Specialist access and leg amputations among Texas Medicaid patients.

Medicaid coverage among patients with peripheral artery disease (PAD) has been associated with higher rates of primary amputations. We sought to determine the relative contributions of clinical, demographic, and hospital factors to leg amputations among Texas Medicaid patients. Patient-level data were used to identify patients who underwent treatment for PAD-related foot complications in Texas. Patients were categorized into groups by insurance provider (Medicaid, Medicare, dual-enrollee, commercial, and provider network). Individual- and area-level multivariate analyses were used to find associations with primary amputation. Of 21,592 patients identified, 8.8% were covered by Medicaid, 35.3% by Medicare, 27.8% by Medicare and Medicaid, 7.3% by commercial insurance, and 20.7% by a provider network. Compared with commercially insured patients, Medicaid patients more often underwent amputation (33% v 49%), were categorized as Black or Hispanic (45% v 64%), presented with gangrene (61% v 71%), were admitted through an emergency department (61% v 73%), and were admitted to a safety net hospital (3% v 16%). They had lower relative rates of outpatient evaluation (1.33 v 0.55) and their hospitalizations were less centralized (Gini coefficient 0.43 v 0.39) (P < .001 for all). Amputations among Medicaid patients were associated with infection and gangrene, care at safety net hospitals, rate of outpatient visits, and Black and Hispanic race, even after risk-adjustment (P < .001). Leg amputations among Medicaid patients were associated with race, disease severity, hospital characteristics, and outpatient evaluation rates, but not with provider density and location. Focusing efforts on preventative care and early outpatient referrals could help address this disparity.

Polymicrobial Foot Infection Patterns Are Common and Associated With Treatment Failure.

Background: That foot infections are predominately polymicrobial has long been recognized, but it is not clear if the various species co-occur randomly or in patterns. We sought nonrandom species co-occurrence patterns that might help better predict prognosis or guide antimicrobial selection. Methods: We analyzed tissue (bone, skin, and other soft tissue), fluid, and swab specimens collected from initial foot infection episodes during a 10-year period using a hospital registry. Nonrandom co-occurrence of microbial species was identified using simple pairwise co-occurrence rates adjusted for multiple comparisons, Markov and conditional random fields, and factor analysis. A historical cohort was used to validate pattern occurrence and identify clinical significance. Results: In total, 156 unique species were identified among the 727 specimens obtained from initial foot infection episodes in 694 patients. Multiple analyses suggested that Staphylococcus aureus is negatively associated with other staphylococci. Another pattern noted was the co-occurrence of alpha-hemolytic Streptococcus, Enterococcus fecalis, Klebsiella, Proteus, Enterobacter, or Escherichia coli, and absence of both Bacteroides and Corynebacterium. Patients in a historical cohort with this latter pattern had significantly higher risk-adjusted rates of treatment failure. Conclusions: Several nonrandom microbial co-occurrence patterns are frequently seen in foot infection specimens. One particular pattern with many Proteobacteria species may denote a higher risk for treatment failure. Staphylococcus aureus rarely co-occurs with other staphylococci.

Hospital Payer Mix and Amputation Rates Among Patients with Peripheral Artery Disease Complications.

BACKGROUND: Studies have shown that Medicaid coverage is associated with higher rates of primary amputation among patients with peripheral artery disease (PAD). We sought to identify whether hospital payer makeup also influences outcomes among these patients. METHODS: Patients who underwent treatment for foot complications in Texas were identified and aggregated by hospital. Hospitals were grouped by payer mix: low-income payer predominant versus high-income payer predominant. Variance analyses were used to find differences between the groups. Individual and hospital-level regression analyses were used to find associations with amputation rates. RESULTS: Out of 21,592 patients, 9,098 (42%) underwent amputation. They presented to 337 hospitals out of which 49 (15%) had a low-income predominant payer mix, and 109 (32%) had a high-income predominant payer mix. Patients at low-income payer predominant hospitals were more likely to present with gangrene (0.74 vs. 0.65, P < 0.01), undergo emergency admissions (0.67 vs. 0.50, P < 0.01), undergo amputation (0.53 vs. 0.42, P < 0.05), and incur higher per-day charges ($8,145 vs. $6,790, P < 0.05). At the individual level, despite risk-adjusting for disease-specific factors, amputation rate was associated with hospital payer mixes with greater proportions of Medicaid and lower proportions of commercially insured patients. At the hospital level, amputation rate was associated with higher proportion of Medicaid patients in hospital payer mix, lower hospital volumes, lower per-day charges, and higher gangrene and osteomyelitis rates (R2 = 0.30, P < 0.01). CONCLUSIONS: Higher proportion of Medicaid patients in a hospital payer mix is associated with an increased risk of primary amputation for PAD patients regardless of insurance coverage.

Racial and ethnic disparities in abdominal aortic aneurysm evaluation and treatment rates in Texas.

BACKGROUND: Screening identifies intact abdominal aortic aneurysms (iAAAs) before progression to ruptured AAAs (rAAAs). However, screening efforts have been limited by the low overall diagnostic yield and unequal screening among minority populations. The goal of the present study was to identify equitable AAA screening strategies for both majority and minority populations. METHODS: We performed epidemiologic and geospatial analyses of inpatient and outpatient procedures for iAAAs and rAAAs at Texas hospitals from 2006 through 2014 at all nonfederal hospitals and clinics in Texas. The data were aggregated by area (metropolitan statistical area vs rural region) and then supplemented by six additional data sources to estimate the AAA repair incidence rates, rates of AAA-related clinic and ultrasound visits, travel distance to providers, and the location and number of unrecognized AAAs. RESULTS: Most AAA repairs had occurred among men aged 65 to 84 years and categorized as White in large metropolitan areas. The area procedure rates for rAAAs and iAAAs were strongly correlated (R2 = 0.47). Two other variables-the proportions of persons categorized as White and those aged ≥65 years in a region-identified subgroups within the majority population with a high risk of iAAAs (R2 = 0.46). Lower rates of clinic visits and AAA ultrasound scans were seen among persons categorized as Black. Several areas with disproportionately higher rAAA/iAAA repair ratios were found, mainly affecting persons categorized as Black. CONCLUSIONS: Multiple focused AAA screening strategies could be required to address the disproportionately lower AAA identification among persons categorized as Black.