RESUMO
PURPOSE: We sought to estimate the prevalence, incidence, and timing of surgery for elective and non-elective hernia repairs. METHODS: We performed a retrospective cohort study, abstracting data on children < 18 years from the 2005-2014 DoD Military Health System Data Repository, which includes > 3 million dependents of U.S. Armed Services members. Our primary outcome was initial hernia repair (inguinal, umbilical, ventral, or femoral), stratified by elective versus non-elective repair and by age. We calculated prevalence, incidence rate, and time from diagnosis to repair. RESULTS: 19,398 children underwent hernia repair (12,220 inguinal, 5761 umbilical, 1373 ventral, 44 femoral). Prevalence of non-elective repairs ranged from 6% (umbilical) to 22% (ventral). Incidence rates of elective repairs ranged from 0.03 [95% CI: 0.02-0.04] (femoral) to 8.92 [95% CI: 8.76-9.09] (inguinal) per 10,000 person-years, while incidence rates of non-elective repairs ranged from 0.005 [95% CI: 0.002-0.01] (femoral) to 0.68 [95% CI: 0.64-0.73] (inguinal) per 10,000 person-years. Inguinal (median = 20, interquartile range [IQR] = 0-46 days), ventral (median = 23, IQR = 5-62 days), and femoral hernias (median = 0, IQR = 0-12 days) were repaired more promptly and with less variation than umbilical hernias (median = 66, IQR = 23-422 days). CONCLUSIONS: These data describe the burden of hernia repair in the U.S. The large variation in time between diagnosis and repair by hernia type identifies an important area of research to understand mechanisms underlying such heterogeneity and determine the ideal timing for repair. LEVEL OF EVIDENCE: Prognosis study II.
Assuntos
Hérnia Femoral/epidemiologia , Hérnia Inguinal/epidemiologia , Hérnia Umbilical/epidemiologia , Hérnia Ventral/epidemiologia , Herniorrafia/estatística & dados numéricos , Parede Abdominal/cirurgia , Adolescente , Criança , Pré-Escolar , Feminino , Virilha/cirurgia , Hérnia Femoral/diagnóstico , Hérnia Femoral/cirurgia , Hérnia Inguinal/diagnóstico , Hérnia Inguinal/cirurgia , Hérnia Umbilical/diagnóstico , Hérnia Umbilical/cirurgia , Hérnia Ventral/diagnóstico , Hérnia Ventral/cirurgia , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Prevalência , Estudos RetrospectivosRESUMO
OBJECTIVE: To describe variability in and consequences of opioid prescriptions following pediatric laparoscopic appendectomy. SUMMARY BACKGROUND DATA: Postoperative opioid prescribing patterns may contribute to persistent opioid use in both adults and children. METHODS: We included children <18 years enrolled as dependents in the Military Health System Data Repository who underwent uncomplicated laparoscopic appendectomy (2006-2014). For the primary outcome of days of opioids prescribed, we evaluated associations with discharging service, standardized to the distribution of baseline covariates. Secondary outcomes included refill, Emergency Department (ED) visit for constipation, and ED visit for pain. RESULTS: Among 6732 children, 68% were prescribed opioids (range = 1-65 d, median = 4 d, IQR = 3-5 d). Patients discharged by general surgery services were prescribed 1.23 (95% CI = 1.06-1.42) excess days of opioids, compared with those discharged by pediatric surgery services. Risk of ED visit for constipation (n = 61, 1%) was increased with opioid prescription [1-3 d, risk ratio (RR) = 2.46, 95% CI = 1.31-5.78; 4-6 d, RR = 1.89, 95% CI = 0.83-4.67; 7-14 d, RR = 3.75, 95% CI = 1.38-9.44; >14 d, RR = 6.27, 95% CI = 1.23-19.68], compared with no opioid prescription. There was similar or increased risk of ED visit for pain (n = 319, 5%) with opioid prescription [1-3 d, RR = 1.00, 95% confidence interval (CI) = 0.74-1.32; 4-6 d, RR = 1.31, 95% CI = 0.99-1.73; 7-14 d, RR = 1.52, 95% CI = 1.00-2.18], compared with no opioid prescription. Likewise, need for refill (n = 157, 3%) was not associated with initial days of opioid prescribed (reference 1-3 d; 4-6 d, RR = 0.96, 95% CI = 0.68-1.35; 7-14 d, RR = 0.91, 95% CI = 0.49-1.46; and >14 d, RR = 1.22, 95% CI = 0.59-2.07). CONCLUSIONS: There was substantial variation in opioid prescribing patterns. Opioid prescription duration increased risk of ED visits for constipation, but not for pain or refill.
