Factors Associated With the Ability of US Nursing Homes to Accept Residents With Severe Obesity.

OBJECTIVES: Severe obesity in nursing home (NH) residents is associated with specialized care needs, limited mobility, and challenges in daily living. The COVID-19 pandemic strained NH resources and exacerbated staffing shortages. This study aimed to assess the ability of US NHs to accept and care for residents with severe obesity post-COVID, as well as associated NH factors. DESIGN: Cross-sectional nationwide survey of NH administrators (2021-2022). SETTING AND PARTICIPANTS: 290 NHs from a national sample (n = 224) and a targeted sample in Massachusetts and New Jersey (n = 66). METHODS: A survey designed to assess how NHs approach admitting and caring for people with severe obesity before and after COVID was fielded from 2021 to 2022. Responses were linked to facility information from the Certification and Survey Provider Enhanced Reports, Minimum Data Set, Nursing Home Compare, Area Health Resources File, and US Diabetes Surveillance System. Multivariable logistic regression was used to assess the effect of organizational and survey response variables. RESULTS: Of the 2503 surveys sent to US NHs, 1923 were sent to the national NH stratified sample, and 580 were sent to the MA/NJ sample. Overall, 12% (301 of 2503) of NHs surveyed responded. The response rates were similar between the 2 samples. Of 290 NHs with complete data, 34% reported being unlikely to accept residents with severe obesity after COVID-19, compared with 25% before the pandemic (P < .001). The main barriers to acceptance were staffing shortages and difficulties meeting equipment and space needs. NHs with higher proportions of Black residents were more likely to admit individuals with severe obesity. CONCLUSIONS AND IMPLICATIONS: The decline in acceptance of residents with severe obesity during and after COVID-19 highlights potential challenges that this population faces in accessing care. Our results also raise concerns that an intersection of disparities may exist in Black patients with severe obesity.

Patient Location and Disparities in Access to Fertility Preservation for Women With Gynecologic or Breast Cancer.

OBJECTIVE: To assess the effect of geographic factors on fertility-sparing treatment or assisted reproductive technology (ART) utilization among women with gynecologic or breast cancers. METHODS: We conducted a cohort study of reproductive-aged patients (18-45 years) with early-stage cervical, endometrial, or ovarian cancer or stage I-III breast cancer diagnosed between January 2000 and December 2015 using linked data from the California Cancer Registry, the California Office of Statewide Health Planning and Development, and the Society for Assisted Reproductive Technology. Generalized linear mixed models were used to evaluate associations between distance from fertility and gynecologic oncology clinics, as well as California Healthy Places Index score (a Census-level composite community health score), and ART or fertility-sparing treatment receipt. RESULTS: We identified 7,612 women with gynecologic cancer and 35,992 women with breast cancer. Among all patients, 257 (0.6%) underwent ART. Among patients with gynecologic cancer, 1,676 (22.0%) underwent fertility-sparing treatment. Stratified by quartiles, residents who lived at increasing distances from gynecologic oncology or fertility clinics had decreased odds of undergoing fertility-sparing treatment (gynecologic oncology clinics: Q2, odds ratio [OR] 0.76, 95% CI, 0.63-0.93, P=.007; Q4, OR 0.72, 95% CI, 0.56-0.94, P=.016) (fertility clinics: Q3, OR 0.79, 95% CI, 0.65-0.97, P=.025; Q4, OR 0.67, 95% CI, 0.52-0.88, P=.004), whereas this relationship was not observed among women who resided within other quartiles (gynecologic oncology clinics: Q3, OR 0.81 95% CI, 0.65-1.01, P=.07; fertility clinics: Q2, OR 0.87 95% CI, 0.73-1.05, P=.15). Individuals who lived in communities with the highest (51st-100th percentile) California Healthy Places Index scores had greater odds of undergoing fertility-sparing treatment (OR 1.29, 95% CI, 1.06-1.57, P=.01; OR 1.66, 95% CI, 1.35-2.04, P=.001, respectively). The relationship between California Healthy Places Index scores and ART was even more pronounced (Q2 OR 1.9, 95% CI, 0.99-3.64, P=.05; Q3 OR 2.86, 95% CI, 1.54-5.33, P<.001; Q4 OR 3.41, 95% CI, 1.83-6.35, P<.001). CONCLUSION: Geographic disparities affect fertility-sparing treatment and ART rates among women with gynecologic or breast cancer. By acknowledging geographic factors, health care systems can ensure equitable access to fertility-preservation services.

