Publications by authors named "Thomas C Tsai"

49 Publications

The ACA at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future.

J Surg Res 2021 Feb 25;263:102-109. Epub 2021 Feb 25.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.
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http://dx.doi.org/10.1016/j.jss.2020.12.056DOI Listing
February 2021

Association of balanced abdominal organ transplant center volumes with patient outcomes.

Clin Transplant 2021 Jan 6:e14217. Epub 2021 Jan 6.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.

Background: The volume-outcome relationship for organ-specific transplantation is well-described; it is unknown if the relative balance of kidney compared with liver volumes within an institution relates to organ-specific outcomes. We assessed the association between relative balance within a transplant center and outcomes.

Methods: National retrospective analysis of isolated kidney and liver transplants in United States 2005-2014 followed through 2019. Latent class analysis defined transplant center phenotypes. Multivariate Cox models estimated death-censored graft loss and mortality.

Results: Latent class analysis identified four phenotypes: kidney only (n = 117), kidney dominant (n = 36), mixed/balanced (n = 90), and liver dominant (n = 13). Compared to mixed centers, the risk of kidney graft loss was higher at kidney-dominant (HR 1.07, p < .001) and liver-dominant (HR 1.10, p < .001) centers, while kidney-only (HR 1.06, p = .01) centers had higher mortality. Liver graft loss was not associated with phenotype, but risk of patient death was lower (HR 0.93, p = .02) at liver dominant and higher (HR 1.06, p = .02) at kidney-dominant centers.

Conclusions: A mixed phenotype was associated with improved kidney transplant outcomes, whereas liver transplant outcomes were best at liver-dominant centers. While these findings need to be verified with center-level resources, optimization of shared resources could improve patient and organ outcomes.
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http://dx.doi.org/10.1111/ctr.14217DOI Listing
January 2021

Health Insurance Profitability During the COVID-19 Pandemic.

Ann Surg 2021 Mar;273(3):e88-e90

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1097/SLA.0000000000004696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869966PMC
March 2021

Relationship Between Health Care Spending and Clinical Outcomes in Bariatric Surgery: Implications for Medicare Bundled Payments.

Ann Surg 2020 Jun 12. Epub 2020 Jun 12.

*National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan †Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan ‡Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts §Department of Surgery, University of Michigan, Ann Arbor, Michigan ¶Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts ||Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Objective: To evaluate sources of 90-day episode spending variation in Medicare patients undergoing bariatric surgery and whether spending variation was related to quality of care.

Summary Of Background Data: Medicare's bundled payments for care improvement-advanced program includes the first large-scale episodic bundling program for bariatric surgery. This voluntary program will pay bariatric programs a bonus if 90-day spending after surgery falls below a predetermined target. It is unclear what share of bariatric episode spending may be due to unnecessary variation and thus modifiable through care improvement.

Methods: Retrospective analysis of fee-for-service Medicare claims data from 761 acute care hospitals providing inpatient bariatric surgery between January 1, 2011 and September 30, 2016. We measured associations between patient and hospital factors, clinical outcomes, and total Medicare spending for the 90-day bariatric surgery episode using multivariable regression models.

Results: Of 64,537 patients, 46% underwent sleeve gastrectomy, 22% revisited the emergency department (ED) within 90 days, and 12.5% were readmitted. Average 90-day episode payments were $14,124, ranging from $12,220 at the lowest-spending quintile of hospitals to $16,887 at the highest-spending quintile. After risk adjustment, 90-day episode spending was $11,447 at the lowest quintile versus $15,380 at the highest quintile (difference $3932, P < 0.001). The largest components of spending variation were readmissions (44% of variation, or $2043 per episode), post-acute care (19% or $871), and index professional fees (15% or $450). The lowest spending hospitals had the lowest complication, ED visit, post-acute utilization, and readmission rates (P < 0.001).

Conclusions And Relevance: In this retrospective analysis of Medicare patients undergoing bariatric surgery, the largest components of 90-day episode spending variation are readmissions, inpatient professional fees, and post-acute care utilization. Hospitals with lower spending were associated with lower rates of complications, ED visits, post-acute utilization, and readmissions. Incentives for improving outcomes and reducing spending seem to be well-aligned in Medicare's bundled payment initiative for bariatric surgery.
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http://dx.doi.org/10.1097/SLA.0000000000003979DOI Listing
June 2020

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis.

Clin Lung Cancer 2020 May 7. Epub 2020 May 7.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA; Division of Thoracic Surgery, West Roxbury Veterans Administration, West Roxbury, MA; Harvard Medical School, Boston, MA.

Background: The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

Methods: A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

Results: A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

Conclusion: Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.
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http://dx.doi.org/10.1016/j.cllc.2020.04.017DOI Listing
May 2020

Maximizing the US Department of Veterans Affairs' Reserve Role in National Health Care Emergency Preparedness-The Fourth Mission.

JAMA Surg 2020 10;155(10):913-914

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2020.4153DOI Listing
October 2020

Racial Disparity in Pancreatoduodenectomy for Borderline Resectable Pancreatic Adenocarcinoma.

Ann Surg Oncol 2021 Feb 10;28(2):1088-1096. Epub 2020 Jul 10.

Division of Surgical Oncology, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.

Background: Previous studies have found racial disparity in pancreatectomies for resectable pancreatic adenocarcinoma. The aim of this study was to investigate if racial disparities were worse in the performance of pancreaticoduodenectomy for borderline resectable pancreatic adenocarcinoma.

