Variations in mortality in Medicare recipients on extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a rescue modality against severe cardiac and pulmonary compromise. We sought to assess variation in mortality and associated environmental and infrastructural predictors among Medicare beneficiaries on ECMO. METHODS: We used Medicare claims data to evaluate hospitalizations between 2017 and 2019 during which beneficiaries required ECMO. The primary outcome of interest was mortality. We evaluated the influence on mortality of Medicare Case Mix Index (CMI), Medicare Wage Index, hospital size, ECMO cannulations, cardiology volume, region, and gender and modeled necessity and sufficiency relations involving ECMO volume, hospital size, cardiology volume, US region, and the mortality index through qualitative comparative analysis (QCA). RESULTS: 5368 ECMO cases were performed at 306 hospitals. Compared to institutions with a mortality index equal to or below 2, those above this threshold had statistically significant higher number of beds, cardiology volumes, and lower survival percentages (p < 0.05). Moreover, we observed a smaller proportion of institutions with an ECMO volume < 20 (78.3% vs 63.4%), which had mortality index > 2. The QCA analysis indicated that low cardiology volume and central/east location are necessary but not sufficient conditions for a mortality index above 2. CONCLUSION: Trends in mortality are influenced by prevailing socioeconomic, utilization, infrastructural characteristics, and volume. As such, ECMO mortality may be more accurately predicted by models that account for more factors than clinical parameters alone.

Diversifying the Medical Pathway in a Post-Affirmative Action World.

This Viewpoint discusses a pathway toward individual, institutional, professional, and societal actions to increase the number of underrepresented individuals in medicine within the medical workforce in a "post­affirmative action" landscape.

Achieving greater value for veterans through full cost transparency in primary care.

The COVID-19 pandemic has led to increased use of telephone and video encounters in the Veterans Health Administration and many other healthcare systems. One important difference between these virtual modalities and traditional face-to-face encounters is the different cost-sharing, travel costs, and time costs that patients face. Making the full costs of different visit modalities transparent to patients and their clinicians can help patients obtain greater value from their primary care encounters. From April 6, 2020 to September 30, 2021 the VA waived all copayments for Veterans receiving care from the VA, but since this policy was temporary it is important that Veterans receive personalized information about their expected costs so they can obtain the most value from their primary care encounters. To test the feasibility, acceptability, and preliminary effectiveness of this approach, our team conducted a 12 week pilot project at the VA Ann Arbor Healthcare System from June-August 2021 in which we made personalized estimates of out-of-pocket, travel, and time costs available and transparent to patients and clinicians in advance of scheduled encounters and at the point of care. We found that it was feasible to generate and deliver personalized cost estimates in advance of visits, that this information was acceptable to patients, and that patients who used cost estimates during a visit with a clinician found this information helpful and would want to receive it again in the future. To achieve greater value in healthcare, systems must continue to pursue new ways to provide transparent information and needed support to patients and clinicians. This means ensuring clinical visits provide the highest levels of access, convenience, and return on patients' healthcare-associated spending while minimizing financial toxicity.

Area Deprivation Index and Rurality in Relation to Financial Toxicity among Breast Cancer Surgical Patients: Retrospective Cross-Sectional Study of Geospatial Differences in Risk Profiles.

BACKGROUND: Financial toxicity (FT) depicts the burden of cancer treatment costs and is associated with lower quality of life and survival in breast cancer patients. We examined the relationship between geospatial location, represented by rurality and Area Deprivation Index (ADI), and risk of FT. STUDY DESIGN: A single-institution, cross-sectional study was performed on adult female surgical breast cancer patients using survey data retrospectively collected between January 2018 and June 2019. Chart reviews were used to obtain patient information, and FT was identified using the COmprehensive Score for Financial Toxicity questionnaire, which is a validated instrument. Patients' home addresses were used to determine rurality using the Rural Urban Continuum Codes and linked to national ADI score. ADI was analyzed in tertiles for univariate statistical analyses, and as a continuous variable to develop multivariable logistic regression models to evaluate the independent associations of geospatial location with FT. RESULTS: A total of 568 surgical breast cancer patients were included. Univariate analyses found significant differences across ADI tertiles with respect to race/ethnicity, marital status, insurance type, education, and rurality. In multivariable analysis, advanced cancer stage (odds ratio [OR] 2.26, 95% CI 1.15 to 4.44) and higher ADI (OR 1.012, 95% CI 1.01 to 1.02) were associated with worsening odds of FT. Increasing age (continuous) (OR 0.976, 95% CI 0.96 to 0.99), married status (vs unmarried) (OR 0.46, 95% CI 0.30 to 0.70), and receipt of bilateral mastectomy (OR 0.56, 95% CI 0.32 to 0.96) were protective of FT. CONCLUSIONS: FT was significantly associated with areas of greater socioeconomic deprivation as measured by the ADI. However, in adjusted analyses, rurality was not significantly associated with FT. ADI can be useful for preoperative screening of at-risk populations and the targeted deployment of community-based interventions to alleviate FT.