Minimally invasive colorectal cancer surgery: an observational study of medicare advantage and fee-for-service beneficiaries.

BACKGROUND: Enrollment of Medicare beneficiaries in medicare advantage (MA) plans has been steadily increasing. Prior research has shown differences in healthcare access and outcomes based on Medicare enrollment status. This study sought to compare utilization of minimally invasive colorectal cancer (CRC) surgery and postoperative outcomes between MA and Fee-for-Service (FFS) beneficiaries. METHODS: A retrospective cohort study of beneficiaries ≥ 65.5 years of age enrolled in FFS and MA plans was performed of patients undergoing a CRC resection from 2016 to 2019. The primary outcome was operative approach, defined as minimally invasive (laparoscopic) or open. Secondary outcomes included robotic assistance, hospital length-of-stay, mortality, discharge disposition, and hospital readmission. Using balancing weights, we performed a tapered analysis to examine outcomes with adjustment for potential confounders. RESULTS: MA beneficiaries were less likely to have lymph node (12.9 vs 14.4%, p < 0.001) or distant metastases (15.5% vs 17.0%, p < 0.001), and less likely to receive chemotherapy (6.2% vs 6.7%, p < 0.001), compared to FFS beneficiaries. MA beneficiaries had a higher risk-adjusted likelihood of undergoing laparoscopic CRC resection (OR 1.12 (1.10-1.15), p < 0.001), and similar rates of robotic assistance (OR 1.00 (0.97-1.03), p = 0.912), compared to FFS beneficiaries. There were no differences in risk-adjusted length-of-stay (ß coefficient 0.03 (- 0.05-0.10), p = 0.461) or mortality at 30-60-and 90-days (OR 0.99 (0.95-1.04), p = 0.787; OR 1.00 (0.96-1.04), p = 0.815; OR 0.98 (0.95-1.02), p = 0.380). MA beneficiaries had a lower likelihood of non-routine disposition (OR 0.77 (0.75-0.78), p < 0.001) and readmission at 30-60-and 90-days (OR 0.76 (0.73-0.80), p < 0.001; OR 0.78 (0.75-0.81), p < 0.001; OR 0.79 (0.76-0.81), p < 0.001). CONCLUSIONS: MA beneficiaries had less advanced disease at the time of CRC resection and a greater likelihood of undergoing a laparoscopic procedure. MA enrollment is associated with improved health outcomes for elderly beneficiaries undergoing operative treatment for CRC.

Indications and Outcomes of Laser Retinopexy in Eyes With High-Risk Lattice Degeneration.

Purpose: To examine the characteristics of eyes with high-risk lattice degeneration treated with laser retinopexy and determine the indications, safety, and outcomes of the treatment. Methods: This interventional single-surgeon consecutive retrospective study was conducted at Wills Eye Hospital between 2014 and 2021. The series included eyes with lattice degeneration with high-risk lesions. Documented characteristics and outcomes of these eyes and fellow eyes were documented. Results: The study comprised 167 eyes of 143 patients (53.3% women; mean age [±SD], 50 ± 17 years). Complications after laser treatment included new posterior vitreous detachment (PVD) (n = 21), epiretinal membrane (ERM) (n = 13), retinal detachment (RD) (n = 5), and additional laser required (n = 22). Eyes that developed ERMs were more likely to develop PVDs (odds ratio, 5.39; 95% CI, 1.57-18.47). Patents who developed ERMs were older (mean, 60 ± 7 years vs 49 ± 17 years; P = .016), as were those developing PVDs (mean, 59 ± 8 years vs 48 ± 17; P = .005). No eye with a new ERM required surgery (n = 13). Four eyes with a new RD required laser retinopexy alone; 1 eye was treated surgically. No eye had an RD at the most recent evaluation. Conclusions: Despite high-risk lesions in areas of lattice degeneration, few eyes developed RDs after prophylactic laser retinopexy. Older patients may have a higher risk for ERM or PVD after laser treatment. Eyes with post-laser PVD were more likely to develop an ERM.

Revisiting the Relationship Between Tumor Size and Risk in Well-Differentiated Thyroid Cancer.

