Fady Saleh

Downwardly mobile: the accidental cost of being uninsured.

HYPOTHESIS Given the pervasive evidence of disparities in screening, hospital admission, treatment, and outcomes due to insurance status, a disparity in outcomes in trauma patients (in-hospital death) among the uninsured may exist, despite preventive regulations (such as the Emergency Medical Treatment and Active Labor Act). DESIGN Data were collected from the National Trauma Data Bank from January 1, 2002, through December 31, 2006 (version 7.0). We used multiple logistic regression to compare mortality rates by insurance status. SETTING The National Trauma Data Bank contains information from 2.7 million patients admitted for traumatic injury to more than 900 US trauma centers, including demographic data, medical history, injury severity, outcomes, and charges. PATIENTS Data from patients (age, >or=18 years; n = 687 091) with similar age, race, injury severity, sex, and injury mechanism were evaluated for differences in mortality by payer status. MAIN OUTCOME MEASURE In-hospital death after blunt or penetrating traumatic injury. RESULTS Crude analysis revealed a higher mortality for uninsured patients (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.36-1.42; P < .001). Controlling for sex, race, age, Injury Severity Score, Revised Trauma Score, and injury mechanism (adjusted for clustering on hospital), uninsured patients had the highest mortality (OR, 1.80; 95% CI, 1.61-2.02; P < .001). Subgroup analysis of young patients unlikely to have comorbidities revealed higher mortality for uninsured patients (OR, 1.89; 95% CI, 1.66-2.15; P < .001), as did subgroup analyses of patients with head injuries (OR, 1.65; 95% CI, 1.42-1.90; P < .001) and patients with 1 or more comorbidities (OR, 1.52; 95% CI, 1.30-1.78; P < .001). CONCLUSIONS Uninsured Americans have a higher adjusted mortality rate after trauma. Treatment delay, different care (via receipt of fewer diagnostic tests), and decreased health literacy are possible mechanisms.

Lack of insurance negatively affects trauma mortality in US children

PURPOSE Uninsured children face health-related disparities in screening, treatment, and outcomes. To ensure payer status would not influence the decision to provide emergency care, the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986, which states patients cannot be refused treatment or transferred from one hospital to another when medically unstable. Given findings indicating the widespread nature of disparities based on insurance, we hypothesized that a disparity in patient outcome (death) after trauma among the uninsured may exist, despite the EMTALA. METHODS Data on patients age 17 years or younger (n = 174,921) were collected from the National Trauma Data Bank (2002-2006), containing data from more than 900 trauma centers in the United States. We controlled for race, injury severity score, sex, and injury type to detect differences in mortality among the uninsured and insured. Logistic regression with adjustment for clustering on hospital was used. RESULTS Crude analysis revealed higher mortality for uninsured children and adolescents compared with the commercially or publicly insured (odds ratio [OR] 2.97; 95% confidence interval [CI], 2.64-3.34; P < .001). Controlling for sex, race, age, injury severity, and injury type, and clustering within hospital facility, uninsured children had the highest mortality compared with the commercially insured (OR, 3.32; 95% CI, 2.95-3.74; P < .001], whereas children and adolescents with Medicaid also had higher mortality (OR, 1.19; 95% CI, 1.07-1.33; P = .001). CONCLUSIONS These results demonstrate that uninsured and publicly insured American children and adolescents have higher mortality after sustaining trauma while accounting for a priori confounders. Possible mechanisms for this disparity include treatment delay, receipt of fewer diagnostic tests, and decreased health literacy, among others.

Safety of laparoscopic and open approaches for repair of the unilateral primary inguinal hernia: an analysis of short-term outcomes

BACKGROUND Primary laparoscopic repair of unilateral inguinal hernias has not achieved widespread recognition mainly because of concerns over safety. METHODS Prospective cohort study using the American College of Surgeons National Surgery Quality Improvement Program between 2005 and 2010. Complications in patients undergoing unilateral first-time, elective laparoscopic unilateral inguinal hernia repair (LIHR) were compared with open inguinal hernia repair (OIHR). RESULTS Of 37,645 identified patients, 6,356 (16.9%) underwent LIHR and 31,289 (83.1%) underwent OIHR. Both groups had similar 30-day overall complications, major complications, and mortality rates: 62 (1.0%) vs 307 (1.0%), P = 1.00; 31 (.5%) vs 173 (.5%), P = .57; and 1 (.02%) vs 16 (.05%), P = .34, respectively. Using multivariable logistic regression, overall complications showed no difference, OR 1.01 (95% CI .76 to 1.34; P = .94), as did major complications, OR .90 (95% CI .61 to 1.34; P = .62), although favoring the LIHR group, where OR and CI represent the odss ratio and confidence intervals. CONCLUSION These data demonstrate no significant difference between elective unilateral LIHR and OIHR with regard to 30-day morbidity and mortality.

Management of umbilical hernias in patients with ascites: development of a nomogram to predict mortality

BACKGROUND The objective of this study was to develop an easy-to-use nomogram to assist clinicians in predicting patient-specific mortality in this patient population. METHODS American College of Surgeons National Surgical Quality Improvement Program participant use files were used from 2005 to 2011. Multivariable logistic regression was used to model 30-day postoperative mortality in patients with ascites who underwent umbilical hernia repair. RESULTS A total of 688 patients with ascites undergoing umbilical hernia repair were included. There were 643 (94%) survivors and 45 (7%) mortalities. A total of 300 (44%) patients were classified as emergent cases. Using logistic regression to predict 30-day mortality, preoperative Model for End-Stage Liver Disease score, albumin, white blood cell count, and platelet count were found to be significant predictors (P < .05) of mortality and were included in our model. CONCLUSION We propose a nomogram to enable clinicians to better estimate mortality in patients with ascites undergoing umbilical hernia repair.

Short-term morbidity associated with removal and revision of the laparoscopic adjustable gastric band☆

BACKGROUND Laparoscopic adjustable gastric band (LAGB) insertion is a commonly performed bariatric procedure with low associated short-term risk. Given that a significant number of patients will require additional revision/removal procedures, overall morbidity may be underestimated. The objective of this study was to define the 30-day morbidity associated with LAGB removal and revision procedures. METHODS Patients undergoing revision or removal of LAGB were identified within The American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) participant use file using current procedural terminology and ICD-9 coding. Patients having concurrent procedures were excluded. Primary outcomes included 30-day morbidity. The rate of complications in the removal/revision patients versus primary LAGB insertion was compared. We also analyzed trends over time. RESULTS A total of 3,236 patients underwent LAGB removal (n = 1,580), revision (n = 1,111) or port site revision (n = 545) from 2006-2011. The overall 30-day complication rate was 5.6% (95% confidence interval [CI]: 4.8%, 6.4%) and was higher in patients undergoing LAGB removal with a 6.8% (95% CI: 5.6%, 8.1%) adverse event rate (2.5% infectious, 2.3% wound, 2.4% reoperation). A total of 24,438 patients underwent primary LAGB insertion within the data set with a 30-day complication rate of 2.6% (95% CI: 2.4%, 2.8%). Patients undergoing LABG removal had a significantly higher complication rate than those having primary LAGB insertion with an odds ratio of 2.72 (95% CI: 2.18, 3.37). The proportion of LAGB revision/removal compared to primary placement increased annually over the study period (P for trend<.001). CONCLUSION The 30-day morbidity associated with LAGB revision is significant and higher than that associated with primary LAGB insertions. The potential need for future procedures and the associated additional morbidity should be considered when evaluating LAGB as a treatment option for morbid obesity.