. Herein, the authors review the conception, technologic advancements, and modern use of PACs, as well as the criticisms regarding the clinical utility, reliability, and safety of PACs. The authors comment on the current understanding of the benefits and limitations of alternative hemodynamic monitors, which is important for providers caring for critically ill patients. The authors also briefly discuss the use of hemodynamic monitoring in goal-directed fluid therapy algorithms in Enhanced Recovery After Surgery programs.

Disparities in mortality after abdominal aortic aneurysm repair are linked to insurance status.

OBJECTIVE: The objective of this study was to determine differences in mortality after abdominal aortic aneurysm (AAA) repair based on insurance type. METHODS: In this retrospective cohort study, data from all-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California from January 2007 to December 2014 (excluding California, ending December 2011) were extracted from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. There were 90,102 patients ≥18 years old with available insurance data who underwent open AAA repair or endovascular aneurysm repair (EVAR) identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 3844, 3925, and 3971. EVAR patients were identified using the procedure code 3971, and the remainder of cases were categorized as open. Patients were divided into cohorts by insurance type as Medicare, Medicaid, uninsured (self-pay/no charge), other, or private insurance. Patients were further stratified for subgroup analyses by procedure type. Unadjusted rates of in-hospital mortality, the primary outcome, as well as secondary outcomes, such as surgical urgency, 30-day and 90-day readmissions, length of stay, total charges, and postoperative complications, were examined by insurance type. Adjusted odds ratios (ORs) for in-hospital mortality were calculated using multivariate logistic regression models fitted to the data. The multivariate models included patient-, surgical-, and hospital-specific factors with bivariate baseline testing suggestive of association with insurance status in addition to variables that were selected a priori. RESULTS: Medicaid and uninsured patients had the highest rates of mortality relative to private insurance beneficiaries in all cohorts. Medicaid patients incurred a 47% increase in the odds of mortality, the highest among the insured, after all AAA repairs (OR, 1.47; 95% confidence interval [CI], 1.23-1.76), whereas uninsured patients experienced a 102% increase in the odds of mortality (OR, 2.02; 95% CI, 1.54-2.67). Subgroup analyses for open AAA repair and EVAR corroborated that Medicaid insurance (open repair OR, 1.37 [95% CI, 1.14-1.64]; EVAR OR, 2.06 [95% CI, 1.40-3.04]) and uninsured status (open repair OR, 1.85 [95% CI, 1.35-2.54]; EVAR OR, 2.96 [95% CI, 1.82-4.81]) were associated with the highest odds of mortality after both procedures separately. CONCLUSIONS: This study demonstrates that Medicaid insurance and uninsured status are associated with higher unadjusted rates and adjusted ORs for in-hospital mortality after AAA repair relative to private insurance status. Primary payer status therefore serves as an independent predictor of the risk of death subsequent to AAA surgical interventions.

Sociodemographic Characteristics Predict Readmission Rates After Lumbar Spinal Fusion Surgery.

OBJECTIVE: To evaluate the impact of social determinants of health (race/ethnicity, household income, insurance) and hospital surgical volume on 30- and 90-day readmissions after lumbar spinal fusion surgery. METHODS: A retrospective review of the State Inpatient Databases (SID) Healthcare Cost and Utilization Project (HCUP) included all patients age ≥18 years who underwent an index lumbar spinal fusion procedure and met inclusion criteria in California (2007-2011), Maryland (2012-2014), Florida, and New York (2007-2014). Primary outcomes were unadjusted rates and adjusted odds of readmission at 30 and 90 days postoperatively. RESULTS: After assessing for exclusion criteria, 267,976 patients were included in analyses. The overall 30-day readmission rate was 7.5%, and the 90-day readmission rate was 11.6%. Black patients (odds ratio [OR] = 1.12, 95% confidence interval [CI] = 1.06-1.19) and patients with nonprivate insurance (Medicare OR = 1.44, 95% CI = 1.37-1.51; Medicaid OR = 1.46, 95% CI = 1.36-1.56; or uninsured OR = 1.16, 95% CI = 1.00-1.35) had higher odds of 30-day readmission, with comparable effects at 90 days. The three highest quartiles of hospital lumbar spine surgical volume had decreased odds for 30- and 90-day readmission when compared with the lowest quartile. Median income had no effect on readmission rates, save for the top quartile having lower odds of 90-day readmission than the bottom quartile. CONCLUSIONS: Sociodemographic disparities in primary insurance payer, race/ethnicity, and hospital surgical volume affect lumbar spinal fusion surgery readmission rates. Public health interventions may improve readmissions and clinical outcomes and reduce health care costs.

