Resident Physicians as Clinical Educators in Anesthesiology: A Narrative Review.

The importance of resident physicians as clinical educators is widely acknowledged in many clinical specialties and by national accreditation organizations for medical education. Within anesthesiology training programs, there is growing attention to the role of trainees as clinical educators. This narrative review describes the theoretical and demonstrated benefits of clinical teaching by residents in anesthesiology and other medical fields, summarizes current efforts to support and promote residents as educators, and suggests ways in which anesthesiology training programs can further assess and develop the role of residents as clinical educators.

Medicare and Medicaid insurance status is associated with increased allogeneic red blood cell transfusion in cardiac surgery patients: 2007-2018.

BACKGROUND AND AIM: Allogeneic red blood cell (RBC) transfusion and health insurance status are independently associated with perioperative morbidity. The aim of this study was to evaluate the effect of insurance status on allogeneic and autologous transfusion risk in cardiac surgery patients. METHODS: We conducted a retrospective observational study of data spanning 2007-2018 from six states from the State Inpatient Databases. Patients were cohorted by medical insurance type. Rates and risk-adjusted odds ratios (aOR) were calculated for allogenic and autologous RBC transfusions. Interactions between insurance and race/ethnicity were assessed. RESULTS: A total of 710,296 cardiac surgery patients were included. Allogeneic infusions occurred in 34.7% of Medicare patients, 31.9% of Medicaid patients, 24.7% of privately insured patients, and 26.1% of uninsured patients. Autologous rates were 2.3%, 2.5%, 3.4%, and 2.6% for Medicare, Medicaid, privately insured, and uninsured patients, respectively. Medicare and Medicaid patients were more likely to receive allogeneic RBC than privately insured patients (Medicare: aOR: 1.42, 99% confidence interval [CI]: 1.40-1.44, p < .001, Medicaid: aOR: 1.18, 99% CI: 1.14-1.21, p < .001). Nonwhite Medicare patients showed higher odds of allogeneic transfusion compared with White patients with private insurance (Black Medicare: aOR 1.74, 99% CI: 1.65-1.83, p < .001, Hispanic Medicare: aOR 1.92, 99% CI: 1.84-2.00, p < .001). CONCLUSION: Cardiac surgery patients with Medicare and Medicaid insurance demonstrate increased risk of allogeneic RBC transfusion; nonwhite patient groups are particularly vulnerable. Further research is needed to understand the causes and implications of these disparities, and to help ensure equitable care across patient groups.

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.

Economic burden of lives lost due to COVID-19 in California State.

Aim: To examine the economic impact of lives lost due to the coronavirus pandemic across California and Los Angeles (LA) County. Patients & methods: Years of potential life lost (YPLL) and the value of statistical life (VSL) were calculated using mortality data from the California Department of Public Health, the LA County Department of Public Health and the Social Security Administration websites. Results: In California and LA County, the average YPLL per person were 14.3 and 14.7 and the VSLs were approximately US$219.9 billion and $82.7 billion, respectively. YPLL and VSL were greatest for Latinos aged 50-64. Conclusion: The economic burden of lives lost due to the coronavirus across California and LA County is substantial. Latinos aged 50-64 were most affected.

Social determinants of health affect unplanned readmissions following acute myocardial infarction.

Background: Low socioeconomic status predicts inferior clinical outcomes in many patient populations. The effects of patient insurance status and hospital safety-net status on readmission rates following acute myocardial infarction are unclear. Materials & methods: A retrospective review of State Inpatient Databases for New York, California, Florida and Maryland, 2007-2014. Results: A total of 1,055,162 patients were included. Medicaid status was associated with 37.7 and 44.0% increases in risk-adjusted readmission odds at 30 and 90 days (p < 0.0001). Uninsured status was associated with reduced odds of readmission at both time points. High-burden safety-net status was associated with 9.6 and 9.5% increased odds of readmission at 30 and 90 days (p < 0.0003). Conclusion: Insurance status and hospital safety-net burden affect readmission odds following acute myocardial infarction.

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.

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.

Clinical Management of Venoarterial Extracorporeal Membrane Oxygenation.

Venoarterial extracorporeal membrane oxygenation (ECMO) is a well-established technique to rescue patients experiencing cardiogenic shock. As a form of temporary mechanical circulatory support, venoarterial ECMO can be life-saving, but it is resource intensive and associated with substantial morbidity and mortality. Optimal clinical outcomes require specific expertise in the principles and nuances of ECMO physiology and management. Key considerations discussed in this review include hemodynamic assessment and goals; pharmacologic anticoagulation; ECMO weaning strategies; and the prevention, evaluation, and treatment of common complications.

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.