Impact of the Affordable Care Act on Providing Equitable Healthcare Access for IBD in the Kentucky Appalachian Region.

BACKGROUND: Medicaid expansion improved insurance coverage for patients with chronic conditions and low income. The effect of Medicaid expansion on patients with IBD from high-poverty communities is unknown. OBJECTIVE: This study aimed to evaluate the impact of Medicaid expansion in Kentucky on care for patients with IBD from the Eastern Kentucky Appalachian community, a historically impoverished area. DESIGN: This study was a retrospective, descriptive, and ecological study. SETTINGS: This study was conducted in Kentucky using the Hospital Inpatient Discharge and Outpatient Services Database. PATIENTS: All encounters for IBD care for 2009-2020 for patients from the Eastern Kentucky Appalachian region were included. MAIN OUTCOME MEASURES: The primary outcomes measured were proportions of inpatient and emergency encounters, total hospital charge, and hospital length of stay. RESULTS: Eight hundred twenty-five preexpansion and 5726 postexpansion encounters were identified. Postexpansion demonstrated decreases in the uninsured (9.2%-1.0%; p < 0.001), inpatient encounters (42.7%-8.1%; p < 0.001), emergency admissions (36.7%-12.3%; p < 0.001), admissions from the emergency department (8.0%-0.2%; p < 0.001), median total hospital charge ($7080-$3260; p < 0.001), and median total hospital length of stay (4-3 days; p < 0.001). Similarly, postexpansion demonstrated increases in Medicaid coverage (18.8%-27.7%; p < 0.001), outpatient encounters (57.3%-91.9%; p < 0.001), elective admissions (46.9%-76.2%; p < 0.001), admissions from the clinic (78.4%-90.2%; p < 0.001), and discharges to home (43.8%-88.2%; p < 0.001). LIMITATIONS: This study is subject to the limitations inherent in being retrospective and using a partially de-identified database. CONCLUSION: This study is the first to demonstrate the changes in trends in care after Medicaid expansion for patients with IBD in the Commonwealth of Kentucky, especially Appalachian Kentucky, showing significantly increased outpatient care utilization, reduced emergency department encounters, and decreased length of stays. IMPACTO DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO EN LA PROVISIN DE ACCESO EQUITATIVO A LA ATENCIN MDICA PARA LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LA REGIN DE LOS APALACHES DE KENTUCKY: ANTECEDENTES: La expansión de Medicaid mejoró la cobertura de seguro para pacientes con enfermedades crónicas y bajos ingresos. Se desconoce el efecto de la expansión de Medicaid en pacientes con enfermedad inflamatoria intestinal de comunidades de alta pobreza.OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la expansión de Medicaid en Kentucky en la atención de pacientes con enfermedad inflamatoria intestinal de la comunidad de los Apalaches del este de Kentucky, un área históricamente empobrecida.DISEÑO: Este estudio fue un estudio retrospectivo, descriptivo, ecológico.ESCENARIO: Este estudio se realizó en Kentucky utilizando la base de datos de servicios ambulatorios y de alta hospitalaria en pacientes hospitalizados.PACIENTES: Se incluyeron todos los encuentros para la atención de la enfermedad inflamatoria intestinal de 2009-2020 para pacientes de la región de los Apalaches del este de Kentucky.MEDIDAS DE RESULTADO PRINCIPALES: Los resultados primarios medidos fueron proporciones de encuentros de pacientes hospitalizados y de emergencia, cargo hospitalario total y duración de la estancia hospitalaria.RESULTADOS: Se identificaron 825 encuentros previos a la expansión y 5726 posteriores a la expansión. La posexpansión demostró disminuciones en los no asegurados (9.2% a 1.0%, p < 0.001), encuentros de pacientes hospitalizados (42.7% a 8.1%, p < 0.001), admisiones de emergencia (36.7% a 12.3%, p < 0,001), admisiones desde el servicio de urgencias (8.0% a 0.2%, p < 0.001), la mediana de los gastos hospitalarios totales ($7080 a $3260, p < 0.001) y la mediana de la estancia hospitalaria total (4 a 3 días, p < 0.001). De manera similar, la cobertura de Medicaid (18.8% a 27.7%, p < 0.001), consultas ambulatorias (57.3% a 91.9%, p < 0.001), admisiones electivas (46.9% a 76.2%, p < 0.001), admisiones desde la clínica (78.4% al 90.2%, p < 0.001), y las altas domiciliarias (43.8% al 88.2%, p < 0.001) aumentaron después de la expansión.LIMITACIONES: Este estudio está sujeto a las limitaciones inherentes de ser retrospectivo y utilizar una base de datos parcialmente desidentificada.CONCLUSIONES: Este estudio es el primero en demostrar los cambios en las tendencias en la atención después de la expansión de Medicaid para pacientes con enfermedad inflamatoria intestinal en el Estado de Kentucky, especialmente en los Apalaches de Kentucky, mostrando un aumento significativo en la utilización de la atención ambulatoria, visitas reducidas al departamento de emergencias y menor duración de la estancia hospitalaria. (Traducción-Dr. Jorge Silva Velazco ).

