Search

This study aimed to evaluate associations of Medicaid expansion with health care access for adults with obesity and to explore racial/ethnic differences in these changes in health care access.Using 2011 to 2017 Behavioral Risk Factor Surveillance System data, the study compared health care access measures among adults who were aged ≥18 years and who had BMI ≥ 30 kg/mMedicaid expansion was associated with improvements in health care access, including lower proportions of those without a usual source of care (-3.6%, 95% confidence interval [CI]: -5.8% to -1.4%, p 0.01) and cost as a barrier to medical care (-4.5%, 95% CI: -7.0% to -1.9%, p 0.01). No significant changes were found in routine medical checkups in the last year (-1.8%, 95% CI: -4.4% to 0.8%, p = 0.12). However, across these measures, Medicaid expansion was consistently associated with better access among non-Hispanic White adults (-6.0% to -7.9%, p 0.01) and not at all among non-Hispanic Black and Hispanic adults (p 0.05).Medicaid expansion was associated with significant improvements in health care access among adults with obesity, but these improvements were variable across race and ethnicity.

Background and Aims Food impactions are a common reason for emergent upper endoscopy. Current guidelines call for urgent upper endoscopy (within 24 hours) for food impactions without complete esophageal obstruction and emergent endoscopy (within 6 hours) for those with complete esophageal obstruction. Multiple adverse events can arise from esophageal foreign bodies. Cases with longer delays from symptom onset to presentation have been associated with higher rates of surgical intervention. However, data on esophageal soft food impactions are scant. We set out to determine differences in outcomes for food impactions undergoing intervention within 12 hours versus over 12 hours of symptom onset. Methods A retrospective review of medical records was conducted to identify patients who presented to our hospital with an esophageal soft food impaction and underwent an EGD between January 2010 and January 2018. Patients were divided into 2 groups based on the timing from symptom onset to EGD. An EGD within 12 hours was considered an early intervention and over 12 hours was considered a delayed intervention. Patients who had ingested bones or hard objects were not included. Primary outcomes studied were rates of aspiration, admission, local esophageal adverse events, and 30-day all-cause mortality. Results We identified 110 patients with a soft food impaction who underwent an EGD. Forty- two patients had an early intervention and 68 a delayed intervention. There were no differences in basic demographics and comorbidities. Additionally, there were no differences in rates of local esophageal adverse events, aspiration, admission, or 30-day mortality. Multivariate analysis revealed endoscopic accessory use was associated with increased odds of local esophageal adverse events (odds ratio, 6.37; P = .01). Conclusions The overall rates of serious adverse events in esophageal soft food impactions are low. Delayed intervention is not associated with increased adverse events or 30-day mortality compared with early intervention. However, accessory use is associated with higher adverse event rates.

Background Diabetes mellitus has reached epidemic proportions in the United States. As the prevalence of diabetes continues to rise, the burden of disease is divided unevenly among different populations. Racial/ethnic disparities in diabetes care are pervasive, including the provision of care for prevention of complications. Prevention efforts should be focused on the time that immediately follows a diagnosis of diabetes. The aim of this study was to assess racial/ethnic differences in the receipt of guideline-directed diabetes care for complication prevention by individuals recently diagnosed with diabetes. Methods We used repeated cross-sections of individuals recently diagnosed with diabetes (within the past 5 years) from the National Health Interview Survey from 2011 to 2017. Multivariate regression was used to estimate the associations between race/ethnicity (non-Hispanic White, non-Hispanic Black and Hispanic) and guideline-directed process measures for prevention of diabetes complications (visits to an eye and foot specialist, and blood pressure and cholesterol checks by a health professional - each in the prior year). We assessed effect modification of these associations by socioeconomic status (SES). Results In a sample of 7,341 participants, Hispanics had lower rates of having any insurance coverage (75.9 %) than Non-Hispanic Whites (93.2 %) and Blacks (88.1 %; pp=0.04) and a blood pressure check (OR 0.42; (95 % CI 0.28-0.65); p Conclusions Hispanics recently diagnosed with diabetes were less likely to receive some indicators of guideline-directed care for the prevention of complications. Lack of insurance and SES may partially explain those differences. Future work should consider policy change and providers’ behaviors linked to racial/ethnic disparities in diabetes care.

The 30-day hospital readmission rate is a nationally recognized quality measure. Nearly one-fifth of medicare beneficiaries are hospitalized within 30 days of discharge, resulting in a cost of over $26 billion dollars annually. Endoscopic retrograde cholangiopancreatography (ERCP) remains the endoscopic procedure with the highest risk of morbidity and mortality. We set out to analyze the clinical characteristics predictive of 30-day readmission after an inpatient ERCP. We performed a retrospective chart review of all inpatient ERCPs performed at our institution between 12/1/2014 and 9/30/2018. Clinical characteristics and outcomes of these patients were compared to determine predictors of 30-day readmission. A total of 497 inpatient ERCP procedures done for biliary or pancreatic indications, constituting 483 patients, were identified. There were 52 readmissions that occurred among 48 patients within 30 days of discharge. Basic demographic characteristics were similar between both groups. Comorbidities were significantly higher in those who were readmitted. Multivariate analysis revealed significantly greater odds of readmission with prior liver transplantation (OR = 4.15), cirrhosis (OR = 3.20), and pancreatic duct stent placement (OR = 2.56). Subgroup analysis for biliary indications revealed cholecystectomy before discharge and early ERCP to be protective against readmission. A history of liver transplantation and cirrhosis are predictive of increased 30-day readmission rates after an inpatient ERCP. Pancreatic duct stent placement is associated with readmission; however, this phenomenon is likely related to stenting for pancreatic endotherapy. Cholecystectomy before discharge and early ERCP are predictive of decreased need for readmission in procedures done for biliary indications.

