Gender Disparity in Composition and Compensation Among Maryland Hospital Executives

Introduction: Senior executive positions in hospitals have traditionally been held by men, and do not reflect the gender, racial, ethnic, and cultural diversities of the communities they serve. Despite sex parity in medical school graduates, women remain underrepresented in hospital executive leadership positions. In this study, the authors examined differences in gender composition and compensation of Maryland hospital executives. Methods: The authors examined 47 Maryland hospitals’ publicly available tax forms from 2013-2018. Data collected included hospital revenue and executive positions’ count, salary, and gender. Executive positions included President and/or Chief Executive Officer (P/CEO), Chief Financial Officer (CFO), Chief Medical Officer (CMO), Chief Nursing Officer (CNO), and Chief Operating Officer (COO). All monetary values were inflation-adjusted to the 2017 dollar. Results: Women executives were underrepresented across most roles: P/CEO (41/272, 15%), CFO (72/260, 28%), CMO (28/182, 15%), and COO (44/147, 30%). CNO showed a higher proportion of women executives (129/140, 92%). There were no significant changes in the proportion of women executives over the study period (p=0.19). Men CNO’s had significantly higher salaries as a percentage of hospital revenue (0.16% vs 0.12%, p=0.04) and men COOs had significantly higher salaries as a percentage of hospital positive profit (3.65% vs 2.24%, p\u3c0.01). Conclusion: Data from Maryland hospitals suggest that women remain underrepresented in healthcare executive roles. Further, women executives are generally undercompensated compared to men in similar roles. This study further highlights the need for mentorship and dedicated career pathways to improve women representation in leadership roles in healthcare

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration

BACKGROUND: Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery. AIM: To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients. METHODS: In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of \u3c 7 g/dL hemoglobin in asymptomatic patients and \u3c 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P \u3c 0.05. RESULTS: Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P \u3c 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P \u3c 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring \u3e 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort. CONCLUSION: The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery

Predictors of Hospice Discharge Following Surgical Fixation of Hip Fracture

Introduction: Each year, over 300,000 people over the age of 65 are hospitalized for hip fractures, and even with co-management of patients perioperatively with a geriatric team, hip fractures in the elderly are associated with significant morbidity and mortality. Given the extreme morbidity and mortality faced by elderly patients in the post-injury period, recommendations have been put forth for the integration of palliative and even hospice care, to help improve patients’ quality of life. Our objectives were to 1) determine the proportion of patients discharged to hospice following hip fracture surgery and their 30-day mortality rates of these patients, and 2) identify the independent predictors of discharge to hospice. Methods: We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) for all hip fractures surgeries between the years of 2016 and 2018. Included cases were stratified into two cohorts: cases involving a discharge to hospice and non-hospice discharge. Variables assessed included patient demographics, comorbidities, perioperative characteristics, and postoperative outcomes. Differences between hospice and non-hospice patients were compared using chi-squared analysis or Fisher\u27s exact test for categorical variables and Student’s t-tests for continuous variables. A binary logistic regression model was used to assess independent predictors of hospice discharge with 30-day mortality. Results: Overall, 31,531 operatively treated hip fractures were identified, of which 281 (0.9%) involved a discharge to hospice. Patients discharged to hospice had a 67% 30-day mortality rate in comparison to 5.6% of patients not discharged to hospice (p \u3c 0.001). Disseminated cancer, dependent functional status, \u3e10% weight loss over six months preoperatively, and preoperative cognitive deficit were the strongest predictors of hospice discharge with 30-day mortality following hip fracture surgery. Conclusions: Current hospice utilization in hip fracture patients remains low, but 30-day mortality in these patients is high. An awareness of the associations between patient characteristics and discharge to hospice with 30-day mortality is important for surgeons to consider when discussing postoperative expectations and outcomes with these patients

Penicillin Allergy in Spine Surgery: Increased Rates of Sepsis, Emergency Room Visits, and Readmission.

