Exploring ethnic differences in post-discharge patterns of surgical care for older adults admitted with diverticulitis.

AIM: We aimed to evaluate ethnic differences in patterns of care following an index nonoperative admission for acute diverticulitis amongst a universally insured patient cohort. METHODS: We identified nationwide Medicare beneficiaries aged 65.5 years or older hospitalized between 1 July 2015 and 1 November 2017 for nonoperative management of an index admission for diverticulitis. Patients were followed for 1 year to examine patterns of care. Primary categorical outcomes included receipt of an elective operation, emergency operation, nonoperative readmission or no further hospitalizations for diverticulitis. Multinomial regression was performed to determine the association between ethnicity and receipt of each primary outcome category whilst adjusting for potential confounders. We examined the use of percutaneous drainage during the index admission to better understand its association with subsequent care patterns. RESULTS: Amongst 22 630 study patients, subsequent operative treatment was less common for Black, Hispanic, Asian and American Indian patients relative to White patients. Multinomial logistic regression noted that Black (relative risk 0.40; 95% CI 0.32-0.50) and Asian (relative risk 0.37; 95% CI 0.15-0.91) patients were associated with the lowest relative risk of undergoing an elective interval operation compared to White patients. Black patients were also associated with a 1.43 (95% CI 1.19-1.73) increased risk of requiring subsequent nonoperative readmissions for disease recurrence compared to White patients. The use of percutaneous drainage was higher amongst White patients relative to Black patients (6.9% vs. 4.0%, P value < 0.001). CONCLUSION: We have identified ongoing inequities in the consumption of medical resources, with White patients being more likely to undergo elective colectomy and percutaneous drainage. Differences in care are not fully alleviated by equal access to insurance.

Evaluating Changes in Surgical Outcomes for Patients With Inflammatory Bowel Disease Following Medicaid Expansion.

BACKGROUND: Little is known about the impact of Medicaid expansion on the surgical care of inflammatory bowel disease. We sought to determine whether Medicaid expansion is associated with improved postsurgical outcomes for patients with inflammatory bowel disease undergoing a colorectal resection. METHODS: We performed a risk-adjusted difference-in-difference study examining postsurgical outcomes for patients ages 26 to 64 with Crohn's disease or ulcerative colitis undergoing a colorectal resection across 15 states that did and did not expand Medicaid before (2012-2013) and after (2016-2018) policy reform. Primary study outcomes included 30-day readmission and postoperative complication. RESULTS: Study population included 11 394 patients with inflammatory bowel disease that underwent a colorectal resection. States that underwent Medicaid expansion were associated with a rise in Medicaid enrollment following policy reform (11.8% pre-Medicaid expansion vs 19.7% post-Medicaid expansion). Difference-in-difference analysis revealed a statistically significant lower odds of 30-day readmission in patients undergoing a colorectal resection in expansion states following policy reform relative to patients in nonexpansion states prior to reform (odds ratio, 0.56; 95% confidence interval, 0.36-0.86). No changes in odds of postoperative complication were noted across expansion and nonexpansion states. CONCLUSIONS: Medicaid expansion is associated with a rise in Medicaid enrollment in expansion states following policy reform. There were greater improvements in postoperative outcomes associated with patients in expansion states following policy reform relative to patients in nonexpansion states prior to reform, which may have been related to improved perioperative care and medical management.

Simulated data-driven hospital selection for surgical treatment of well-differentiated thyroid cancer in older adults.

BACKGROUND: Thyroid surgery at high-quality hospitals is associated with fewer complications. We evaluated the impact of referring older adults with thyroid cancer to higher-performing local hospitals. METHODS: We performed a simulation study of Surveillance, Epidemiology, and End Results-Medicare patients, aged ≥66 years, who underwent a thyroidectomy for well-differentiated thyroid cancer (2013-2017). An 80% sample was used to calculate each hospital's risk-standardized 30-day serious adverse event rate, dividing hospitals into quartiles by performance. Hospitals located ≤30 miles of the remaining 20% of patients were compared, and 30-day serious adverse event rates and costs were simulated as if patients were treated at higher-quality hospitals using logistic regression with each alternative hospital's fixed-effect. RESULTS: We identified 8,946 patients who underwent thyroid resection at 843 hospitals. Average risk-adjusted serious adverse event rates ranged from 13.9% to 52.9% between quartile 1 and 4 hospitals (P < .001). We identified higher-quality hospitals for 43.7% of patients. Simulating care at the best local hospital reduced predicted serious adverse event rates from 25.6% (95% confidence interval, 24.7-26.4) to 16.2% (95% confidence interval, 15.5-16.8; P < .001), while modestly lowering average costs from $12,883 (95% confidence interval, 12,500-13,267) to $12,679 (95% confidence interval, 12,304-13,056; P = .029). CONCLUSION: Simulated care at higher-performing hospitals decreased serious adverse event rates after thyroid resection. Optimizing hospital selection may reduce postoperative morbidity without compromising preferences for local treatment.