Trends in Obesity Prevalence among US Older Adults in the Last Two Years of Life, 1998-2018.

CONTEXT: The prevalence of obesity has grown in the US over the decades. The temporal trends of body mass index categories in the last two years of life are poorly understood. OBJECTIVES: To describe the trends in body mass categories in the last two years of life over the past two decades controlling for other demographic changes. METHODS: We performed a cross-sectional study of prospectively collected survey data from the nationally representative Health and Retirement Study (HRS) among decedents who died between 1998 and 2018. We categorized BMI into five categories and calculated the proportion of decedents with each BMI category during each four epochs (1998-2003, 2004-2008, 2009-2013, 2014-2018). We examined trends in regression models with survey wave groupings modeled as an orthogonal polynomial and adjusted for factors commonly associated with BMI: sex, age, race, ethnicity, education, and tobacco use. RESULTS: The analytic cohort included 14,797 decedents. From 1998-2003 to 2014-2018 time periods, those categorized as having mild-to-moderate obesity in the last two years of life increased from 12.4% to 14.8% (linear trend P < 0.001), a 19% increase. Severe obesity increased from 1.9% to 4.3%, a 126% increase (linear trend P < 0.001). Underweight decreased from 9.9% to 5.9%, a 40% decrease (linear trend P < 0.001), adjusted for demographic factors. Adjusted quadratic temporal trends for BMI category were nonsignificant, except for in mild-to-moderate obesity. CONCLUSION: Severe obesity has increased greatly while underweight has decreased. As obesity increases in the final years of life, it is critical to assess how the existing and future palliative services and end of life care system address body size and weight.

Impact of satellite clinics on geographic access to assisted reproductive technology services in the United States.

BACKGROUND: Many assisted reproductive technology (ART) centers utilize satellite clinics to expand reach and access to clinical services, but their contribution to lowering geographic barriers in access to care has not been examined. This study's purpose is to determine the extent to which satellite clinics impact geographic access to ART and estimate the percentage of reproductive-age women who have geographic access to ART services. METHODS: A systematic web-search collected the locations of all main and satellite ART clinics in the United States (US). Driving times were calculated between satellite clinics and main clinics. The percentage of women with geographic access to care was characterized by clinic type using US Census Core Based Statistical Areas (CBSAs). Logistic regression was used to statistically model the presence of main and satellite clinics as a function of CBSA median income and female reproductive-age population. RESULTS: Four hundred sixty-nine main clinics with embryology labs and 583 satellite clinics were found in the US. Practices with satellite clinics tend to perform more ART cycles. Satellite clinics are located on average 66 minutes from their practice's main clinic and 31 minutes from any main clinic. 22% of satellite clinics were in CBSAs without a main clinic. 46 M (72%) US reproductive-age women live in a CBSA with a main clinic, 5.1 M (8%) women live in a CBSA without a main clinic but at least one satellite clinic, and 13 M (20%) women live in an area with no ART clinic of either type. Female reproductive-age population was found to be a more important predictor of clinic presence than median income. CONCLUSIONS: The majority of satellite clinics in the US are positioned in relative proximity to a main clinic. 85% of satellite clinics are located closer to the main clinic of other practices than to their own main clinic. Less than a quarter of ART satellite clinics expand geographic access to ART services by being located in areas without a main clinic, and the vast majority of practices with satellite clinics position their satellite clinics close to another practice's main clinic. TRIAL REGISTRATION: Not applicable.

Analysis of human Tribbles 2 (TRIB2) pseudokinase.

