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Background: In the United States, Black maternal mortality is 2-4 × higher than that of White maternal mortality, with differences also present in severe maternal morbidity and other measures. However, limited research has comprehensively studied multilevel social determinants of health, and their confounding and effect modification on obstetrical outcomes. Materials and Methods: We performed a retrospective multistate analysis of adult inpatient delivery hospitalizations (Florida, Kentucky, Maryland, New Jersey, New York, North Carolina, and Washington) between 2007 and 2020. Multilevel multivariable models were used to test the confounder-adjusted association for race/ethnicity and the binary outcomes (1) in-hospital mortality or maternal end-organ injury and (2) in-hospital mortality only. Stratified analyses were performed to test effect modification. Results: The confounder-adjusted odds ratio showed that Black (1.33, 95% confidence interval [CI]: 1.30-1.36) and Hispanic (1.14, 95% CI: 1.11-1.18) as compared with White patients were more likely to die in-hospital or experience maternal end-organ injury. For Black and Hispanic patients, stratified analysis showed that findings remained significant in almost all homogeneous strata. After statistical adjustment, Black as compared with White patients were more likely to die in-hospital (1.49, 95% CI: 1.21-1.82). Conclusions: Black and Hispanic patients had higher adjusted odds of in-patient mortality and end-organ damage after birth than White patients. Race and ethnicity serve as strong predictors of health care inequality, and differences in outcomes may reflect broader structural racism and individual implicit bias. Proposed solutions require immense and multifaceted active efforts to restructure how obstetrical care is provided on the societal, hospital, and patient level.

Background: Geographic-based healthcare determinants and choice of anesthesia have been shown to be associated with maternal morbidity and mortality. We explored whether differences in maternal outcomes based on maternal residence, and anesthesia type for cesarean and vaginal birth, exist., Methods: This study was a retrospective multi-state analysis; patient residence was the predictor variable of interest and a composite binary measure of maternal end-organ injury or inpatient mortality was the primary outcome. Our secondary outcomes included a binary measure of anesthesia type for cesarean birth (general vs. neuraxial [NA]) and NA analgesia for vaginal birth (no NA vs. NA). Our predictor variable of interest was patient residency (reference category central metropolitan areas of >1 million population), fringe large metropolitan county, medium metropolitan, small metropolitan, micropolitan, and non-metropolitan or micropolitan county., Results: Women residing in micropolitan (OR 1.17; 95% CI 1.09 to 1.27) and non-metropolitan or micropolitan counties (OR 1.14; 95% CI 1.04 to 1.24) had the highest adjusted increased odds of adverse maternal outcomes. Those residing in suburban, medium, and small metropolitan areas underwent general anesthesia less often during cesarean births than those residing in urban areas. Patients residing in micropolitan rural (OR 2.07; 95% CI 2.02 to 2.12) and non-metropolitan or micropolitan (2.25; 95% CI 2.16 to 2.34) counties underwent vaginal births without NA analgesia more than twice as often as those residing in urban areas., Conclusions: Rural-urban disparities in maternal end-organ damage and mortality exist and anesthesia choice may play an important role in these disparate outcomes., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Colectomies are common yet costly, with high surgical-site infection rates. Safety-net hospitals (SNHs) carry a large proportion of uninsured or Medicaid-insured patients, which has been associated with poorer surgical outcomes. Few studies have examined the effect of safety-net burden (SNB) status on colectomy outcomes. We aimed to quantify the independent effects of hospital SNB and surgical site infection (SSI) status on colectomy outcomes, as well as the interaction effect between SSIs and SNB., Methods: We used the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky. We included 459,568 colectomies (2009 to 2014) for analysis, excluding patients age <18 y and rectal cases. The primary and secondary outcomes were inpatient mortality and complications, respectively., Results: Adjusting for patient, procedure, and hospital factors, colectomy patients were more likely to die in-hospital at high-burden SNHs (adjusted OR [aOR]: 1.38, 95% confidence interval [CI]: 1.25-1.51, P < 0.001), compared with low SNB hospitals and to experience perioperative complications (aOR: 1.12, 95% CI: 1.04-1.20, P < 0.01). Colectomy patients with SSIs also had greater odds of in-hospital mortality (aOR: 1.92, 95% CI: 1.83-2.02, P < 0.001) and complications (aOR: 3.65, 95% CI: 3.55-3.75, P < 0.001) compared with those without infections. Patients treated at SNHs who developed a SSI were even more likely to have an additional perioperative complication (aOR: 4.33, 95% CI: 3.98-4.71, P < 0.001)., Conclusions: Our study demonstrated that colectomy patients at SNHs have poorer outcomes, and for patients with SSIs, this disparity was even more pronounced in the likelihood for a complication. SNB should be recognized as a significant hospital-level factor affecting colectomy outcomes, with SSIs as an important quality metric., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: A retrospective analysis of patient hospitalization and discharge records., Objective: To examine the association between race and inpatient postoperative complications following lumbar spinal fusion surgery., Summary of Background Data: Racial disparities in healthcare have been demonstrated across a range of surgical procedures. Previous research has identified race as a social determinant of health that impacts outcomes after lumbar spinal fusion surgery. However, these studies are limited in that they are outdated, contain data from a single institution, analyze small limited samples, and report limited outcomes. Our study aims to expand and update the literature examining the association between race and inpatient postoperative complications following lumbar spine surgery., Methods: We analyzed 267,976 patient discharge records for inpatient lumbar spine surgery using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky from 2007 through 2014. We used unadjusted bivariate analysis, adjusted multivariable, and stratified analysis to compare patient demographics, present-on-admission comorbidities, hospital characteristics, and complications by categories of race/ethnicity., Results: Black patients were 8% and 14% more likely than white patients to experience spine surgery specific complications (adjusted odds ratios [aOR]: 1.08, 95% confidence interval [CI]: 1.03-1.13) and general postoperative complications (aOR: 1.14, 95% CI: 1.07-1.20), respectively. Black patients, compared with white patients, also had increased adjusted odds of 30-day readmissions (aOR: 1.13, 95% CI: 1.07-1.20), 90-day readmissions (aOR: 1.07, 95% CI: 1.02-1.13), longer length of stay (LOS) (adjusted Incidence Rate Ratio: 1.15, 95% CI: 1.14-1.16), and higher total charges (adjusted Incidence Rate Ratio: 1.08, 95% CI: 1.07-1.09)., Conclusion: Our findings demonstrate that black patients, as compared with white patients, are more likely to have postoperative complications, longer postoperative lengths of stay, higher total hospital charges, and increased odds of 30- and 90-day readmissions following lumbar spinal fusion surgery., Level of Evidence: 4.

Aim: To examine the effect of race/ethnicity, insurance status and median household income on postoperative readmissions following colectomy. Patients & methods: Multivariate analysis of hospital discharge data from California, Florida, Maryland and New York from 2009 to 2014. Primary outcomes included adjusted odds of 30- and 90-day readmissions following colectomy by race, insurance status and median income quartile. Results:  Total 330,840 discharges included. All 30-day readmissions were higher for black patients (adjusted odds ratio [aOR]: 1.07). Both 30- and 90-day readmissions were higher for Medicaid (aOR: 1.30 and 1.26) and Medicare (aOR: 1.30 and 1.29). The 30- and 90-day readmissions were lower in the highest income quartiles. Conclusion: Race, insurance status and median household income are all independent predictors of disparity in readmissions following colectomy.