Assuntos
Analgésicos Opioides/uso terapêutico , Apendicectomia/métodos , Prescrições de Medicamentos/estatística & dados numéricos , Laparoscopia , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Adolescente , Analgésicos Opioides/efeitos adversos , Criança , Pré-Escolar , Estudos de Coortes , Constipação Intestinal/induzido quimicamente , Constipação Intestinal/epidemiologia , Serviço Hospitalar de Emergência , Feminino , Humanos , Lactente , MasculinoRESUMO
BACKGROUND: In prior reports from population-based databases, black patients with extremity soft tissue sarcoma (ESTS) have lower reported rates of limb-sparing surgery and adjuvant treatment. The objective of this study was to compare the multimodality treatment of ESTS between black and white patients within a universally insured and equal-access health care system. METHODS: Claims data from TRICARE, the US Department of Defense insurance plan that provides health care coverage for 9 million active-duty personnel, retirees, and dependents, were queried for patients younger than 65 y with ESTS who underwent limb-sparing surgery or amputation between 2006 and 2014 and identified as black or white race. Multivariable logistic regression analysis was used to evaluate the impact of race on the utilization of surgery, chemotherapy, and radiation. RESULTS: Of the 719 patients included for analysis, 605 patients (84%) were white and 114 (16%) were black. Compared with whites, blacks had the same likelihood of receiving limb-sparing surgery (odds ratio [OR], 0.861; 95% confidence interval [95% CI], 0.284-2.611; P = 0.79), neoadjuvant radiation (OR, 1.177; 95% CI, 0.204-1.319; P = 0.34), and neoadjuvant (OR, 0.852; 95% CI, 0.554-1.311; P = 0.47) and adjuvant (OR, 1.211; 95% CI, 0.911-1.611; P = 0.19) chemotherapy; blacks more likely to receive adjuvant radiation (OR, 1.917; 95% CI, 1.162-3.162; P = 0.011). CONCLUSIONS: In a universally insured population, racial differences in the rates of limb-sparing surgery for ESTS are significantly mitigated compared with prior reports. Biologic or disease factors that could not be accounted for in this study may contribute to the increased use of adjuvant radiation among black patients.
Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Planos de Seguro sem Fins Lucrativos/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Sarcoma/terapia , United States Department of Defense/estatística & dados numéricos , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Fatores Etários , Bases de Dados Factuais/estatística & dados numéricos , Extremidades , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Planos de Seguro sem Fins Lucrativos/economia , Tratamentos com Preservação do Órgão/economia , Tratamentos com Preservação do Órgão/estatística & dados numéricos , Radioterapia Adjuvante/economia , Radioterapia Adjuvante/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , United States Department of Defense/economia , População Branca/estatística & dados numéricos , Adulto JovemRESUMO
PURPOSE: To determine whether TRT in men with hypogonadism is associated with an increased risk of urolithiasis. METHODS: We conducted a population-based matched cohort study utilizing data sourced from the Military Health System Data Repository (a large military-based database that includes beneficiaries of the TRICARE program). This included men aged 40-64 years with no prior history of urolithiasis who received continuous TRT for a diagnosis of hypogonadism between 2006 and 2014. Eligible individuals were matched using both demographics and comorbidities to TRICARE enrollees who did not receive TRT. The primary outcome was 2-year absolute risk of a stone-related event, comparing men on TRT to non-TRT controls. RESULTS: There were 26,586 pairs in our cohort. Four hundred and eighty-two stone-related events were observed at 2 years in the non-TRT group versus 659 in the TRT group. Log-rank comparisons showed this to be a statistically significant difference in events between the two groups (p < 0.0001). This difference was observed for topical (p < 0.0001) and injection (p = 0.004) therapy-type subgroups, though not for pellet (p = 0.27). There was no significant difference in stone episodes based on secondary polycythemia diagnosis, which was used as an indirect indicator of higher on-treatment testosterone levels (p = 0.14). CONCLUSION: We observed an increase in 2-year absolute risk of stone events among those on TRT compared to those who did not undergo this hormonal therapy. These findings merit further investigation into the pathophysiologic basis of our observation and consideration by clinicians when determining the risks and benefits of placing patients on TRT.
