A Cross-Sectional Analysis of Pediatric Necrotizing Soft Tissue Infection Cases and Racial Disparities From the 2016 to 2020 National Inpatient Sample.

INTRODUCTION: The incidence, treatment, and outcomes of necrotizing soft tissue infections (NSTIs) and associated racial disparities have been described in adults, but research in the pediatric population is limited. The purpose of this study is to provide a nationally representative characterization of pediatric NSTI and determine the presence of any racial disparities. METHODS: The National Inpatient Sample was analyzed from 2016 through 2020. Patients aged less than 20 y with a diagnosis of necrotizing fasciitis, Fournier's gangrene, or gas gangrene (based on International Classification of Diseases, Tenth Revision, Clinical Modification codes) were included for analysis. RESULTS: A total of 355 patients were identified. Black and Hispanic patients accounted for the most admissions in 2016 and 2018, respectively (P = 0.024). Compared to White patients, more Black patients were insured by Medicaid (P = 0.037) and were in the first zip code-based income quartile (P = 0.005). The leading infection overall was necrotizing fasciitis and most patients (81.7%) underwent a surgical procedure by the first calendar day after admission. Although the proportion of Black patients undergoing subcutaneous tissue and fascia excisions was more than that of White patients (P = 0.005), there were no significant differences by race in the time to first procedure, the total number of procedures, or number of postoperative complications. Our amputation and mortality rates were low and unreportable, but there were no differences by race. CONCLUSIONS: NSTI is rare in the pediatric population and mortality is low. Black patients are disproportionately diagnosed, but these disparities do not extend to disease treatment or outcomes.

More problems, more money: Identifying and predicting high-cost rescue after colorectal surgery.

Background: Successful rescue after elective surgery is associated with increased healthcare costs, but costs vary widely. Treating all rescue events the same may overlook targeted opportunities for improvement. The purpose of this study was to predict high-cost rescue after elective colorectal surgery. Methods: We identified adult patients in the National Inpatient Sample (2016-2021) who underwent elective colectomy or proctectomy. Rescued patients were defined as those who underwent additional major procedures. Three groups were stratified: 1) uneventful recovery; 2) Low-cost rescue; 3) High-cost rescue. Multivariable Poisson regression was used to identify preoperative clinical predictors of high-cost versus low-cost rescue. Results: We identified 448,590 elective surgeries, and rescued patients composed 4.8 %(21,635) of the total sample. The median increase in costs in rescued patients was $25,544(p < 0.001). Median total inpatient costs were $95,926 in the most expensive rescued versus $34,811 in the less expensive rescued versus $16,751 in the uneventfully discharged(p < 0.001). When comparing the secondary procedures between the less expensive and most expensive rescued groups, the most expensive had an increased proportion of reoperation (73.4 % versus 53.0 %,p < 0.001). When controlling for other factors and stratification by congestive heart failure due to an interaction effect, a reoperation was independently associated with high-cost rescue (RR with CHF = 3.29,95%CI:2.69-4.04; RR without CHF = 2.29,95%CI:1.97-2.67). Conclusions: High-cost rescue after colorectal surgery is associated with disproportionately greater healthcare utilization and reoperation. For cost-conscious care, preemptive strategies that reduce reoperation-related complications can be prioritized.

Common comorbid and secondary conditions leading to hospitalization in multiple sclerosis patients in the United States.

