Exploring ethnic differences in post-discharge patterns of surgical care for older adults admitted with diverticulitis.

AIM: We aimed to evaluate ethnic differences in patterns of care following an index nonoperative admission for acute diverticulitis amongst a universally insured patient cohort. METHODS: We identified nationwide Medicare beneficiaries aged 65.5 years or older hospitalized between 1 July 2015 and 1 November 2017 for nonoperative management of an index admission for diverticulitis. Patients were followed for 1 year to examine patterns of care. Primary categorical outcomes included receipt of an elective operation, emergency operation, nonoperative readmission or no further hospitalizations for diverticulitis. Multinomial regression was performed to determine the association between ethnicity and receipt of each primary outcome category whilst adjusting for potential confounders. We examined the use of percutaneous drainage during the index admission to better understand its association with subsequent care patterns. RESULTS: Amongst 22 630 study patients, subsequent operative treatment was less common for Black, Hispanic, Asian and American Indian patients relative to White patients. Multinomial logistic regression noted that Black (relative risk 0.40; 95% CI 0.32-0.50) and Asian (relative risk 0.37; 95% CI 0.15-0.91) patients were associated with the lowest relative risk of undergoing an elective interval operation compared to White patients. Black patients were also associated with a 1.43 (95% CI 1.19-1.73) increased risk of requiring subsequent nonoperative readmissions for disease recurrence compared to White patients. The use of percutaneous drainage was higher amongst White patients relative to Black patients (6.9% vs. 4.0%, P value < 0.001). CONCLUSION: We have identified ongoing inequities in the consumption of medical resources, with White patients being more likely to undergo elective colectomy and percutaneous drainage. Differences in care are not fully alleviated by equal access to insurance.

Prospective implementation of a standardized screening protocol for deep venous thrombosis in abdominal surgical oncology patients.

BACKGROUND AND OBJECTIVES: Venous thromboembolism (VTE) remains a major cause of perioperative morbidity and mortality despite implementation of prophylaxis guidelines. We sought to identify risk factors for occult deep venous thrombosis (DVT) following abdominal surgery for cancer and measure the clinical impact of a prospectively implemented standardized postoperative DVT screening protocol. METHODS: Patients undergoing abdominal surgery for malignant indication were screened with early postoperative lower extremity duplex to identify DVT. Clinical and pathologic factors associated with DVT were identified. RESULTS: Among 255 patients meeting study criteria, 25 (9.8%) had occult lower extremity DVT on routine postoperative screening. Prior history of VTE and lower preoperative hemoglobin were independently associated with DVT (OR, 9.05; P = 0.004; and OR, 1.27; P = 0.025, respectively). Preoperative chemotherapy within 1 year and thrombocytopenia were associated with DVT in univariate analyses only. Five patients developed postoperative pulmonary emboli (2.0%); three following negative duplex and two following positive duplex for distal DVT for which the patients were not therapeutically anticoagulated due to a contraindication. There were no pulmonary emboli in duplex-positive patients who were anticoagulated or who had vena cava filter placed. CONCLUSION: Despite prophylaxis, the prevalence of occult DVT in abdominal oncologic surgery patients is considerable. Postoperative screening duplex can identify these events to guide management.

Evaluating Changes in Surgical Outcomes for Patients With Inflammatory Bowel Disease Following Medicaid Expansion.

BACKGROUND: Little is known about the impact of Medicaid expansion on the surgical care of inflammatory bowel disease. We sought to determine whether Medicaid expansion is associated with improved postsurgical outcomes for patients with inflammatory bowel disease undergoing a colorectal resection. METHODS: We performed a risk-adjusted difference-in-difference study examining postsurgical outcomes for patients ages 26 to 64 with Crohn's disease or ulcerative colitis undergoing a colorectal resection across 15 states that did and did not expand Medicaid before (2012-2013) and after (2016-2018) policy reform. Primary study outcomes included 30-day readmission and postoperative complication. RESULTS: Study population included 11 394 patients with inflammatory bowel disease that underwent a colorectal resection. States that underwent Medicaid expansion were associated with a rise in Medicaid enrollment following policy reform (11.8% pre-Medicaid expansion vs 19.7% post-Medicaid expansion). Difference-in-difference analysis revealed a statistically significant lower odds of 30-day readmission in patients undergoing a colorectal resection in expansion states following policy reform relative to patients in nonexpansion states prior to reform (odds ratio, 0.56; 95% confidence interval, 0.36-0.86). No changes in odds of postoperative complication were noted across expansion and nonexpansion states. CONCLUSIONS: Medicaid expansion is associated with a rise in Medicaid enrollment in expansion states following policy reform. There were greater improvements in postoperative outcomes associated with patients in expansion states following policy reform relative to patients in nonexpansion states prior to reform, which may have been related to improved perioperative care and medical management.

Reporting of Discrimination by Health Care Consumers Through Online Consumer Reviews.

IMPORTANCE: Little is known about how discrimination in health care relates to inequities in hospital-based care because of limitations in the ability to measure discrimination. Consumer reviews offer a novel source of data to capture experiences of discrimination in health care settings. OBJECTIVE: To examine how health care consumers perceive and report discrimination through public consumer reviews. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study assessed Yelp online reviews from January 1, 2011, to December 31, 2020, of 100 randomly selected acute care hospitals in the US. Word filtering was used to identify reviews potentially related to discrimination by using keywords abstracted from the Everyday Discrimination Scale, a commonly used questionnaire to measure discrimination. A codebook was developed through a modified grounded theory and qualitative content analysis approach to categorize recurrent themes of discrimination, which was then applied to the hospital reviews. EXPOSURES: Reported experiences of discrimination within a health care setting. MAIN OUTCOMES AND MEASURES: Perceptions of how discrimination in health care is experienced and reported by consumers. RESULTS: A total of 10 535 reviews were collected. Reviews were filtered by words commonly associated with discriminatory experiences, which identified 2986 reviews potentially related to discrimination. Using the codebook, the team manually identified 182 reviews that described at least 1 instance of discrimination. Acts of discrimination were categorized by actors of discrimination (individual vs institution), setting (clinical vs nonclinical), and directionality (whether consumers expressed discriminatory beliefs toward health care staff). A total of 53 reviews (29.1%) were coded as examples of institutional racism; 89 reviews (48.9%) mentioned acts of discrimination that occurred in clinical spaces as consumers were waiting for or actively receiving care; 25 reviews (13.7%) mentioned acts of discrimination that occurred in nonclinical spaces, such as lobbies; and 66 reviews (36.3%) documented discrimination by the consumer directed at the health care workforce. Acts of discrimination are described through 6 recurrent themes, including acts of commission, omission, unprofessionalism, disrespect, stereotyping, and dehumanizing. CONCLUSIONS AND RELEVANCE: In this qualitative study, consumer reviews were found to highlight recurrent patterns of discrimination within health care settings. Applying quality improvement tools, such as the Plan-Do-Study-Act cycle, to this source of data and this study's findings may help inform assessments and initiatives directed at reducing discrimination within the health care setting.