Introduction: Large tumor size is associated with poorer outcomes in well-differentiated thyroid cancer, yet it remains unclear whether size >4 cm alone confers increased risk, independent of other markers of aggressive disease. The goal of this study was to assess the relationship between tumor size, other high-risk histopathological features, and survival in well-differentiated thyroid cancer and to evaluate the significance of 4 cm as a cutoff for management decisions. Methods: Patients with well-differentiated thyroid cancer were identified from the National Cancer Database (2010-2015) and categorized by tumor size (i.e., small [≤4 cm] or large [>4 cm]) and presence of high-risk histopathological features (e.g., extrathyroidal extension). First, propensity score matching was used to identify patients who were similar across all other observed characteristics except for small versus large tumor size, and a multivariable Cox proportional hazards model was used to estimate the relationship between tumor size and survival. Second, we assessed whether the presence of high-risk features demonstrates conditional effects on survival based on the presence of tumor size >4 cm using an interaction term. Finally, additional models assessed the relationship between incremental 1 cm increases in tumor size and survival. Analyses were repeated using a validation cohort from the Surveillance, Epidemiology, and End Results Program (2008-2013). Results: Of 193,133 patients in the primary cohort, 7.9% had tumors >4 cm, and 30% had at least one high-risk feature. After matching, tumor size >4 cm was independently associated with worse survival (HR 1.63, p < 0.001). However, tumor size >4 cm and one or more other high-risk features together yielded worse survival than either size >4 cm alone (MMD: 0.70, p < 0.001) or other high-risk features alone (MMD: 0.49, p < 0.001). When assessed in 1 cm increments, the largest increases in hazard of death occurred at 2 cm and 5 cm, not 4 cm. Results from the validation cohort were largely consistent with our primary findings. Conclusions: Concomitant high-risk features confer worse survival than large tumor size alone, and a 4 cm cutoff is not associated with the greatest increase in risk. These findings support a more nuanced approach to tumor size in the management of well-differentiated thyroid cancer.

The influence of primary language on postoperative stroke outcomes.

BACKGROUND: Language barriers have the potential to influence acute stroke outcomes. Thus, we examined postoperative stroke outcomes among non-English primary language speakers. METHODS: Utilizing the Healthcare Cost and Utilization Project State Inpatient Database (2016-2019), we conducted a retrospective cohort study of adults diagnosed with a postoperative stroke in Michigan, Maryland, and New Jersey. Patients were classified by primary language spoken: English (EPL) or non-English (n-EPL). The primary outcome was hospital length-of-stay. Secondary outcomes included stroke intervention, feeding tube, tracheostomy, mortality, cost, disposition, and readmission. Propensity-score matching and post-match regression were used to quantify outcomes. RESULTS: Among 3078 postoperative stroke patients, 6.2 â€‹% were n-EPL. There were no differences in length-of-stay or secondary outcomes, except for higher odds of feeding tube placement (OR 1.95, 95 â€‹% CI 1.10-3.47, p â€‹= â€‹0.0227) in n-EPL. CONCLUSIONS: Postoperative stroke outcomes were comparable by primary language spoken. However, higher odds of feeding tube placement in n-EPL may suggest differences in patient-provider communication.

Thyroid Eye Disease: Pilot Study Comparison Between Patients in United States-Based and India-Based Practices.

PURPOSE: Thyroid eye disease (TED) phenotype varies by ethnicity/race and genetic/environmental factors. This study compared demographic and clinical characteristics of TED patients from the US and India. DESIGN: Observational pilot study . METHODS: Sixty-four patients with TED ages ≥18 years old with active disease (onset of symptoms ≤18 months or presenting clinical activity score (CAS) ≥4) were recruited between March and October 2021 from clinical practices in the United States (Philadelphia, PA) (n = 30) and India (Hyderabad, India) (n = 34). Data collection at baseline and 3 months included clinical measurements, thyroid disease history, and photographs. Ocular symptoms and quality of life data were obtained by phone interview. CAS was calculated using the standard 7-point scale. RESULTS: There was no statistically significant difference in age, TED duration, or smoking status between patient groups. Both groups had good vision, a low rate of optic neuropathy, and comparable exophthalmometry. US patients were predominantly female (86.7% [26/30]), with a history of hyperthyroidism (96% 29/30). In comparison, Indian patients were 52.9% (18/34, P = .004) female; underlying thyroid disease was distributed between hyperthyroidism (52%), hypothyroidism (17.6%) and euthyroid (9.7%). Mean (SD) CAS in the US cohort was double the score in the India cohort (4.2 (1.7) vs 1.65 (1.7), respectively) (P < .0001). However, patients at both sites experienced subjective symptoms of TED at a similar frequency. CONCLUSIONS: Observed differences in TED between US and Indian patients warrant further investigation to elucidate differences in pathogenesis, disease expression, or other factors that may influence TED in diverse populations.