OBJECTIVE: To identify the burden of hospitalization and common primary admitting diagnoses among MS patients in the United States (US). BACKGROUND: The burden of hospitalizations and conditions leading to hospitalizations in MS patients in the US has not been well described. DESIGN/METHODS: Using the Nationwide Inpatient Sample for 2001-2010, all patients with principal or secondary diagnosis of MS were identified, and the principal admitting diagnoses were compared with that of non-MS patients. Trends in hospitalizations were studied in specific age groups (1-9 yrs, 10-19 yrs, 20-29 yrs, 30-39 yrs, 40-49 yrs, 50-59 yrs, 60-69 yrs,70-79 yrs, 80-84 yrs and ≥85 yrs), and population level rates were obtained and compared with non-MS patients to obtain rate ratios (RR) and odds ratios (OR). RESULTS: A total of 1,240,410 MS patients were identified representing 4 out of every 1000 US hospital admissions, with an estimated female/male ratio of 2.72/1. The median age for MS hospitalizations was 53 years (Interquartile range=18). The majority of all MS hospitalizations occurred in the 30-69-year age bracket (82.17 %). The average length of in-patient hospital stays for MS patients compared to the non-MS population was 5.8 vs. 4.5 days (p < 0.001), and more MS patients had Medicare insurance (50.36 % vs. 42.24 %, p < 0.001). Overall, conditions such as urinary tract infections (UTI) - (RR11.43, p < 0.001), septicemia (RR8.53, p < 0.001), pneumonia (RR2.84, p < 0.001), chronic skin ulcers (RR20.64, p < 0.001), and lower limb and femoral neck fractures (RR2.86, p < 0.001) were present with increased frequency among MS patients. Patterns of comorbidity varied markedly by age group. The estimated average annual in-hospital charges adjusted to 2010 dollars for all MS inpatient hospitalizations was 3 billion U.S. dollars. CONCLUSIONS: Patients with MS are admitted into hospital at a younger age, are hospitalized longer and consume more Medicare resources than the similar patients without MS in the general population. Infections account for a large proportion of MS-associated hospitalizations, from young adulthood onward. These findings are particularly significant in light of the increasing availability of disease modifying therapies with more potent immunosuppressive properties, as well as the accumulating data that systemic infection can drive MS relapses.

Popular to a Point: The Enduring Political Challenges of the Public Option.

Policy Points A decade after failing to make it into the Affordable Care Act, the public option reemerged as a health reform goal at both the national and state levels, with polls reporting strong, bipartisan support. A 2020 poll that probed both support for one public option approach (Medicare "buy-in") and attitudes toward government suggests that differences in these attitudes could plague reform advocates' efforts. Although the COVID-19 pandemic viscerally highlighted the need for a more coherent health care system-including universal coverage-other recent evolutions in the broader US political context could undermine reform.

Rural disparities in the quality of clinical care are notable and larger for males.

PURPOSE: To investigate whether rural-urban differences in quality of care for Medicare Advantage (MA) enrollees vary between females and males. METHODS: Data for this study came from the 2019 Healthcare Effectiveness Data and Information Set. Linear regression was used to investigate urban-rural differences in individual MA enrollee scores on 34 clinical care measures grouped into 7 categories, and how those differences varied by sex (through evaluation of statistical interactions). FINDINGS: Across all 7 categories of measures, scores for rural residents were worse than scores for urban residents. For 4 categories-care for patients with (suspected) chronic obstructive pulmonary disease, avoiding prescription misuse, behavioral health, and diabetes care-the average difference across measures in the category was greater than 3 percentage points. Across all 34 measures, there were 15 statistically significant rural-by-sex interactions that exceeded 1 percentage point. In 11 of those cases, the deficit associated with living in a rural area was greater for males than for females. In 3 cases, the deficit associated with living in a rural area was larger for females than for males. In 1 case involving Follow-up After Hospitalization for Mental Illness, rural residents had an advantage, and it was larger for males than for females. CONCLUSIONS: Interventions may help address patient- (eg, health literacy and patient activation), provider- (eg, workforce recruitment and retention), and structural-level issues contributing to these disparities, especially for rural males.

Non-Operative Shoulder Dysfunction in the United States Military.

