Targeting Health-Related Social Risks in the Clinical Setting: New Policy Momentum and Practice Considerations.

The federal government is funding a sea change in health care by investing in interventions targeting social determinants of health, which are significant contributors to illness and health inequity. This funding power has encouraged states, professional and accreditation organizations, health care entities, and providers to focus heavily on social determinants. We examine how this shift in focus affects clinical practice in the fields of oncology and emergency medicine, and highlight potential areas of reform.

Racial Disparities in Complications, Length of Stay, and Costs Among Patients Receiving Orthognathic Surgery in the United States.

INTRODUCTION: Black and Hispanic/Latino patients in the United States often experience poorer health outcomes in comparison to White patients. We aimed to assess the impact of race on complications, length of stay, and costs after orthognathic surgery. METHODS: Pediatric and young adult orthognathic surgeries (age <21) were isolated from the Kids Inpatient Database from 2000-2012. Procedures were grouped into cohorts based on the preoperative diagnosis: apnea, malocclusion, or congenital anomaly. T tests and χ2 analyses were employed to compare complications, length of stay (LOS), and costs among Black, Hispanic, Asian/Pacific Islander, and other patients in comparison to White patients. Multivariable regression was performed to identify associations between sociodemographic variables and the primary outcomes. Post-hoc χ2 analyses were performed to compare proportions of patients of a given race/ethnicity across the 3 surgical cohorts. RESULTS: There were 8,809 patients identified in the KID database (mean age of 16.3 years). Compared to White patients, complication rates were increased among Hispanic patients (2.1 vs 1.3%, P = .037) and other patients treated for apnea (8.7 vs 0.83%, P = .002). Hospital LOS was increased in both Black (3.3 vs 2.1 days, P < .001) and Hispanic (2.9 days, P < .001) patients. Costs were higher than Whites ($35,633.47) among Hispanic ($48,029.15, P < .001), Black ($47,034.41, P < .001), and Asian/Pacific-Islander ($44,192.49, P < .001) patients. White patients comprised a larger proportion of the malocclusion group (77.8%) than apnea (66.9%, P < .001) or congenital anomaly (59.1%, P < .001), while the opposite was true for Black, Hispanic, and Asian/Pacific-Islander patients. CONCLUSION: There are significant differences in complications, LOS, and costs after orthognathic surgery among patients of different race/ethnicity. Further studies are needed to better understand the causes of disparity and their clinical manifestations.

Hospital Volume Improves Primary, Revision, and Delayed Cleft Palate Repair.

BACKGROUND: High volume centers (HVC) is commonly associated with increased resources and improved patient outcomes. This study assesses efficacy and outcomes of high volume centers in cleft palate repair. METHODS: Cleft palate procedures were identified in the Kids' Inpatient Database from 2003-2009. Demographics, perioperative factors, co-morbidities, and complications in HVC (90th percentile, >48 cases/year) and non-high volume centers (NHVC) were compared across various cohorts of cleft repair. RESULTS: Four thousand five hundred sixty-three (61.7%) total cleft palate surgeries were performed in HVC and 3388 (38.3%) were performed in NHVC. The NHVC treated a higher percentage of Medicaid patients (P = 0.005) and patients from low-income quartiles (P = 0.018). HVC had larger bedsizes (P <0.001), were more often government/private owned (P <0.001), and were more often teaching hospitals (P <0.001) located predominantly in urban settings (P <0.001). The HVC treated patients at younger ages (P = 0.008) and performed more concurrent procedures (P = 0.047). The most common diagnosis at HVC was complete cleft palate with incomplete cleft lip, while the most common diagnosis at NHVC was incomplete cleft palate without lip. Overall, length of stay and specific complication rates were lower in HVC (P = 0.048, P = 0.042). Primaries at HVCs showed lower pneumonia (P = 0.009) and specific complication rates (P = 0.023). Revisions at HVC were associated with older patients, fewer cardiac complications (P = 0.040), less wound disruption (P = 0.050), but more hemorrhage (P = 0.040).

Racial Disparities in Cleft Palate Repair.