Belonging in Surgery: A Validated Instrument and Single Institutional Pilot.

OBJECTIVE: The aim of this study was to develop and validate an instrument to measure Belonging in Surgery among surgical residents. BACKGROUND: Belonging is the essential human need to maintain meaningful relationships and connections to one's community. Increased belongingness is associated with better well-being, job performance, and motivation to learn. However, no tools exist to measure belonging among surgical trainees. METHODS: A panel of experts adapted a belonging instrument for use among United States surgery residents. After administration of the 28-item instrument to residents at a single institution, a Cronbach alpha was calculated to measure internal consistency, and exploratory principal component analyses were performed. Multiple iterations of analyses with successively smaller item samples suggested the instrument could be shortened. The expert panel was reconvened to shorten the instrument. Descriptive statistics measured demographic factors associated with Belonging in Surgery. RESULTS: The overall response rate was 52% (114 responses). The Cronbach alpha among the 28 items was 0.94 (95% CI: 0.93-0.96). The exploratory principal component analyses and subsequent Promax rotation yielded 1 dominant component with an eigenvalue of 12.84 (70% of the variance). The expert panel narrowed the final instrument to 11 items with an overall Cronbach alpha of 0.90 (95% CI: 0.86, 0.92). Belonging in Surgery was significantly associated with race (Black and Asian residents scoring lower than White residents), graduating with one's original intern cohort (residents who graduated with their original class scoring higher than those that did not), and inversely correlated with resident stress level. CONCLUSIONS: An instrument to measure Belonging in Surgery was validated among surgical residents. With this instrument, Belonging in Surgery becomes a construct that may be used to investigate surgeon performance and well-being.

The use and costs of same-day surgery versus overnight admission for total thyroidectomy: A multi-state, all-payer analysis.

BACKGROUND: Outpatient thyroidectomy is increasingly favored, given evidence of safety and convenience for selected patients. However, the prevalence of same-day discharge is unclear. We aimed to evaluate temporal trends, hospital characteristics, and costs associated with same-day discharge after total thyroidectomy in an all-payer, multi-state cohort. METHODS: We included patients aged ≥18 years who underwent a total thyroidectomy (2013-2019) using Healthcare Cost and Utilization Project data. Admission type was defined as same-day, overnight, or inpatient based on length of stay. Same-day patients were propensity-score matched 1:1 with overnight patients. Hospital characteristics and costs were compared in the matched cohort. RESULTS: Among 86,187 patients who underwent total thyroidectomy, 16,743 (19.4%) cases were same-day, 59,778 (69.4%) were overnight, and 9,666 (11.2%) were inpatient. The proportion of patients who underwent same-day thyroidectomy increased from 14.8% to 20.8% over the study period (P < .001), whereas overnight admissions decreased from 72.9% to 68.8% (P < .001). In total, 9,571 same-day patients were matched to 9,571 overnight patients. Same-day patients had higher odds of treatment at a certified cancer center (odds ratio 1.77; 95% confidence interval 1.65-1.90), Accreditation Council for Graduate Medical Education-accredited teaching hospital (odds ratio 1.72; 95% confidence interval 1.61-1.85), and high-volume hospital (odds ratio 1.53; 95% confidence interval 1.42-1.65). Pairwise cost differences showed median savings of $974 (interquartile range -1,610 to 3,491) for same-day relative to overnight admission (P < .001). CONCLUSION: Although over two-thirds of patients are admitted overnight, same-day total thyroidectomy is increasingly performed. Same-day thyroidectomy may be a lower-cost option for selected patients, particularly in specialty centers with experience in thyroidectomy.

The effect of Section 1557 of the Affordable Care Act on surgical outcomes in non-English primary language speakers.

