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The Uninsured and Underserved and the Hospitals That Care for Them: Who’s to Blame?

The Uninsured and Underserved and the Hospitals That Care for Them: Who’s to Blame? It has been said if you want to control health care costs, solve poverty. The pervasive effect of poverty stymies efforts to improve health and is associated with more illness, poorer outcomes, and a resultant significant increase in cost expended to care for this population. In this issue of JAMA Surgery, Hoehn and colleagues1 offer the proposition that intrinsic factors inherent in safety-net hospitals may explain inferior outcomes after selected surgical procedures. In all the procedures studied, the percentage of patients with an extreme severity of illness was greatest at the hospitals with a high safety-net burden (HBHs). At the HBHs, the patients were sicker preoperatively and more likely to undergo emergency operations, and comorbidities2,3 and emergency operations4 are well documented to have an adverse effect on postoperative outcomes. Once a complication occurs, the length of stay and cost increase.5 Patients who develop postoperative complications also are more likely to require a readmission.6 Thus, patient factors clearly have at least some influence on the inferior surgical outcomes observed at HBHs. The authors analyzed data from only 231 of the 416 hospitals (55.5%) that report on the University HealthSystem Consortium database, which likely excluded operations performed at many smaller community hospitals or those academic medical centers that were low safety-net burden hospitals. Reasons for the exclusion and the types of hospitals that were excluded would be helpful in drawing additional conclusions from the data. Information regarding complications was gathered from publicly reported data, which are not as reliable as those analyzed by other databases that report clinical, highly risk-adjusted and peer-reviewed outcome data. Certain complications, such as iatrogenic pneumothorax, occur in medical and surgical patients, and the reported data would not differentiate between these groups. Parenthetically, one has to ask why the authors chose to stratify hospitals into groups determined by safety-net burden rather than considering safety-net burden as a continuous value in their analysis. At best, emergency department throughput as a surrogate for staffing adequacy and systems efficiency is an indirect estimate of these important hospital factors. Deficiencies in documentation and coding may or may not be influenced by overall hospital performance but could have a significant influence on expected rates of death and complications. The authors also acknowledge that they did not have access to patient-level data such as medical comorbidities, which are potentially important factors related to outcome. The cost data examined in this study are based on Medicare experience and may not be applicable to the large group of patients with Medicaid or to the surgical cohort. The fact that the authors did not use risk-adjusted mortality, length of stay, or observed to expected cost ratios questions their basic premise that surgical outcomes are inferior at HBHs. Thus, future analyses using the University HealthSystem Consortium database will be able to calculate surgical patient value using risk-adjusted quality and cost metrics where value is defined as quality divided by cost. Safety-net hospitals remain a vital component of our health care system. The challenge before us is to maximize the value of the services offered in the care of those patients whose problems often extend well beyond their acute illness. Back to top Article Information Corresponding Author: Larry R. Kaiser, MD, Office of the Dean, Temple University School of Medicine, 3500 N Broad St, Ste 1141, Philadelphia, PA 19140 (larry.kaiser@temple.edu). Published Online: October 14, 2015. doi:10.1001/jamasurg.2015.3216. Conflict of Interest Disclosures: None reported. References 1. Hoehn RS, Wima K, Vestal MA, et al. Effect of hospital safety-net burden on cost and outcomes after surgery [published online October 14, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3209.Google Scholar 2. Parikh P, Shiloach M, Cohen ME, et al. Pancreatectomy risk calculator: an ACS-NSQIP resource. HPB (Oxford). 2010;12(7):488-497.PubMedGoogle ScholarCrossref 3. Afilalo J, Mottillo S, Eisenberg MJ, et al. Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity. Circ Cardiovasc Qual Outcomes. 2012;5(2):222-228.PubMedGoogle ScholarCrossref 4. Ingraham AM, Cohen ME, Raval MV, Ko CY, Nathens AB. Comparison of hospital performance in emergency versus elective general surgery operations at 198 hospitals. J Am Coll Surg. 2011;212(1):20-28.e1. doi:10.1016/j.jamcollsurg.2010.09.026.PubMedGoogle ScholarCrossref 5. Ceppa EP, Pitt HA, House MG, et al. Reducing surgical site infections in hepatopancreatobiliary surgery. HPB (Oxford). 2013;15(5):384-391.PubMedGoogle ScholarCrossref 6. Kassin MT, Owen RM, Perez SD, et al. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. 2012;215(3):322-330.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

The Uninsured and Underserved and the Hospitals That Care for Them: Who’s to Blame?

JAMA Surgery , Volume 151 (2) – Feb 1, 2016

The Uninsured and Underserved and the Hospitals That Care for Them: Who’s to Blame?