Assuntos
Terapia de Reposição Hormonal , Testosterona/efeitos adversos , Urolitíase/induzido quimicamente , Urolitíase/epidemiologia , Adulto , Estudos de Coortes , Humanos , Hipogonadismo/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Medição de Risco , Testosterona/uso terapêuticoRESUMO
BACKGROUND: Prior opioid use has been shown to be associated with adverse outcomes in surgical and trauma patients. We sought to evaluate the influence of prior opioid use on prescription opioid requirements after orthopedic trauma. MATERIALS AND METHODS: This was a retrospective review of TRICARE claims (2006-2014). We evaluated the records of 11,752 patients treated for orthopedic injuries. Surveillance for prior opioid exposure extended to 6 mo before the traumatic event, with similar postinjury surveillance. Preinjury opioid use was categorized as unexposed, exposed without sustained use (nonsustained users), and sustained use (6 mo or longer of continuous opioid prescriptions without interruption). Multivariable Cox proportional hazard models were used to adjust for confounding and determine factors independently associated with the discontinuation of prescription opioid use after traumatic injury. RESULTS: Prior opioid exposure among nonsustained users (hazard ratio 0.78; 95% CI 0.74, 0.83) and sustained use at the time of injury (hazard ratio 0.40; 95% CI: 0.35, 0.47) were associated with lower likelihoods of opioid discontinuation. Additional factors associated with lower likelihoods of opioid discontinuation included our proxy for lower socioeconomic status, history of depression or anxiety, injury severity, and intensive care unit admission. CONCLUSIONS: Prior opioid use is one of the strongest predictors of continued use following treatment, along with socioeconomic status, behavioral health disorders, and severity of injury. Appropriate discharge planning and early engagement of ancillary services in individuals with one or more of the risk factors identified here may reduce the likelihood of sustained opioid use after injury.
Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Sistema Musculoesquelético/lesões , Procedimentos Ortopédicos/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Ferimentos e Lesões/cirurgia , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Given the rarity of pediatric surgical disease, it is important to consider available large-scale data resources as a means to better study and understand relevant disease-processes and their treatments. The Military Health System Data Repository (MDR) includes claims-based information for > 3 million pediatric patients who are dependents of members and retirees of the United States Armed Services, but has not been externally validated. We hypothesized that demographics and selected outcome metrics would be similar between MDR and the previously validated American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) for several common pediatric surgical operations. METHODS: We selected five commonly performed pediatric surgical operations: appendectomy, pyeloplasty, pyloromyotomy, spinal arthrodesis for scoliosis, and facial reconstruction for cleft palate. Among children who underwent these operations, we compared demographics (age, sex, and race) and clinical outcomes (length of hospital stay [LOS] and mortality) in the MDR and NSQIP-P, including all available overlapping years (2012-2014). RESULTS: Age, sex, and race were generally similar between the NSQIP-P and MDR. Specifically, these demographics were generally similar between the resources for appendectomy (NSQIP-P, n = 20,602 vs. MDR, n = 4363; median age 11 vs. 12 years; female 40% vs. 41%; white 75% vs. 84%), pyeloplasty (NSQIP-P, n = 786 vs. MDR, n = 112; median age 0.9 vs. 2 years; female 28% vs. 28%; white 71% vs. 80%), pyloromyotomy, (NSQIP-P, n = 3827 vs. MDR, n = 227; median age 34 vs. < 1 year, female 17% vs. 16%; white 76% vs. 89%), scoliosis surgery (NSQIP-P, n = 5743 vs. MDR, n = 95; median age 14.2 vs. 14 years; female 75% vs. 67%; white 72% vs. 75%), and cleft lip/palate repair (NSQIP-P, n = 6202 vs. MDR, n = 749; median age, 1 vs. 1 year; female 42% vs. 45%; white 69% vs. 84%). Length of stay and 30-day mortality were similar between resources. LOS and 30-day mortality were also similar between datasets. CONCLUSION: For the selected common pediatric surgical operations, patients included in the MDR were comparable to those included in the validated NSQIP-P. The MDR may comprise a valuable clinical outcomes research resource, especially for studying infrequent diseases with follow-up beyond the 30-day peri-operative period.