BACKGROUND: In 2016, Section 1557 mandated use of qualified language interpreter services. We examined the effect of Section 1557 on surgical outcomes. METHODS: Utilizing the Healthcare Cost and Utilization Project State Inpatient Database (2013-2020), we performed a difference-in-differences analysis of adult surgical patients (Maryland, New Jersey). The exposure was implementation of Section 1557 (pre-period: 2013-2015; post-period: 2017-2020). The treatment group was non-English primary language speakers (n-EPL). The comparison group was English primary language speakers (EPL). Outcomes included length-of-stay, postoperative complications, mortality, discharge disposition, and readmissions. RESULTS: Among 2,298,584 patients, 198,385 (8.6%) were n-EPL. After implementation of Section 1557, n-EPL saw no difference in readmission rates but did experience significantly higher rates of mortality (+0.43%, p â€‹= â€‹0.049) and non-routine discharges (+1.81%, p â€‹= â€‹0.031) in Maryland, and higher rates of post-operative complications (+0.31%, p â€‹= â€‹0.001) in both states, compared to pre-Section 1557. CONCLUSIONS: Contrary to our hypothesis, Section 1557 did not improve surgical outcomes for n-EPL.

Exocrine gland-resident memory CD8+ T cells use mechanosensing for tissue surveillance.

Tissue-resident CD8+ T cells (TRM) continuously scan peptide-MHC (pMHC) complexes in their organ of residence to intercept microbial invaders. Recent data showed that TRM lodged in exocrine glands scan tissue in the absence of any chemoattractant or adhesion receptor signaling, thus bypassing the requirement for canonical migration-promoting factors. The signals eliciting this noncanonical motility and its relevance for organ surveillance have remained unknown. Using mouse models of viral infections, we report that exocrine gland TRM autonomously generated front-to-back F-actin flow for locomotion, accompanied by high cortical actomyosin contractility, and leading-edge bleb formation. The distinctive mode of exocrine gland TRM locomotion was triggered by sensing physical confinement and was closely correlated with nuclear deformation, which acts as a mechanosensor via an arachidonic acid and Ca2+ signaling pathway. By contrast, naïve CD8+ T cells or TRM surveilling microbe-exposed epithelial barriers did not show mechanosensing capacity. Inhibition of nuclear mechanosensing disrupted exocrine gland TRM scanning and impaired their ability to intercept target cells. These findings indicate that confinement is sufficient to elicit autonomous T cell surveillance in glands with restricted chemokine expression and constitutes a scanning strategy that complements chemosensing-dependent migration.

Incidence and Risk Factors for Retinal Detachment and Retinal Tear after Cataract Surgery: IRIS® Registry (Intelligent Research in Sight) Analysis.

Objective: To report the incidence of and evaluate demographic, ocular comorbidities, and intraoperative factors for rhegmatogenous retinal detachment (RRD) and retinal tear (RT) after cataract surgery in the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight). Design: Retrospective cohort study. Participants: Patients aged ≥ 40 years who underwent cataract surgery between 2014 and 2017. Methods: Multivariable logistic regression was used to evaluate demographic, comorbidity, and intraoperative factors associated with RRD and RT after cataract surgery. Main Outcome Measures: Incidence and risk factors for RRD or RT within 1 year of cataract surgery. Results: Of the 3 177 195 eyes of 1 983 712 patients included, 6690 (0.21%) developed RRD and 5489 (0.17%) developed RT without RRD within 1 year after cataract surgery. Multivariable logistic regression odds ratios (ORs) showed increased risk of RRD and RT, respectively, among men (OR 3.15; 95% confidence interval [CI], 2.99-3.32; P < 0.001 and 1.79; 95% CI, 1.70-1.89; P < 0.001), and younger ages compared with patients aged > 70, peaking at age 40 to 50 for RRD (8.61; 95% CI, 7.74-9.58; P < 0.001) and age 50 to 60 for RT (2.74; 95% CI, 2.52-2.98; P < 0.001). Increased odds of RRD were observed for procedure eyes with lattice degeneration (LD) (10.53; 95% CI, 9.82-11.28; P < 0.001), hypermature cataract (1.61; 95% CI, 1.06-2.45; P = 0.03), complex cataract surgery (1.52; 95% CI, 1.4-1.66; P < 0.001), posterior vitreous detachment (PVD) (1.24; 95% CI, 1.15-1.34; P < 0.001), and high myopia (1.2; 95% CI, 1.14-1.27; P < 0.001). Lattice degeneration conferred the highest odds of RT (43.86; 95% CI, 41.39-46.49; P < 0.001). Conclusion: In the IRIS Registry, RRD occurs in approximately 1 in 500 cataract surgeries in patients aged > 40 years within 1 year of surgery. The presence of LD conferred the highest odds for RRD and RT after surgery. Additional risk factors for RRD included male gender, younger age, hypermature cataract, PVD, and high myopia. These data may be useful during the informed consent process for cataract surgery and help identify patients at a higher risk of retinal complications. Financial Disclosures: The author(s) have no proprietary or commercial interest in any materials discussed in this article.

