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OBJECTIVE - To identify nonclinical factors affecting postoperative complication rates in patients with neurogenic bladder undergoing benign genitourinary (GU) reconstruction.
METHODS - Adult patients with neurogenic bladder undergoing benign GU reconstruction between October 2010 and November 2015 were included. Patients were excluded if a diversion was performed for malignancy, if patients had a history of radiation or if a new bowel segment was not utilized at the time of the operation. Clinical and nonclinical factors were abstracted from the patients' electronic medical records. Health literacy was assessed via the Brief Health Literacy Screen (BHLS), a validated 3-question assessment. Education, marital status, and distance from the medical center were also queried.
RESULTS - Forty-nine patients with a neurogenic bladder undergoing complex GU reconstruction met inclusion and exclusion criteria. On average, patients lived 111 miles (standard deviation 89) from the hospital. Overall, mean BHLS score was 10.4 (standard deviation 4.6) with 35% of patients scoring a BHLS of ≤9. Mean years of educational attainment was 9.7, and only 31% of patients completed high school education. In the first month after surgery, 37 patients (76%) experienced a complication, and 22% were readmitted; however, analysis of complication data did not identify an association between any nonclinical variables and complication rates.
CONCLUSION - Nonclinical factors including unmarried status, poor health literacy, and marked distance from quaternary care are prevalent in patients with neurogenic bladder undergoing complex GU reconstruction. To mitigate these potential risk factors, the authors recommend acknowledgment of these factors and multidisciplinary support perioperatively to counteract them.
Copyright © 2018. Published by Elsevier Inc.
BACKGROUND - Readmission to the hospital within 30 days is a measure of quality care; however, only few modifiable risk factors for 30-day readmission in adults with sickle cell disease are known.
METHODS - We performed a retrospective review of the medical records of adults with sickle cell disease at a tertiary care center, to identify potentially modifiable risk factors for 30-day readmission due to vasoocclusive pain episodes. A total of 88 patients ≥18 years of age were followed for 3.5 years between 2010 and 2013, for 158 first admissions for vasoocclusive pain episodes. Of these, those subsequently readmitted (cases) or not readmitted (controls) within 30 days of their index admissions were identified. Seven risk factors were included in a multivariable model to predict readmission: age, sex, hemoglobin phenotype, median oxygen saturation level, listing of primary care provider, type of health insurance, and number of hospitalized vasoocclusive pain episodes in the prior year.
RESULTS - Mean age at admission was 31.7 (18-59) years; median time to readmission was 11 days (interquartile range 20 days). Absence of a primary care provider listed in the electronic medical record (odds ratio 0.38; 95% confidence interval, 0.16-0.91; P = .030) and the number of vasoocclusive pain episodes requiring hospitalization in the prior year were significant risk factors for 30-day readmission (odds ratio 1.30; 95% confidence interval, 1.16-1.44; P <.001).
CONCLUSION - Improved discharge planning and ensuring access to a primary care provider may decrease the 30-day readmission rate in adults with sickle cell disease.
Copyright © 2017 Elsevier Inc. All rights reserved.
The Hispanic population is the United States' largest minority and one of the fastest growing as well. In the next 30 to 40 years, the proportion of open-angle glaucoma patients represented by Hispanics is expected to dramatically rise. Here we examine the unique considerations and challenges of glaucoma care in this population, from demographics to risk factors to treatments and outcomes. Currently, access to care and the under-diagnosis of glaucoma in this population are significant issues that look only to grow in significance as the glaucoma burden continues to grow. Additionally, utilization of medical and surgical therapy remains lower in Hispanics than in many other ethnic groups. Understanding and proactively addressing the unique challenges in the screening and treatment of Hispanics will be of utmost importance to providing effective care to this population.
The elderly population in the United States (age 65 and older) is growing rapidly, estimated by the U.S. Census Department to reach 83.7 million by 2050.(1) Visual impairment increases with age among all racial and ethnic groups.(2) In the elderly, the most common culprits for vision loss are cataract, glaucoma, and age-related macular degeneration (AMD).(2) In the developed world, vision loss from cataract has been dramatically reduced by increased access to cataract surgery. However, AMD and glaucoma lead to irreversible vision loss without early diagnosis and intervention. In the U.S., cases of AMD are expected to double by 2050, reaching 17.8 million among patients age 50 or older.(3) Similarly, cases of glaucoma are expected to reach 5.5 million by 2050, an increase of over 90% from 2014.(3) The visually impaired elderly face disparities in access to eye care, and subsequent general medical and psychosocial complications.
