Insurance-Based Disparities in Congenital Cardiac Operations in the Era of the Affordable Care Act.

A body of literature has previously highlighted the impact of health insurance on observed disparities in congenital cardiac operations. With aims of improving access to healthcare for all patients, the Affordable Care Act (ACA) expanded Medicaid coverage to nearly all eligible children in 2010. Therefore, the present population-based study aimed to examine the association of Medicaid coverage with clinical and financial outcomes in the era the ACA. Records for pediatric patients (≤ 18 years) who underwent congenital cardiac operations were abstracted from the 2010-2018 Nationwide Readmissions Database. Operations were stratified using the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Category. Multivariable regression models were developed to evaluate the association of insurance status on index mortality, 30-day readmissions, care fragmentation, and cumulative costs. Of an estimated 132,745 hospitalizations for congenital cardiac surgery from 2010 to 2018, 74,925 (56.4%) were insured by Medicaid. The proportion of Medicaid patients increased from 57.6 to 60.8% during the study period. On adjusted analysis, patients with Medicaid insurance were at an increased odds of mortality (1.35, 95%CI: 1.13-1.60) and 30-day unplanned readmission (1.12, 95%CI: 1.01-1.25), experienced longer lengths of stay (+ 6.5 days, 95%CI 3.7-9.3), and exhibited higher cumulative hospitalization costs (+ $21,600, 95%CI: $11,500-31,700). The total hospitalization cost-burden for patients with Medicaid and private insurance were $12.6 billion and $8.06 billion, respectively. Medicaid patients exhibited increased mortality, readmissions, care fragmentation, and costs compared to those with private insurance. Our results of outcome variation by insurance status indicate the necessity of policy changes to attempt to approach equality in surgical out comes for this high-risk cohort. Baseline characteristics, trends, and outcomes by insurance status over the ACA rollout period 2010-2018.

Association of frailty with clinical and financial outcomes of esophagectomy hospitalizations in the United States.

Background: Frailty, defined as impaired physiologic reserve and function, has been associated with inferior results after surgery. Using a coding-based tool, we examined the clinical and financial impact of frailty on outcomes following esophagectomy. Methods: Adults undergoing elective esophagectomy were identified using the 2010-2018 Nationwide Readmissions Database. Using the binary Johns Hopkins Adjusted Clinical Groups frailty indicator, patients were classified as frail or nonfrail. Multivariable regression models were used to evaluate the association of frailty with in-hospital mortality, complications, hospitalization duration, costs, nonhome discharge, and unplanned 30-day readmission. Results: Of 45,361 patients who underwent esophagectomy, 18.7% were considered frail. Most frail patients were found to have diagnoses of malnutrition (70%) or weight loss (15%) at the time of surgery. After adjustment, frailty was associated with increased risk of in-hospital mortality (adjusted odds ratio 1.67, 95% confidence interval 1.29-2.16) and overall complications (adjusted odds ratio 1.57, 95% confidence interval 1.44-1.71). Frailty conferred a 5.6-day increment in length of stay (95% confidence interval 4.94-6.45) and an additional $19,900 hospitalization cost (95% confidence interval $16,700-$23,100). Frail patients had increased odds of nonhome discharge (adjusted odds ratio 1.53, 95% confidence interval 1.35-1.75) as well as unplanned 30-day readmissions (adjusted odds ratio 1.17, 95% confidence interval 1.02-1.34). Conclusion: Frailty, as detected by an administrative tool, is associated with worse clinical and financial outcomes following esophagectomy. The inclusion of standardized assessment of frailty in risk models may better inform patient selection and shared decision-making prior to operative intervention.

Factors and Outcomes Associated With Venous Thromboembolism Following Bariatric Surgery.

BACKGROUND: The present national study characterized the incidence and factors associated with VTE following bariatric operations and its association with postoperative outcomes and resource use. METHODS: Adults (≥18 years) undergoing elective sleeve gastrectomy or gastric bypass (laparoscopic and open) were identified in the 2016-2018 Nationwide Readmissions Database. International Classification of Diseases 10th Revision codes for deep venous thrombosis and/or pulmonary embolism were used to ascertain the presence of VTE. Multivariable linear and logistic models were developed to evaluate the independent association of VTE with outcomes of interest. RESULTS: Of an estimated 537,522 patients meeting inclusion criteria, .55% developed VTE during index hospitalization (.14%) or within 90 days of index discharge (.41%). Compared to others, VTE patients were older (51.8 vs 44.9 years, P<.001), more commonly male (20.0% vs 31.5%, P<.001), and had gastric bypass (56.3% vs 31.9%, P<.001) or an open procedure (21.9% vs 2.6%, P<.001). After risk adjustment, several factors including increasing age, male gender, gastric bypass and open approach remained associated with increased odds of VTE. Patients with VTE during index hospitalization had greater odds of mortality (AOR 11.6, 95% CI: 6.12-22.19) and increased index LOS (ß:+14.1 days, 95% CI: 11.7-16.5) and hospitalization costs (ß: +$53,100, 95% CI: 43,100-63,500). Additionally, VTE patients had greater odds of readmission within 90 days (AOR 1.86, 95% CI: 1.40-2.47). CONCLUSIONS: Although VTE is uncommon following bariatric operations, it is significantly associated with increased mortality, readmission, and resource use. Further research is necessary to ascertain optimal management of VTE for bariatric surgery patients.