Preoperative opioid, sedative, and antidepressant use is associated with increased postoperative hospital costs in colorectal surgery.

BACKGROUND: Opioid (OPD), sedative (SDT), and antidepressant (ADM) prescribing has increased dramatically over the last 20 years. This study evaluated preoperative OPD, SDT, and ADM use on hospital costs in patients undergoing colorectal resection at a single institution. METHODS: This study was a retrospective record review. The local ACS-NSQIP database was queried for adult patients (age ≥ 18 years) undergoing open/laparoscopic, partial/total colectomy, or proctectomy from January 1, 2013 to December 31, 2016. Individual patient medical records were reviewed to determine preoperative OPD, SDT, and AD use. Hospital cost data from index admission were captured by the hospital cost accounting system and matched to NSQIP query-identified cases. All ACS-NSQIP categorical patient characteristic, operative risk, and outcome variables were compared in medication groups using chi-square tests or Fisher's exact tests, and continuous variables were compared using Mann-Whitney U tests. RESULTS: A total of 1185 colorectal procedures were performed by 30 different surgeons. Of these, 27.6% patients took OPD, 18.5% SDT, and 27.8% ADM preoperatively. Patients taking OPD, SDT, and ADM were found to have increased mean total hospital costs (MTHC) compared to non-users (30.8 vs 23.6 for OPD, 31.6 vs 24.4 for SDT, and 30.7 vs 23.8 for ADM). OPD and SDT use were identified as independent risk factors for increased MTHC on multivariable analysis. CONCLUSION: Preoperative OPD and SDT use can be used to predict increased MTHC in patients undergoing colorectal resections.

A Retrospective Review: Patient-Reported Preoperative Prescription Opioid, Sedative, or Antidepressant Use Is Associated with Worse Outcomes in Colorectal Surgery.