Human Tribbles 2 (TRIB2) is a cancer-associated pseudokinase with a broad human protein interactome, including the well-studied AKT, C/EBPα and MAPK modules. Several lines of evidence indicate that human TRIB2 promotes cell survival and drug-resistance in solid tumors and blood cancers and is therefore of interest as a potential therapeutic target, although its physiological functions remain relatively poorly understood. The unique TRIB2 pseudokinase domain lacks the canonical 'DFG' motif, and subsequently possesses very low affinity for ATP in both the presence and absence of metal ions. However, TRIB2 also contains a unique cysteine-rich αC-helix, which interacts with a conserved peptide motif in its own carboxyl-terminal tail. This regulatory flanking region drives regulated interactions with distinct E3 ubiquitin ligases that serve to control the stability and turnover of TRIB2 client proteins. TRIB2 is also a low-affinity target of several known small-molecule protein kinase inhibitors, which were originally identified using purified recombinant TRIB2 proteins and a thermal shift assay. In this chapter, we discuss laboratory-based procedures for purification, stabilization and analysis of human TRIB2, including screening procedures that can be used for the identification of both reversible and covalent small molecule ligands.

Same-day discharge after minimal invasive hysterectomy: Applications for improved value of care.

OBJECTIVE: Hysterectomy is one of the most common surgical procedures. Same-day discharge (SDD) is increasingly utilized for minimally invasive hysterectomies, but its uptake varies across healthcare systems and surgical specialties. An evidence-based initiative was developed to aid in the incorporation of SDD into the practice of minimally invasive hysterectomy (MIH) in the UPMC Health System. The objective of this study was to identify trends of SDD utilization across various gynecologic specialties at UPMC, as well as evaluate the impact of SDD on length of stay (LOS) and complications after the implementation of SDD initiative. STUDY DESIGN: We retrospectively identified 5554 patients who underwent MIH between 2014 and 2017 and were eligible for SDD, as determined by physicians and authorized by patients' insurance plans. Multivariable logistic regression models evaluated the trend of SDD utilization among four specialty types (general gynecologists, urogynecologists, specialized minimally invasive surgeons, and oncologists) and trends in complications. Multivariable logistic and linear regression models were applied to compare complications and LOS between patients with SDD vs. those with overnight admissions. RESULTS: SDD utilization increased from 28.55% to 74.99% during the study period. SDD significantly increased over the study period for all specialty types, with urogynecologists having the highest uptake from 3.9% in 2014 to 95.8% in 2017 (p<.01). After adjusting for year, specialty types, MIH procedure type, and total case time, SDD utilization was associated with shorter mean LOS (p<.01); such that mean LOS was 764.43 min (95% CI: 735.46-793.40) for SDD patients and 2041.84 min (95% CI: 2015.99-2067.70) for patients with overnight admissions. SDD was also associated with 42% lower odds (95% CI: 0.37-0.93, p=.02) of complications compared with patients with overnight admissions. CONCLUSION: Same-day discharge uptake increased over years and was associated with lower odds of complications and decreased length of stay. More studies are needed to explore same-day discharge process to improve patient outcomes, patient satisfaction, and value of care.

Nurse Aide Retention in Nursing Homes.

BACKGROUND AND OBJECTIVES: The association of nurse aide retention with three quality indicators is examined. Retention is defined as the proportion of staff continuously employed in the same facility for a defined period of time. RESEARCH DESIGN AND METHODS: Data used in this investigation came from survey responses from 3,550 nursing facilities, Certification and Survey Provider Enhanced Reporting data, and the Area Resource File. Staffing characteristics, quality indicators, facility, and market information from these data sources were all measured in 2016. Nurse aide retention was measured at 1, 2, and 3 years of employment. The quality indicators examined were a count of all deficiency citations, quality of care deficiency citations, and J, K, L deficiency citations. Negative binomial regression analyses were used to study the associations between the three different retention measures and these three quality indicators. RESULTS: The 1-, 2-, and 3-year nurse aide retention measures were 53.2%, 41.4%, and 36.1%, respectively. The regression analyses show low levels of retention to be generally associated with poor performance on the three deficiency citation quality indicators examined. DISCUSSION AND IMPLICATIONS: The research presented starts to provide information on nurse aide retention as an important workforce challenge and its potential impact on quality. Retention may be an additional staffing characteristic of nursing facilities with substantial policy and practice relevance.

Cataloguing the dead: breathing new life into pseudokinase research.