Methods: This study used the National Cancer Database (2004-2016) and included patients with non-metastatic and head of the pancreas borderline resectable pancreatic adenocarcinoma. Multivariable, Poisson regression models with robust standard errors evaluated the relative risk (RR) of undergoing a pancreaticoduodenectomy among non-White patients (Black, Asian, and non-White Hispanic) compared with White patients. A Poisson regression model with hospital fixed effects was performed to evaluate if findings were due to within-hospital or between-hospital variation. Interaction between race and neoadjuvant therapy was also evaluated.

Results: There were 15,482 patients (median age 68 years, interquartile range 60-76 years; 48.6% male) with borderline resectable pancreatic adenocarcinoma who were predominantly White (84.3%, n = 13,058; non-White, 15.7%, n = 2424). Overall, 18.4% (n = 2853) had a pancreatic resection. Non-White patients had a significantly lower likelihood of undergoing a pancreatic resection for borderline resectable pancreatic adenocarcinoma when compared with White patients (RR 0.75, 95% confidence interval 0.68-0.83; p < 0.001). These findings persisted in the hospital fixed-effects model. In the interaction analysis, there were no significant differences in the likelihood of pancreatic resection if patients received neoadjuvant therapy.

Conclusions: Non-White patients were 25% less likely to undergo a pancreatic resection for borderline resectable pancreatic adenocarcinoma compared with White patients. This racial disparity was due to variation in care within-hospitals and disappeared if non-White patients were treated with neoadjuvant therapy.
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http://dx.doi.org/10.1245/s10434-020-08717-xDOI Listing
February 2021

Examining the link between positive affectivity and anxiety reactivity to social stress in individuals with and without social anxiety disorder.

J Anxiety Disord 2020 08 20;74:102264. Epub 2020 Jun 20.

University of California, San Diego, United States.

Background: Positive affect (PA) attenuates negative reactivity to stress; however, this adaptive function of PA is seldom studied in psychiatric conditions characterized by more extreme forms of affective responding. We tested distinct associations of PA and negative affect (NA) with anxiety reactivity in participants with social anxiety disorder (SAD)-a condition characterized by heightened NA and diminished PA-and non-SAD control subjects.

Method: Adults with a principal diagnosis of SAD (n = 71) and those without a psychiatric history (n = 36) rated their PA and NA during the past week, and were exposed to a laboratory stressor wherein they delivered a video-recorded speech on a controversial topic. Anxiety reactivity was assessed in terms of anticipatory anxiety prior to the speech, and observer-rated anxiety-related behavior during the speech.

Results: Across all participants, higher PA significantly predicted lower anticipatory anxiety and less anxiety-related behavior, beyond level of NA; lower NA significantly predicted attenuated anticipatory anxiety, but not anxiety-related behavior, beyond level of PA. The association between PA and stress reactivity was diminished for individuals with especially elevated NA, as well as for individuals with SAD compared to those without.

Conclusions: PA may be protective against negative reactivity to social stress; however, theoretical models and clinical applications should consider possible interactive effects of PA and NA in modulating stress reactivity.
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http://dx.doi.org/10.1016/j.janxdis.2020.102264DOI Listing
August 2020

Association Between Blood Lead Level and Uncontrolled Hypertension in the US Population (NHANES 1999-2016).

J Am Heart Assoc 2020 07 23;9(13):e015533. Epub 2020 Jun 23.

Environmental Research Center Duke Kunshan University Kunshan China.

Background This study aims to explore whether higher blood lead levels (BLL) may be associated with failure to control blood pressure and subsequent uncontrolled hypertension. Methods and Results We used serial cross-sectional waves of the US National Health and Nutrition Examination Survey (NHANES) from 1999 to 2016. 30 762 subjects aged 20 years and above were included. Uncontrolled hypertension was defined as systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg. We estimated odds ratios (ORs) of quartiles of BLL for any hypertension and uncontrolled hypertension by sex using logistic regression, adjusted for demographics, smoking status, serum cotinine, alcohol intake, body mass index, and menopause status in women. The weighted prevalence of hypertension was 46.7%, of which 80.1% were uncontrolled. Men, younger ages, ethnic minorities, people with lower income, never and current smokers, and people with higher BLL were less likely to have their hypertension controlled. In men, compared with the lowest quartile of BLL (<0.94 μg/dL), the highest 2 quartiles (0.94-1.50 μg/dL, 1.50-2.30 μg/dL) were associated with hypertension (Q2: OR, 1.12; 95% CI, 0.96-1.30; Q3: OR, 1.16; 95% CI, 1.01-1.34; Q4: OR, 1.25; 95% CI, 1.08-1.45), but not in women. In hypertensive men, higher BLL was related to uncontrolled hypertension compared with the lowest quartile (Q2: OR, 1.34; 95% CI, 0.98-1.85; Q3: OR, 1.70; 95% CI, 1.26-2.30; Q4: OR, 1.96; 95% CI, 1.45-2.65). In women, the relationship was similar (Q2: OR, 1.26; 95% CI, 0.95-1.67; Q3: OR, 1.48; 95% CI, 1.10-2.00; Q4: 1.70; 95% CI, 1.26-2.30). Conclusions BLL is associated with higher prevalence of hypertension and uncontrolled hypertension, with more pronounced association in men.
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http://dx.doi.org/10.1161/JAHA.119.015533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670543PMC
July 2020

Perpetuation of Inequity: Disproportionate Penalties to Minority-serving and Safety-net Hospitals Under Another Medicare Value-based Payment Model.