BACKGROUND: Prescription opioid, sedative, and antidepressant use has been on the rise. The effect of these medications on outcomes in colorectal surgery has not been established. OBJECTIVE: This study aimed to evaluate the impact of preoperative prescription opioid, sedative, and antidepressant use on postoperative outcomes following colorectal surgery. DESIGN: This study was a retrospective database and medical record review. SETTINGS: This study was conducted at University of Kentucky utilizing the local American College of Surgeons National Surgical Quality Improvement Project database. PATIENTS: All patients ≥18 years of age who underwent colorectal resection for all indications, excluding trauma, between January 1, 2013, and December 31, 2016, were included. MAIN OUTCOME MEASURES: The primary outcomes measured were the rates of 30-day postoperative morbidity and mortality. RESULTS: Of 1201 patients, 30.2% used opioids, 18.4% used sedatives, and 28.3% used antidepressants preoperatively. Users of any medication class had higher ASA classification, rates of dyspnea, and severe chronic obstructive pulmonary disease than nonusers. Opioid users also had higher rates of ostomy creation, contaminated wound classification, prolonged operation time, and postoperative transfusion. Postoperatively, patients had higher rates of intra-abdominal infection (opioids: 21.5% vs 15.2%, p = 0.009; sedatives: 23.1% vs 15.7%, p = 0.01; antidepressants: 22.4% vs 15.0%, p = 0.003) and respiratory failure (opioids: 11.0% vs 6.3%, p = 0.007; sedatives: 12.2% vs 6.7%, p = 0.008; antidepressants: 10.9% vs 6.5%, p = 0.02). Reported opioid or sedative users had a prolonged hospital length of stay of 2 days (p < 0.001) compared with nonusers. After adjustment for all predictors of poor outcome, opioid and sedative use was associated with increased 30-day morbidity and mortality following colorectal procedures (OR, 1.43; 95% CI, 1.07-1.91 and OR, 1.48; 95% CI, 1.05-2.08). LIMITATIONS: This study was a retrospective review and a single-institution study, and it had unmeasured confounders. CONCLUSIONS: We identified that patient-reported prescription opioid and sedative use is associated with higher 30-day composite adverse outcomes in colorectal resections, highlighting the need for the evaluation of opioid and sedative use as a component of the preoperative risk stratification. See Video Abstract at http://links.lww.com/DCR/B226. REVISIÓN RETROSPECTIVA: EL USO DE OPIOIDES, SEDANTES O ANTIDEPRESORES EN EL PREOPERATORIO SE ASOCIAN CON MALOS RESULTADOS EN CIRUGÍA COLORECTAL: El uso de opioides, sedantes y antidepresores esta en aumento. No se ha establecido el efecto de estos medicamentos en los resultados de la cirugía colorrectal.Evaluar el impacto del uso preoperatorio de opioides, sedantes y antidepresores en los resultados después de una cirugía colorrectal.Base de datos retrospectiva y revisión de registros médicos.Este estudio se realizó en la Universidad de Kentucky utilizando la base de datos del Proyecto de Mejora de Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Todos los pacientes ≥ 18 años que se sometieron a una resección colorrectal por diversas indicaciones, excluyendo los traumas, entre el 1 de Enero de 2013 y el 31 de Diciembre de 2016.Tasas de morbilidad y mortalidad postoperatorias a los 30 días.De 1201 pacientes, 30.2% usaron opioides, 18.4% usaron sedantes y 28.3% usaron antidepresores antes de la cirugía. Los pacientes tratados con cualquiera de los medicamentos mencionados, presentaban un ASA mas elevado, tasas de disnea y EPOC mas graves en comparación con pacientes sin tratamiento previo. Los consumidores de opioides también tuvieron tasas más altas de creación de ostomías, clasificación mas alta de heridas contaminadas, un tiempo de operación prolongado y transfusión postoperatoria mayor. Después de la cirugía los pacientes que tuvieron tasas más altas de infección intraabdominal (opioides: 21.5% vs 15.2%, p = 0.009, sedantes: 23.1% vs 15.7%, p = 0.01, antidepresivos: 22.4% vs 15.0%, p = 0.003) e insuficiencia respiratoria (opioides: 11.0% vs 6.3%, p = 0.007, sedantes: 12.2% vs 6.7%, p = 0.008, antidepresivos: 10.9% vs 6.5%, p = 0.02). Los consumidores de opioides o sedantes tuvieron una estadía hospitalaria prolongada de más de 2 días (p <0.001) en comparación con los consumidores. Después de haber realizado el ajuste de todos los predictores de mal pronóstico, el uso de opioides y sedantes se asoció con una mayor morbilidad y mortalidad a los 30 días después de cirugía colorrectal (OR 1.43 [IC 95% 1.07-1.91] y OR 1.48 [IC 95% 1.05-2.08], respectivamente)Revisión retrospectiva, estudio de una sola institución, factores de confusión no evaluados.Identificamos que el consumo de opiáceos y sedantes recetados a los pacientes se asocian con resultados adversos complejos más allá de 30 días en casos de resección colorrectal, destacando la necesidad de su respectiva evaluación como componentes de la estratificación de riesgo preoperatorio. Consulte Video Resumen http://links.lww.com/DCR/B226. (Traducción-Dr. Xavier Delgadillo).