Study Objective: To understand the effect of obstructive sleep apnea on readmission rates and post-operative atrial fibrillation in the cardiac surgical population., Design: Retrospective cohort study., Setting: Administrative database consisting of 2007-2014 data from California, Florida, New York, Kentucky, and Maryland from the State Inpatient Databases, Healthcare Cost and Utilization Project., Patients: A total of 506,604 patients ≥18 years old who underwent coronary artery bypass grafting surgery (CABG) and/or valve surgery were included in the study. After excluding for death during the index hospitalization and missing data, 396,657 patients remained for 30-day readmission analysis., Interventions: None., Measurements: Primary outcomes were unadjusted rates and adjusted odds of 30-day readmission. Secondary outcomes included post-operative atrial fibrillation and readmission diagnoses. Bivariate associations were assessed between OSA status, covariates and potential confounders, and outcomes. Odds ratios (OR) with 95% confidence intervals (CI) were estimated. Statistical significance was assessed at p < 0.05., Main Results: The overall 30-day readmission rate was 17.2%, with a rate of 19.6% vs. 17.1% in the OSA vs. non-OSA group (p < 0.001). Patients with OSA had higher odds of 30-day readmission (OR = 1.08, 95% CI 1.06-1.11) and higher odds of developing post-operative atrial fibrillation (OR = 1.04, 95% CI 1.01-1.08) compared to non-OSA patients. The most common reason for readmission was atrial fibrillation (38.6%), with OSA patients presenting with atrial fibrillation more frequently than their counterparts (41.7% vs. 38.4%, p < 0.001)., Conclusions: Patients with OSA are at increased risk of 30-day readmission and post-operative atrial fibrillation following cardiac surgery compared to those without OSA. Although the importance of OSA is increasingly recognized, it remains a significant risk factor for post-operative readmissions and morbidity. Further research is needed to optimize perioperative management of patients with OSA, but these results highlight the importance of this disease on patient outcomes and healthcare costs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To compare in-hospital mortality, postoperative stroke, and combined stroke/mortality in carotid artery stenting (CAS) patients and carotid endarterectomy (CEA) patients., Design: Retrospective observational study using data from the State Inpatient Database, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality., Setting: All coded CAS or CEA hospitalizations from 2007 to 2014 in California, Florida, New York, Kentucky, and Maryland., Participants: A total of 198,120 patients, 18 years of age or older, undergoing CAS or CEA., Interventions: None., Measurements and Main Results: Primary outcomes of the study were unadjusted rates and adjusted odds of in-hospital mortality, postoperative stroke, postoperative cardiovascular complications, and combined stroke/mortality, before and after correcting for confounders, following either CEA or CAS. In multivariate logistic regression analyses, in each successive individual year, CAS was associated with higher odds of in-hospital mortality (odds ratio [OR] ≥1.5 and p < 0.05), postoperative stroke (OR ≥1.4 and p < 0.05), and combined stroke/mortality (OR ≥1.5 and p < 0.05). Similar significant results were obtained when multivariate logistic regression was stratified by symptomatology. Carotid artery stenting was associated with higher odds of cardiovascular complications in 2012 (OR = 1.5, p < 0.05) and lower odds in 2009 (OR = 0.8, p < 0.05)., Conclusion: This study associated carotid stenting, as compared to endarterectomy, with an increased risk of dying and/or stroke. These associations persisted after statistical adjustment for patient demographics, comorbidities, and symptomatology, as well as after post-stratification by patient symptomatology. Despite this study's large, representative sample and well-defined a priori statistical methods, further research into real-world revascularization outcomes with longer-term follow-up is needed to formulate treatment guidelines., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: To compare readmission rates between patients with sickle cell disease (SCD) and non-sickle cell disease undergoing total hip and knee arthroplasty (THA and TKA)., Methods: Identified adult patients who underwent THA or TKA from 2007 to 2014 in California, Florida, New York, Maryland and Kentucky using a multistate database. Outcomes were 30- and 90-day readmission rates, mortality, complications, length of stay and hospital charges. Logistic regression models were used for analysis., Results: Compared with non-sickle cell disease patients following TKA and THA, SCD patients had higher odds of 30- (odds ratio [OR]: 3.79) and 90-day readmissions (OR: 4.15), mortality (OR: 6.54), more complications, longer length of stay, and higher total charges., Conclusion: Following TKA and THA, SCD is associated with higher readmissions and worse outcomes.