Pseudoenzymes are present within many, but not all, known enzyme families and lack one or more conserved canonical amino acids that help define their catalytically active counterparts. Recent findings in the pseudokinase field confirm that evolutionary repurposing of the structurally defined bilobal protein kinase fold permits distinct biological functions to emerge, many of which rely on conformational switching, as opposed to canonical catalysis. In this analysis, we evaluate progress in evaluating several members of the 'dark' pseudokinome that are pertinent to help drive this expanding field. Initially, we discuss how adaptions in erythropoietin-producing hepatocellular carcinoma (Eph) receptor tyrosine kinase domains resulted in two vertebrate pseudokinases, EphA10 and EphB6, in which co-evolving sequences generate new motifs that are likely to be important for both nucleotide binding and catalysis-independent signalling. Secondly, we discuss how conformationally flexible Tribbles pseudokinases, which have radiated in the complex vertebrates, control fundamental aspects of cell signalling that may be targetable with covalent small molecules. Finally, we show how species-level adaptions in the duplicated canonical kinase protein serine kinase histone (PSKH)1 sequence have led to the appearance of the pseudokinase PSKH2, whose physiological role remains mysterious. In conclusion, we show how the patterns we discover are selectively conserved within specific pseudokinases, and that when they are modelled alongside closely related canonical kinases, many are found to be located in functionally important regions of the conserved kinase fold. Interrogation of these patterns will be useful for future evaluation of these, and other, members of the unstudied human kinome.

Obesity and Disparities in Human Papillomavirus Vaccination for U.S. Adolescent Girls and Young Women.

BACKGROUND: Obesity is recognized as a barrier to receiving women's preventive health services, including cervical and breast cancer screening. Little is known about whether obesity is associated with a lower incidence of human papillomavirus (HPV) vaccination, another important preventive care service for adolescent girls and young women. The objective of this study was to determine if adolescent girls and young women with obesity are less likely to receive HPV vaccination compared with individuals with normal weight. METHODS: We examined whether HPV vaccination was associated with obesity status in women aged 9-30 years surveyed from 2009 to 2016 by the U.S. National Health and Nutrition Examination Survey. Results from logistic and linear regression models were adjusted for age, race, income, insurance status, self-reported health, and health care use, accounting for the weighted survey design. RESULTS: The final cohort included 5,517 women. Overall, 32.9% of participants reported vaccination, with a mean age at vaccination of 15.8 years. Adolescent girls and young women with obesity were less likely to report vaccination; the adjusted odds ratio of vaccination was 0.79 (p = .01) compared with normal weight women. Among those vaccinated, the age at vaccination was significantly older for women with obesity, 16.3 years compared with 15.2 years (p = .002), but there was no difference in the completion of the vaccination series rate by obesity. CONCLUSIONS: Adolescent girls and young women with obesity were less likely to report HPV vaccination and, if they were vaccinated, received the vaccination at a later age.

Geographic access to assisted reproductive technology health care in the United States: a population-based cross-sectional study.

OBJECTIVE: To evaluate the geographic distribution of assisted reproductive technology (ART) clinics and the number of ART clinics within U.S. Census metropolitan areas and to estimate the number of reproductive-age women who have geographic access to ART services in the United States. DESIGN: A population-based cross-sectional study. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Number of U.S. reproductive-age women living in areas with no ART clinic, a single ART clinic, or more than one ART clinic. RESULT(S): There were 510 ART clinics in the United States in 2009-2013. Multiple ART clinics were present in 76 metropolitan areas (median population of 1.45 million people), where a total of 442 clinics were located. A single ART clinic was present in 68 metropolitan areas (median population of 454,000 people). Among U.S. reproductive-age women in 2010, 38.1 million (60.4% of the U.S. population) lived in an area with multiple ART clinics, 6.8 million (10.8% of the U.S. population) lived in an area with a single clinic, and 18.2 million (28.8% of the U.S. population) lived in an area (metropolitan and nonmetropolitan) with no ART clinics. CONCLUSION(S): Nearby geographic access to ART services is limited or absent for more than 25 million reproductive-age women (39.6% of the U.S. population) in the United States. This population estimate should spur continued policy and technological progress to increase access to ART services.

The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study.