OBJECTIVE: To determine if a penicillin allergy is an independent risk factor for poor outcomes after anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF). METHODS: A retrospective database review was performed using the PearlDiver data set. The study population included all patients younger than 85 years who underwent elective PLF or ACDF with diagnosis of penicillin allergy using International Classification of Diseases codes. Study patients were compared with controls for 90-day complications and 1-year reoperation rates. A multivariate logistic regression was used to determine the independent effect of penicillin allergy on the postoperative outcomes. RESULTS: PLF cohort multivariate analysis showed that patients with a penicillin allergy had a significantly increased risk of sepsis (2.6% vs. 2.0%; P = 0.020), urinary tract infection (10.8% vs. 8.4%; P \u3c 0.001), emergency room visits (27.3% vs. 20.2%; P \u3c 0.001), and readmissions (9.6% vs. 6.4%; P \u3c 0.001) within 90 days index of surgery. Similarly, the ACDF cohort multivariate analysis showed that a penicillin allergy was associated with an increased risk of sepsis (1.8% vs. 1.1%; P \u3c 0.001), emergency room visits (27.2% vs. 20.7%; P \u3c 0.001), and readmissions (6.8% vs. 5.6%; P = 0.003) within 90 days index of surgery. CONCLUSIONS: The present study found that a reported penicillin allergy is associated with an increase in sepsis, urinary tract infection, emergency room visit, and readmission postoperatively within 90 days after PLF and ACDF. The findings can help physicians provide patients with more comprehensive preoperative counseling in the setting of patient-reported penicillin allergy

Fragility Fracture Risk in Elderly Patients With Cervical Myelopathy

Retrospective review. To identify and compare the incidences of fragility fractures amongst three elderly populations: the general population, patients with surgically treated cervical spondylotic myelopathy (CSM), and patients with CSM not surgically treated. CSM is a common disease in the elderly. Progression of myelopathic symptoms, including gait imbalance, can be a source of morbidity as it can lead to increased falls. Records of elderly patients with Medicare insurance from 2005 to 2014 were retrospectively reviewed. Three mutually exclusive populations of patients were identified for analysis, including a cohort of patients with a diagnosis of CSM who were not treated with surgery; a cohort of patients with CSM who were treated with surgery; and a group of control patients who had never been treated with cervical spine surgery nor were diagnosed with CSM. Incidence of fractures of the distal radius, proximal humerus, proximal femur, and lumbar spine were assessed and compared between cohorts, adjusted by age, sex, osteoporosis, dementia, cerebrovascular disease, and Charlson Comorbidity Index. A total of 891,864 patients were identified, of which 60,332 had a diagnosis of CSM and 24,439 underwent cervical spine surgery. Compared to general population controls, the 12-month adjusted odds of experiencing at least one fragility fracture were 1.59 times higher in patients with CSM who were not treated with surgery (P < 0.001). The analogous odds ratio was 1.34 (P < 0.001) at 3 years. Compared to nonsurgically treated patients with CSM, the odds of experiencing at least one fragility fracture were reduced to 0.89 in surgically treated patients (P = 0.008). Fragility fractures are a significant source of morbidity and mortality in elderly patients. CSM is associated with increased rates of fragility fractures, although surgical management of CSM may be protective against risk of fragility fracture. 3

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P145. Risk factors, additional length of stay and cost associated with postoperative ileus following anterior lumbar interbody fusion in the elderly

The incidence of lumbar fusion surgery for the treatment of degenerative conditions is increasing rapidly in the elderly population. In appropriately selected patients with symptomatic lumbar degenerative disease, lumbar interbody fusion has been shown to provide substantial improvement, regardless of the specific technique chosen. The anterior approach affords a number of benefits, but has been associated with a 2-3times higher incidence of postoperative ileus compared to the transforaminal or posterior approaches. The purpose of this study was to identify the independent risk factors, additional length of stay, and additional cost associated with postoperative ileus following anterior lumbar interbody fusion in the elderly. Retrospective analysis of Medicare insurance database. Elderly patients with Medicare insurance treated between 2005 and 2014. The primary outcome measure studied was the incidence of postoperative ileus. Secondary outcome measures included average hospitalization cost and length of stay. Records of patients with Medicare insurance were retrospectively reviewed to identify patients 65years of age and older undergoing 1 or 2 level primary elective anterior lumbar interbody fusion from 2005 to 2014. Independent risk factors, additional length of stay and additional cost associated with postoperative ileus were evaluated with multivariate analysis. A total of 13,139 patients were identified. Of the identified patients, 642 experienced postoperative ileus within 3days of surgery. Multivariate analysis identified fluid and electrolyte imbalance within 3days of surgery (odds ratio=4.03, P<.001) and male sex (odds ratio=1.72, P<.001) as independent risk factors for ileus. Multivariate analysis also associated postoperative ileus with additional length of stay of 2.83 days±0.11days (P <.001) and additional cost of $2,349±$419 (P<.001). Patients with perioperative fluid and electrolyte imbalances were 4times as likely to experience postoperative ileus. Fluid balance and electrolytes should be carefully monitored during the perioperative period in patients undergoing anterior lumbar interbody fusion as a potential means to reduce the incidence of postoperative ileus and the additional length of stay and cost burden associated with this complication