Assuntos
Bases de Dados Factuais , Serviços de Saúde Militar/estatística & dados numéricos , Melhoria de Qualidade , Sociedades Médicas , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adolescente , Negro ou Afro-Americano/estatística & dados numéricos , Apendicectomia/estatística & dados numéricos , Povo Asiático/estatística & dados numéricos , Criança , Fissura Palatina/cirurgia , Feminino , Humanos , Rim/cirurgia , Tempo de Internação , Masculino , Readmissão do Paciente/estatística & dados numéricos , Piloromiotomia/estatística & dados numéricos , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Escoliose/cirurgia , Fusão Vertebral/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/mortalidade , Estados Unidos , População Branca/estatística & dados numéricosRESUMO
OBJECTIVES: To assess the association of testosterone replacement therapy (TRT) with thromboembolism, cardiovascular disease (stroke, coronary artery disease and heart failure) and obstructive sleep apnoea (OSA). METHODS: A cohort of 3 422 male US military service members, retirees and their dependents, aged 40-64 years, was identified, who were prescribed TRT between 2006 and 2010 for low testosterone levels. The men in this cohort were matched on a 1:1 basis for age and comorbidities to men without a prescription for TRT. Event-free survival and rates of thromboembolism, cardiovascular events and OSA were compared between men using TRT and the control group, with a median follow-up of 17 months. RESULTS: There was no difference in event-free survival with regard to thromboembolism (P = 0.239). Relative to controls, men using TRT had improved cardiovascular event-free survival (P = 0.004), mainly as a result of lower incidence of coronary artery disease (P = 0.008). The risk of OSA was higher in TRT users (2-year risk 16.5% [95% confidence interval 15.1-18.1] in the TRT group vs 12.7% [11.4-14.1] in the control group. CONCLUSIONS: This study adds to growing evidence that the cardiovascular risk associated with TRT may be lower than once feared. The elevated risk of OSA in men using TRT is noteworthy.
Assuntos
Androgênios , Doenças Cardiovasculares/tratamento farmacológico , Terapia de Reposição Hormonal , Apneia Obstrutiva do Sono/tratamento farmacológico , Testosterona , Tromboembolia/tratamento farmacológico , Adulto , Androgênios/uso terapêutico , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/fisiopatologia , Medicina Baseada em Evidências , Humanos , Masculino , Saúde do Homem , Pessoa de Meia-Idade , Apneia Obstrutiva do Sono/sangue , Apneia Obstrutiva do Sono/fisiopatologia , Testosterona/uso terapêutico , Tromboembolia/sangue , Tromboembolia/fisiopatologia , Resultado do TratamentoRESUMO
BACKGROUND: TRICARE military beneficiaries are increasingly referred for major surgeries to civilian hospitals under "purchased care." This loss of volume may have a negative impact on the readiness of surgeons working in the "direct-care" setting at military treatment facilities and has important implications under the volume-quality paradigm. The objective of this study is to assess the impact of care source (direct versus purchased) and surgical volume on perioperative outcomes and costs of colorectal surgeries. METHODS: We examined TRICARE claims and medical records for 18- to 64-year-old patients undergoing major colorectal surgery from 2006 to 2015. We used a retrospective, weighted estimating equations analysis to assess differences in 30-day outcomes (mortality, readmissions, and major or minor complications) and costs (index and total including 30-day postsurgery) for colorectal surgery patients between purchased and direct care. RESULTS: We included 20,317 patients, with 24.8% undergoing direct-care surgery. Mean length of stay was 7.6 vs 7.7 days for direct and purchased care, respectively (P = .24). Adjusted 30-day odds between care settings revealed that although hospital readmissions (odds ratio 1.40) were significantly higher in direct care, overall complications (odds ratio 1.05) were similar between the 2 settings. However, mean total costs between direct and purchased care differed ($55,833 vs $30,513, respectively). Within direct care, mean total costs ($50,341; 95% confidence interval $41,509-$59,173) were lower at very high-volume facilities compared to other facilities ($54,869; 95% confidence interval $47,822-$61,916). CONCLUSION: Direct care was associated with higher odds of readmissions, similar overall complications, and higher costs. Contrary to common assumptions regarding volume and quality, higher volume in the direct-care setting was not associated with fewer complications.