Ann Surg 2020 06;271(6):994-995

Department of Surgery, Brigham and Women's Hospital, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA.

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http://dx.doi.org/10.1097/SLA.0000000000003911DOI Listing
June 2020

Surgical site occurrences, not body mass index, increase the long-term risk of ventral hernia recurrence.

Surgery 2020 04 13;167(4):765-771. Epub 2020 Feb 13.

Department of Surgery, Brigham and Women's Hospital, Boston, MA; Laboratory for Metabolic and Surgical Research, Brigham and Women's Hospital, Boston, MA.

Background: Recurrence rates after ventral hernia repair vary widely and evidence about risk factors for recurrence are conflicting. There is little evidence for risk factors for long-term recurrence.

Methods: Patients who underwent ventral hernia repair at our institution and were captured in the American College of Surgeons-National Surgical Quality Improvement Program database between 2002 and 2015 were included. We reviewed all demographic, procedural, and hernia-specific data.

Results: Six hundred and thirty patients were included for analysis with a median follow-up of 4.9 years (inter-quartile range, 2-7.3 years). By univariate analysis, index hernia repairs were more likely to recur if defect size was ≥4 cm (P = .019), no mesh was used (P = .026), or if the repair was for a recurrent hernia (P = .001). Five-year cumulative incidence of recurrence and reoperation was 24.3% and 16.0%, respectively. Patients with a perioperative surgical site occurrence, which included superficial, deep-incisional, and organ space surgical site infections as well as wound disruption, had a 5-year cumulative incidence of recurrence of 54.9% compared with 22.6% for those without surgical site occurrence. By multivariable analysis, non-primary hernia repair (hazard ratio 1.7, 95% confidence interval 1.2-2.4, P = .005) and any postoperative surgical site occurrence (hazard ratio 1.9, 95% confidence interval 1.1-3.6, P = .02) were the only risk factors predictive of recurrence. Patient body mass index had no independent effect on recurrence.

Conclusion: 1 in 4 patients undergoing an open ventral hernia repair will have a recurrence after 5 years, and this risk is doubled among patients who experience any perioperative surgical site occurrence. After controlling for patient comorbidities, including body mass index, hernia size, and mesh position, the most significant risk factor for recurrence after ventral hernia repair was a non-primary hernia and surgical site occurrence.
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http://dx.doi.org/10.1016/j.surg.2020.01.001DOI Listing
April 2020

Oncological Outcomes of Lobar Resection, Segmentectomy, and Wedge Resection for T1a Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-Analysis.

Semin Thorac Cardiovasc Surg 2020 Autumn;32(3):582-590. Epub 2019 Aug 9.

Division of Surgery, Slingeland Ziekenhuis, Doetinchem, the Netherlands; Division of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands.

The optimal treatment of early-stage non-small-cell lung cancer (NSCLC) remains subject to debate. Lobar resection is considered the standard of care, but sublobar resections are a lung parenchymal-sparing treatment offering promising results. We conducted a systematic review and meta-analysis to compare oncological outcomes of lobar resections and parenchymal-sparing resections for T1a NSCLC. PubMed, EMBASE, Web of Knowledge Search, and the Cochrane Central Register of Controlled Trials were searched for studies reporting oncological outcomes following lobar or parenchymal-sparing resections. Two researchers independently identified studies and extracted data. Oncological outcomes were compared for each surgical modality using the Mantel-Haenszel method, and outcomes were pooled for each modality using the inverse variance method. A total of 11,195 studies were identified and 28 articles were included. For pT1a tumors, there was no difference in 5-year overall survival when lobar resection (n = 15,003) was compared to parenchymal-sparing resection (n = 1224), with a relative risk of 0.92 (95% confidence interval: 0.84-1.01). Five-year overall survival and disease-free survival after segmentectomy yielded equal survival compared to lobar resection in directly comparing studies and point estimates of noncomparative studies. In most comparisons, wedge resection showed comparable results to lobar resections and segmentectomy. Subanalysis of intentional parenchymal-sparing surgery showed favorable results. This study shows that parenchymal-sparing surgery yields equivocal survival compared to lobar surgery for stage T1a NSCLC. However, a drawback in implementing parenchymal-sparing resection for lobectomy-tolerable patients is the risk of nodal upstaging.
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http://dx.doi.org/10.1053/j.semtcvs.2019.08.004DOI Listing
October 2020

Corrigendum to "Surgical evaluation of lymph nodes in esophageal adenocarcinoma: Standardized approach or personalized medicine?" [European Journal of Surgical Oncology (2018) 1177-1180].

Eur J Surg Oncol 2018 12 14;44(12):2003. Epub 2018 Sep 14.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; VA Boston Healthcare System, Boston, MA, USA.

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http://dx.doi.org/10.1016/j.ejso.2018.08.008DOI Listing
December 2018

Surgical evaluation of lymph nodes in esophageal adenocarcinoma: Standardized approach or personalized medicine?

Eur J Surg Oncol 2018 08 19;44(8):1177-1180. Epub 2018 Apr 19.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; VA Boston Healthcare System, Boston, MA, USA.