Effect of Medicaid expansion on inflammatory bowel disease and healthcare utilization.

BACKGROUND: Kentucky was among the first to adopt Medicaid expansion, resulting in reducing uninsured rates from 14.3% to 6.4%. We hypothesize that Medicaid expansion resulted in increased elective healthcare utilization and reductions in emergency treatments by patients suffering Inflammatory Bowel Disease (IBD). METHODS: The Hospital Inpatient Discharge and Outpatient Services Database (HIDOSD) identified all encounters related to IBD from 2009 to 2020 in Kentucky. Several demographic variables were compared in pre- and post-Medicaid expansion adoption. RESULTS: Our study analyzed 3386 pre-expansion and 24,255 post-expansion encounters for IBD patients. Results showed that hospitalization rates dropped (47.7%-8.4%), outpatient visits increased (52.3%-91.6%) and Emergency visits decreased (36.7%-11.4%). Admission following a clinical referral similarly increased with a corresponding drop in emergency room admissions. Hospital costs and lengths of stay also dropped following Medicaid expansion. CONCLUSION: In the IBD population, Medicaid expansion improved access to preventative care, reduced hospital costs by decreasing emergency care, and increased elective care pathways.

A Review of Quality Improvement Process Measures for Colorectal Surgery in the United States Using the American College of Surgeons National Surgical Quality Improvement Program Database - Have We Made Progress?

Numerous guidelines have been published regarding Enhanced Recovery Programs (ERP) following colorectal surgery over the past decade. Participation in these guidelines at a national level is unclear. We hypothesize that the adaptation of ERP for patients undergoing elective colorectal surgery is limited but the use of quality improvement measures has increased and while outcomes have improved over the past several years. A total of 86 402 patients were evaluated undergoing elective colectomy between 2013-2018 using the ACS-NSQIP database. Over a 5-year period, there was a significant increase in the use of quality improvement process measures: mechanical and oral bowel preparation and minimally invasive approach. During this time, there was a significant decrease in overall perioperative morbidities (P <.001). These encouraging results from a large national database suggest that evidence-based, quality improvement guidelines are being embraced and that overall outcomes for patients undergoing elective colectomy are improving.

Improving physician documentation for malnutrition: A sustainable quality improvement initiative.

This study compares documentation and reimbursement rates before and after provider education in nutritional status documentation. Our study aimed to evaluate accurate documentation of nutrition status between registered dietitian nutritionists and licensed independent practitioners before and after the implementation of a dietitian-led Nutrition-Focused Physical Exam intervention at an academic medical center in the southeastern US. ICD-10 codes identified patients from 10/1/2016-1/31/2018 with malnutrition. The percentage of patients with an appropriate diagnosis of malnutrition and reimbursement outcomes attributed to malnutrition documentation were calculated up to 24 months post-intervention. 528 patients were analyzed. Pre-intervention, 8.64% of patients had accurate documentation compared to 46.3% post-intervention. Post-intervention, 68 encounters coded for malnutrition resulted in an estimated $571,281 of additional reimbursement, sustained at 6, 12, 18, and 24 months. A multidisciplinary intervention improved physician documentation accuracy of malnutrition status and increased reimbursement rates.

Impact of the Affordable Care Act Medicaid Expansion on Reimbursement in Emergency General Surgery.

