When the economy falters, hearts suffer: Economic recessions as a social determinant of health in cardiovascular emergencies.

INTRODUCTION: While the relationships between cardiovascular disease (CVD), stress, and financial strain are well studied, the association between recessionary periods and macroeconomic conditions on incidence of disease-specific CVD emergency department (ED) visits is not well established. OBJECTIVES: This retrospective observational study aimed to assess the relationship between macroeconomic trends and CVD ED visits. METHODS: This study uses data from the National Hospital Ambulatory Care Survey (NHAMCS), Federal Reserve Economic Database (FRED), National Bureau of Economic Research (NBER), and CVD groupings from National Vital Statistics (NVS) and Center for Medicare and Medicaid Services (CMS) from 1999 to 2020 to analyze ED visits in relation to macroeconomic indicators and NBER defined recessions and expansions. RESULTS: CVD ED visits grew by 79.7% from 1999 to 2020, significantly more than total ED visits (27.8%, p < 0.001). A national estimate of 213.2 million CVD ED visits, with 22.9 million visits in economic recessions were analyzed. A secondary group including a 6-month period before and after each recession (defined as a "broadened recession") was also analyzed to account for potential leading and lagging effects of the recession, with a total of 50.0 million visits. A significantly higher proportion of CVD ED visits related to heart failure (HF) and other acute ischemic heart diseases (IHD) was observed during recessionary time periods both directly and with a 6-month lead and lag (p < 0.05). The proportion of aortic aneurysm and dissection (AAA) and atherosclerosis (ASVD) ED visits was significantly higher (p = 0.024) in the recession period with a 6-month lead and lag. When controlled for common demographic factors, economic approximations of recession such as the CPI, federal funds rate, and real disposable income were significantly associated with increased CVD ED visits. CONCLUSION: Macroeconomic trends have a significant relationship with the overall mix of CVD ED visits and represent an understudied social determinant of health.

Preference Sensitive Care and Shared Decision-Making in Lumbar Spinal Stenosis: A Scoping Review.

STUDY DESIGN: Scoping review. OBJECTIVE: The objective of this study was to conduct a scoping review exploring the extent to which preference sensitivity has been studied in treatment decisions for lumbar spinal stenosis (LSS), utilizing shared decision-making (SDM) as a proxy. BACKGROUND: Preference-sensitive care involves situations where multiple treatment options exist with significant tradeoffs in cost, outcome, recovery time, and quality of life. LSS has gained research focus as a preference-sensitive care scenario. MATERIALS AND METHODS: A scoping review protocol in accordance with "Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews" regulations was registered with the Open Science Framework (ID: 9ewup) and conducted across multiple databases from January 2000 to October 2022. Study selection and characterization were performed by 3 independent reviewers and an unbiased moderator. RESULTS: The search resulted in the inclusion of 16 studies varying in design and sample size, with most published between 2016 and 2021. The studies examined variables related to SDM, patient preferences, surgeon preferences, and decision aids (DAs). The outcomes assessed included treatment choice, patient satisfaction, and patient understanding. Several studies reported that SDM influenced treatment choice and patient satisfaction, while the impact on patient understanding was less clear. DAs were used in some studies to facilitate SDM. CONCLUSION: The scoping review identified a gap in comprehensive studies analyzing the preference sensitivity of treatment for LSS and the role of DAs. Further research is needed to better understand the impact of patient preferences on treatment decisions and the effectiveness of DAs in LSS care. This review provides a foundation for future research in preference-sensitive care and SDM in the context of lumbar stenosis treatment.

Relative Value Unit (RVU) and Medicare Severity Diagnosis-related Group (MS-DRG) Reimbursement in Cervical Spinal Fusion: A 2011-2023 Trends Report.

STUDY DESIGN: Level 3 retrospective database study. OBJECTIVE: This study aims to compare work RVU (wRVU), practice expense RVU (peRVU), malpractice RVU (mpRVU), and inflation-adjusted facility price alongside MS-DRG relative weight length of stay (LOS) for cervical spine fusions between 2011 and 2023. SUMMARY OF BACKGROUND DATA: Both RVU and MS-DRG reimbursement have been studied in various surgical subspecialties; however, little investigation has centered on cervical spine fusions. To the best of our knowledge, this is the first study to investigate trends in RVU and MS-DRG reimbursement in cervical spine fusion throughout the COVID-19 pandemic. METHODS: Center for Medicaid and Medicare Services (CMS) physician fee schedule was queried between 2011 and 2023 for RVU and facility reimbursement using common single and multilevel anterior and posterior cervical fusion codes. RVU facility prices were inflation adjusted to 2023. MS-DRG reimbursement data from 2011 to 2022 were compiled for cervical spinal fusion procedures with major complication or comorbidity (MCC) 471, complication or comorbidity (CC) 472, and without CC/MCC 473. Compound annual growth rates (CAGRs), Mean Annual Change, and yearly percent changes were calculated. RESULTS: No changes in wRVU were seen for all cervical CPT codes; however, the CAGR of peRVU (-0.51%±0.60%) and mpRVU (0.69%±0.41%) demonstrated marginal fluctuations. Every CPT code displayed an inflation-adjusted facility price decrease (-2.18%±0.24%). When assessing MS-DRG, there were marginal changes in geometric mean LOS (0.17%±0.45%), arithmetic mean LOS (-0.15%±0.84%), and relative weight (1.09%±0.68%). Unlike RVU reimbursement, the yearly percent change differs between each MS-DRG code. CONCLUSIONS: Inflation-adjusted RVU reimbursement facility prices demonstrated a consistent decrease, while DRG code reimbursement stayed relatively consistent over the study period. This data may help surgeons and hospitals become cognizant of temporal variations in reimbursement patterns as it may affect their personal practice. LEVEL OF EVIDENCE: Level III retrospective study.

Impact of Social Determinants of Health in Spine Surgery.

PURPOSE OF REVIEW: Social determinants of health (SDH) are factors that affect patient health outcomes outside the hospital. SDH are "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." Current literature has shown SDH affecting patient reported outcomes in various specialties; however, there is a dearth in research relating spine surgery with SDH. The aim of this review article is to identify connections between SDH and post-operative outcomes in spine surgery. These are important, yet understudied predictors that can impact health outcomes and affect health equity. RECENT FINDINGS: Few studies have shown associations between SDH pillars (environment, race, healthcare, economic, and education) and spine surgery outcomes. The most notable relationships demonstrate increased disability, return to work time, and pain with lower income, education, environmental locations, healthcare status and/or provider. Despite these findings, there remains a significant lack of understanding between SDH and spine surgery. Our manuscript reviews the available literature comparing SDH with various spine conditions and surgeries. We organized our findings into the following narrative themes: 1) education, 2) geography, 3) race, 4) healthcare access, and 5) economics.