A study analyzing outcomes after bariatric surgery by primary language.

BACKGROUND: Communication is key to success in bariatric surgery. This study aims to understand how outcomes after bariatric surgery differ between patients with a non-English primary language and those with English as their primary language. METHODS: This retrospective, observational cohort study of bariatric surgery patients age ≥ 18 years utilized the Michigan, Maryland, and New Jersey State Inpatient Databases and State Ambulatory Surgery and Services Databases, 2016 to 2018. Patients were classified by primary spoken language: English and non-English. Primary outcome was complications. Secondary outcomes included length of stay (LOS) and cost, with cost calculated using cost-to-charge ratios provided by Healthcare Cost and Utilization Project and reported in 2019 United States dollars. Multivariable regression models (logistic, Poisson, and quantile) were used to examine associations between primary language and outcomes. Given the uneven distribution of race by primary language, interaction terms were used to examine conditional effects of race. RESULTS: Among 69,749 bariatric surgery patients, 2811 (4.2%) spoke a non-English primary language. Covariates, notably race distribution, and unadjusted outcomes differed significantly by primary language. However, after adjustment, non-English primary language was not associated with significantly increased odds of complications (odds ratio 1.24, p = 0.389), significantly different LOS (- 0.02 days, p = 0.677), nor significantly different mean healthcare costs (- $265, p = 0.309). There were no significant conditional effects of race seen among outcomes. CONCLUSIONS: Though non-English primary language was associated with a significantly different distribution of observable characteristics (including race, income quartile, and insurance type), after adjustment, non-English primary language was not associated with significant differential risk of adverse outcomes after bariatric surgery, and there were no significant conditional effects of race. As such, this study suggests that disparities in bariatric surgery by primary spoken language more likely related to access to care, or the pre- and post-hospital care continuum, rather than index hospitalization after surgery.

Thyroid Eye Disease and its Vision-Threatening Manifestations in the Academy IRIS Registry: 2014-2018.

PURPOSE: To evaluate prevalence of thyroid eye disease (TED) and associated factors in the American Academy of Ophthalmology IRISⓇ Registry (Intelligent Research in Sight). DESIGN: Cross-sectional analysis of the IRIS Registry. METHODS: IRIS Registry patients (18-90 years old) were classified as TED (ICD-9: 242.00, ICD-10: E05.00 on ≥2 visits) or non-TED cases, and prevalence was estimated. Odds ratios (OR) and 95% Confidence Intervals (CIs) were estimated using logistic regression. RESULTS: 41,211 TED patients were identified. TED prevalence was 0.09%, showed a unimodal age distribution (highest prevalence in ages 50-59 years (y) (0.12%)), higher rates in females than males (0.12% vs. 0.04%) and in non-Hispanics than Hispanics (0.10% vs. 0.05%). Prevalence differed by race (from 0.08% in Asians to 0.12% in Black/African-Americans), with varying peak ages of prevalence. Factors associated with TED in multivariate analysis included age: ((18-<30y (reference), 30-39y: OR (95%CI) 2.2 (2.0, 2.4), 40-49y: 2.9 (2.7,3.1), 50-59y: 3.3 (3.1, 3. 5), 60-69y: 2.7 (2.54, 2.85), 70+: 1.5 (1.46, 1.64)); female sex vs male (reference), 3.5 (3.4,3.6), race: White (reference), Blacks: 1.1 (1.1,1.2), Asian: 0.9 (0.8,0.9), Hispanic ethnicity vs not Hispanic (reference), 0.68 (0.6,0.7), smoking status: (never (ref), former: 1.64 (1.6,1.7), current 2.16: (2.1,2.2)) and Type 1 diabetes (yes vs no (reference): 1.87 (1.8, 1.9). CONCLUSIONS: This epidemiologic profile of TED includes new observations such as a unimodal age distribution and racial variation in prevalence. Associations with female sex, smoking, and Type 1 diabetes are consistent with prior reports. These findings raise novel questions about TED in different populations.

Development of a Machine Learning Model to Identify Colorectal Cancer Stage in Medicare Claims.

