Jennifer E. Rosen

Massachusetts reform and disparities in inpatient care utilization.

Background:The 2006 Massachusetts health reform substantially decreased uninsurance rates. Yet, little is known about the reform’s impact on actual health care utilization among poor and minority populations, particularly for receipt of inpatient surgical procedures that are commonly initiated by outpatient physician referral. Methods:Using discharge data on Massachusetts hospitalizations for 21 months before and after health reform implementation (7/1/2006–12/31/2007), we identified all nonobstetrical major therapeutic procedures for patients aged 40 or older and for which ≥70% of hospitalizations were initiated by outpatient physician referral. Stratifying by race/ethnicity and patient residential zip code median (area) income, we estimated prereform and postreform procedure rates, and their changes, for those aged 40–64 (nonelderly), adjusting for secular changes unrelated to reform by comparing to corresponding procedure rate changes for those aged 70 years and above (elderly), whose coverage (Medicare) was not affected by reform. Results:Overall increases in procedure rates (among 17 procedures identified) between prereform and postreform periods were higher for nonelderly low area income (8%, P=0.04) and medium area income (8%, P<0.001) cohorts than for the high area income cohort (4%); and for Hispanics and blacks (23% and 21%, respectively; P<0.001) than for whites (7%). Adjusting for secular changes unrelated to reform, postreform increases in procedure utilization among nonelderly were: by area income, low=13% (95% confidence interval (CI)=[9%, 17%]), medium=15% (95% CI [6%, 24%]), and high=2% (95% CI [−3%, 8%]); and by race/ethnicity, Hispanics=22% (95% CI [5%, 38%]), blacks=5% (95% CI [−20%, 30%]), and whites=7% (95% CI [5%, 10%]). Conclusions:Postreform use of major inpatient procedures increased more among nonelderly lower and medium area income populations, Hispanics, and whites, suggesting potential improvements in access to outpatient care for these vulnerable subpopulations.

Disparities in Potentially Preventable Hospitalizations: Near-National Estimates for Hispanics

OBJECTIVE To obtain near-national rates of potentially preventable hospitalization (PPH)-a marker of barriers to outpatient care access-for Hispanics; to examine their differences from other race-ethnic groups and by Hispanic national origin; and to identify key mediating factors. DATA SOURCES/STUDY SETTING Data from all-payer inpatient discharge databases for 15 states accounting for 85 percent of Hispanics nationally. STUDY DESIGN Combining counts of inpatient discharges with census population for adults aged 18 and older, we estimated age-sex-adjusted PPH rates. We examined county-level variation in race-ethnic disparities in these rates to identify the mediating role of area-level indicators of chronic condition prevalence, socioeconomic status (SES), health care access, acculturation, and provider availability. PRINCIPAL FINDINGS Age-sex-adjusted PPH rates were 13 percent higher among Hispanics (1,375 per 100,000 adults) and 111 percent higher among blacks (2,578) compared to whites (1,221). Among Hispanics, these rates were relatively higher in areas with predominantly Puerto Rican and Cuban Americans than in areas with Hispanics of other nationalities. Small area variation in chronic condition prevalence and SES fully accounted for the higher rates among Hispanics, but only partially among blacks. CONCLUSIONS Hispanics and blacks face higher barriers to outpatient care access; the higher barriers among Hispanics (but not blacks) seem mediated by SES, lack of insurance, cost barriers, and limited provider availability.

Primer on outcomes research

Outcomes research uses diverse inputs to examine innovative end results aimed to deliver quality patient care. Yet defining “outcomes research” remains a challenge, and its interpretation is often nuanced. In this review, we discuss the definition of outcomes research in the context of its historical evolution along with the rise of other similar types of research. We then discuss key considerations in interpreting the results of outcomes analysis. J. Surg. Oncol. 2014 110:489–493.

Prophylactic Central Compartment Neck Dissection in Papillary Thyroid Cancer and Effect on Locoregional Recurrence

BackgroundProphylactic central compartment neck dissection (pCCND) in addition to total thyroidectomy (TT) includes removal of central compartment lymph nodes in the absence of clinical involvement on preoperative and intraoperative evaluation. The data regarding the influence of pCCND on oncologic outcomes and surgical complication rates is mixed and, therefore, is the focus of this analysis.MethodsA systematic review of the literature on total thyroidectomy with prophylactic central compartment neck dissection (TT + pCCND) from January 1990 to October 2017 identified 221 abstracts of which 17 met inclusion criteria and were reviewed (1 randomized-control trial, 13 retrospective cohort studies, and 3 meta-analyses).ResultsTT + pCCND was found to detect occult lymph node metastasis in approximately 50% of patients who had no clinical evidence of lymph node metastasis on preoperative imaging. Permanent hypoparathyroidism occurs more frequently following TT + pCCND (TT = 1.55% vs. TT + pCCND = 3.45%), but the rates of permanent recurrent laryngeal nerve dysfunction are similar (TT = 0.89% vs. TT + pCCND = 0.96%). The locoregional recurrence rates across all 14 studies included in this analysis was 6.75% for TT alone and 4.55% for TT + pCCND. The rate of locoregional recurrence was significantly lower in patients who underwent pCCND in a few studies and one meta-analysis, but were not significantly different in the majority of studies.ConclusionsTT + pCCND in clinically node-negative papillary thyroid cancer will detect occult lymph node metastasis in approximately half of patients. This may change their postoperative management with regard to adjuvant radioiodine therapy. There is a higher risk of hypoparathyroidism with pCCND, and the effect on rates of locoregional recurrence remains uncertain.