INTRODUCTION: Recent epidemiological evidence shows that shoulder and upper-arm complaints impose a substantial burden on the armed forces of the United States and create significant challenges for all components of the physical fitness domain of total force fitness. Clinicians, epidemiologists, and health-services researchers interested in shoulder and upper-arm injuries and their functional limitations rarely have objective, validated criteria for rigorously evaluating diagnostic practices, prescribed treatments, or the outcomes of alternative approaches. We sought to establish and quantify patient volume, types of care, and costs within the Military Health System (MHS) in assessing and managing active duty members with nonoperative shoulder and upper-arm dysfunction. MATERIALS AND METHODS: We performed a retrospective cohort study using data from the MHS Data Repository and MHS MART (M2) from fiscal year 2014 to identify active duty individuals with a diagnosis of shoulder and upper-arm injury or impairment defined by one of the International Classification of Disease Ninth Edition diagnosis codes that were selected to reflect nonoperative conditions such as fractures or infections. Statistical analyses include descriptive statistics on patient demographics and clinical visits, such as the range and frequency of diagnoses, number and types of appointments, and clinical procedure information following the diagnosis. We also examined treatment costs related to shoulder dysfunction and calculated the total cost to include medications, radiological, procedural, and laboratory test costs for all shoulder dysfunction visits in 2014 and the average cost for each visit. We further examined the category of each medication prescribed. RESULTS: A total of 55,643 individuals met study criteria and accrued 193,455 shoulder-dysfunction-related clinical visits in fiscal year 2014. This cohort represents approximately 4.8% of the 1,155,183 active duty service members assigned to the United States and its territories during FY 2014. Most patients were male (85.32%), younger (85.25% were under 40 years old), and Caucasian/White (71.12%). The most common diagnosis code was 719.41 (pain in joint, shoulder region; 42.48%). The majority of the patients 42,750 (76.8%) had four or fewer medical visits during the study period and 12,893 (23.2%) had more than four visits. A total of 4,733 patients (8.5%) underwent arthrocentesis aspiration or injection. The total cost for all visits was $65,066,767.89. The average and median cost for each visit were $336.34 (standard deviation was $1,493.87) and $163.11 (range was from 0 to $84,183.88), respectively. Three out of four patients (75.3%) underwent radiological examinations, and 74.2% of these individuals had more than one radiological examination. Medications were prescribed to 50,610 (91.0%) patients with the three most common being IBUPROFEN (12.21%), NAPROXEN (8.51%), and OXYCODONE-ACETAMINOPHEN (5.04%), respectively. CONCLUSIONS: Nearly 1 in 20 active duty military service members presented for nonoperative care of shoulder and/or upper-arm dysfunction during FY2014. Further examinations of the etiology and potential impact of shoulder/upper-arm dysfunction on force readiness are clearly warranted, as are additional studies directed at identifying best practices for preventing injury-related dysfunction and determining best practices for the treatment of shoulder dysfunction to optimize service member fitness and force readiness.

Return on Investment of the COVID-19 Vaccination Campaign in New York City.

Importance: New York City, an early epicenter of the pandemic, invested heavily in its COVID-19 vaccination campaign to mitigate the burden of disease outbreaks. Understanding the return on investment (ROI) of this campaign would provide insights into vaccination programs to curb future COVID-19 outbreaks. Objective: To estimate the ROI of the New York City COVID-19 vaccination campaign by estimating the tangible direct and indirect costs from a societal perspective. Design, Setting, and Participants: This decision analytical model of disease transmission was calibrated to confirmed and probable cases of COVID-19 in New York City between December 14, 2020, and January 31, 2022. This simulation model was validated with observed patterns of reported hospitalizations and deaths during the same period. Exposures: An agent-based counterfactual scenario without vaccination was simulated using the calibrated model. Main Outcomes and Measures: Costs of health care and deaths were estimated in the actual pandemic trajectory with vaccination and in the counterfactual scenario without vaccination. The savings achieved by vaccination, which were associated with fewer outpatient visits, emergency department visits, emergency medical services, hospitalizations, and intensive care unit admissions, were also estimated. The value of a statistical life (VSL) lost due to COVID-19 death and the productivity loss from illness were accounted for in calculating the ROI. Results: During the study period, the vaccination campaign averted an estimated $27.96 (95% credible interval [CrI], $26.19-$29.84) billion in health care expenditures and 315 724 (95% CrI, 292 143-340 420) potential years of life lost, averting VSL loss of $26.27 (95% CrI, $24.39-$28.21) billion. The estimated net savings attributable to vaccination were $51.77 (95% CrI, $48.50-$55.85) billion. Every $1 invested in vaccination yielded estimated savings of $10.19 (95% CrI, $9.39-$10.87) in direct and indirect costs of health outcomes that would have been incurred without vaccination. Conclusions and Relevance: Results of this modeling study showed an association of the New York City COVID-19 vaccination campaign with reduction in severe outcomes and avoidance of substantial economic losses. This significant ROI supports continued investment in improving vaccine uptake during the ongoing pandemic.