OBJECTIVE - To evaluate the impact of health insurance expansion on racial disparities in severity of peripheral arterial disease.
BACKGROUND - Lack of insurance and non-white race are associated with increased severity, increased amputation rates, and decreased revascularization rates in patients with peripheral artery disease (PAD). Little is known about how expanded insurance coverage affects disparities in presentation with and management of PAD. The 2006 Massachusetts health reform expanded coverage to 98% of residents and provided the framework for the Affordable Care Act.
METHODS - We conducted a retrospective cohort study of nonelderly, white and non-white patients admitted with PAD in Massachusetts (MA) and 4 control states. Risk-adjusted difference-in-differences models were used to evaluate changes in probability of presenting with severe disease. Multivariable linear regression models were used to evaluate disparities in disease severity before and after the 2006 health insurance expansion.
RESULTS - Before the 2006 MA insurance expansion, non-white patients in both MA and control states had a 12 to 13 percentage-point higher probability of presenting with severe disease (P < 0.001) than white patients. After the expansion, measured disparities in disease severity by patient race were no longer statistically significant in Massachusetts (+3.0 percentage-point difference, P = 0.385) whereas disparities persisted in control states (+10.0 percentage-point difference, P < 0.001). Overall, non-white patients in MA had an 11.2 percentage-point decreased probability of severe PAD (P = 0.042) relative to concurrent trends in control states.
CONCLUSIONS - The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe PAD and resolution of measured racial disparities in severe PAD in MA.
Because of limitations in the availability of data on primary care encounters, patient retention in human immunodeficiency virus (HIV) care is often estimated using laboratory measurement dates as proxies for clinical encounters, leading to possible outcome misclassification. This study included 83,041 HIV-infected adults from 14 clinical cohorts in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) who had ≥1 HIV primary care encounters during 2000-2010, contributing 468,816 person-years of follow-up. Encounter-based retention (REB) was defined as ≥2 encounters in a calendar year, ≥90 days apart. Laboratory-based retention (RLB) was defined similarly, using the dates of CD4-positive cell counts or HIV-1 RNA measurements. Percentage of agreement and the κ statistic were used to characterize agreement between RLB and REB. Logistic regression with generalized estimating equations and stabilized inverse-probability-of-selection weights was used to elucidate temporal trends and the discriminatory power of RLB as a predictor of REB, accounting for age, sex, race/ethnicity, primary HIV risk factor, and cohort site as potential confounders. Both REB and RLB increased from 2000 to 2010 (from 67% to 78% and from 65% to 77%, respectively), though REB was higher than RLB throughout (P < 0.01). RLB agreed well with REB (80%-86% agreement; κ = 0.55-0.62, P < 0.01) and had a strong, imperfect ability to discriminate between persons retained and not retained in care by REB (C statistic: C = 0.81, P < 0.05). As a proxy for REB, RLB had a sensitivity and specificity of 84% and 77%, respectively, with misclassification error of 18%.
© The Author 2015. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
BACKGROUND - Despite the documented survival benefit conferred by neoadjuvant (NAC) and adjuvant chemotherapy (AC), there has been a slow adoption of guideline recommendations for the use of perioperative chemotherapy (POC) in patients with muscle-invasive bladder cancer (MIBC).
OBJECTIVE - To evaluate temporal trends in POC utilization and identify factors influencing POC delivery in a representative cohort of patients with MIBC.
DESIGN, SETTING, AND PARTICIPANTS - Retrospective cohort study identifying factors associated with receipt of POC and evaluating temporal changes in NAC and AC utilization. We included patients from the National Cancer Data Base (NCDB) with no prior malignancy who ultimately underwent radical cystectomy for ≥ cT2/cN0/cM0 MIBC between 2006 and 2010.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS - Relationships between demographic and hospital factors and the likelihood of receiving POC were evaluated using Pearson chi-square and Wilcoxon rank-sum tests, and multivariable logistic regression. Temporal changes in NAC and AC use were detected using a linear test of trend.
RESULTS AND LIMITATIONS - A total of 5692 patients met our inclusion criteria. POC use increased from 29.5% in 2006 to 39.8% in 2010 (p < 0.001). NAC use increased from 10.1% in 2006 to 20.8% in 2010 (p = 0.005); AC remained stable between 18.1% and 21.3% (p = 0.68). Multivariable modeling revealed advanced age, increasing comorbidity, lack of insurance, increased travel distance, geographic location outside the northeastern United States, and lower income as negatively associated with POC receipt (all p < 0.05). Limitations include retrospective design and potential sampling bias, excluding patients treated at non-NCDB facilities.
