Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions.

OBJECTIVE: Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time. BACKGROUND: EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition. METHODS: This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days. RESULTS: Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management. CONCLUSIONS: Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions.

INTRODUCTION: Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken. METHODS: Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes. RESULTS: One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation. CONCLUSIONS: Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.

Health System Structure: An Opportunity to Address Structural Racism and Discrimination.

OBJECTIVE: To examine the role of hub-and-spoke systems as a factor in structural racism and discrimination. BACKGROUND: Health systems are often organized in a "hub-and-spoke" manner to centralize complex surgical care to 1 high-volume hospital. Although the surgical health care disparities are well described across health care systems, it is not known how they seem across a single system's hospitals. METHODS: Adult patients who underwent 1 of 10 general surgery operations in 12 geographically diverse states (2016-2018) were identified using the Healthcare Cost and Utilization Project's State Inpatient Databases. System status was assigned using the American Hospital Association dataset. Hub designation was assigned in 2 ways: (1) the hospital performing the most complex operations (general hub) or (2) the hospital performing the most of each specific operation (procedure-specific hub). Independent multivariable logistic regression was used to evaluate the risk-adjusted odds of treatment at hubs by race and ethnicity. RESULTS: We identified 122,236 patients across 133 hospitals in 43 systems. Most patients were White (73.4%), 14.2% were Black, and 12.4% Hispanic. A smaller proportion of Black and Hispanic patient underwent operations at general hubs compared with White patients (B: 59.6% H: 52.0% W: 62.0%, P <0.001). After adjustment, Black and Hispanic patients were less likely to receive care at hub hospitals relative to White patients for common and complex operations (general hub B: odds ratio: 0.88 CI, 0.85, 0.91 H: OR: 0.82 CI, 0.79, 0.85). CONCLUSIONS: When White, Black, and Hispanic patients seek care at hospital systems, Black and Hispanic patients are less likely to receive treatment at hub hospitals. Given the published advantages of high-volume care, this new finding may highlight an opportunity in the pursuit of health equity.

Algorithms identifying low-acuity emergency department visits: A review and validation study.

OBJECTIVE: To characterize and validate the landscape of algorithms that use International Classification of Disease (ICD) codes to identify low-acuity emergency department (ED) visits. DATA SOURCES: Publicly available ED data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). STUDY DESIGN: We systematically searched for studies that specify algorithms consisting of ICD codes that identify preventable or low-acuity ED visits. We classified ED visits in NHAMCS according to these algorithms and compared agreements using the Jaccard index. We then evaluated the performance of each algorithm using positive predictive value (PPV) and sensitivity, with the reference group specified using low-acuity composite (LAC) criteria consisting of both triage and clinical components. In sensitivity analyses, we repeated our primary analysis using only triage or only clinical criteria for reference. DATA COLLECTION: We used the 2011-2017 NHAMCS data, totaling 163,576 observations before survey weighting and after dropping observations missing a primary diagnosis. We translated ICD-9 codes (years 2011-2015) to ICD-10 using a standard crosswalk. PRINCIPAL FINDINGS: We identified 15 papers with an original list of ICD codes used to identify preventable or low-acuity ED presentations. These papers were published between 1992 and 2020, cited an average of 310 (SD 360) times, and included 968 (SD 1175) codes. Pairwise Jaccard similarity indices (0 = no overlap, 1 = perfect congruence) ranged from 0.01 to 0.82, with mean 0.20 (SD 0.13). When validated against the LAC reference group, the algorithms had an average PPV of 0.308 (95% CI [0.253, 0.364]) and sensitivity of 0.183 (95% CI [0.111, 0.256]). Overall, 2.1% of visits identified as low acuity by the algorithms died prehospital or in the ED, or needed surgery, critical care, or cardiac catheterization. CONCLUSIONS: Existing algorithms that identify low-acuity ED visits lack congruence and are imperfect predictors of visit acuity.

Disruptions in preventive care: Mammograms during the COVID-19 pandemic.

OBJECTIVE: To measure the extent to which the provision of mammograms was impacted by the COVID-19 pandemic and surrounding guidelines. DATA SOURCES: De-identified summary data derived from medical claims and eligibility files were provided by Independence Blue Cross for women receiving mammograms. STUDY DESIGN: We used a difference-in-differences approach to characterize the change in mammograms performed over time and a queueing formula to estimate the time to clear the queue of missed mammograms. DATA COLLECTION: We used data from the first 30 weeks of each year from 2018 to 2020. PRINCIPAL FINDINGS: Over the 20 weeks following March 11, 2020, the volume of screening mammograms and diagnostic mammograms fell by 58% and 38% of expected levels, on average. Lowest volumes were observed in week 15 (April 8 to 14), when screening and diagnostic mammograms fell by 99% and 74%, respectively. Volumes began to rebound in week 19 (May), with diagnostic mammograms reaching levels to similar to previous years' and screening mammograms remaining 14% below expectations. We estimate it will take a minimum of 22 weeks to clear the queue of missed mammograms in our study sample. CONCLUSIONS: The provision of mammograms has been significantly disrupted due to the COVID-19 pandemic.

Splenic Laceration: A Rare Complication of Abdominal Paracentesis.