PURPOSE: Staging information is essential for colorectal cancer research. Medicare claims are an important source of population-level data but currently lack oncologic stage. We aimed to develop a claims-based model to identify stage at diagnosis in patients with colorectal cancer. METHODS: We included patients age 66 years or older with colorectal cancer in the SEER-Medicare registry. Using patients diagnosed from 2014 to 2016, we developed models (multinomial logistic regression, elastic net regression, and random forest) to classify patients into stage I-II, III, or IV on the basis of demographics, diagnoses, and treatment utilization identified in Medicare claims. Models developed in a training cohort (2014-2016) were applied to a testing cohort (2017), and performance was evaluated using cancer stage listed in the SEER registry as the reference standard. RESULTS: The cohort of patients with 30,543 colorectal cancer included 14,935 (48.9%) patients with stage I-II, 9,203 (30.1%) with stage III, and 6,405 (21%) with stage IV disease. A claims-based model using elastic net regression had a scaled Brier score (SBS) of 0.45 (95% CI, 0.43 to 0.46). Performance was strongest for classifying stage IV (SBS, 0.62; 95% CI, 0.59 to 0.64; sensitivity, 93%; 95% CI, 91 to 94) followed by stage I-II (SBS, 0.45; 95% CI, 0.44 to 0.47; sensitivity, 86%; 95% CI, 85 to 76) and stage III (SBS, 0.32; 95% CI, 0.30 to 0.33; sensitivity, 62%; 95% CI, 61 to 64). CONCLUSION: Machine learning models effectively classified colorectal cancer stage using Medicare claims. These models extend the ability of claims-based research to risk-adjust and stratify by stage.

Non-English Primary Language: A Growing Population's Access to Cholecystectomy.

OBJECTIVE: To examine access to cholecystectomy and postoperative outcomes among non-English primary-speaking patients. BACKGROUND: The population of U.S. residents with limited English proficiency is growing. Language affects health literacy and is a well-recognized barrier to health care in the United States of America. Historically marginalized communities are at greater risk of requiring emergent gallbladder operations. However, little is known about how primary language affects surgical access and outcomes of common surgical procedures, such as cholecystectomy. METHODS: We conducted a retrospective cohort study of adult patients after receipt of cholecystectomy in Michigan, Maryland, and New Jersey utilizing the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database (2016-2018). Patients were classified by primary spoken language: English or non-English. The primary outcome was admission type. Secondary outcomes included operative setting, operative approach, in-hospital mortality, postoperative complications, and length of stay. Multivariable logistics and Poisson regression were used to examine outcomes. RESULTS: Among 122,013 patients who underwent cholecystectomy, 91.6% were primarily English speaking and 8.4% were non-English primary language speaking. Primary non-English speaking patients had a higher likelihood of emergent/urgent admissions (odds ratio: 1.22, 95% CI: 1.04-1.44, P = 0.015) and a lower likelihood of having an outpatient operation (odds ratio: 0.80, 95% CI: 0.70-0.91, P = 0.0008). There was no difference in the use of a minimally invasive approach or postoperative outcomes based on the primary language spoken. CONCLUSIONS: Non-English primary language speakers were more likely to access cholecystectomy through the emergency department and less likely to receive outpatient cholecystectomy. Barriers to elective surgical presentation for this growing patient population need to be further studied.

Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair.

OBJECTIVE: Lack of insurance has been independently associated with an increased risk of in-hospital mortality after abdominal aortic aneurysm repair, possibly due to worse control of comorbidities and delays in diagnosis and treatment. Medicaid expansion has improved insurance rates and access to care, potentially benefiting these patients. We sought to assess the association between Medicaid expansion and outcomes after abdominal aortic aneurysm repair. METHODS: A retrospective analysis of Healthcare Cost and Utilization Project State Inpatient Databases data from 14 states between 2012 and 2018 was conducted. The sample was restricted to first-record abdominal aortic aneurysm repairs in adults under age 65 in states that expanded Medicaid on January 1, 2014 (Medicaid expansion group) or had not expanded before December 31, 2018 (non-expansion group). The Medicaid expansion and non-expansion groups were compared between pre-expansion (2012-2013) and post-expansion (2014-2018) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors, open vs endovascular repair, and standard errors clustered by state. Our primary outcome was in-hospital mortality. Outcomes were stratified by insurance type. RESULTS: We examined 8995 patients undergoing abdominal aortic aneurysm repair, including 3789 (42.1%) in non-expansion states and 5206 (57.9%) in Medicaid expansion states. Rates of Medicaid insurance were unchanged in non-expansion states but increased in Medicaid expansion states post-expansion (non-expansion: 10.9% to 9.8%; P = .346; expansion: 9.7% to 19.7%; P < .001). One in 10 patients from both non-expansion and Medicaid expansion states presented with ruptured aneurysms, which did not change over time. Rates of open repair decreased in both non-expansion and Medicaid expansion states over time (non-expansion: 25.1% to 19.2%; P < .001; expansion: 25.2% to 18.4%; P < .001). On adjusted difference-in-differences analysis between expansion and non-expansion states pre-to post-expansion, Medicaid expansion was associated with a 1.02% absolute reduction in in-hospital mortality among all patients (95% confidence interval, -1.87% to -0.17%; P = .019). Additionally, among patients who were either on Medicaid or were uninsured (ie, the patients most likely to be impacted by Medicaid expansion), a larger 4.17% decrease in in-hospital mortality was observed (95% confidence interval, -6.47% to -1.87%; P < .001). In contrast, no significant difference-in-difference in mortality was observed for privately insured patients. CONCLUSIONS: Medicaid expansion was associated with decreased in-hospital mortality after abdominal aortic aneurysm repair among all patients and particularly among patients who were either on Medicaid or were uninsured. Our results provide support for improved access to care for patients undergoing abdominal aortic aneurysm repair through Medicaid expansion.