Preexisting Opioid Use Disorder and Outcomes After Lower Extremity Arthroplasty: A Multistate Analysis, 2007-2014.

OBJECTIVE: The aim of this study was to examine the association of preexisting opioid use disorder and postoperative outcomes in patients undergoing total hip or knee arthroplasty (THA and TKA, respectively) in the overall population and in the Medicare-only population. METHODS: This retrospective cohort study examined data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for the years 2007-2014 from California, Florida, New York, Maryland, and Kentucky. We compared patients with and without opioid use disorders on unadjusted rates and calculated adjusted odds ratios (aORs) of in-hospital mortality, postoperative complications, length of stay, and 30-day and 90-day readmission status; analyses were repeated in a subgroup of Medicare insurance patients only. SUBJECTS: After applying our exclusion criteria, our study included 1,422,210 adult patients undergoing lower extremity arthroplasties, including 818,931 Medicare insurance patients. In our study, 0.4% of THA patients and 0.3% of TKA patients had present-on-admission opioid use disorder. RESULTS: Opioid use disorder patients were at higher risk for in-hospital mortality (aOR = 3.10), 30- and 90-day readmissions (aORs = 1.81, 1.81), and pulmonary and infectious complications (aORs = 1.25, 1.96). CONCLUSIONS: Present-on-admission opioid use disorder was a risk factor for worse postoperative outcomes and increased health care utilization in the lower extremity arthroplasty population. Opioid use disorder is a potentially modifiable risk factor for mortality, postoperative complications, and health care utilization, especially in the at-risk Medicare population.

Socioeconomic Disparities in Carotid Revascularization Procedures.

OBJECTIVES: Several studies have demonstrated healthcare disparities in postoperative outcomes after carotid endarterectomy and carotid artery stenting, including increased hospital mortality, postoperative stroke, and readmission rates. The objective of the present study was to examine the intersectionality between race/ethnicity, insurance status, and postoperative outcomes in carotid procedures. DESIGN: Records of adults from 2007 to 2014 were retrospectively identified, and patients with appropriate International Classification of Diseases Ninth Revision Clinical Modification codes for carotid endarterectomy or carotid artery stenting were identified. Primary outcomes were unadjusted rates and adjusted odds ratios (aORs) of postoperative in-hospital mortality, stroke, combined stroke/mortality, and cardiovascular complications. SETTING: Data were sourced from the State Inpatient Databases data from California, Florida, Kentucky, Maryland, and New York during the years 2007 to 2014. PARTICIPANTS: Patients undergoing carotid revascularization procedures. INTERVENTIONS: The effects of race and insurance status as independent variables and as effect modifiers on postoperative outcomes. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression models were used to examine the associations between race and/or insurance status with respect to study outcomes. Race, but not payer status, was significantly associated with adverse outcomes after carotid artery procedures, with blacks, Hispanics, and other non-Caucasian races demonstrating a significantly greater risk of postoperative stroke and mortality (aOR range 1.24-1.59). This relationship persisted even when stratified by procedure type (aOR range 1.25-1.56) and symptomatology (aOR range 1.51-1.63). CONCLUSIONS: These results suggest that disparities in postoperative outcomes after carotid artery procedures are associated with race but not with primary insurance status. Multiple contributing factors exist, including racial inequities in prevalence of comorbidities, health literacy, and procedure type performed.

Sex Differences in Outcomes After Coronary Artery Bypass Grafting.

OBJECTIVE: To examine sex differences in inpatient mortality and 30-day and 90-day readmissions after coronary artery bypass grafting (CABG) among a multistate population. DESIGN: A retrospective analysis of patient hospitalization and discharge records. SETTING: All-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California. PARTICIPANTS: A total of 304,080 patients from the State Inpatient Databases Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality from January 2007 to December 2014 who underwent CABG surgery. INTERVENTIONS: Bivariate analysis and multivariate logistic regression were performed to obtain unadjusted rates and adjusted odds ratios, respectively, for in-hospital mortality and readmissions by sex. MEASUREMENTS AND MAIN RESULTS: Of the patients who underwent CABG, 5,699 patients (1.87%) died, including 2,131 women (2.65%) and 3,568 men (1.60%). The authors found that women were 32% more likely to die compared with men (adjusted odds ratio [aOR]: 1.32, 95% confidence interval [CI]: 1.25-1.40) after adjusting for age, race, insurance status, median income, Elixhauser comorbidity index measures, year of procedure, state, and hospital surgical volume. Women, compared with men, also had significantly increased adjusted odds of 30-day and 90-day readmissions (30-day aOR: 1.24, 95% CI: 1.21-1.28; 90-day aOR: 1.25, 95% CI: 1.22-1.28). CONCLUSION: This study demonstrated that female patients who undergo CABG are at a greater risk of in-hospital death and 30-day and 90-day readmission compared with men. This sex-based disparity in outcomes has persisted since identification some 40 years ago.