BACKGROUND: Obesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use and Medicare expenditures is unknown. OBJECTIVE: To describe the associations between body mass index (BMI) and hospice use and Medicare expenditures in the last 6 months of life. DESIGN: Retrospective cohort. SETTING: The HRS (Health and Retirement Study). PARTICIPANTS: 5677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012. MEASUREMENTS: Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death. Body mass index was modeled as a continuous variable with a quadratic functional form. RESULTS: For decedents with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3% (95% CI, 36.5% to 40.2%), hospice duration was 42.8 days (CI, 42.3 to 43.2 days), probability of in-home death was 61.3% (CI, 59.4% to 63.2%), and total Medicare expenditures were $42 803 (CI, $41 085 to $44 521). When BMI increased to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (CI, -9.3 to -4.0 percentage points), hospice duration decreased by 3.8 days (CI, -4.4 to -3.1 days), probability of in-home death decreased by 3.2 percentage points (CI, -6.0 to -0.4 percentage points), and total Medicare expenditures increased by $3471 (CI, $955 to $5988). For morbidly obese decedents (BMI ≥40 kg/m2), the predicted probability of hospice enrollment decreased by 15.2 percentage points (CI, -19.6 to -10.9 percentage points), hospice duration decreased by 4.3 days (CI, -5.7 to -2.9 days), and in-home death decreased by 6.3 percentage points (CI, -11.2 to -1.5 percentage points) versus decedents with BMI of 20 kg/m2. LIMITATION: Baseline data were self-reported, and the interval between reported BMI and time of death varied. CONCLUSION: Among community-dwelling decedents in the HRS, increasing obesity was associated with reduced hospice use and in-home death and higher Medicare expenditures in the last 6 months of life. PRIMARY FUNDING SOURCE: Robert Wood Johnson Foundation Clinical Scholars Program.

A retrospective cohort study of hemostatic agent use during hysterectomy and risk of post-operative complications.

OBJECTIVE: To determine if the use of intraoperative hemostatic agents was a risk factor for post-operative adverse events within 30 days of patients undergoing hysterectomy. METHOD: A population-based retrospective cohort study included data from patients undergoing hysterectomy for any indication between January 1, 2013, and December 31, 2014, at 52 hospitals in Michigan, USA. Any individuals with missing covariate data were excluded, and multivariable logistic regression and propensity score-matching were used to estimate the rate of post-operative adverse events associated with intra-operative hemostatic agents independent of demographic and surgical factors. RESULTS: There were 17 960 surgical procedures included in the analysis, with 4659 (25.9%) that included the use of hemostatic agents. Hemostatic agent use was associated with an increase in predicted hospital re-admissions (P=0.007). Among all hysterectomy approaches, and after adjusting for demographic and surgical factors, hemostatic agent use during robotic-assisted laparoscopic hysterectomy was associated with an increased predicted rate of blood transfusions (P=0.019), an increased predicted rate of pelvic abscess diagnoses (P=0.001), an increased predicted rate of hospital re-admission (P=0.001), and an increased predicted rate of re-operation (P=0.021). CONCLUSION: Hemostatic agents should be used carefully owing to associations with increased post-operative re-admissions and re-operations when used during hysterectomy.

Are perioperative bundles associated with reduced postoperative morbidity in women undergoing benign hysterectomy? Retrospective cohort analysis of 16,286 cases in Michigan.