The extent of lymphadenectomy for esophageal adenocarcinoma remains controversial. Outstanding issues include the appropriate technical approach such as transthoracic versus transhiatal, or open versus minimally invasive, both of which have implications on overall lymph node harvest numbers and morbidity. Recent data on the relationship of total number of lymph nodes harvested and oncologic survival have been conflicting, due in part to a likely differential impact of lymphadenectomy on survival based on tumor stage and response to neoadjuvant therapy. While standardizing the extent of lymphadenectomy may be desirable, a more useful approach might be to tailor lymphadenectomy considering the multidimensional impact of surgical technique and multimodal treatment strategy.
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http://dx.doi.org/10.1016/j.ejso.2018.03.007DOI Listing
August 2018

Age and sex of surgeons and mortality of older surgical patients: observational study.

BMJ 2018 04 25;361:k1343. Epub 2018 Apr 25.

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.

Objective: To investigate whether patients' mortality differs according to the age and sex of surgeons.

Design: Observational study.

Setting: US acute care hospitals.

Participants: 100% of Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 20 major non-elective surgeries between 2011 and 2014.

Main Outcome Measure: Operative mortality rate of patients, defined as death during hospital admission or within 30 days of the operative procedure, after adjustment for patients' and surgeons' characteristics and indicator variables for hospitals.

Results: 892 187 patients who were treated by 45 826 surgeons were included. Patients' mortality was lower for older surgeons than for younger surgeons: the adjusted operative mortality rates were 6.6% (95% confidence interval 6.5% to 6.7%), 6.5% (6.4% to 6.6%), 6.4% (6.3% to 6.5%), and 6.3% (6.2% to 6.5%) for surgeons aged under 40 years, 40-49 years, 50-59 years, and 60 years or over, respectively (P for trend=0.001). There was no evidence that adjusted operative mortality differed between patients treated by female versus male surgeons (adjusted mortality 6.3% for female surgeons versus 6.5% for male surgeons; adjusted odds ratio 0.97, 95% confidence interval 0.93 to 1.01). After stratification by sex of surgeon, patients' mortality declined with age of surgeon for both male and female surgeons (except for female surgeons aged 60 or older); female surgeons in their 50s had the lowest operative mortality.

Conclusion: Using national data on Medicare beneficiaries in the US, this study found that patients treated by older surgeons had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915700PMC
http://dx.doi.org/10.1136/bmj.k1343DOI Listing
April 2018

Lower emergency general surgery (EGS) mortality among hospitals with higher-quality trauma care.

J Trauma Acute Care Surg 2018 03;84(3):433-440

From the Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (J.W.S., T.C.T., P.U.N.); Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (J.W.S., A.H.H., A.S., J.M.H.); Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, UC Davis Health System, Sacramento, California (G.J.J., G.H.U.); and Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (A.H.H., A.S., J.M.H.).

Background: Patients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to nonmodifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Although the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality.

Methods: Using the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with more than 400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with more than 200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile.

Results: Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21% (interquartile range, 0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile as well as patients' community income-level and race/ethnicity (p < 0.05 for all). Mean risk-adjusted EGS mortality was 1.09% (95% confidence interval, 0.94-1.25%) at hospitals in the lowest quartile for risk-adjusted trauma mortality, and 1.64% (95% confidence interval, 1.48-1.80%) at hospitals in the highest quartile of trauma mortality (p < 0.01). Sensitivity analyses limited to (1) high-mortality procedures and (2) high-volume facilities; both found similar trends (p < 0.01).

Conclusions: Patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower risk of mortality after admission for EGS procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. Emergency general surgery-specific systems measures and process measures are needed to better understand drivers of variation in quality of EGS outcomes.

Level Of Evidence: Epidemiological, level III; Care management, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001768DOI Listing
March 2018

Potential impact of Affordable Care Act-related insurance expansion on trauma care reimbursement.

J Trauma Acute Care Surg 2017 05;82(5):887-895

From the Department of Surgery, Center for Surgery and Public Health (J.W.S., P.N., T.C.T., A.S., A.H.H.), Brigham & Women's Hospital; Program in Global Surgery and Social Change (J.W.S., M.G.S.), Harvard Medical School, Boston; John F. Kennedy School of Government (P.U.), Harvard University, Cambridge, Massachusetts; David Geffen School of Medicine at the University of California (P.U.), Los Angeles, Los Angeles, California; Harvard Business School (P.N.); Department of Health Policy and Management (T.C.T.), Harvard T.H. Chan School of Public Health; Harvard Medical School (K.W.S.); Department Of Otolaryngology & Office of Global Surgery (M.G.S.), Massachusetts Eye & Ear Infirmary, Boston; Department of Economics (D.M.C.), Harvard University; National Bureau of Economics Research (D.M.C.); and Division of Trauma, Department of Surgery (A.S., A.H.H.), Brigham & Women's Hospital, Boston, Massachusetts.

Background: Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect.

Methods: We abstracted nonelderly adults (ages 18-64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010-the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population.

Results: There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8-14.7), yielding a national margin of -7.9% (95% CI, -10.6 to -5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7-17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, -0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains.

Conclusion: Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities.

Level Of Evidence: Economic analysis, level II.
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http://dx.doi.org/10.1097/TA.0000000000001400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468098PMC
May 2017

Cured into Destitution: Catastrophic Health Expenditure Risk Among Uninsured Trauma Patients in the United States.

Ann Surg 2018 06;267(6):1093-1099

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.

Objective: To characterize the economic hardship for uninsured patients admitted for trauma using catastrophic health expenditure (CHE) risk.

Background: Medical debts are the greatest cause of bankruptcies in the United States. Injuries are often unpredictable, expensive to treat, and disproportionally affect uninsured patients. Current measures of economic hardship are insufficient and exclude those at greatest risk.

