Quality of Care and Outcomes of Patients With Gynecologic Malignancies Treated at Safety-Net Hospitals.
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ABSTRACT:
SUBMITTER: Gamble CR
PROVIDER: S-EPMC6735612 | biostudies-literature | 2019 Sep
REPOSITORIES: biostudies-literature
Publications
Quality of Care and Outcomes of Patients With Gynecologic Malignancies Treated at Safety-Net Hospitals.
Gamble Charlotte R CR Huang Yongmei Y Tergas Ana I AI Khoury-Collado Fady F Hou June Y JY St Clair Caryn M CM Ananth Cande V CV Neugut Alfred I AI Hershman Dawn L DL Wright Jason D JD
JNCI cancer spectrum 20190607 3
<h4>Background</h4>Although safety-net hospitals (SNH) provide a valuable role serving vulnerable patients, the quality of gynecologic oncology care at these hospitals remains inadequately documented. We examined the quality of care at SNH for women with gynecologic cancers.<h4>Methods</h4>We used the National Cancer Database to identify hospitals that treated patients with uterine, ovarian, or cervical cancer from 2004 to 2015. Hospitals with the greatest proportion of uninsured patients or Med ...[more]
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Project description:ObjectivesEvidence suggests that homeless patients experience worse quality of care and poorer health outcomes across a range of medical conditions. It remains unclear, however, whether differences in care delivery at safety-net versus non-safety-net hospitals explain these disparities. We aimed to investigate whether homeless versus non-homeless adults hospitalised for cardiovascular conditions (acute myocardial infarction (AMI) and stroke) experience differences in care delivery and health outcomes at safety-net versus non-safety-net hospitals.DesignCross-sectional study.SettingData including all hospital admissions in four states (Florida, Massachusetts, Maryland, and New York) in 2014.ParticipantsWe analysed 167 105 adults aged 18 years or older hospitalised for cardiovascular conditions (age mean=64.5 years; 75 361 (45.1%) women; 2123 (1.3%) homeless hospitalisations) discharged from 348 hospitals.Outcome measuresRisk-adjusted diagnostic and therapeutic procedure and in-hospital mortality, after adjusting for patient characteristics and state and quarter fixed effects.ResultsAt safety-net hospitals, homeless adults hospitalised for AMI were less likely to receive coronary angiogram (adjusted OR (aOR), 0.42; 95% CI, 0.36 to 0.50; p<0.001), percutaneous coronary intervention (aOR, 0.52; 95% CI, 0.44 to 0.62; p<0.001) and coronary artery bypass graft (aOR, 0.43; 95% CI, 0.26 to 0.71; p<0.01) compared with non-homeless adults. Homeless patients treated for strokes at safety-net hospitals were less likely to receive cerebral arteriography (aOR, 0.23; 95% CI, 0.16 to 0.34; p<0.001), but were as likely to receive thrombolysis therapy. At non-safety-net hospitals, we found no evidence that the probability of receiving these procedures differed between homeless and non-homeless adults hospitalised for AMI or stroke. Finally, there were no differences in in-hospital mortality rates for homeless versus non-homeless patients at either safety-net or non-safety-net hospitals.ConclusionDisparities in receipt of diagnostic and therapeutic procedures for homeless patients with cardiovascular conditions were observed only at safety-net hospitals. However, we found no evidence that these differences influenced in-hospital mortality markedly.
| S-EPMC8039275 | biostudies-literature
Project description:Safety-net hospitals, which include urban hospitals serving large numbers of low-income, uninsured, and otherwise vulnerable populations, have historically faced greater financial strains than hospitals that serve more affluent populations. These strains can affect hospitals' quality of care, perhaps resulting in worse outcomes that are commonly used as indicators of care quality-mortality and readmission rates. We compared risk-standardized rates of both of these clinical outcomes among fee-for-service Medicare beneficiaries admitted for acute myocardial infarction, heart failure, or pneumonia. These beneficiaries were admitted to urban hospitals within Metropolitan Statistical Areas that contained at least one safety-net and at least one non-safety-net hospital. We found that outcomes varied across the urban areas for both safety-net and non-safety-net hospitals for all three conditions. However, mortality and readmission rates were broadly similar, with non-safety-net hospitals outperforming safety-net hospitals on average by less than one percentage point across most conditions. For heart failure mortality, there was no difference between safety-net and non-safety-net hospitals. These findings suggest that safety-net hospitals are performing better than many would have expected.