RISK FACTORS FOR SURGERY OR BLINDNESS IN NEOVASCULAR GLAUCOMA EYES TREATED WITH ANTI-VEGF INJECTIONS BY A RETINA SPECIALIST.

PURPOSE: To determine baseline patient characteristics that predict the need for glaucoma surgery or blindness in eyes with neovascular glaucoma (NVG) despite intravitreal antivascular endothelial growth factor therapy. METHODS: This is a retrospective cohort study of patients with NVG who had not previously received glaucoma surgery and were treated with intravitreal antivascular endothelial growth factor injections at the time of diagnosis, from September 8, 2011, to May 8, 2020, at a large, retina subspecialty practice. RESULTS: Of 301 newly presenting NVG eyes, 31% required glaucoma surgery and 20% progressed to no light perception vision despite treatment. Patients with intraocular pressure >35 mmHg ( P < 0.001), two or more topical glaucoma medications ( P = 0.003), worse than 20/100 vision ( P = 0.024), proliferative diabetic retinopathy ( P = 0.001), eye pain or discomfort ( P = 0.010), and new patient status ( P = 0.015) at the time of NVG diagnosis were at a higher risk of glaucoma surgery or blindness regardless of antivascular endothelial growth factor therapy. The effect of panretinal photocoagulation was not statistically significant in a subgroup analysis of patients without media opacity ( P = 0.199). CONCLUSION: Several baseline characteristics at the time of presentation to a retina specialist with NVG seem to portend a higher risk of uncontrolled glaucoma despite the use of antivascular endothelial growth factor therapy. Prompt referral of these patients to a glaucoma specialist should be strongly considered.

Open-Globe Injury Repairs in the American Academy of Ophthalmology IRIS® Registry 2014 - 2018: Incidence, Risk Factors, and Visual Outcomes.

PURPOSE: To estimate incidence and evaluate demographic risk factors and visual acuity (VA) outcomes of open-globe injuries requiring surgical repair in the IRIS® Registry (Intelligent Research in Sight). DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with open-globe injury repairs (OGRs) were identified by Current Procedural Terminology codes (65275, 65280, 65285, 65286, 65235, 65260, and 65265) from 2014 through 2018 in the IRIS Registry. METHODS: Logistic regression models adjusting for age, sex, race, ethnicity, United States region, concurrent and subsequent surgeries, and baseline VA. MAIN OUTCOME MEASURES: Outcomes included annual and 5-year incidence rates per 100 000 people and factors associated with OGR, VA better than 20/40, and VA of 20/200 or worse at final follow-up (3-12 months after OGR). RESULTS: Thirteen thousand seven hundred sixty-six OGRs were identified; 5-year cumulative incidence was 28.0 per 100 000 patients. Open-globe repair was associated with age 21 to 40 years compared with younger than 21 years (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.5-1.7]), male sex (OR, 2.8; 95% CI, 2.7-2.9), Black versus White race (OR, 1.3; 95% CI, 1.2-1.4), Hispanic versus non-Hispanic ethnicity (OR, 1.7; 95% CI, 1.6-1.8), and South (OR, 1.4; 95% CI, 1.3-1.5) and West (OR, 1.3; 95% CI, 1.2-1.4) versus Midwest regions and associated inversely with Asian versus White race (OR, 0.6; 95% CI, 0.6-0.7). Visual acuity outcomes, analyzed in a subset of 2966 patients with VA data available, showed vision impairment (VA < 20/40) at final follow-up was associated with VA of 20/200 or worse at presentation (20/200 better than 20/40; OR, 11.1; 95% CI, 8.0-15.7), older age (e.g., > 80 years vs. < 21 years; OR, 5.8; 95% CI, 3.2-10.7), and Black versus White race (OR, 1.8; 95% CI, 1.3-2.6). Risk factors were similar for VA of 20/200 or worse after OGR. Among the 1063 patients undergoing OGR with VA of 20/200 or worse at presentation, VA did not improve to better than 20/200 at follow-up in 35% of patients (1063/2996). CONCLUSIONS: Our findings bring to light racial disparities in risk of OGR and poor visual outcomes that warrant further exploration. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Hemorrhagic Complications Following Trabecular Bypass Microstent Surgery in the Setting of Antithrombotic Therapy.