Increasing Equity While Improving the Quality of Care: JACC Focus Seminar 9/9.

This review summarizes racial and ethnic disparities in the quality of cardiovascular care-a challenge given the fragmented nature of the health care delivery system and measurement. Health equity for all racial and ethnic groups will not be achieved without a substantially different approach to quality measurement and improvement. The authors adapt a tool frequently used in quality improvement work-the driver diagram-to chart likely areas for diagnosing root causes of disparities and developing and testing interventions. This approach prioritizes equity in quality improvement. The authors demonstrate how this approach can be used to create interventions that reduce systemic racism within the institutions and professions that deliver health care; attends more aggressively to social factors related to race and ethnicity that affect health outcomes; and examines how hospitals, health systems, and insurers can generate effective partnerships with the communities they serve to achieve equitable cardiovascular outcomes.

Patient-Reported Care Coordination is Associated with Better Performance on Clinical Care Measures.

BACKGROUND: Prior studies using aggregated data suggest that better care coordination is associated with higher performance on measures of clinical care process; it is unclear whether this relationship reflects care coordination activities of health plans or physician practices. OBJECTIVE: Estimate within-plan relationships between beneficiary-reported care coordination measures and HEDIS measures of clinical process for the same individuals. DESIGN: Mixed-effect regression models in cross-sectional data. PARTICIPANTS: 2013 Medicare Advantage CAHPS respondents (n=152,069) with care coordination items linked to independently collected HEDIS data on clinical processes. MAIN MEASURES: Care coordination measures assessed follow-up, whether doctors had medical records during visits, whether doctors discussed medicines being taken, how informed doctors seemed about specialist care, and help received with managing care among different providers. HEDIS measures included mammography, colorectal cancer screening, cardiovascular LDL-C screening, controlling blood pressure, 5 diabetes care measures (LDL-C screening, retinal eye exam, nephropathy, blood sugar/HbA1c <9%, LCL-C<100 mg/dL), glaucoma screening in older adults, BMI assessment, osteoporosis management for women with a fracture, and rheumatoid arthritis therapy. KEY RESULTS: For 9 of the 13 HEDIS measures, within health plans, beneficiaries who reported better care coordination also received better clinical care (p<0.05) and none of the associations went in the opposite direction; HEDIS differences between those with excellent and poor coordination exceeded 5 percentage points for 7 measures. Nine measures had positive associations (breast cancer screening, colorectal cancer screening, cardiovascular care LDL-C screening, 4 of 5 diabetes care measures, osteoporosis management, and rheumatoid arthritis therapy). CONCLUSIONS: Within health plans, beneficiaries who report better care coordination also received higher-quality clinical care, particularly for care processes that entail organizing patient care activities and sharing information among different healthcare providers. These results extend prior research showing that health plans with better beneficiary-reported care coordination achieved higher HEDIS performance scores.

The Affordable Care Act's Missing Consensus: Values, Attitudes, and Experiences Associated with Competing Health Reform Preferences.