Methods: We performed a retrospective review, using data from the 2007-2011 Nationwide Inpatient Samples of all uninsured nonelderly adults (18-64 yrs) admitted with primary diagnoses of trauma. We used US Census data to estimate annual postsubsistence income and inhospital charges for trauma-related admission. Our primary outcome measure was catastrophic health expenditure risk, defined as any charges ≥40% of annual postsubsistence income.

Results: Our sample represented 579,683 admissions for uninsured nonelderly adults over the 5-year study period. Median estimated annual income was $40,867 (interquartile range: $21,286-$71.733). Median inpatient charges were $27,420 (interquartile range: $15,196-$49,694). Overall, 70.8% (95% posterior confidence interval: 70.7%-71.1%) of patients were at risk for CHE. The risk of CHE was similar across most demographic subgroups. The greatest risk, however, was concentrated among patients from low-income communities (77.5% among patients in the lowest community income quartile) and among patients with severe injuries (81.8% among those with ISS ≥ 16).

Conclusions: Over 7 in 10 uninsured patients admitted for trauma are at risk of catastrophic health expenditures. This analysis is the first application of CHE to a US trauma population and will be an important measure to evaluate the effectiveness of health care and coverage strategies to improve financial risk protection.
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http://dx.doi.org/10.1097/SLA.0000000000002254DOI Listing
June 2018

The Association Between Medicare Eligibility and Gains in Access to Rehabilitative Care: A National Regression Discontinuity Assessment of Patients Ages 64 Versus 65 Years.

Ann Surg 2017 Apr;265(4):734-742

*Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, and the Department of Surgery, Brigham & Women's Hospital, Boston, MA†Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, MA‡Department of Surgery, Howard University College of Medicine, Washington, DC.

Objectives: The aims of this study were to assess for changes in uninsured rates among trauma patients at age 64 versus 65 years and whether there are associated changes in post-discharge rehabilitation; determine whether changes are driven by rehabilitation provided at home, skilled nursing facilities (SNFs), or acute inpatient facilities; and determine whether changes vary among stratified subgroups of trauma-related "best-practice" factors.

Summary Background Data: Rehabilitation is an important component of high-quality trauma systems with access heavily influenced by insurance status. In the wake of policy changes affecting insurance coverage, it remains unknown the extent to which insurance changes associate with variations in rehabilitation access/use among otherwise similar patients.

Methods: Regression discontinuity models were used to assess for changes in insurance status and rehabilitation at age 64 versus 65 years among adults ages 54 to 75 years (±10 years age-related Medicare eligibility). Data were extracted from the 2007-2012 National Trauma Data Bank.

Results: A total of 305,198 patients were included; 40.1% were discharged to rehabilitation. Medicare eligibility was associated with an abrupt 6.4 (95% confidence interval: 5.8-7.0) percentage-point decline in uninsured and a 9.6 (95% confidence interval: 6.5-12.6) percentage-point increase in rehabilitation at age 64 versus 65 years, enabling an additional 1-in-10 patients to access rehabilitation. Differences were driven by SNF use and were greatest among patients with less-severe clinical presentations. Restriction based on Medicare-payment eligibility to patients with length of stay ≥3days (SNF requirement) and ≥1 "presumptive diagnosis codes" (inpatient facilities' 60% rule) demonstrated abrupt gains in both SNF and inpatient care.

Conclusions: The results reveal the magnitude of changes in access to rehabilitation associated with changes in insurance coverage at age 65 years. Use of quasiexperimental models enabled meaningful consideration of health-policy change.
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http://dx.doi.org/10.1097/SLA.0000000000001754DOI Listing
April 2017

The effect of Massachusetts health reform on access to care for Medicaid beneficiaries.

Am J Manag Care 2017 Jan 1;23(1):e24-e30. Epub 2017 Jan 1.

Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA 02215. E-mail

Objectives: To address concerns that expanding insurance coverage without expanding provider supply can lead to worse access for the previously insured, we examined whether previously insured Medicaid beneficiaries faced greater difficulties accessing primary care after statewide insurance expansion in Massachusetts.

Study Design: We used the Medicaid Analytic eXtract databases for Massachusetts and 3 New England control states for 2006 and 2009. We calculated rates of overall, acute, and chronic preventable admissions (or Prevention Quality Indicators [PQIs]) and a composite of control conditions for adults aged 21 to 64 years.

Methods: We used multivariate Poisson regression models, adjusting for age, race, gender, reason for Medicaid eligibility, and state-level physician supply, as well as a difference-in-differences (DID) approach to compare the change in the rate of PQIs and control admissions in Massachusetts versus control states before and after health reform.

Results: Massachusetts and control states had increases in unadjusted rates of overall, acute, and chronic PQIs. When adjusting for age, race, gender, reason for eligibility, and physician supply, this increase persisted for overall and chronic PQIs in control states, with no significant difference in the relative increase between the 2 groups for any of the PQI measures. For the within-Massachusetts analysis, low-uptake counties had a significant increase in admission for chronic PQIs that was greater than that observed for high-uptake counties (+148.0 vs +36.0; P = .045 for DID). There was no significant DID for acute or overall PQIs between the 2 groups.

Conclusions: We found no evidence that insurance expansion in Massachusetts, compared with control states, reduced access to primary care for vulnerable Medicaid beneficiaries.
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January 2017

Hospital Factors Associated With Care Discontinuity Following Emergency General Surgery.

