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.

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.

Coronary artery bypass grafting at safety-net versus non-safety-net hospitals.

Objectives: Safety-net hospitals (SNHs) provide essential services to predominantly underserved patients regardless of their ability to pay. We hypothesized that patients who underwent coronary artery bypass grafting (CABG) would have inferior observed outcomes at SNHs compared with non-SNHs but that matched cohorts would have comparable outcomes. Methods: We queried the Nationwide Readmissions Database for patients who underwent isolated CABG from 2016 to 2018. We ranked hospitals by the percentage of all admissions in which the patient was uninsured or insured with Medicaid; hospitals in the top quartile were designated as SNHs. We used propensity-score matching to mitigate the effect of confounding factors and compare outcomes between SNHs and non-SNHs. Results: A total of 525,179 patients underwent CABG, including 96,133 (18.3%) at SNHs, who had a greater burden of baseline comorbidities (median Elixhauser score 8 vs 7; P = .04) and more frequently required urgent surgery (57.1% vs 52.8%; P < .001). Observed in-hospital mortality (2.1% vs 1.8%; P = .004) and major morbidity, length of stay (9 vs 8 days; P < .001), cost ($46,999 vs $38,417; P < .001), and readmission rate at 30 (12.4% vs 11.3%) and 90 days (19.0% vs 17.7%) were greater at SNHs (both P < .001). After matching, none of these differences persisted except length of stay (9 vs 8 days) and cost ($46,977 vs $39,343) (both P < .001). Conclusions: After matching, early outcomes after CABG were comparable at SNHs and non-SNHs. Improved discharge resources could reduce length of stay and curtail cost, improving the value of CABG at SNHs.

Examining healthcare inequities relative to United States safety net hospitals.

INTRODUCTION: The impact of safety net (SN) hospitals relative to racial and healthcare disparities remains largely unknown. METHODS: Using the Nationwide Inpatient Sample, adults undergoing coronary artery bypass grafting, colectomy, or total hip arthroplasty were identified. Multivariable regression analysis was performed to determine association between SN burden and outcomes. Within each SN burden tier, the association between race/ethnic group and outcomes was defined. RESULTS: Overall 865,648 patients were identified. After adjustment for potential confounders, patients operated at the highest SN burden hospitals had increased odds of complications (OR 1.14, 95%CI 1.10-1.18), death (OR 1.41, 95%CI 1.31-1.52), FTR (OR 1.36, 95%CI 1.25-1.47) and a never event (OR 1.57, 95%CI 1.47-1.68). Irrespective of hospital SN burden, racial minorities had greater odds of a complication, and prolonged LOS compared to whites (p < 0.05). CONCLUSION: While overall degree of safety net burden was associated with worse overall outcomes, SN hospitals did not mitigate racial disparities experienced by minority patients.

Hospital safety net burden is associated with increased inpatient mortality and postoperative morbidity after total hip arthroplasty: a retrospective multistate review, 2007-2014.

BACKGROUND: Total hip arthroplasty (THA) is one of the most widely performed surgical procedures in the USA. Safety net hospitals, defined as hospitals with a high proportion of cases billed to Medicaid or without insurance, deliver a significant portion of their care to vulnerable populations, but little is known about the effects of a hospital's safety net burden and its role in healthcare disparities and outcomes following THA. We quantified safety net burden and examined its impact on in-hospital mortality, complications and length of stay (LOS) in patients who underwent THA. METHODS: We analyzed 500 189 patient discharge records for inpatient primary THA using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland and Kentucky from 2007 to 2014. We compared patient demographics, present-on-admission comorbidities and hospital characteristics by hospital safety net burden status. We estimated mixed-effect generalized linear models to assess hospital safety burden status' effect on in-hospital mortality, patient complications and LOS. RESULTS: Patients undergoing THA at a hospital with a high or medium safety net burden were 38% and 30% more likely, respectively, to die in-hospital compared with those in a low safety net burden hospital (high adjusted OR: 1.38, 95% CI 1.10 to 1.73; medium adjusted OR: 1.30, 95% CI 1.07 to 1.57). Compared with patients treated in hospitals with a low safety net burden, patients treated in high safety net hospitals were more likely to develop a postoperative complication (adjusted OR: 1.11, 95% CI 1.00 to 1.24) and require a longer LOS (adjusted IRR: 1.06, 95% CI 1.05, 1.07). CONCLUSIONS: Our study supports our hypothesis that patients who underwent THA at hospitals with higher safety net burden have poorer outcomes than patients at hospitals with lower safety net burden.