Ten years after its enactment, public support for the Affordable Care Act (ACA) still only reaches a scant majority. Candidates for the presidency-and the sitting president-have endorsed health reforms that would radically transition US health care away from the current system upon which the ACA was built. Few opinion surveys to date have captured dominant preferences among alternative health reform policies or characterized attitudes and experiences that might be associated with policy preferences. Using a 2019 nationally representative telephone survey, this article considers how variations in political values, attitudes toward government, and experiences with the health care system relate to competing health reform preferences. Differences between those who favor Medicare for All over building on the ACA largely reflect different levels of satisfaction with the status quo and views of private health insurance. By contrast, differences between ACA supporters and those who would favor replacing it with a state-based alternative reflect sharply different political values and attitudes. Key differences remain significant after controlling for demographic, health, and political characteristics. Overwhelming public support still eludes the ACA, and reaching consensus on future directions for health reform will remain challenging given differences in underlying beliefs.

Strange Bedfellows: Coordinating Medicare and Medicaid to Achieve Cost-Effective Care for Patients with the Greatest Health Needs.

This perspective describes federal efforts in the United States (U.S.) to integrate care for an especially complex, vulnerable, and costly patient population: adults eligible for both Medicare and Medicaid insurance. The goal of the paper is to demystify for clinical policy leaders and practicing clinicians the origins and evolution of the Dual-Eligible Special Needs Plans (D-SNPs) recently permanently authorized by the U.S. Congress and to explore the potential for these policy changes to help such health plans improve care for the sickest and most vulnerable Americans.

Primary Care Physicians' Role In Coordinating Medical And Health-Related Social Needs In Eleven Countries.

Primary care physicians in the US, like their colleagues in several other high-income countries, are increasingly tasked with coordinating services delivered not just by specialists and hospitals but also by home care professionals and social service agencies. To inform efforts to improve care coordination, the 2019 Commonwealth Fund International Health Policy Survey of Primary Care Physicians queried primary care physicians in eleven high-income countries about their ability to coordinate patients' medical care with specialists, across settings of care, and with social service providers. Compared to physicians in other countries, substantial proportions of US physicians did not routinely receive timely notification or the information needed for managing ongoing care from specialists, after-hours care centers, emergency departments, or hospitals. Primary care practices in a handful of countries, including the US, are not routinely exchanging information electronically outside the practice. Top-performing countries demonstrate the feasibility of improving two-way communication between primary care and other sites of care. The surveyed countries share the challenge of coordinating with social service providers, and the results call for solutions to support primary care physicians.

Financial Hardships Of Medicare Beneficiaries With Serious Illness.

In a national survey, seriously ill Medicare beneficiaries described financial hardships resulting from their illness-despite high beneficiary satisfaction with Medicare overall and the fact that many have supplemental insurance. About half reported a serious problem paying medical bills, with prescription drugs proving most onerous.

Effect of Travel Time for Thyroid Surgery on Treatment Cost and Morbidity.

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time-related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients' home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1-107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.

Variation in the use of MRI for cervical spine clearance: an opportunity to simultaneously improve clinical care and decrease cost.