Preoperative Opioid Use Disorder Is Associated With Poorer Outcomes After Coronary Bypass and Valve Surgery: A Multistate Analysis, 2007-2014.

OBJECTIVE: To determine the effect of preoperative opioid use disorder (OUD) on postoperative outcomes in patients undergoing coronary artery bypass grafting (CABG) and heart valve surgery. DESIGN: Retrospective, observational study using data from the State Inpatient Database and the Healthcare Cost and Utilization Project. SETTING: Inpatient data from Florida, California, New York, Maryland, and Kentucky between 2007 and 2014. PARTICIPANTS: A total of 377,771 CABG patients and 194,469 valve surgery patients age ≥18 years. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prevalence of OUD was 2,136 (0.57%) in the CABG group and 2,020 (1.04%) in the valve surgery group. There was no significant difference in mortality between the OUD and non-OUD groups in both surgical cohorts (both p > 0.05). On adjusted analyses, preoperative OUD was significantly associated with increased adjusted odds ratios (aORs) of 30-day hospital readmission (CABG aOR 1.47 [95% confidence interval {CI} 1.30-1.66]; valve surgery aOR 1.41 [95% CI 1.27-1.56]) and 90-day hospital readmission (CABG aOR 1.47 [95% CI 1.31-1.64]; valve surgery aOR 1.33 [95% CI 1.23-1.43]). Preoperative OUD was significantly associated with increased adjusted risk ratios (aRRs) of hospital length of stay (CABG aRR 1.13 [95% CI 1.10-1.16]; valve surgery aRR 1.63 [95% CI 1.54-1.72]) and total hospitalization charges (CABG aRR 1.05 [95% CI 1.03-1.07]; valve surgery aRR 1.28 [95% CI 1.24-1.32]). CONCLUSION: Preoperative OUD is significantly associated with poorer outcomes after cardiac surgery, including increased 30- and 90-day readmissions, hospital length of stay, and total hospitalization charges. Opioid use should be considered a modifiable risk factor in cardiac surgery, and interventions should be attempted preoperatively.

Insurance Status and Socioeconomic Markers Affect Readmission Rates After Cardiac Valve Surgery.

OBJECTIVE: To characterize the effect of insurance status and other socioeconomic markers on readmission rates after cardiac valve surgery. DESIGN: Retrospective cohort study using data from the State Inpatient Databases and Healthcare Cost and Utilization Project. SETTING: Multistate database of all hospitalizations from 2007-2014 from New York, Florida, California, and Maryland. PARTICIPANTS: A total of 147,752 patients ≥18 years old who underwent valve repair and/or replacement were included in the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were unadjusted rates and adjusted odds of 30- and 90-day readmissions. The overall 30-day readmission rate was 19.4%, with the highest rates in the Medicaid (22.9%) and Medicare (21.3%) groups and lowest rates in the private insurance group (14.3%; p < 0.001). Similarly, the overall 90-day readmission rate was 27.6%, with Medicaid (32.7%) and Medicare (30.3%) again demonstrating the highest rates and private insurance (20.0%; p < 0.001) demonstrating the lowest. Compared with private insurance, Medicaid conferred the highest odds of 30-day readmission (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.23-1.39) followed by Medicare (OR 1.27, 95% CI 1.21-1.33). Similarly, increased odds were seen for 90-day readmission for Medicaid (OR 1.36, 95% CI 1.28-1.43) and Medicare (OR 1.32, 95% CI 1.26-1.37). Other readmission risk factors included black or Hispanic race and low household income. CONCLUSIONS: Markers of low socioeconomic status, including insurance status, race, and household income, are associated with an increased odds of readmission after cardiac valve surgery. Such findings may point to inequalities in health care; additional investigation is necessary to understand the causal link.

Insurance Status and Socioeconomic Factors Affect Early Mortality After Cardiac Valve Surgery.