TIDE: Inter-chromosomal translocation and insertion detection using embeddings

Structural variations (SVs) are deletions, duplications and rearrangements of medium to large segments (>100 base pairs (bp)) of the genome. Such genomic mutations are often described as being the primary cause of many diseases, including cancer. Breakpoint detection using next-generation sequencing (NGS) platforms still remains an open problem since computational methods to detect SVs face the big challenge of accurately predicting the precise location of breakpoints, which are typically spanned by a very small number of reads among millions that are generated during the sequencing process. In this work, we propose a method called TIDE to identify reads from paired-end sequencing data containing inter-chromosomal translocation or insertion breakpoints, which are specific types of SVs involving different chromosomes. To achieve this, we use discordant read pairs to narrow the search space and split prospective breakpoint-spanning reads into windows that are subsequently represented by a sequence of k-mers indexes, which we call fingerprints. We then apply a distance-preserving embedding algorithm to solve the approximate nearest neighbor problem of pairing the most similar fingerprints originated from the sample and reference genome. Experimental results show the efficacy of the method to find reads containing breakpoints characterizing the PAX8-PPARγ rearrangement found in thyroid cancer samples. We also compare our results with the ones provided by two recently published algorithms for detecting structural variation in clinical data.

Racial/ethnic disparities among Asian Americans in inpatient acute myocardial infarction mortality in the United States

BackgroundAcute myocardial infarction (AMI) is a common high-risk disease with inpatient mortality of 5% nationally. But little is known about this outcome among Asian Americans (Asians), a fast growing racial/ethnic minority in the country. The objectives of the study are to obtain near-national estimates of differences in AMI inpatient mortality between minorities (including Asians) and non-Hispanic Whites and identify comorbidities and sociodemographic characteristics associated with these differences.MethodThis is a retrospective analysis of 2010–2011 state inpatient discharge data from 10 states with the largest share of Asian population. We identified hospitalization with a primary diagnosis of AMI using the ICD-9 code and used self-reported race/ethnicity to identify White, Black, Hispanic, and Asian. We performed descriptive analysis of sociodemographic characteristics, medical comorbidities, type of AMI, and receipt of cardiac procedures. Next, we examined overall inpatient AMI mortality rate based on patients’ race/ethnicity. We also examined the types of AMI and a receipt of invasive cardiac procedures by race/ethnicity. Lastly, we used sequential multivariate logistic regression models to study inpatient mortality for each minority group compared to Whites, adjusting for covariates.ResultsOver 70% of the national Asian population resides in the 10 states. There were 496,472 hospitalizations with a primary diagnosis of AMI; 75% of all cases were Whites, 10% were Blacks, 12% were Hispanics, and 3% were Asians. Asians had a higher prevalence of cardiac comorbidities, including hypertension, diabetes, and kidney failure compared to Whites (p-value< 0.01). There were 158,623 STEMI (ST-elevation AMI), and the proportion of hospitalizations for STEMI was the highest for Asians (35.2% for Asians, 32.7% for Whites, 25.3% for Blacks, and 32.1% for Hispanics). Asians had the highest rates of inpatient AMI mortality: 7.2% for Asians, 6.3% for Whites, 5.4% for Blacks, and 5.9% for Hispanics (ANOVA p-value < 0.01). In adjusted analyses, Asians (OR = 1.11 [95% CI: 1.04–1.19]) and Hispanics (OR = 1.14 [1.09–1.19]) had a higher likelihood of inpatient mortality compared to Whites.ConclusionsAsians had a higher risk-adjusted likelihood of inpatient AMI mortality compared to Whites. Further research is needed to identify the underlying reasons for this finding to improve AMI disparities for Asians.