BACKGROUND: Kentucky had one of the nation's largest increases in insurance coverage with the Affordable Care Act's (ACA) Medicaid expansion, quadrupling the proportion of Kentuckians with insurance coverage. This study compares reimbursement rates for surgical procedures performed by emergency general surgery (EGS) services at the University of Kentucky (UK) before and after Medicaid expansion in January 2014. METHODS: This IRB-approved, single-institution study retrospectively evaluated all patients undergoing surgical treatment by our EGS team from 1/1/2011 to 12/31/2016. We queried operative records for the most frequently performed procedures by the EGS service. We reviewed patient electronic medical records and hospital financial records to identify insurance status, diagnosis codes, and expected hospital reimbursements, based on UK Hospital's procedure/payer accounting models. RESULTS: Four thousand six hundred ninety-three patient procedures met inclusion criteria; 46.5% of these came before ACA expansion and 53.5% after expansion. The most frequent procedures performed were incision and drainage, laparoscopic appendectomy, laparoscopic cholecystectomy, and exploratory laparotomy. After ACA expansion, the proportion of patients with Medicaid nearly doubled (19.8% vs. 35.6%, p < 0.001). Concomitantly, there was a more than fivefold decrease in the uninsured patient population after expansion (23.3% vs. 4.6%, p < 0.001), and mean hospital reimbursement increased for laparoscopic appendectomy (13.7%, p < 0.001), laparoscopic cholecystectomy (50.7%, p < 0.001), and incision and drainage (70.2%, p < 0.001). CONCLUSION: After ACA expansion, there was a sustained decrease in proportion of uninsured patients and a concomitant sustained increase in proportion of patients with access to Medicaid services in the EGS operative population, leading to increased mean hospital reimbursements and decreased patient financial burden.

Abdominal Wall Thickness is a Predictor for Surgical Site Infections in Patients Undergoing Colorectal Operations.

BACKGROUND: Surgical site infections (SSIs) are an established complication following colorectal operations, with rates up to 30% reported in the literature. Obesity is a known risk factor for SSI; however, body mass index (BMI), body fat percentage, waist-hip ratio, or abdominal circumference are imperfect measures. The purpose of our study was to determine whether abdominal wall thickness (AWT) is predictive of SSI. METHODS: We queried our American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database for patients (age ≥18 years) undergoing a colectomy at the University of Kentucky (UK) from January 1, 2013 to December 31, 2018. The exclusion criteria included patients with open abdomens or the lack of preoperative computed tomography (CT) within 3 months of their operation. AWT was measured at the level of the anterior superior iliac spine (ASIS) on abdominal CT. SSI was defined by superficial SSI, deep SSI, and wound dehiscence. RESULTS: Of 1261 patients enrolled, 52.2% were female, with an average age of 57.4 years. More patients had laparoscopic operations (51%), and the median length of stay was 7 days. Our study demonstrated an SSI rate of 9.4% and a 30-day readmission rate of 11%. The overall mean AWT was 2.6 cm (range .1-13.1), and patients with the highest AWT quintile were more likely to develop an SSI than the lowest quintile (12% vs. 5%). After controlling for risk factors and confounders, the odds of an SSI were 3.6 times higher for patients with the highest AWT than patients with the lowest AWT. CONCLUSIONS: Among colorectal surgery patients, AWT is an independent risk factor predictive for SSI.

Nonadherence to Standard of Care for Locally Advanced Colon Cancer as a Contributory Factor for High Mortality Rates in Kentucky.

BACKGROUND: Kentucky has one of the highest mortality rates for colon cancer, despite dramatic improvements in screening. The National Comprehensive Cancer Network (NCCN) guidelines recommend operation and adjuvant chemotherapy for locally advanced (stage IIb/c and stage III) colon cancer (LACC). The purpose of this study was to determine the rate of nonadherence with current standard of care (SOC) and associated factors as possible contributors to mortality. METHODS: The Kentucky Cancer Registry database linked with administrative health claims was queried for individuals (20 years and older) diagnosed with LACC from 2007 to 2012. Bivariate and logistic regression of nonadherence was performed. Survival analysis was performed with Cox regression and Kaplan-Meier plots. RESULTS: A total of 1,404 patients with LACC were included. Approximately 42% of patients with LACC were noted to be nonadherent to SOC, with nearly all (95.7%) failing to receive adjuvant chemotherapy. After adjusting for all significant factors, we found the factors associated with nonadherence included the following: age older than 75 years, stage III colon cancer, high Charlson Comorbidity Index (3+), low poverty level, Medicaid coverage, and disability. Adherence to SOC is associated with a significant improvement in the 5-year survival rate compared with nonadherence (63.0% and 27.4%, respectively; p < 0.0001). CONCLUSIONS: Our study identified multiple factors associated with the failure of patients with LACC to receive SOC, particularly adjuvant chemotherapy, suggesting the need to focus on improving adjuvant chemotherapy compliance in specific populations. Nonadherence to LACC SOC is likely a major contributor to the persistently high mortality rates in Kentucky.