BACKGROUND: Healthcare teams that frequently follow a bundle of evidence-based processes provide care with lower rates of morbidity. Few process bundles to improve surgical outcomes in hysterectomy have been identified. OBJECTIVE: The purpose of this study was to investigate whether a bundle of 4 perioperative care processes is associated with fewer postoperative complications and readmissions for hysterectomies in the Michigan Surgical Quality Collaborative. STUDY DESIGN: A bundle of perioperative care process goals was developed retrospectively with 30-day peri- and postoperative outcome data from the Hysterectomy Initiative in Michigan Surgical Quality Collaborative. All benign hysterectomies that had been performed between January 2013 and January 2015 were included. Based on evidence of lower complication rates after benign hysterectomy, the following processes were considered to be the "bundle": use of guideline-appropriate preoperative antibiotics, a minimally invasive surgical approach, operative duration <120 minutes, and avoidance of intraoperative hemostatic agent use. Each process was considered present or absent, and the number of processes was summed for a bundle score that ranged from 0-4. Cases with a score of zero were excluded. Outcomes measured were rates of complications (any and major) and hospital readmissions, all within 30 days of surgery. Postoperative events that were considered a "major complication" included acute renal failure, cardiac arrest that required cardiopulmonary resuscitation, central line infection, cerebral vascular accident, death, deep vein thrombosis, intestinal obstruction, myocardial infarction, pelvic abscess, pulmonary embolism, rectovaginal fistula, sepsis, surgical site infection (deep and organ-space), unplanned intubation, ureteral obstruction, and ureterovaginal and vesicovaginal fistula. The outcome "any complication" included all those events already described in addition to blood transfusion within 72 hours of surgery, urinary tract infection, and superficial surgical site infection. Outcomes were adjusted for patient demographics, surgical factors, and hospital-level clustering effects. RESULTS: There were 16,286 benign hysterectomies available for analysis. Among all hysterectomies that were reviewed, 33.6% met criteria for all bundle processes; however, there was wide variation in the rate among the 56 hospitals in the study sample with 9.1% of cases at the lowest quartile and 60.4% at the highest quartile of hospitals that met criteria for all bundle processes. Overall, the rate of any complication was 6.8% and of any major complication was 2.3%. The rate of hospital readmissions was 3.6%. After adjustment for confounders, in cases in which all bundle criterion were met compared with cases in which all bundle criterion were not met, the rate of any complications increased from 4.3-7.8% (P<.001); major complications increased from 1.7-2.6% (P<.001), and readmissions increased from 2.6-4.1% (P<.001). After adjustment for confounders, hospitals with greater rates of meeting all 4 criteria were associated significantly with lower hospital-level rates of postoperative complications (P<.001) and readmissions (P<.001). CONCLUSIONS: This multiinstitutional evaluation reveals that reduced morbidity and readmission are associated with rates of bundle compliance. The proposed bundle is a surgical goal, which is not possible in every case, and there is significant variation in the proportion of cases meeting all 4 bundle processes in Michigan hospitals. Implementation of evidence-based process bundles at a healthcare system level are worthy of prospective study to determine whether improvements in patient outcomes are possible.

Timing of and Reasons for Unplanned 30-Day Readmission After Hysterectomy for Benign Disease.

OBJECTIVE: To characterize timing and reasons associated with unplanned 30-day readmissions after hysterectomy for benign indications. METHODS: We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Project database files from 2012 to 2013. We identified patterns of 30-day readmission after benign hysterectomy for all surgical approaches (abdominal, laparoscopic, vaginal). Readmission timing was determined from discharge date and readmission diagnoses were tabulated. Statistical analyses included χ tests and multivariable logistic regression. RESULTS: The 30-day readmission rate was 2.8% (1,118/40,580 hysterectomies). Readmissions complicated 3.7% (361/9,869) of abdominal, 2.6% (576/22,266) of laparoscopic, and 2.1% (181/8,445) of vaginal hysterectomies. Readmissions were more likely when hysterectomy was performed abdominally (adjusted odds ratio [OR] 1.45, 95% confidence interval [CI] 1.2-1.76) but not laparoscopically (adjusted OR 1.1, 95% CI 0.9-1.4) compared with a vaginal approach. Eighty-two percent of readmissions occurred within 15 days of discharge. The shortest median time to readmission was associated with pain (3 days), and the longest was associated with noninfectious wound complications (10 days). Surgical site infection was the most common diagnosis (abdominal 36.6%, laparoscopic 28.3%, vaginal 32.6%). Surgical site infections, surgical injuries, and wound complications combined accounted for 51.5% of abdominal, 51.9% of laparoscopic, and 50.8% of vaginal hysterectomy readmissions. Medical complications such as cardiovascular events and venous thromboembolism were responsible for 5.8% of abdominal, 6.9% of laparoscopic, and 8.8% of vaginal hysterectomy readmissions. Surgical injuries were responsible for more readmissions after laparoscopic (unadjusted OR 2.3, 95% CI 1.48-3.65) and vaginal hysterectomies (unadjusted OR 2.3, 95% CI 1.29-3.97) than abdominal cases. CONCLUSION: Readmissions after hysterectomy tend to occur shortly after discharge. Most readmissions are related to surgical issues, most commonly surgical site infection. Medical complications, including venous thromboembolism, account for less than 10% of readmissions. Readmission reduction efforts should focus on early postdischarge follow-up, preventing infectious complications, and determining preventability of surgical-related reasons for readmission.