Abstract

It has been said if you want to control health care costs, solve poverty. The pervasive effect of poverty stymies efforts to improve health and is associated with more illness, poorer outcomes, and a resultant significant increase in cost expended to care for this population. In this issue of JAMA Surgery, Hoehn and colleagues1 offer the proposition that intrinsic factors inherent in safety-net hospitals may explain inferior outcomes after selected surgical procedures. In all the procedures...
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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2015.3216
Publisher site
See Article on Publisher Site

Abstract

It has been said if you want to control health care costs, solve poverty. The pervasive effect of poverty stymies efforts to improve health and is associated with more illness, poorer outcomes, and a resultant significant increase in cost expended to care for this population. In this issue of JAMA Surgery, Hoehn and colleagues1 offer the proposition that intrinsic factors inherent in safety-net hospitals may explain inferior outcomes after selected surgical procedures. In all the procedures studied, the percentage of patients with an extreme severity of illness was greatest at the hospitals with a high safety-net burden (HBHs). At the HBHs, the patients were sicker preoperatively and more likely to undergo emergency operations, and comorbidities2,3 and emergency operations4 are well documented to have an adverse effect on postoperative outcomes. Once a complication occurs, the length of stay and cost increase.5 Patients who develop postoperative complications also are more likely to require a readmission.6 Thus, patient factors clearly have at least some influence on the inferior surgical outcomes observed at HBHs. The authors analyzed data from only 231 of the 416 hospitals (55.5%) that report on the University HealthSystem Consortium database, which likely excluded operations performed at many smaller community hospitals or those academic medical centers that were low safety-net burden hospitals. Reasons for the exclusion and the types of hospitals that were excluded would be helpful in drawing additional conclusions from the data. Information regarding complications was gathered from publicly reported data, which are not as reliable as those analyzed by other databases that report clinical, highly risk-adjusted and peer-reviewed outcome data. Certain complications, such as iatrogenic pneumothorax, occur in medical and surgical patients, and the reported data would not differentiate between these groups. Parenthetically, one has to ask why the authors chose to stratify hospitals into groups determined by safety-net burden rather than considering safety-net burden as a continuous value in their analysis. At best, emergency department throughput as a surrogate for staffing adequacy and systems efficiency is an indirect estimate of these important hospital factors. Deficiencies in documentation and coding may or may not be influenced by overall hospital performance but could have a significant influence on expected rates of death and complications. The authors also acknowledge that they did not have access to patient-level data such as medical comorbidities, which are potentially important factors related to outcome. The cost data examined in this study are based on Medicare experience and may not be applicable to the large group of patients with Medicaid or to the surgical cohort. The fact that the authors did not use risk-adjusted mortality, length of stay, or observed to expected cost ratios questions their basic premise that surgical outcomes are inferior at HBHs. Thus, future analyses using the University HealthSystem Consortium database will be able to calculate surgical patient value using risk-adjusted quality and cost metrics where value is defined as quality divided by cost. Safety-net hospitals remain a vital component of our health care system. The challenge before us is to maximize the value of the services offered in the care of those patients whose problems often extend well beyond their acute illness. Back to top Article Information Corresponding Author: Larry R. Kaiser, MD, Office of the Dean, Temple University School of Medicine, 3500 N Broad St, Ste 1141, Philadelphia, PA 19140 (larry.kaiser@temple.edu). Published Online: October 14, 2015. doi:10.1001/jamasurg.2015.3216. Conflict of Interest Disclosures: None reported. References 1. Hoehn RS, Wima K, Vestal MA, et al. Effect of hospital safety-net burden on cost and outcomes after surgery [published online October 14, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3209.Google Scholar 2. Parikh P, Shiloach M, Cohen ME, et al. Pancreatectomy risk calculator: an ACS-NSQIP resource. HPB (Oxford). 2010;12(7):488-497.PubMedGoogle ScholarCrossref 3. Afilalo J, Mottillo S, Eisenberg MJ, et al. Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity. Circ Cardiovasc Qual Outcomes. 2012;5(2):222-228.PubMedGoogle ScholarCrossref 4. Ingraham AM, Cohen ME, Raval MV, Ko CY, Nathens AB. Comparison of hospital performance in emergency versus elective general surgery operations at 198 hospitals. J Am Coll Surg. 2011;212(1):20-28.e1. doi:10.1016/j.jamcollsurg.2010.09.026.PubMedGoogle ScholarCrossref 5. Ceppa EP, Pitt HA, House MG, et al. Reducing surgical site infections in hepatopancreatobiliary surgery. HPB (Oxford). 2013;15(5):384-391.PubMedGoogle ScholarCrossref 6. Kassin MT, Owen RM, Perez SD, et al. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. 2012;215(3):322-330.PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: Feb 1, 2016

Keywords: hospital economics,length of stay,medically underserved area,medically uninsured,socioeconomic factors,surgical procedures, operative,health care disparities,safety-net providers,hospital care,comorbidity,adverse effects,postoperative complications,intrinsic factor,iatrogenic pneumothorax,patient readmission

References

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