BACKGROUND: Various factors can influence outcomes in cleft palate care. This study sought to determine the impact of race on admissions, hospital costs, and short-term complications in cleft palate repair. METHODS: Cleft palate operations were identified in the Kids' Inpatient Database data, from 2000 to 2009. Data were combed for demographics, perioperatives, complications, and hospital characteristics. Bivariate and multivariate analyses were performed between races in total, primary, and revision cohorts. RESULTS: There were 3464 white, 1428 Hispanic, 413 black, 398 Asian/Pacific-Islander, and 470 patients of other races captured. Black patients experienced more emergent admissions (p = 0.005) and increased length of stay (p = 0.029). Hospital charges were highest for black and Hispanic patients and lowest for white patients (p = 0.019). Black patients had more total complications than non-black patients (p = 0.039), including higher rates of postoperative fistula (p = 0.020) and nonspecific complications among revision repairs (p = 0.003). Asian/Pacific Islander in the primary cohort experienced higher rates of accidental puncture (p = 0.031) and fistula (p < 0.001). Other patients had the highest rates of wound disruption (p = 0.013). After controlling for race, diagnosis, Charlson Comorbidity Index score, region, elective/nonelective, payer, and income quartile, length of stay (p < 0.001) and age (p < 0.001) were associated with increases in both total complications and costs. CONCLUSIONS: Race may play a significant role in cleft palate repair, as white patients had fewer complications, shorter length of stay, and lower costs following repair. Delayed age at treatment may predispose patients to adverse sequelae in minority populations, in terms of influencing length of stay and costs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

National Longitudinal Comparison of Patients Undergoing Surgical Management of Craniosynostosis.

PURPOSE: Limited cross-institutional studies compare strip craniectomy versus cranial vault remodeling (CVR) for craniosynostosis management. Given competing surgical preferences, the authors conducted a large-scale analysis of socioeconomic differences, costs, and complications between treatment options. METHODS: Nonsyndromic craniosynostosis patients receiving strip craniectomies or CVR were identified in the Kids' Inpatient Database for years 2000 to 2009. Demographics, socioeconomic background, hospital characteristics, charge, and outcomes were tabulated. Univariate and multivariate analyses were performed for comparison. RESULTS: Two hundred fifty-one strip craniectomies and 1811 CVR patients were captured. Significantly more strip craniectomy patients were White while more CVR patients were Hispanic or Black (P < 0.0001). Strip craniectomy patients more often had private insurance and CVR patients had Medicaid (P < 0.0001). Over time, CVR trended toward treating a higher proportion of Hispanic and Medicaid patients (P = 0.036). Peri-operative charges associated with CVR were $27,962 more than strip craniectomies, and $11,001 after controlling for patient payer, income, bedsize, and length of stay (P < 0.0001). Strip craniectomies were performed more frequently in the West and Midwest, while CVR were more common in the South (P = 0.001). Length of stay was not significant. Postsurgical complications were largely equivocal; CVR was associated with increased accidental puncture (P = 0.025) and serum transfusion (P = 0.002). CONCLUSION: Our national longitudinal comparison demonstrates widening socioeconomic disparities between strip craniectomy and CVR patients. Cranial vault remodeling is more commonly performed in underrepresented minorities and patients with Medicaid, while strip craniectomy is common in the White population and patients with private insurance. While hospital charges and complications were higher among CVR, differences were smaller than expected.

A propensity matched analysis of outcomes and long term survival in stented versus stentless valves.

BACKGROUND: To compare the perioperative and long term survival after aortic valve replacement using stentless versus stented valves in a large cohort of patients grouped using propensity score matching. METHODS: From 1991 to 2012, 4,563 patients underwent aortic valve replacement with stentless and stented valves at our institution. Propensity score matching identified 444 pairs using 13 independent variables: incidence of operation, smoking status, renal failure, hypertension, diabetes, peripheral vascular disease, cerebrovascular disease, chronic lung disease, ejection fraction, gender, age, valve status, and use of coronary artery bypass graft. Data were collected from our Society of Thoracic Surgeons database and the Social Security Death Index. Groups were compared using univariate and Kaplan-Meier analysis. RESULTS: The two groups demonstrated no significant differences for the 13 matching variables and the majority of 30-day outcomes (p > 0.05). The stented valve group showed a higher incidence of postoperative bleeding (3.6% vs 1.1%, p = 0.015), but a lower incidence of stroke (0.9% vs. 2.9%, p = 0.028). One, five, and 10-year survival was 95.0, 80.7, and 52.8% for stented and 93.2, 80.5, and 51.3% for stentless valves. Overall survival did not differ significantly between the two groups (p = 0.641). CONCLUSIONS: Stentless and stented valves had identical 30-day outcomes except for a higher postoperative incidence of bleeding and a lower incidence of stroke in the stented group. There was no significant difference in long term survival between valve types. Both valves may be used for aortic valve replacement with low morbidity and excellent long term survival.