Medicaid Insurance Predicts Increased Postoperative Care Encounters Among Patients on Long-Term Opioid Therapy.

OBJECTIVE: This study examined the association between insurance type and postoperative unplanned care encounters among patients on long-term opioid therapy prior to surgery. SUMMARY BACKGROUND DATA: Preoperative long-term opioid therapy is associated with unique risks and poorer outcomes following surgery. To date, the extent to which insurance coverage influences postoperative outcomes in this population remains unclear. METHODS: Among individuals receiving a supply of greater than 120 total days or at least 10 opioid prescriptions in the year prior to surgery, we examined patients with Medicaid or private insurance who underwent abdominopelvic surgery from 2017 to 2021 across 70 hospitals in the state of Michigan. The primary outcome was unplanned care encounters, defined as an emergency department visit or unplanned readmission within 30 days of discharge from surgery. Multivariable logistic regression was used to assess the likelihood of acute care events with insurance type as the primary covariate of interest. RESULTS: Among 1212 patients on long-term opioid therapy prior to surgery, 45.6% (n = 553) had Medicaid insurance. Overall, one in eight (n=151) patients met criteria for a postoperative unplanned care encounter within 30 days. The probability of an unplanned encounter was 4.5 percentage points higher among patients with Medicaid insurance compared to private insurance (95% CI: 0.5%, 8.4%). CONCLUSIONS: Among patients on preoperative long-term opioid therapy, unplanned care encounters were higher among patients with Medicaid when compared to private insurance. While this is likely multifactorial, differences by insurance status may point to disparities in underlying social determinants of health and suggest the need for postoperative care pathways that address these gaps.

Acute type A intramural hematoma: The less-deadly acute aortic syndrome?

OBJECTIVE: To evaluate the short- and midterm outcomes of surgically managed acute type A intramural hematoma (IMH) versus classic acute type A aortic dissection (ATAAD). METHODS: From 1996 to February 2023, a total of 106 patients with acute type A IMH and 795 patients with classic ATAAD presented for open aortic repair at our institution. Data were obtained from the local Society of Thoracic Surgeons' Data Warehouse and medical chart review. RESULTS: Compared with the classic ATAAD group, the IMH group was older (65 vs 59 years, P < .001) and more likely to be female (45% vs 32%, P = .005), with fewer comorbidities such as severe aortic insufficiency (5.0% vs 25%, P < .001), acute stroke (2.8% vs 8.3%, P = .05), acute renal failure (5.7% vs 13%, P = .04), and malperfusion syndrome (8.5% vs 26%, P < .001) but more cardiac tamponade (18% vs 11%, P = .03). The IMH group had less aortic root replacement (15% vs 33%, P < .001), zone 2 arch replacements (9.4% vs 18%, P = .02), and shorter crossclamp times (120 minutes vs 150 minutes, P < .001). The operative mortality was significantly lower in the IMH group (0.9% vs 8.8%, P = .005) and a multivariable regression model showed IMH to be protective, odds ratio of 0.11, P = .03. The 10-year survival was similar between the 2 groups (65% vs 61%, P = .35). The hazard ratio of IMH for midterm mortality after surgery was 0.73, P = .12. CONCLUSIONS: Acute type A IMH could be treated with emergency open aortic repair with excellent short- and midterm outcomes.

Financial model for a transitional pain service at a large tertiary academic center in the USA.

Approximately 1 in 10 patients undergoing surgery is considered at high risk for poor pain and opioid-related outcomes due to chronic pain or persistent opioid use prior to surgery, leading to increased hospital lengths of stay, emergency department visits, hospital readmissions, and worse long-term outcomes. Multidisciplinary transitional pain services (TPSs) have been shown to effectively identify and optimize high-risk patients before surgery, leading to a reduction in healthcare utilization. We conducted a series of semistructured interviews, a literature search, and a financial analysis to develop a reproducible business case for establishing a TPS. These interviews involved discussions with clinicians and administrators at Michigan Medicine, as well as leaders of TPS initiatives at peer institutions across the USA and Canada. The aim was to understand possible operational structures and potential sources of revenue and cost savings that needed inclusion in our model. Subsequently, the authors developed a modifiable financial modeling tool, which is freely available for download and adaptable to any healthcare institution. The model suggests that the primary source of cost savings can be attributed to a reduction in length of stay. Furthermore, several operational options exist for incorporating a TPS that performs at breakeven or positive net profit. This tool and these findings are important for informing health systems of operational and financial considerations when implementing a TPS program. Future research should evaluate this financial tool's reproducibility in community health system contexts.