Impact of the Affordable Care Act on Colorectal Cancer Screening, Incidence, and Survival in Kentucky.

BACKGROUND: Kentucky ranks first in the US in cancer incidence and mortality. Compounded by high poverty levels and a high rate of medically uninsured, cancer rates are even worse in Appalachian Kentucky. Being one of the first states to adopt the Affordable Care Act (ACA) Medicaid expansion, insurance coverage markedly increased for Kentucky residents. The purpose of our study was to determine the impact of Medicaid expansion on colorectal cancer (CRC) screening, diagnosis, and survival in Kentucky. STUDY DESIGN: The Kentucky Cabinet for Health and Family Services and the Kentucky Cancer Registry were queried for individuals (≥20 years old) undergoing CRC screening (per US Preventative Services Task Force) or diagnosed with primary invasive CRC from January 1, 2011 to December 31, 2016. Colorectal cancer screening rates, incidence, and survival were compared before (2011 to 2013) and after (2014 to 2016) ACA implementation. RESULTS: Colorectal cancer screening was performed in 930,176 individuals, and 11,441 new CRCs were diagnosed from 2011 to 2016. Screening for CRC increased substantially for Medicaid patients after ACA implementation (+230%, p < 0.001), with a higher increase in screening among the Appalachian (+44%) compared with the non-Appalachian (+22%, p < 0.01) population. The incidence of CRC increased after ACA implementation in individuals with Medicaid coverage (+6.7%, p < 0.001). Additionally, the proportion of early stage CRC (stage I/II) increased by 9.3% for Appalachians (p = 0.09), while there was little change for non-Appalachians (-1.5%, p = 0.60). Colorectal cancer survival was improved after ACA implementation (hazard ratio 0.73, p < 0.01), particularly in the Appalachian population with Medicaid coverage. CONCLUSIONS: Implementation of Medicaid expansion led to a significant increase in CRC screening, CRC diagnoses, and overall survival in CRC patients with Medicaid, with an even more profound impact in the Appalachian population.

Laparoscopic Surgery for Diverticular Fistulas: Outcomes of 111 Consecutive Cases at a Single Institution.

BACKGROUND: The purpose of this study was to review our experience with laparoscopic colectomy and fistula resection, evaluate the frequency of conversion to open, and to compare the perioperative courses of the complete laparoscopic and conversion groups. METHODS: This study is a retrospective analysis of 111 consecutive adult patients with diverticular fistulae diagnosed clinically or radiographically over 11 years at a single institution. Five patients were excluded for preoperative comorbidities. The remaining 106 consecutive patients underwent minimally invasive sigmoid colectomy with primary anastomosis. Preoperative, intraoperative, and postoperative variables were collected from the colorectal surgery service database. A retrospective cohort analysis was performed between laparoscopic and converted groups. RESULTS: Within the group, 47% had colovesical fistulas, followed by colovaginal, coloenteric, colocutaneous, and colocolonic fistulas. The overall conversion rate to laparotomy was 34.7% (n = 37). The most common reason for conversion was dense fibrosis. Mean operative time was similar between groups. Combined postoperative complications occurred in 26.4% of patients (21.4% laparoscopic and 37.8% converted, p = 0.075). Length of stay was significantly shorter in the laparoscopic group (5.8 vs 8.1 days, p = 0.014). There were two anastomotic leaks, both in the open group. There were no 30-day mortalities. CONCLUSIONS: Laparoscopic sigmoid colectomy for diverticular fistula is safe, with complication rates comparable to open sigmoid resection. We identify a conversion rate which allows the majority of patients to benefit from minimally invasive procedures.