Assuntos
Colectomia/estatística & dados numéricos , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Serviços de Saúde Militar/tendências , Protectomia/estatística & dados numéricos , Encaminhamento e Consulta/tendências , Adolescente , Adulto , Colectomia/efeitos adversos , Colectomia/tendências , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/economia , Procedimentos Cirúrgicos do Sistema Digestório/tendências , Humanos , Enteropatias/epidemiologia , Enteropatias/cirurgia , Tempo de Internação , Pessoa de Meia-Idade , Serviços de Saúde Militar/economia , Serviços de Saúde Militar/normas , Serviços de Saúde Militar/estatística & dados numéricos , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/tendências , Protectomia/efeitos adversos , Protectomia/tendências , Encaminhamento e Consulta/economia , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto JovemRESUMO
Importance: The increased use of prescription opioid medications has contributed to an epidemic of sustained opioid use, misuse, and addiction. Adults of working age are thought to be at greatest risk for prescription opioid dependence. Objective: To develop a risk score (the Stopping Opioids After Surgery score) for sustained prescription opioid use after surgery in a working-age population using readily available clinical information. Design, Setting, and Participants: In this case-control study, claims from TRICARE (the insurance program of the US Department of Defense) for working-age adult (age 18-64 years) patients undergoing 1 of 10 common surgical procedures from October 1, 2005, to September 30, 2014, were queried. A logistic regression model was used to identify variables associated with sustained prescription opioid use. The point estimate for each variable in the risk score was determined by its ß coefficient in the model. The risk score for each patient represented the summed point totals, ranging from 0 to 100, with a lower score indicating lower risk of sustained prescription opioid use. Data were analyzed from September 25, 2018, to February 5, 2019. Exposures: Exposures were age; race; sex; marital status; socioeconomic status; discharge disposition; procedure intensity; length of stay; intensive care unit admission; comorbid diabetes, liver disease, renal disease, malignancy, depression, or anxiety; and prior opioid use status. Main Outcomes and Measures: The primary outcome was sustained prescription opioid use, defined as uninterrupted use for 6 months following surgery. A risk score for each patient was calculated and then used as a predictor of sustained opioid use after surgical intervention. The area under the curve and the Brier score were used to determine the accuracy of the scoring system and the Hosmer-Lemeshow goodness-of-fit test was used to evaluate model calibration. Results: Of 86â¯356 patients in the analysis (48â¯827 [56.5%] male; mean [SD] age, 46.5 [14.5] years), 6365 (7.4%) met criteria for sustained prescription opioid use. The sample used for model generation consisted of 64â¯767 patients, while the validation sample had 21â¯589 patients. Prior opioid exposure was the factor most strongly associated with sustained opioid use (odds ratio, 13.00; 95% CI, 11.87-14.23). The group with the lowest scores (<31) had a mean (SD) 4.1% (2.5%) risk of sustained opioid use; those with intermediate scores (31-50) had a mean (SD) risk of 14.9% (6.3%); and those with the highest scores (>50) had a mean (SD) risk of 35.8% (3.6%). Conclusions and Relevance: This study developed an intuitive and accessible opioid risk assessment applicable to the care of working-age patients following surgery. This tool is scalable to clinical practice and can potentially be incorporated into electronic medical record platforms to enable automated calculation and clinical alerts that are generated in real time.
Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos , Transtornos Relacionados ao Uso de Opioides , Dor Pós-Operatória , Padrões de Prática Médica , Medição de Risco/métodos , Adulto , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Prescrição Inadequada/prevenção & controle , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Medicamentos sob Prescrição/uso terapêutico , Melhoria de Qualidade/organização & administraçãoRESUMO
BACKGROUND: Children who have undergone splenectomy may develop impaired immunologic function and heightened risk of overwhelming postsplenectomy infection. We sought to define the long-term rate of and risk factors for postsplenectomy sepsis. METHODS: We leveraged the Military Health System Data Repository, a nationally representative claims database including >3 million children registered as dependents of members of the United States Armed Services (2005-2014). Inclusion criterion was splenectomy at age 18 years or prior. The primary outcome was hospitalization for sepsis. RESULTS: Among 195 children who underwent splenectomy, 7% (nâ¯=â¯13) were hospitalized with sepsis, with an incidence of 1.8 (95% CIâ¯=â¯1.0-3.1) events per 100 person-years. The median time to sepsis was 224â¯days (IQRâ¯=â¯109-606) and 38% (5/13) of events occurred within the first postsplenectomy year. The postsplenectomy mortality rate was 1% (nâ¯=â¯3). After adjusting for underlying diagnosis, older age at splenectomy (HRâ¯=â¯0.90 per year, 95% CIâ¯=â¯0.81-0.99) was associated with decreased hazard of sepsis. CONCLUSIONS: In a contemporary national cohort, the prevalence of postsplenectomy sepsis was 7% (1.8 events per 100 person-years). Although most presented during the first year after splenectomy, many (62%) sepsis events occurred later, suggesting that postsplenectomy immunologic dysfunction persists beyond one year. The immunologic consequences of asplenia must continue to be acknowledged, as postsplenectomy sepsis remains a serious concern. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level III.