Increased Variation in Esophageal Cancer Treatment and Geographic Healthcare Disparity in Michigan.

BACKGROUND: Regional variation in complex healthcare is shown to negatively impact health outcomes. We sought to characterize geographic variance in esophageal cancer operation in Michigan. STUDY DESIGN: Data for patients with locoregional esophageal cancer from the Michigan Cancer Surveillance Program from 2000 to 2013 was analyzed. We reviewed the incidence of esophageal cancer by county and region, and those with locoregional disease receiving an esophagectomy. Counties were aggregated into existing state-level "urban vs rural" designations, regions were aggregated using the Michigan Economic Recovery Council designations, and data was analyzed with ANOVA, F-test, and chi-square test. RESULTS: Of the 8,664 patients with locoregional disease, 2,370 (27.4%) were treated with operation. Men were significantly more likely to receive esophagectomy than women (p < 0.001). Likewise, White, insured, and rural patients were more likely than non-White (p < 0.001), non-insured (p = 0.004), and urban patients (p < 0.001), respectively. There were 8 regions and 83 counties, with 61 considered rural and 22 urban. Region 1 (Detroit metro area, southeast) comprises the largest urban and suburban populations; with 4 major hospital systems it was considered the baseline standard for access to care. Regions 2 (west; p = 0.011), 3 (southwest; p = 0.024), 4 (east central; p = 0.012), 6 (northern Lower Peninsula; p = 0.008), and 8 (Upper Peninsula; p < 0.001) all had statistically significant greater variance in annual rates of operation compared with region 1. Region 8 had the largest variance and was the most rural and furthest from region 1. The variance in operation rate between urban and rural differed significantly (p = 0.005). CONCLUSIONS: A significant increase in variation of care was found in rural vs urban counties, as well as in regions distant to larger hospital systems. Those of male sex, White race, rural residence, and those with health insurance were significantly more likely to receive operation.

Effects of MYBPC3 loss-of-function mutations preceding hypertrophic cardiomyopathy.

Mutations in cardiac myosin binding protein C (MyBP-C, encoded by MYBPC3) are the most common cause of hypertrophic cardiomyopathy (HCM). Most MYBPC3 mutations result in premature termination codons (PTCs) that cause RNA degradation and a reduction of MyBP-C in HCM patient hearts. However, a reduction in MyBP-C has not been consistently observed in MYBPC3-mutant induced pluripotent stem cell cardiomyocytes (iPSCMs). To determine early MYBPC3 mutation effects, we used patient and genome-engineered iPSCMs. iPSCMs with frameshift mutations were compared with iPSCMs with MYBPC3 promoter and translational start site deletions, revealing that allelic loss of function is the primary inciting consequence of mutations causing PTCs. Despite a reduction in wild-type mRNA in all heterozygous iPSCMs, no reduction in MyBP-C protein was observed, indicating protein-level compensation through what we believe is a previously uncharacterized mechanism. Although homozygous mutant iPSCMs exhibited contractile dysregulation, heterozygous mutant iPSCMs had normal contractile function in the context of compensated MyBP-C levels. Agnostic RNA-Seq analysis revealed differential expression in genes involved in protein folding as the only dysregulated gene set. To determine how MYBPC3-mutant iPSCMs achieve compensated MyBP-C levels, sarcomeric protein synthesis and degradation were measured with stable isotope labeling. Heterozygous mutant iPSCMs showed reduced MyBP-C synthesis rates but a slower rate of MyBP-C degradation. These findings indicate that cardiomyocytes have an innate capacity to attain normal MyBP-C stoichiometry despite MYBPC3 allelic loss of function due to truncating mutations. Modulating MyBP-C degradation to maintain MyBP-C protein levels may be a novel treatment approach upstream of contractile dysfunction for HCM.