Hospital case volume and outcomes for proximal femoral fractures in the USA: an observational study

Objective: To explore whether older adults with isolated hip fractures benefit from treatment in high-volume hospitals. Design: Population-based observational study. Setting: All acute hospitals in California, USA. Participants: All individuals aged >65 that underwent an operation for an isolated hip fracture in California between 2007 and 2011. Patients transferred between hospitals were excluded. Primary and secondary outcomes: Quality indicators (time to surgery) and patient outcomes (length of stay, in-hospital mortality, unplanned 30-day re-admission, and selected complications). Results: 91,401 individuals satisfied the inclusion criteria. Time to operation and length of stay were significantly prolonged in low volume hospitals, by 1.96 (95% CI 1.20-2.73) and 0.70 (0.38-1.03) days respectively. However, there were no differences in clinical outcomes, including in-hospital mortality, 30-day re-admission, and rates of pneumonia, pressure ulcers, and venous thromboembolism. Conclusion: These data suggest that there is no patient safety imperative to limit hip fracture care to high-volume hospitals

Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients

Importance: Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law’s impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation. Objective: To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act. Design, Setting, and Participants: Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states. Interventions/Exposure: Policy implementation in January 2014. Main Outcomes and Measures: Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation. Results: A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity–, age-, and sex-based disparities in which patients use rehabilitation. Conclusions and relevance: This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.</br

Association of Medicaid expansion with access to rehabilitative care in adult trauma patients

Importance Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law’s impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation. Objective To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act. Design, Setting, and Participant Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states. Intervention/Exposure Policy implementation in January 2014. Main Outcomes And Measures Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation. Results A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity–, age-, and sex-based disparities in which patients use rehabilitation. Conclusions and relevance This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states

Association of Medicaid expansion with access to rehabilitative care in adult trauma patients

Importance Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law’s impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation. Objective To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act. Design, Setting, and Participant Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states. Intervention/Exposure Policy implementation in January 2014. Main Outcomes And Measures Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation. Results A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity–, age-, and sex-based disparities in which patients use rehabilitation. Conclusions and relevance This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states

Geographic distribution of trauma burden, mortality and services in the United States: does availability correspond to patient need?

Background The association between the need of trauma care and trauma services has not previously been characterized. We compared the distribution of trauma admissions to state-level availability of trauma centers (TCs), Surgical Critical Care (SCC) providers, and SCC fellowships; and assessed the association between trauma-care provision and state-level trauma mortality. Study Design We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality-rates. Normalized densities (per-million-population, PMP) were calculated and generalized linear models used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per capita income, and age-adjusted mortality-rates. Results There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP) and 1,987 TCs across the country, of which 521 were Level 1 or 2 (1.65 PMP). There was substantial variation between the top-five vs. bottom-five states in terms of L1/L2TCs and SCC surgeon availability (~8.0:1.0), despite showing less variation in trauma admissions density (1.5:1.0). The distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p&lt;0.001), and inversely associated with per-capita income (p&lt;0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC providers PMP, there was a decrease of 618 deaths/year Conclusions There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and the location of L1/L2TCs. In the wake of efforts to regionalize TCs, further efforts are needed to address disparities in the provision of quality care to trauma patients.</p

Hospital characteristics associated with increased conversion rates among organ donors in New England

Background It is unknown whether hospital characteristics affect institutional performance with regard to organ donation. We sought to determine which hospital- and patient-level characteristics are associated with high organ donor conversion rates after brain death (DBD). Methods Data were extracted from the regional Organ Procurement Organization (2011–2014) and other sources. Hospitals were stratified into high-conversion hospitals (HCH; upper-tertile) and low-conversion hospitals (LCH; lower-tertile) according to conversion rates. Hospital- and patient-characteristics were compared between groups. Results There were 564 potential DBD donors in 27 hospitals. Conversion rates differed between hospitals in different states (p < 0.001). HCH were more likely to be small (median bed size 194 vs. 337; p = 0.024), non-teaching hospitals (40% vs. 88%; p = 0.025), non-trauma center (30% vs. 77%; p = 0.040). Potential donors differed between HCH and LCH in race (p < 0.01) and mechanism of injury/disease process (p < 0.01). Conclusion There is significant variation between hospitals in terms of organ donor conversion rates. This suggests that there is a pool of potential donors in large specialized hospitals that are not successfully converted to DBD

Geographic distribution of trauma burden, mortality and services in the United States: does availability correspond to patient need?

Background The association between the need of trauma care and trauma services has not previously been characterized. We compared the distribution of trauma admissions to state-level availability of trauma centers (TCs), Surgical Critical Care (SCC) providers, and SCC fellowships; and assessed the association between trauma-care provision and state-level trauma mortality. Study Design We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality-rates. Normalized densities (per-million-population, PMP) were calculated and generalized linear models used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per capita income, and age-adjusted mortality-rates. Results There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP) and 1,987 TCs across the country, of which 521 were Level 1 or 2 (1.65 PMP). There was substantial variation between the top-five vs. bottom-five states in terms of L1/L2TCs and SCC surgeon availability (~8.0:1.0), despite showing less variation in trauma admissions density (1.5:1.0). The distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p Conclusions There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and the location of L1/L2TCs. In the wake of efforts to regionalize TCs, further efforts are needed to address disparities in the provision of quality care to trauma patients.</p