Abdominal paracentesis is a commonly performed diagnostic and therapeutic procedure with a low complication rate. Previously described complications include injury to the abdominal wall, small bowel perforation, and abdominal hemorrhage. Splenic injury has also been described as a complication from bedside procedures including colonoscopy, upper gastrointestinal endoscopy, thoracentesis, and pleural biopsy. This case highlights a previously unreported complication from an abdominal paracentesis, splenic laceration.

Spatial and temporal patterns of particulate matter sources and pollution in four communities in Accra, Ghana.

Sources of air pollution in developing country cities include transportation and industrial pollution, biomass fuel use, and re-suspended dust from unpaved roads. We examined the spatial patterns of particulate matter (PM) and its sources in four neighborhoods of varying socioeconomic status (SES) in Accra. PM data were from 1 week of morning and afternoon mobile and stationary air pollution measurements in each of the study neighborhoods. PM(2.5) and PM(10) were measured continuously, with matched GPS coordinates. Data on biomass fuel use were from the Ghana 2000 population and housing census and from a census of wood and charcoal stoves along the mobile monitoring paths. We analyzed the associations of PM with sources using a mixed-effects regression model accounting for temporal and spatial autocorrelation. After adjusting for other factors, the density of wood stoves, fish smoking, and trash burning along the mobile monitoring path as well as road capacity and surface were associated with higher PM(2.5). Road capacity and road surface variables were also associated with PM(10), but the association with biomass sources was weak or absent. While wood stoves and fish smoking were significant sources of air pollution, addressing them would require financial and physical access to alternative fuels for low-income households and communities.

Altitude, life expectancy and mortality from ischaemic heart disease, stroke, COPD and cancers: national population-based analysis of US counties.

BACKGROUND: There is a substantial variation in life expectancy across US counties, primarily owing to differentials in chronic diseases. The authors' aim was to examine the association of life expectancy and mortality from selected diseases with altitude. METHODS: The authors used data from the National Elevation Dataset, National Center for Heath Statistics and US Census. The authors analysed the crude association of mean county altitude with life expectancy and mortality from ischaemic heart disease (IHD), stroke, chronic obstructive pulmonary disease (COPD) and cancers, and adjusted the associations for socio-demographic factors, migration, average annual solar radiation and cumulative exposure to smoking in multivariable regressions. RESULTS: Counties above 1500 m had longer life expectancies than those within 100 m of sea level by 1.2-3.6 years for men and 0.5-2.5 years for women. The association between altitude and life expectancy became non-significant for women and non-significant or negative for men in multivariate analysis. After adjustment, altitude had a beneficial association with IHD mortality and harmful association with COPD, with a dose-response relationship. IHD mortality above 1000 m was 4-14 per 10,000 people lower than within 100 m of sea level; COPD mortality was higher by 3-4 per 10,000. The adjusted associations for stroke and cancers were not statistically significant. CONCLUSIONS: Living at higher altitude may have a protective effect on IHD and a harmful effect on COPD. At least in part due to these two opposing effects, living at higher altitude appears to have no net effect on life expectancy.

The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States.

BACKGROUND: Counties are the smallest unit for which mortality data are routinely available, allowing consistent and comparable long-term analysis of trends in health disparities. Average life expectancy has steadily increased in the United States but there is limited information on long-term mortality trends in the US counties This study aimed to investigate trends in county mortality and cross-county mortality disparities, including the contributions of specific diseases to county level mortality trends. METHODS AND FINDINGS: We used mortality statistics (from the National Center for Health Statistics [NCHS]) and population (from the US Census) to estimate sex-specific life expectancy for US counties for every year between 1961 and 1999. Data for analyses in subsequent years were not provided to us by the NCHS. We calculated different metrics of cross-county mortality disparity, and also grouped counties on the basis of whether their mortality changed favorably or unfavorably relative to the national average. We estimated the probability of death from specific diseases for counties with above- or below-average mortality performance. We simulated the effect of cross-county migration on each county's life expectancy using a time-based simulation model. Between 1961 and 1999, the standard deviation (SD) of life expectancy across US counties was at its lowest in 1983, at 1.9 and 1.4 y for men and women, respectively. Cross-county life expectancy SD increased to 2.3 and 1.7 y in 1999. Between 1961 and 1983 no counties had a statistically significant increase in mortality; the major cause of mortality decline for both sexes was reduction in cardiovascular mortality. From 1983 to 1999, life expectancy declined significantly in 11 counties for men (by 1.3 y) and in 180 counties for women (by 1.3 y); another 48 (men) and 783 (women) counties had nonsignificant life expectancy decline. Life expectancy decline in both sexes was caused by increased mortality from lung cancer, chronic obstructive pulmonary disease (COPD), diabetes, and a range of other noncommunicable diseases, which were no longer compensated for by the decline in cardiovascular mortality. Higher HIV/AIDS and homicide deaths also contributed substantially to life expectancy decline for men, but not for women. Alternative specifications of the effects of migration showed that the rise in cross-county life expectancy SD was unlikely to be caused by migration. CONCLUSIONS: There was a steady increase in mortality inequality across the US counties between 1983 and 1999, resulting from stagnation or increase in mortality among the worst-off segment of the population. Female mortality increased in a large number of counties, primarily because of chronic diseases related to smoking, overweight and obesity, and high blood pressure.