Predictors of Hospice Discharge After Surgical Fixation of Hip Fractures.

BACKGROUND: Each year, over 300,000 people older than 65 years are hospitalized for hip fractures. Given the notable morbidity and mortality faced by elderly patients in the postinjury period, recommendations have been put forth for integrating palliative and, when needed, hospice care to improve patients\u27 quality of life. Our objective was to (1) understand the proportion of patients discharged to hospice after hip fracture surgery and their 30-day mortality rates and (2) identify the independent predictors of discharge to hospice. METHODS: We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program for all hip fracture surgeries between the years of 2016 and 2018. Included cases were stratified into two cohorts: cases involving a discharge to hospice and nonhospice discharge. Variables assessed included patient demographics, comorbidities, perioperative characteristics, and postoperative outcomes. Differences between hospice and nonhospice patients were compared using chi-squared analysis or the Fisher exact test for categorical variables and Student t -tests for continuous variables. A binary logistic regression model was used to assess independent predictors of hospice discharge with 30-day mortality. RESULTS: Overall, 31,531 surgically treated hip fractures were identified, of which only 281 (0.9%) involved a discharge to hospice. Patients discharged to hospice had a 67% 30-day mortality rate in comparison with 5.6% of patients not discharged to hospice ( P \u3c 0.001). Disseminated cancer, dependent functional status, \u3e10% weight loss over 6 months preoperatively, and preoperative cognitive deficit were the strongest predictors of hospice discharge with 30-day mortality after hip fracture surgery. CONCLUSIONS: Current hospice utilization in hip fracture patients remains low, but 30-day mortality in these patients is high. An awareness of the associations between patient characteristics and discharge to hospice with 30-day mortality is important for surgeons to consider when discussing postoperative expectations and outcomes with these patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study

Improvement of postural stability and gait velocity after cervical decompression surgery in patients with cervical spondylotic myelopathy.

OBJECTIVE: Cervical spondylotic myelopathy (CSM) is a progressive degenerative condition that can lead to significant neurological deficits, including gait instability. Biomechanical alterations of gait and its various components are poorly understood. The goal of the current study was to determine how spatiotemporal gait parameters, as well as postural and dynamic stability, change after surgery in CSM patients. METHODS: A total of 47 subjects were included, with 23 test subjects and 24 controls. Baseline measurements were made for both cohorts. In the CSM cohort, repeat measurements were made at 3 and 6 months postoperatively. To record spatiotemporal and dynamic stability parameters, subjects performed walking trials over force plates on a 15-m runway. To assess postural stability, standing balance trials were conducted on a floor-mounted force plate. Three-dimensional motion analysis cameras and gait modeling software were used to quantify and visually represent results. Statistical analysis was completed using repeated-measures ANOVA and paired t-tests. Significance was set at p \u3c 0.05. RESULTS: CSM patients had significantly increased gait velocity at the 6-month follow-up (mean 0.948 ± 0.248 m/sec/leg length) versus baseline (mean 0.852 ± 0.257 m/sec/leg length) (p = 0.039). The tilted ellipse area was significantly decreased at the 6-month follow-up compared with baseline (mean 979.8 ± 856.7 mm2 vs 598.0 ± 391.1 mm2, p = 0.018). Angular momentum excursion was not significantly different between baseline and the 3- and 6-month follow-ups. CONCLUSIONS: CSM patients displayed significant improvement in gait velocity and postural stability parameters after decompressive surgery. Dynamic stability parameters did not change significantly during the study period