CONCLUSIONS - POC use for MIBC increased from 2006 to 2010, with this increase disproportionately due to rising NAC utilization. Nonetheless, there is persistent variation in the likelihood of receiving POC secondary to nonclinical factors.
PATIENT SUMMARY - When retrospectively analyzing a representative cohort of patients undergoing radical cystectomy for muscle-invasive bladder cancer between 2006 and 2010, we noted that preoperative chemotherapy rates increased steadily while use of chemotherapy after surgery remained stable. Factors related to access to care significantly influenced receipt of chemotherapy.
Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
The optimal healthcare model for follow-up of allogeneic hematopoietic stem cell transplantation (HSCT) recipients after day 100 is not clear. We previously demonstrated that longitudinal follow-up at the transplant center using a multidisciplinary approach is associated with superior survival. Recent data suggest that increased distance from the transplant center is associated with inferior survival. A dedicated long-term transplant clinic (LTTC) was established in 2006 at our center. We hypothesized that geographic distance would not be associated with inferior outcome if patients are followed in the LTTC. We studied 299 consecutive patients who underwent HSCT and established care in an LTTC. The median distance from the transplant center was 118 miles (range, 1 to 1591). The 75th percentile (170 miles) was used as the cut-off to analyze the impact of distance from the center on outcome (219 patients ≤ 75th percentile; 80 patients >75th percentile). The 2 groups were balanced for pretransplant characteristics. In multivariate analyses adjusted for donor type, Center for International Blood and Marrow Transplant Research risk, and transplant regimen intensity, distance from transplant center did not impact outcome. Our study suggests that geographic distance from the transplant center is not associated with inferior outcome when follow-up care is delivered via a dedicated LTTC incorporating well-coordinated multidisciplinary care.
Published by Elsevier Inc.
BACKGROUND - Soft tissue sarcomas (STS) continue to be excised inappropriately without proper preoperative planning. The reasons for this remain elusive. The role of insurance status and patient distance from sarcoma center in influencing such inappropriate excisions were examined in this study.
METHODS - This retrospective review of a single institution prospective database evaluated 400 patients treated for STS of the extremities between January 2000 and December 2008. Two hundred fifty three patients had a primary excision while 147 patients underwent re-excision. Wilcoxon rank sum test and either χ(2) or Fisher's exact were used to compare variables. Multivariable regression analyses were used to take into account potential confounders and identify variables that affected excision status.
RESULTS - Tumor size, site, depth, stage, margins, and histology were significantly different between the primary excision and re-excision groups; P < 0.05. Insurance status and patient distance from the treatment center were not statistically different between the two groups. Large and deep tumors and certain histology types predicted appropriate referral.
CONCLUSIONS - Inappropriate excision of STS is not influenced by patient distance from a sarcoma center or by a patient's insurance status. In this study, tumor size, depth, and certain histology types predicted the appropriate referral of a STS to a sarcoma center.
© 2013 Wiley Periodicals, Inc.
OBJECTIVE - To examine healthcare resource utilization for acute respiratory illness in Latino infants compared with other racial/ethnic groups.
STUDY DESIGN - We studied 674 term-born, previously healthy infants brought in for an unscheduled healthcare visit for an acute respiratory illness. The predictor variable was infant race/ethnicity, and the primary outcome was healthcare resource utilization, adjusted for age and disease severity.
RESULTS - The cohort was 14% Latino, 52% white, 22% African American, and 12% other race/ethnicity. More than one-third (37%) of the mothers of Latino infants were Spanish-speaking. The bronchiolitis severity score was higher (indicating more severe disease) in white infants (median, 6.0; IQR, 3.0-9.0 on a scale of 0-12) compared with Latino (median, 3.0; IQR, 1.0-6.0) and African American (median, 3.5; IQR, 1.0-6.0) infants (P < .001 for the comparison of all groups). Disease severity was similar in Latino and African American infants (P = .96). Latino infants were the most likely to receive antibiotics (58%, compared with 47% of whites and 34% of African Americans; P = .005) and to have body fluid cultures drawn. Latino infants also were more likely than African American infants to undergo chest radiography and respiratory virus rapid antigen testing (P ≤ .01). Latino infants from Spanish-speaking families had a higher rate of respiratory syncytial virus testing compared with those from English-speaking families (76% vs 51%; P = .016).
CONCLUSION - Providers caring for Latino infants with acute respiratory illness ordered more antibiotics and diagnostic testing for this group, particularly compared with African Americans, even though the 2 groups had similar disease severity and socioeconomic disparities. Language barrier may be a possible explanation for these differences.
Copyright © 2013 Mosby, Inc. All rights reserved.