PRCIS: In this retrospective study, the use of chronic antithrombotic therapy (ATT) did not increase the risk of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification. Stent type and female sex were associated with hyphema. PURPOSE: To report the incidence of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification with and without (ATT). METHODS: Retrospective case series on glaucoma patients on chronic ATT who underwent trabecular bypass microstent surgery (iStent, iStent inject, and Hydrus) combined with phacoemulsification between 2013 and 2019 with ≥3-month follow-up. The primary outcome measure was the incidence of hemorrhagic complications within a 3-month postoperative period. Generalized estimating equations were created to account for inter-eye correlation and logistic regression analysis was performed to identify factors predictive of hemorrhagic complications. RESULTS: Of 333 patients (435 eyes), 161 patients (211 eyes) were on ATT and 172 patients (224 eyes) were not on ATT; both groups were similar in age and baseline ocular characteristics. The only hemorrhagic complication was hyphema, which occurred in 84 (19.3%) eyes (41 ATT, 43 non-ATT eyes; P = 1.00). Onset was at postoperative day 1 in 98.8% of eyes, with a duration of 1 week in 73.8% of eyes, without difference between ATT and non-ATT groups. Hyphema was most common with Hydrus microstent (36.4%) versus iStent (19.9%) and iStent inject (8.5%) ( P = 0.003). In the multivariate model, the female sex was a predictor of hyphema [hazard ratio (HR) = 2.062; P = 0.009], iStent inject was protective against hyphema (HR = 0.379; P = 0.033), whereas Hydrus did not reach statistical significance (HR = 2.007; P = 0.081). Age, systemic comorbidities, ATT use, and baseline ocular characteristics were not significant predictors. CONCLUSIONS: Hemorrhagic complications after trabecular bypass microstent surgery were limited to transient hyphema and were not associated with chronic ATT use. Stent type and female sex were associated with hyphema.

Clinical outcomes in children and adolescents referred for increased cup:disk ratio at a tertiary referral center.

PURPOSE: To report clinical outcomes and risk factors for glaucoma in children and adolescents referred for increased cup:disk ratios (CDRs) to a tertiary referral center. METHODS: This retrospective, single-center study examined all pediatric patients evaluated for increased CDR at Wills Eye Hospital. Patients who had previous known ocular disease were excluded. Demographic data, including sex, age, and race/ethnicity were recorded, as were baseline and follow-up ophthalmic examination findings, including intraocular pressure (IOP), CDR, diurnal curve, gonioscopy findings, and refractive error. Risks of glaucoma diagnosis based on these data were analyzed. RESULTS: A total of 167 patients were included, of whom 6 were found to have glaucoma. Despite more than 2 years' follow-up on 61 patients, all glaucoma patients were identified within the first 3 months of evaluation. Baseline IOP was statistically significantly higher in glaucomatous patients than nonglaucomatous patients (28 ± 7 vs 15 ± 4, resp. [P = 0.0002]), as was maximum IOP on diurnal curve (24 ± 3 vs 17 ± 3 [P = 0.0005]). CONCLUSIONS: In our study cohort, diagnosis of glaucoma was apparent in the first year of evaluation. Baseline IOP and maximal IOP on diurnal curve were found to be statistically significantly associated with glaucoma diagnosis in pediatric patients referred for increased CDR.