Assuntos
Complicações Pós-Operatórias/imunologia , Sepse/imunologia , Esplenectomia , Esplenopatias/cirurgia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Complicações Pós-Operatórias/fisiopatologia , Fatores de Risco , Sepse/fisiopatologia , Esplenectomia/efeitos adversos , Esplenopatias/imunologiaRESUMO
In the US, racial disparities in outcomes following coronary artery bypass grafting (CABG) are well documented. TRICARE insurance data represent a large population with universal insurance that allows for the robust assessment of the impact of such insurance on disparities in health care. This study examined racial differences in specific aspects of surgical care quality following CABG, using metrics endorsed by the National Quality Forum that included the prescription of beta-blockers and statins at discharge and thirty-day readmissions. There were no risk-adjusted differences in outcomes between African American and white patients insured through TRICARE. Our study provides a window into the potential impacts of universal insurance and an equal-access health care system on racial disparities in surgical care quality following CABG.
Assuntos
Ponte de Artéria Coronária/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Serviços de Saúde Militar/normas , Grupos Raciais/estatística & dados numéricos , Antagonistas Adrenérgicos beta/uso terapêutico , Negro ou Afro-Americano/estatística & dados numéricos , Ponte de Artéria Coronária/estatística & dados numéricos , Doença das Coronárias/prevenção & controle , Doença das Coronárias/cirurgia , Feminino , Disparidades em Assistência à Saúde/etnologia , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Pessoa de Meia-Idade , Serviços de Saúde Militar/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Estados Unidos , População Branca/estatística & dados numéricosRESUMO
STUDY DESIGN: Review of TRICARE claims (2006-2014) data to assess Emergency Department (ED) utilization following spine surgery. OBJECTIVE: The aim of this study was to determine utilization rates and predictors of ED utilization following spine surgical interventions. SUMMARY OF BACKGROUND DATA: Visits to the ED following surgical intervention represent an additional stress to the healthcare system. While factors associated with readmission following spine surgery have been studied, drivers of postsurgical ED visits, including appropriate and inappropriate use, remain underinvestigated. METHODS: TRICARE claims were queried to identify patients who had undergone one of three common spine procedures (lumbar arthrodesis, discectomy, decompression). ED utilization at 30- and 90 days was assessed as the primary outcome. Outpatient spine surgical clinic utilization was considered the primary predictor variable. Multivariable logistic regression was used to adjust for confounders. RESULTS: Between 2006 and 2014, 48,868 patients met inclusion criteria. Fifteen percent (nâ=â7183) presented to the ED within 30 days postdischarge. By 90 days, 29% of patients (nâ=â14,388) presented to an ED. The 30- and 90-day complication rates were 6% (nâ=â2802) and 8% (nâ=â4034), respectively, and readmission rates were 5% (nâ=â2344) and 8% (nâ=â3842), respectively. Use of outpatient spine clinic services significantly reduced the likelihood of ED utilization at 30 [odds ratio (OR) 0.48; 95% confidence interval (95% CI) 0.46-0.53] and 90 days (OR 0.55; 95% CI 0.52-0.57). CONCLUSION: Within 90 days following spine surgery, 29% of patients sought care in the ED. However, only one-third of these patients had a complication recorded, and even fewer were readmitted. This suggests a high rate of unnecessary ED utilization. Outpatient utilization of spine clinics was the only factor independently associated with a reduced likelihood of ED utilization. LEVEL OF EVIDENCE: 3.