Evaluation of a Thyroid Nodule

Thyroid nodules are a common finding in the general population. The reported prevalence of nodules varies based on the epidemiologic methods for evaluation. The ranges for the prevalence are reported to be 2–6% with palpation, 19–35% with ultrasound, and 8–65% in autopsy data (Dean and Gharib, Best Pract Res Clin Endocrinol Metab 22:901–911, 2008). Although there is no known environmental risk factor for the development of thyroid nodules, there has been a notable increase in the incidence of thyroid nodules and thyroid cancer in the United States over the previous three decades. This observation is explained by two known processes. First, the incidence of nodules increases with age. Second, the median age of the population in the United States has been increasing over the previous decades. Additionally, nodules are being identified more commonly on imaging studies performed for other reasons, as the sensitivity of computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) has increased and their use has increased with more accessibility in developed countries.

Elastic Scattering Spectroscopy for Thyroid Disease

The thyroid gland is anatomically located in the neck, just below the laryngeal prominence, or what’s more commonly referred to as the “Adam’s apple.” The thyroid is a bilobed, butterfly-shaped organ that is connected by an isthmus that wraps around the larynx. The cells of the thyroid gland are arranged in round follicles, surrounding a central core of colloid material and are themselves surrounded by perifollicular c-cells which secrete calcitonin.

Benchmarks and outcomes in surgical oncology: An introduction and current perspective

This edition of Seminars in Surgical Oncology is dedicated to the concept that outstanding care for cancer patients is not complete unless we are able to measure the effect of the surgical benefit for our patients. Since the earliest days of evaluating outcomes through the work of a surgeon, Ernest A. Codman of Boston, surgeons have taken the lead in assuring that data is collected and metrics are utilized to assess our care for patients. Following Codman’s initiatives, surgeons have also taken the lead in developing conferences (Mortality andMorbidity) that create an environment in which discussion can be used to assess surgical outcomes and to, more importantly, measure local outcomes against recognized benchmarks of quality. This is especially true in the management of surgical oncology issues. The genesis for this particular edition of Seminars is to bring together a number of concepts covering different specialty interests that are today utilized to measure outcomes that we, as surgeons, have utilized for our patients and their illnesses. The concept of healthcare outcomes has become a science in itself. Utilizing the basic concepts espoused byAvedisDonabedian, working at the University ofMichigan, who looked at issues of quality in terms of structure, process, and outcomes, the authors of our chapters have utilized their own unique approaches to create structure in order tomeasure surgical benefit for their given patient population. Our readers no doubt will feel that a limitation of this particular seriesmight be that we excluded important areas of surgical care. Hopefully we will dedicate future editions of Seminars to exploring other particular outcomes in surgical oncology. In this particular edition of Seminars we have also concentrated on outcomes for patients in the United States. We realize that many important outcomes initiatives are ongoing throughout other areas of the world. Hopefully a future edition of Seminars will be dedicated to outcome assessment outside of North America. We now offer you the benefits of reading the superb contributions of our invited authors. In our first series of overarching articles, Dr. In provides us with a primer to guide us through the difficult question of “what is outcomes analysis anyway?” Dr. Wright asks whether the paradigm of multidisciplinary care in fact improves outcomes, and makes a strong case for the need for better data. Dr. Berho takes up the issue of our compatriot pathologists, and prosecutes the case that their work provides key information not only in aiding diagnosis and management but in assessing our surgical adequacy as well. Dr. Greene confers to us the evolving and dynamic role of cancer staging, both in how we can incorporate new molecular markers and prognostic factors and in how proper staging is linked closely to determining the treatment most likely to benefit that patient. Dr.’s Piccirillo and Kallogjeri aid us through a coherent discussion of assessing patient factors and how they may (or may not) contribute to morbidity and mortality and the ever‐ important quality of life. Dr. Bilimoria takes on the world of nomograms and risk calculators, their accuracy and utility. Dr. Winchester evaluates the role of costly accreditation and leads us to see that compliance with standards is important not only for patient outcome but continuous program improvement as our world evolves. Dr. Stell enters the fray by discussing the ethical implications of surgeon volume, patient outcome, and the increasingly difficult question of informed consent. Through this discussion he reminds us that our research work can be difficult to interpret and convey to the patient when we ourselves are uncertain of its implications. Dr. Dunn reminds us that we are not alone in managing our patients, but have powerful aids through our navigators in monitoring and treating patients’ distress as they proceed through their care. Dr. Edge looks at outcomes through variations in key quality indicators in breast cancer. In particular, he discusses objective measurement tools and whether their application improves quality of care. In our next series of tumor‐specific review, Dr. Johnstone introduces us to outcomes in thoracic oncology, through the lens of surgical management of non‐small cell lung cancer, with a focus on utility and cost. Dr. Fong presents to us his analysis of outcomes in biliary malignancy, with a focus on assessing the best approach to improve estimates of prognosis, including morbidity and mortality in operative candidates. Drs. Altorki and Paul discuss prognosis in the management of esophageal cancer, in particular both the benefit of improved technology and treatment for short‐term morbidity and the modest benefit of neoadjuvant therapy for longer‐term mortality.