BACKGROUND: For years, controversy has existed about the ideal approach for cervical spine clearance in obtunded, blunt trauma patients. However, recent national guidelines suggest that MRI is not necessary for collar clearance in these patients. The purpose of this study was to identify the extent of national variation in the use of MRI and assess patient-specific and hospital-specific factors associated with the practice. METHODS: We performed a retrospective review of the National Trauma Data Bank from 2007 to 2012. We included blunt trauma patients aged ≥18 years, admitted to level 1 or 2 trauma centers (TCs), with a Glasgow Coma Scale <8, Abbreviated Injury Scale >3 for the head and mechanically ventilated for more than 72 hours. Multilevel modeling was used to identify patient-level and hospital-level factors associated with spine MRI use. RESULTS: 32 125 obtunded, blunt trauma patients treated at 395 unique TCs met our inclusion criteria. The mean proportion of patients who received MRI over the entire sample was 9.9%. The proportions of patients at each hospital who received a spine MRI ranged from 0.5% to 68.7%. Younger patients, with injuries from motor vehicle collisions and pedestrian injuries, were more likely to receive MRI. When controlling for other variables, Injury Severity Score (ISS) was not associated with MRI use. Hospitals in the Northeast, level 1 TCs and non-teaching hospitals were more likely to obtain MRIs in this patient population. CONCLUSION: After controlling for patient-level characteristics, variation remained in MRI use based on geography, trauma center level and teaching status. This evidence suggests that current national guidelines limiting the use of MRI for cervical spine evaluation following blunt trauma are not being followed consistently. This may be due to physicians not being up to date with best practice care, unavailability of locally adopted protocols in institutions or lack of consensus among clinical providers. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Using Human-Centered Design to Build a Digital Health Advisor for Patients With Complex Needs: Persona and Prototype Development.

BACKGROUND: Twenty years ago, a "Guardian Angel" or comprehensive digital health advisor was proposed to empower patients to better manage their own health. This is now technically feasible, but most digital applications have narrow functions and target the relatively healthy, with few designed for those with the greatest needs. OBJECTIVE: The goal of the research was to identify unmet needs and key features of a general digital health advisor for frail elderly and people with multiple chronic conditions and their caregivers. METHODS: In-depth interviews were used to develop personas and use cases, and iterative feedback from participants informed the creation of a low-fidelity prototype of a digital health advisor. Results were shared with developers, investors, regulators, and health system leaders for suggestions on how this could be developed and disseminated. RESULTS: Patients highlighted the following goals: "live my life," "love my life," "manage my health," and "feel understood." Patients and caregivers reported interest in four functions to address these goals: tracking and insights, advice and information, providing a holistic picture of the patient, and coordination and communication. Experts and system stakeholders felt the prototype was technically feasible, and that while health care delivery organizations could help disseminate such a tool, it should be done in partnership with consumer-focused organizations. CONCLUSIONS: This study describes the key features of a comprehensive digital health advisor, but to spur its development, we need to clarify the business case and address the policy, organizational, and cultural barriers to creating tools that put patients and their goals at the center of the health system.

Effectiveness of a multistate quality improvement campaign in reducing risk of surgical site infections following hip and knee arthroplasty.

BACKGROUND: Quality improvement (QI) campaigns appear to increase use of evidence-based practices, but their effect on health outcomes is less well studied. OBJECTIVE: To assess the effect of a multistate QI campaign (Project JOINTS, Joining Organizations IN Tackling SSIs) that used the Institute for Healthcare Improvement's Rapid Spread Network to promote adoption of evidence-based surgical site infection (SSI) prevention practices. METHODS: We analysed rates of SSI among Medicare beneficiaries undergoing hip and knee arthroplasty during preintervention (May 2010 to April 2011) and postintervention (November 2011 to September 2013) periods in five states included in a multistate trial of the Project JOINTS campaign and five matched comparison states. We used generalised linear mixed effects models and a difference-in-differences approach to estimate changes in SSI outcomes. RESULTS: 125 070 patients underwent hip arthroplasty in 405 hospitals in intervention states, compared with 131 787 in 525 hospitals in comparison states. 170 663 patients underwent knee arthroplasty in 397 hospitals in intervention states, compared with 196 064 in 518 hospitals in comparison states. After the campaign, patients in intervention states had a 15% lower odds of developing hip arthroplasty SSIs (OR=0.85, 95% CI 0.75 to 0.96, p=0.01) and a 12% lower odds of knee arthroplasty SSIs than patients in comparison states (OR=0.88, 95% CI 0.78 to 0.99, p=0.04). CONCLUSIONS: A larger reduction of SSI rates following hip and knee arthroplasty was shown in intervention states than in matched control states.