Racial and Ethnic Differences in End-of-Life Medicare Expenditures.

OBJECTIVES: To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life. DESIGN: Retrospective cohort study. SETTING: Health and Retirement Study (HRS). PARTICIPANTS: Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105). MEASUREMENTS: Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected. RESULTS: The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models. CONCLUSION: Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences.

Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications.

BACKGROUND: Despite a lack of evidence showing improved clinical outcomes with robotic-assisted hysterectomy over other minimally invasive routes for benign indications, this route has increased in popularity over the last decade. OBJECTIVE: We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications. STUDY DESIGN: A statewide database was used to analyze utilization and outcomes of minimally invasive hysterectomy performed for benign indications from Jan. 1, 2013, through July 1, 2014. A 1-to-1 propensity score-match analysis was performed between women who had a hysterectomy with robotic assistance vs other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmissions, and reoperations were compared. Cost estimates of hysterectomy routes, surgical site infection, and postoperative blood transfusion were derived from published data. RESULTS: In all, 8313 hysterectomy cases were identified: 4527 performed using robotic assistance and 3786 performed using other minimally invasive routes. A total of 1338 women from each group were successfully matched using propensity score matching. Robotic-assisted hysterectomies had lower estimated blood loss (94.2 ± 124.3 vs 175.3 ± 198.9 mL, P < .001), longer surgical time (2.3 ± 1.0 vs 2.0 ± 1.0 hours, P < .001), larger specimen weights (178.9 ± 186.3 vs 160.5 ± 190 g, P = .007), and shorter length of stay (14.1% [189] vs 21.9% [293] ≥2 days, P < .001). Overall, the rate of any postoperative complication was lower with the robotic-assisted route (3.5% [47] vs 5.6% [75], P = .01) and driven by lower rates of superficial surgical site infection (0.07% [1] vs 0.7% [9], P = .01) and blood transfusion (0.8% [11] vs 1.9% [25], P = .02). Major postoperative complications, intraoperative bowel and bladder injury, readmissions, and reoperations were similar between groups. Using hospital cost estimates of hysterectomy routes and considering the incremental costs associated with surgical site infections and blood transfusions, nonrobotic minimally invasive routes had an average net savings of $3269 per case, or 24% lower cost, compared to robotic-assisted hysterectomy ($10,160 vs $13,429). CONCLUSION: Robotic-assisted laparoscopy does not decrease major morbidity following hysterectomy for benign indications when compared to other minimally invasive routes. While superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, in the absence of substantial reductions in clinically and financially burdensome complications, it will be challenging to find a scenario in which robotic-assisted hysterectomy is clinically superior and cost-effective.

Milestones for the Final Mile: Interspecialty Distinctions in Primary Palliative Care Skills Training.

CONTEXT: Primary palliative care (PPC) skills are useful in a wide variety of medical and surgical specialties, and the expectations of PPC skill training are unknown across graduate medical education. OBJECTIVES: We characterized the variation and quality of PPC skills in residency outcomes-based Accreditation Council for Graduate Medical Education (ACGME) milestones. METHODS: We performed a content analysis with structured implicit review of 2015 ACGME milestone documents from 14 medical and surgical specialties chosen for their exposure to clinical situations requiring PPC. For each specialty milestone document, we characterized the variation and quality of PPC skills in residency outcomes-based ACGME milestones. RESULTS: We identified 959 occurrences of 29 palliative search terms within 14 specialty milestone documents. Within these milestone documents, implicit review characterized 104 milestones with direct saliency to PPC skills and 196 milestones with indirect saliency. Initial interrater agreement of the saliency rating among the primary reviewers was 89%. Specialty milestone documents varied widely in their incorporation of PPC skills within milestone documents. PPC milestones were most commonly found in milestone documents for Anesthesiology, Pediatrics, Urology, and Physical Medicine and Rehabilitation. PPC-relevant milestones were most commonly found in the Interpersonal and Communication Skills core competency with 108 (36%) relevant milestones classified under this core competency. CONCLUSIONS: Future revisions of specialty-specific ACGME milestone documents should focus on currently underrepresented, but important PPC skills.