The impact of patient age and comorbidities on the occurrence of "never events" in cerebrovascular surgery: an analysis of the Nationwide Inpatient Sample.

OBJECT: As health care administrators focus on patient safety and cost-effectiveness, methodical assessment of quality outcome measures is critical. In 2008 the Centers for Medicare and Medicaid Services (CMS) published a series of "never events" that included 11 hospital-acquired conditions (HACs) for which related costs of treatment are not reimbursed. Cerebrovascular procedures (CVPs) are complex and are often performed in patients with significant medical comorbidities. METHODS: This study examines the impact of patient age and medical comorbidities on the occurrence of CMS-defined HACs, as well as the effect of these factors on the length of stay (LOS) and hospitalization charges in patients undergoing common CVPs. RESULTS: The HACs occurred at a frequency of 0.49% (1.33% in the intracranial procedures and 0.33% in the carotid procedures). Falls/trauma (n = 4610, 72.3% HACs, 357 HACs per 100,000 CVPs) and catheter-associated urinary tract infections (n = 714, 11.2% HACs, 55 HACs per 100,000 CVPs) were the most common events. Age and the presence of ≥ 2 comorbidities were strong independent predictors of HACs (p < 0.0001). The occurrence of HACs negatively impacts both LOS and hospital costs. Patients with at least 1 HAC were 10 times more likely to have prolonged LOS (≥ 90th percentile) (p < 0.0001), and 8 times more likely to have high inpatient costs (≥ 90th percentile) (p < 0.0001) when adjusting for patient and hospital factors. CONCLUSIONS: Improved quality protocols focused on individual patient characteristics might help to decrease the frequency of HACs in this high-risk population. These data suggest that risk adjustment according to underlying patient factors may be warranted when considering reimbursement for costs related to HACs in the setting of CVPs.

Racial and socioeconomic disparities in incidence of hospital-acquired complications following cerebrovascular procedures.

BACKGROUND: Patients with cerebrovascular disease undergo complex surgical procedures, often requiring prolonged inpatient hospitalization. Previous studies have demonstrated associations between racial/demographic factors and clinical outcomes in patients undergoing cerebrovascular procedures (CVPs). The Centers for Medicare and Medicaid Services have published a series of 11 hospital-acquired conditions (HACs) deemed "reasonably preventable" for which related costs of treatment are not reimbursed. We hypothesize that race and payer status disparities impact HAC frequency in patients undergoing CVPs and that HAC incidence is associated with length of stay and hospital costs. OBJECTIVE: To assess health disparities in HACs among the cerebrovascular neurosurgical patient population. METHODS: Data were collected from the Nationwide Inpatient Sample (NIS) database from 2002 to 2010. CVPs and HACs were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. HAC incidence was evaluated according to demographics including race, payer status, and median zip code income via multivariable analysis. Secondary outcomes of interest included length of stay and resulting inpatient charges. RESULTS: From 2002 to 2010, there were 1 290 883 CVP discharges with an HAC rate of 0.5%. Significant disparities in HAC frequency existed according to ethnicity and insurance provider. Minorities and Medicaid patients had increased frequency of HACs (P < .05), as well as prolonged length of stay and higher inpatient costs (P < .05). CONCLUSION: HAC incidence is associated with racial and socioeconomic factors in patients who undergo CVPs. Awareness of these disparities may lead to improved processes and protocol implementation, which might help to decrease the frequency of these potentially avoidable events.

Racial and socioeconomic disparities in access to mechanical revascularization procedures for acute ischemic stroke.

BACKGROUND: Mechanical revascularization procedures performed for treatment of acute ischemic stroke have increased in recent years. Data suggest association between operative volume and mortality rates. Understanding procedural allocation and patient access patterns is critical. Few studies have examined these demographics. METHODS: Data were collected from the 2008 Nationwide Inpatient Sample database. Patients hospitalized with ischemic stroke and the subset of individuals who underwent mechanical thrombectomy were characterized by race, payer source, population density, and median wealth of the patient's zip code. Demographic data among patients undergoing mechanical thrombectomy procedures were examined. Stroke admission demographics were analyzed according to thrombectomy volume at admitting centers and patient demographics assessed according to the thrombectomy volume at treating centers. RESULTS: Significant allocation differences with respect to frequency of mechanical thrombectomy procedures among stroke patients existed according to race, expected payer, population density, and wealth of the patient's zip code (P < .0001). White, Hispanic, and Asian/Pacific Islander patients received endovascular treatment at higher rates than black and Native American patients. Compared with the white stroke patients, black (P < .001), Hispanic (P < .001), Asian/Pacific Islander (P < .001), and Native American stroke patients (P < .001) all demonstrated decreased frequency of admission to hospitals performing mechanical thrombectomy procedures at high volumes. Among treated patients, blacks (P = .0876), Hispanics (P = .0335), and Asian/Pacific Islanders (P < .001) demonstrated decreased frequency in mechanical thrombectomy procedures performed at high-volume centers when compared with whites. While present, socioeconomic disparities were not as consistent or pronounced as racial differences. CONCLUSIONS: We demonstrate variances in endovascular acute stroke treatment allocation according to racial and socioeconomic factors in 2008. Efforts should be made to monitor and address potential disparities in treatment utilization.