JAMA Surg 2017 03;152(3):242-249

Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts2Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: Although there is evidence that changes in clinicians during the continuum of care (care discontinuity) are associated with higher mortality and complications among surgical patients, little is known regarding the drivers of care discontinuity among emergency general surgery (EGS) patients.

Objective: To identify hospital factors associated with care discontinuity among EGS patients.

Design, Setting, And Participants: We performed a retrospective analysis of the 100% Medicare inpatient claims file, from January 1, 2008, to November 30, 2011, and matched patient details to hospital information in the 2011 American Hospital Association Annual Survey database. We selected patients aged 65 years and older who had the most common procedures associated with the previously defined American Association for the Surgery of Trauma EGS diagnosis categories and survived to hospital discharge across the United States. The current analysis was conducted from February 1, 2016, to March 24, 2016.

Main Outcomes And Measures: Care discontinuity defined as readmission within 30 days to nonindex hospitals.

Results: There were 109 443 EGS patients readmitted within 30 days of discharge and 20 396 (18.6%) were readmitted to nonindex hospitals. Of the readmitted patients, 61 340 (56%) were female. Care discontinuity was higher among patients who were male (19.5% vs 18.0%), those younger than 85 years old (19.0% vs 16.6%), and those who lived 12.8 km (8 miles) or more away from the index hospitals (23.7% vs 14.8%) (all P < .001). Care discontinuity was independently associated with mortality (adjusted odds ratio [aOR], 1.16; 95% CI, 1.08-1.25). Hospital factors associated with care discontinuity included bed size of 200 or more (aOR, 1.45; 95% CI, 1.36-1.54), safety-net status (aOR, 1.35; 95% CI, 1.27-1.43), and teaching status (aOR, 1.18; 95% CI, 1.09-1.28). Care discontinuity was significantly lower among designated trauma centers (aOR, 0.89; 95% CI, 0.83-0.94) and highest among hospitals in the Midwest (aOR, 1.15; 95% CI, 1.05-1.26).

Conclusions And Relevance: Nearly 1 in 5 older EGS patients is readmitted to a hospital other than where their original procedure was performed. This care discontinuity is independently associated with mortality and is highest among EGS patients who are treated at large, teaching, safety-net hospitals. These data underscore the need for sustained efforts in increasing continuity of care among these hospitals and highlight the importance of accounting for these factors in risk-adjusted hospital comparisons.
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http://dx.doi.org/10.1001/jamasurg.2016.4078DOI Listing
March 2017

Implications of the Patient Protection and Affordable Care Act on Insurance Coverage and Rehabilitation Use Among Young Adult Trauma Patients.

JAMA Surg 2016 12 21;151(12):e163609. Epub 2016 Dec 21.

Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Trauma is the leading cause of death and disability among young adults, who are also among the most likely to be uninsured. Efforts to increase insurance coverage, including passage of the Patient Protection and Affordable Care Act (ACA), were intended to improve access to care and promote improvements in outcomes. However, despite reported gains in coverage, the ACA's success in promoting use of high-quality care and enacting changes in clinical end points remains unclear.

Objectives: To assess for observed changes in insurance coverage and rehabilitation use among young adult trauma patients associated with the ACA, including the Dependent Coverage Provision (DCP) and Medicaid expansion/open enrollment, and to consider possible insurance and rehabilitation differences between DCP-eligible vs -ineligible patients and among stratified demographic and community subgroups.

Design, Setting, And Participants: A longitudinal assessment of DCP implementation and Medicaid expansion/open enrollment using risk-adjusted before-and-after, difference-in-difference, and interrupted time-series analyses was conducted. Eleven years (January 1, 2005, to September 31, 2015) of Maryland Health Services Cost Review Commission data, representing complete patient records from all payers within the state, were used to identify all hospitalized young adult (aged 18-34 years) trauma patients in Maryland during the study period.

Results: Of the 69 507 hospitalized patients included, 50 548 (72.7%) were male, and the mean (SD) age was 25 (5) years. Before implementation of the DCP, 1 of 4 patients was uninsured. After ACA implementation, the number fell to less than 1 of 10, with similar patterns emerging in emergency department and outpatient settings. The change was primarily driven by Medicaid expansion/open enrollment, which corresponded to a 20.1 percentage-point increase in Medicaid (95% CI, 18.9-21.3) and an 18.2 percentage-point decrease in uninsured (95% CI, -19.3 to -17.2). No changes were detected among privately insured patients. Rehabilitation use increased by 5.4 percentage points (95% CI, 4.5-6.2)-a 60% relative increase from a baseline of 9%. Mortality (-0.5; 95% CI, -0.9 to -0.1) and failure-to-rescue rates (-4.5; 95% CI, -7.4 to -1.6) also significantly declined. Stratified changes point to significant differences in the percentage of uninsured patients and rehabilitation access across the board, mitigating or even eradicating disparities in certain cases.

Conclusions And Relevance: For patients who are injured, young, and uninsured, Medicaid expansion/open enrollment in Maryland changed insurance coverage and altered patient outcomes in ways that the DCP alone was never intended to do. Implementation of Medicaid expansion/open enrollment transformed the landscape of trauma coverage, directly affecting the health of one of the country's most vulnerable at-risk groups.
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http://dx.doi.org/10.1001/jamasurg.2016.3609DOI Listing
December 2016

Better Patient Care At High-Quality Hospitals May Save Medicare Money And Bolster Episode-Based Payment Models.

Health Aff (Millwood) 2016 09;35(9):1681-9

Ashish K. Jha is the K. T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health and director of the Harvard Global Health Institute, in Cambridge, Massachusetts.