OBJECTIVE: To characterize the effects markers of socioeconomic status (SES), including race and ethnicity, health insurance status, and median household income by zip code on in-patient mortality after cardiac valve surgery. DESIGN: Retrospective cohort study of adult valve surgery patients included in the State Inpatient Databases and Healthcare Cost and Utilization Project. The primary outcome was mortality during the index admission. Bivariate analyses and multivariate regression models were used to assess the independent effects of race and ethnicity, payer status, and median income by patient zip code on in-hospital mortality. DESIGN: Multistate database of hospitalizations from 2007 to 2014 from New York, Florida, Kentucky, California, and Maryland. PARTICIPANTS: In total, 181,305 patients ≥18 years old underwent mitral or aortic valve repair or replacement and met the inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mortality rates were higher among black (5.59%) than white patients (4.28%, p < 0.001) and among Medicaid (4.66%), Medicare (5.22%), and uninsured (4.58%) patients compared with private insurance (2.45%, p < 0.001). After controlling for age, sex, presenting comorbidities, urgent or emergent operative status, and hospital case volume, mortality odds remained significantly elevated for black (odds ratio [OR] 1.127, confidence interval [CI] 1.038-1.223), uninsured (OR 1.213, CI 1.020-1.444), Medicaid (OR 1.270, 95% CI 1.116-1.449) and Medicare (OR 1.316, 95% CI 1.216-1.415) patients. CONCLUSIONS: Markers of low SES, including race/ethnicity, insurance status, and household income, are associated with increased risk of in-hospital mortality following cardiac valve surgery. Further research is warranted to understand and help decrease mortality risk in underinsured, less-wealthy and non-white patients undergoing cardiac valve surgery.

The impact of hospital safety-net burden on mortality and readmission after CABG surgery.

BACKGROUND AND AIM: Safety-net hospitals (SNHs) serve high proportions of uninsured and Medicaid patients. Data conflict as to the impact of hospital safety-net status on perioperative complications. Our goal was to assess the effect of hospital safety-net burden on mortality and readmission following coronary artery bypass graft (CABG) surgery. METHODS: A retrospective analysis was performed using five State Inpatient Databases (2007-2014) for isolated CABG surgery. High, medium, and low burden hospitals were those with the highest, middle, and lowest tertiles of uninsured and Medicaid admissions, respectively. We compared patient demographics and hospital characteristics by safety-net status. Multivariable logistic regression models assessed adjusted odds of in-hospital mortality and 30- and 90-day readmission. RESULTS: About 304 080 patients were included in our analysis. On univariate analysis, high burden hospitals had higher inpatient mortality (2.06% vs 1.71%; P < .001) and 30 day- (16.3% vs 15.3%; P < .001) and 90-day readmission rates (24.6% vs 23.0%; P < .001). On multivariate analysis, high-burden status was not associated with significantly increased adjusted odds of inpatient mortality (OR, 1.047; 95% CI, 0.878-1.249), or readmission at 30 (OR, 1.035; 95% CI, 0.958-1.118) or 90 days (OR, 1.040; 95% CI, 0.968-1.117). CONCLUSION: SNHs do not have worse mortality and readmission outcomes following CABG, after adjusting for patient and hospital characteristics. These findings are reassuring regarding the quality of cardiac surgery care provided to underinsured patient groups. More research is needed to further elucidate trends in outcomes.

The Disparity of Care and Outcomes for Medicaid Patients Undergoing Colectomy.

BACKGROUND: Colectomies are one of the most common surgeries in the United States with about 275,000 performed annually. Studies have shown that insurance status is an independent risk factor for worse surgical outcomes. This study aims to analyze the effect of insurance on health outcomes of patients undergoing colectomy procedures. METHODS: We examined hospital discharge data from the State Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, from 2009 to 2014 in California, Florida, New York, Maryland, and Kentucky. The primary outcome was in-hospital mortality. Secondary outcomes included complications, length of stay (LOS), total hospital charges, and 30- and 90-d readmissions. RESULTS: A total of 444,877 patients were included in the analysis. Bivariate analysis showed that open surgeries were more common in Medicaid patients (50.5%), whereas robotic and laparoscopic surgeries were more common in private insurance holders (50.4% and 21.7%, respectively). In the adjusted multivariate models, when compared with private insurance patients, Medicaid patients had the highest odds ratio (OR) for mortality (OR, 1.96; 95% confidence interval [CI], 1.78-2.15), complication rates (OR, 1.43; 95% CI, 1.38-1.49), 30-d readmission (OR, 1.47; 95% CI, 1.40-1.55), 90-d readmission (OR, 1.44; 95% CI, 1.37-1.51), longer LOS (coefficient, 1.26; 95% CI, 1.24-1.28), and higher total hospital charges (coefficient, 1.15; 95% CI, 1.13-1.17). CONCLUSIONS: We identified Medicaid insurance status as a predictor of open colectomies and of higher mortality, LOS, complications, readmission rates, and charges after colectomy. Further research and initiatives are necessary to meet the specific needs of patients with different payer types.