BACKGROUND Driven in part by Medicare's Hospital Readmissions Reduction Program, hospitals are focusing on improving the transition from inpatient to outpatient care with particular emphasis on early follow-up with a primary care physician (PCP). OBJECTIVE To assess whether the implementation of a scheduling assistance program changes rates of PCP follow-up or readmissions. DESIGN Retrospective cohort study. SETTING An urban tertiary care center PATIENTS: A total of 20,918 adult patients hospitalized and discharged home between September 2008 and October 2015. INTERVENTION A postdischarge appointment service to facilitate early PCP follow-up. MAIN MEASURES Primary outcomes were rates of follow-up visits with a PCP within seven days of discharge and hospital readmission within 30 days of discharge. Our first analysis assessed differences in outcomes among patients with and without the use of the service. In a second analysis, we exploited the fact that the service was not available on weekends and conducted an instrumental variable analysis that used the interaction between the intervention and day of the week of admission. RESULTS In our multivariable analysis, use of the appointment service was associated with much higher rates of PCP follow-up (+31.9 percentage points, 95% CI: 30.2, 33.6; P < .01) and a decrease in readmission (-3.8 percentage points, 95% CI: -5.2, -2.4; P < .01). In the instrumental variable analysis, use of the service also increased the likelihood of a PCP follow-up visit (33.4 percentage points, 95% CI: 7.9, 58.9; P = .01) but had no significant impact on readmissions (-2.5 percentage points, 95% CI: -22.0, 17.0; P = .80). CONCLUSIONS The postdischarge appointment service resulted in a substantial increase in timely PCP followup, but its impact on the readmission rate was less clear.

BACKGROUND –: There is concern that mental and physical fatigue among endoscopists over the course of the day will lead to lower adenoma detection rate (ADR). There are mixed findings in the prior literature on whether such an association exists. AIMS –: To measure the association between the number of colonoscopies performed in a day and ADR and withdrawal time. METHODS –: We analyzed 86,624 colonoscopy and associated pathology reports between October 2013 to September 2015 from 131 physicians at two medical centers. A previously validated natural language processing program was used to abstract relevant data. We identified the order of colonoscopies performed in the physcians’ schedule and calculated the ADR and withdrawal time for each colonoscopy position. RESULTS –: The ADR for our overall sample was 29.9 (CI, 29.6–30.2). The ADR for colonoscopies performed at the 9(th)+ position was significantly lower than those at the 1(st)–4(th) or 5(th)–8(th) position, 27.2 (CI, 25.8–28.6) vs. 29.9 (CI, 29.5–30.3), 30.2 (CI, 29.6–30.9) respectively. Withdrawal time steadily decreased by colonoscopy position going from 11.6 (CI, 11.4–11.9) minutes for the 1(st) colonoscopy to 9.6 (8.9–10.3) minutes for the 9(th) colonoscopy. CONCLUSION –: In our study population ADR and withdrawal time decrease by roughly 7% and 20% respectively by the end of the day. Our results imply that rather than mental or physical fatigue, lower ADR at the end of the day might be driven by endoscopists rushing.

Cancer screening rates declined sharply early in the COVID-19 pandemic. The impact of the pandemic may have exacerbated existing disparities in cancer screening due to the disproportionate burden of illness and job loss among racial/ ethnic minorities, and potentially, uneven resumption of care between different racial/ ethnic groups. Using electronic health record data from Mass General Brigham (MGB), we assessed changes in rates of breast, cervical, colorectal and lung cancer screening before and during the pandemic. Among patients who received primary care in an MGB-affiliated primary care practice, cancer screening rates were calculated as the number of individuals who received a screening test for each cancer type over the number of individuals due for each test, during each month between April 2019-November 2020. We conducted an interrupted time-series analysis to test for changes in screening rates by race/ethnicity before and during the pandemic. Prior to the pandemic, relative to White individuals, Asian women were less likely to receive breast cancer screening (p

Background The adenoma detection rate (ADR) is a validated and widely used measure of colonoscopy quality. There is uncertainty in the published literature as to which colonoscopy examinations should be excluded when measuring a physician's ADR. Objective To examine the impact of varying the colonoscopy exclusion criteria on physician ADR. Design We applied different exclusion criteria used in 30 previous studies to a dataset of endoscopy and pathology reports. Under each exclusion criterion, we calculated physician ADR. Setting A private practice colonoscopy center affiliated with the University of Illinois College of Medicine. Patients Data on 20,040 colonoscopy examinations performed by 11 gastroenterologists from July 2009 to May 2013 and associated pathology notes. Main Outcome Measurements ADRs across all colonoscopy examinations, each physician's ADR, and ADR ranking. Results There were 28 different exclusion criteria used when measuring the ADR. Each study used a different combination of these exclusion criteria. The proportion of all colonoscopy examinations in the dataset excluded under these combinations of exclusion criteria ranged from 0% to 92.2%. The mean ADR across all colonoscopy examinations was 39.1%. The change in mean ADR after applying the 28 exclusion criteria ranged from −5.5 to +3.0 percentage points. However, the exclusion criteria affected each physician's ADR relatively equally, and therefore physicians' rankings via the ADR were stable. Limitations ADR assessment was limited to a single private endoscopy center. Conclusion There is wide variation in the exclusion criteria used when measuring the ADR. Although these exclusion criteria can affect overall ADRs, the relative rankings of physicians by ADR were stable. A consensus definition of which exclusion criteria are applied when measuring ADR is needed.