US policy makers are making efforts to simultaneously improve the quality of and reduce spending on health care through alternative payment models such as bundled payment. Bundled payment models are predicated on the theory that aligning financial incentives for all providers across an episode of care will lower health care spending while improving quality. Whether this is true remains unknown. Using national Medicare fee-for-service claims for the period 2011-12 and data on hospital quality, we evaluated how thirty- and ninety-day episode-based spending were related to two validated measures of surgical quality-patient satisfaction and surgical mortality. We found that patients who had major surgery at high-quality hospitals cost Medicare less than those who had surgery at low-quality institutions, for both thirty- and ninety-day periods. The difference in Medicare spending between low- and high-quality hospitals was driven primarily by postacute care, which accounted for 59.5 percent of the difference in thirty-day episode spending, and readmissions, which accounted for 19.9 percent. These findings suggest that efforts to achieve value through bundled payment should focus on improving care at low-quality hospitals and reducing unnecessary use of postacute care.
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http://dx.doi.org/10.1377/hlthaff.2016.0361DOI Listing
September 2016

Impact of ACA Insurance Coverage Expansion on Perforated Appendix Rates Among Young Adults.

Med Care 2016 09;54(9):818-26

*Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health †Program For Global Surgery And Social Change, Harvard Medical School ‡Department of Health Policy and Management, Harvard T.H. Chan School of Public Health §Massachusetts Eye & Ear Infirmary, Department Of Otolaryngology & Office of Global Surgery ∥Department of Medicine, Brigham & Women's Hospital ¶Department of Surgery, Division of Trauma, Brigham & Women's Hospital, Boston, MA.

Background: The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act allowed young adults to remain on their parents' health insurance plans until age 26 years. Although the provision improved coverage and survey-reported access to care, little is known regarding its impact on timely access for acute conditions. This study aims to assess changes in insurance coverage and perforation rates among young adults with acute appendicitis-an established metric for population-level health care access-after the DCP.

Methods: The National Inpatient Sample and difference-in-differences linear regression were used to assess prepolicy/postpolicy changes for policy-eligible young adults (aged 19-25 y) compared with a slightly older, policy-ineligible comparator group (aged 26-34 y).

Results: After adjustment for covariates, 19-25 year olds experienced a 3.6-percentage point decline in the uninsured rate after the DCP (baseline 22.5%), compared with 26-34 year olds (P<0.001). This coincided with a 1.4-percentage point relative decline in perforated appendix rate for 19-25 year olds (baseline 17.5%), compared with 26-34 year olds (P=0.023). All subgroups showed significant reductions in uninsured rates; however, statistically significant reductions in perforation rates were limited to racial/ethnic minorities, patients from lower-income communities, and patients presenting to urban teaching hospitals.

Conclusions: Reductions in uninsured rates among young adults after the DCP were associated with significant reductions in perforated appendix rates relative to a comparator group, suggesting that insurance expansion could lead to fewer delays in seeking and accessing care for acute conditions. Greater relative declines in perforation rates among the most at-risk subpopulations hold important implications for the use of coverage expansion to mitigate existing disparities in access to care.
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http://dx.doi.org/10.1097/MLR.0000000000000586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468100PMC
September 2016

Delivering value by focusing on patient experience.

Am J Manag Care 2015 Oct;21(10):735-7

Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115. E-mail:

The use of patient experience as a quality metric in healthcare remains controversial. Clinicians have expressed concern that incentives focused on patient experience may lead to lower quality care. However, empirical evidence from the United States and abroad suggests that hospitals and ambulatory care providers with higher patient satisfaction scores also perform better on clinical process and outcome measures. While it may be that high-performing providers simply have more resources to devote to both patient experience and the technical aspects of care, we suspect that these providers' performance is also driven by a conscious commitment to quality. As the country shifts toward new payment models, we should encourage this type of commitment to quality. Perhaps most importantly, improving the patient experience will build trust in the healthcare system, guard against withholding of services in the face of changing provider incentives, and promote collaboration between clinicians and patients. Therefore, patient experience measures should play a critical role in how we judge high-quality, value-based care.
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October 2015

Rethinking Priorities: Cost of Complications After Elective Colectomy.

Ann Surg 2016 08;264(2):312-22

*Center for Surgery and Public Health: Harvard Medical School, Harvard T.H. Chan School of Public Health, and Department of Surgery, Brigham and Women's Hospital, Boston, MA†Minnesota Gastroenterology, P.A., Saint Paul, MN‡Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

Objective: To compare incremental costs associated with complications of elective colectomy using nationally representative data among patients undergoing laparoscopic/open resections for the 4 most frequent diagnoses.

Summary Background Data: Rising healthcare costs have led to increasing focus on the need to achieve a better understanding of the association between costs and quality. Among elective colectomies, a focus of surgical quality-improvement initiatives, interpretable evidence to support existing approaches is lacking.

Methods: The 2009 to 2011 Nationwide Inpatient Sample (NIS) data were queried for adult (≥18 years) patients undergoing elective colectomy. Patients with primary diagnoses for colon cancer, diverticular disease, benign colonic neoplasm, and ulcerative colitis/regional enteritis were included. Based on system-based complications considered relevant to long-term treatment of elective colectomy, stratified differences in risk-adjusted incremental hospital costs and complications probabilities were compared.

Results: A total of 68,462 patients were included, weighted to represent 337,887 patients nationwide. A total of 16.4% experienced complications. Annual risk-adjusted incremental costs amounted to >$150 million. Magnitudes of complication prevalences/costs varied by primary diagnosis, operative technique, and complication group. Infectious complications contributed the most ($55 million), followed by gastrointestinal ($53 million), pulmonary ($22 million), and cardiovascular ($11 million) complications. Total annual costs for elective colectomies amounted to >$1.7 billion: 11.3% was due to complications [1.9% due to current Centers for Medicare and Medicaid Services (CMS) complications].

Conclusions: The results highlight a need to consider the varied/broad impact of complications, offering a stratified paradigm for priority setting in surgery. As we move forward in the development of novel/adaptation of existing interventions, it will be essential to weigh the cost of complications in an evidence-based way.
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http://dx.doi.org/10.1097/SLA.0000000000001511DOI Listing
August 2016

Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.

Health Aff (Millwood) 2015 Aug;34(8):1304-11

Raffaella Sadun is an associate professor of business administration at Harvard Business School.

National policies to improve health care quality have largely focused on clinical provider outcomes and, more recently, payment reform. Yet the association between hospital leadership and quality, although crucial to driving quality improvement, has not been explored in depth. We collected data from surveys of nationally representative groups of hospitals in the United States and England to examine the relationships among hospital boards, management practices of front-line managers, and the quality of care delivered. First, we found that hospitals with more effective management practices provided higher-quality care. Second, higher-rated hospital boards had superior performance by hospital management staff. Finally, we identified two signatures of high-performing hospital boards and management practice. Hospitals with boards that paid greater attention to clinical quality had management that better monitored quality performance. Similarly, we found that hospitals with boards that used clinical quality metrics more effectively had higher performance by hospital management staff on target setting and operations. These findings help increase understanding of the dynamics among boards, front-line management, and quality of care and could provide new targets for improving care delivery.
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http://dx.doi.org/10.1377/hlthaff.2014.1282DOI Listing
August 2015

Bundling Payments for Episodes of Surgical Care.

JAMA Surg 2015 Sep;150(9):905-6

Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamasurg.2015.1236DOI Listing
September 2015

Racial and Regional Disparities in the Effect of the Affordable Care Act's Dependent Coverage Provision on Young Adult Trauma Patients.

J Am Coll Surg 2015 Aug 9;221(2):495-501.e1. Epub 2015 Apr 9.

Department of Medicine, Massachusetts General Hospital, Boston, MA.

Background: Disparities in trauma outcomes based on insurance and race are especially pronounced among young adults who have relatively high uninsured rates and incur a disproportionate share of trauma in the population. The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed young adults to remain on their parent's health insurance plans until age 26 years, leading to >3 million young adults gaining insurance. We investigated the impact of the DCP on racial disparities in coverage expansion among trauma patients.

Study Design: Using the 2007-2012 National Trauma Data Bank, we compared changes in coverage among 529,844 19- to 25-year-olds with 484,974 controls aged 27 to 34 years not affected by the DCP. Subgroup analyses were conducted by race and ethnicity and by census region.

Results: The pre-DCP uninsured rates among young adults were highest among black patients (48.1%) and Hispanic patients (44.3%), and significantly lower among non-Hispanic white patients (28.9%). However, non-Hispanic white young adults experienced a significantly greater absolute reduction in the uninsured rate (-4.9 percentage points) than black (-2.9; p = 0.01) and Hispanic (-1.7; p < 0.001) young adults. These absolute reductions correspond to a 17.0% relative reduction in the uninsured rate for white patients, 6.1% for black patients, and 3.7% for Hispanic patients. Racial disparities in the provision's impact on coverage among trauma patients were largest in the South and West census regions (p < 0.01).

Conclusions: Although the DCP increased insurance coverage for young adult trauma patients of all races, both absolute and relative racial disparities in insurance coverage widened. The extent of these racial disparities also differed by geographic region. Although this policy produced overall progress toward greater coverage among young adults, its heterogeneous impact by race has important implications for future disparities research in trauma.
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http://dx.doi.org/10.1016/j.jamcollsurg.2015.03.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676942PMC
August 2015

Medicare's Bundled Payment initiative: most hospitals are focused on a few high-volume conditions.

Health Aff (Millwood) 2015 Mar;34(3):371-80

Ashish K. Jha is the K.T. Li Professor of International Health at the Harvard T.H. Chan School of Public Health, in Boston, Massachusetts.

The Bundled Payments for Care Improvement initiative is a federally funded innovation model mandated by the Affordable Care Act. It is designed to help transition Medicare away from fee-for-service payments and toward bundling a single payment for an episode of acute care in a hospital and related postacute care in an appropriate setting. While results from the initiative will not be available for several years, current data can help provide critical early insights. However, little is known about the participating organizations and how they are focusing their efforts. We identified participating hospitals and used national Medicare claims data to assess their characteristics and previous spending patterns. These hospitals are mostly large, nonprofit, teaching hospitals in the Northeast, and they have selectively enrolled in the bundled payment initiative covering patient conditions with high clinical volumes. We found no significant differences in episode-based spending between participating and nonparticipating hospitals. Postacute care explains the largest variation in overall episode-based spending, signaling an opportunity to align incentives across providers. However, the focus on a few selected clinical conditions and the high degree of integration that already exists between enrolled hospitals and postacute care providers may limit the generalizability of bundled payment across the Medicare system.
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http://dx.doi.org/10.1377/hlthaff.2014.0900DOI Listing
March 2015