| S-EPMC3527010 | biostudies-literature
Project description:BACKGROUND:Length of hospital stay (LOS) for hip fracture treatments is associated with mortality. In addition to patient demographic and clinical factors, hospital and payer type may also influence LOS, and thus mortality, among hip fracture patients; accordingly, outcome disparities between groups may arise from where patients are treated and from their health insurance type. The purpose of this study was to examine if where hip fracture patients are treated and how they pay for their care is associated with outcome disparities between patient groups. Specifically, we examined whether LOS differed between patients treated at safety-net and non-safety-net hospitals and whether LOS was associated with patients' insurance type within each hospital category. METHODS:A sample of 48,948 hip fracture patients was extracted from New York State's Statewide Planning and Research Cooperative System (SPARCS), 2014-2016. Using means comparison and X2 tests, differences between safety-net and non-safety-net hospitals on LOS and patient characteristics were examined. Relationships between LOS and hospital category (safety-net or non-safety-net) and LOS and insurance type were further evaluated through negative binomial regression models. RESULTS:LOS was statistically (p???0.001) longer in safety-net hospitals (7.37?days) relative to non-safety-net hospitals (6.34?days). Treatment in a safety-net hospital was associated with a LOS that was 11.7% (p =?0.003) longer than in a non-safety-net hospital. Having Medicaid was associated with a longer LOS relative to having commercial health insurance. CONCLUSION:Where hip fracture patients are treated is associated with LOS and may influence outcome disparities between groups. Future research should examine whether outcome differences between safety-net and non-safety-net hospitals are associated with resource availability and hospital payer mix.
| S-EPMC7011469 | biostudies-literature
Project description:BackgroundQuality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition's Quality Measurement Enhancement Project sought to collect data from primary care providers' (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs' perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare.MethodsQualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes.ResultsThree themes with sub-themes emerged. Theme #1: Minnesota's current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity.ConclusionAligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs' perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them.
| S-EPMC6222992 | biostudies-literature
Project description:ImportanceIn the US, federal value-based incentive programs are more likely to penalize safety-net institutions than non-safety-net institutions. Whether these programs differentially change the rates of targeted health care-associated infections in safety-net vs non-safety-net hospitals is unknown.ObjectiveTo assess the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care-associated infections and disparities in rates among safety-net and non-safety-net hospitals.Design, setting, and participantsThis interrupted time series included all US acute care hospitals enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study that participated in mandatory reporting to the National Healthcare Safety Network from January 1, 2013, through June 30, 2018. Hospital characteristics were obtained from the 2015 American Hospital Association annual survey. Penalty statuses for 2015 to 2018 were obtained from Hospital Compare. Data were analyzed between July 9, 2018, and October 1, 2019.ExposuresHACRP and HVBP implementation in fiscal year 2015 or 2016.Main outcomes and measuresThe primary outcomes were rates of 4 health care-associated infections: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) after colon surgical procedures, and SSI after abdominal hysterectomy procedures. Regression models were fit using generalized estimating equations to assess the association of HACRP and HVBP implementation with health care-associated infection rates and disparities in infection rates.ResultsOf the 618 acute care hospitals included in this study, 473 (76.5%) were non-safety net and 145 (23.5%) were considered safety net. In these hospitals, HACRP and HVBP implementation was not associated with improvements in level or trend for any health care-associated infection examined (eg, CAUTI in safety-net hospitals: incidence rate ratio [IRR] for level change, 0.98 [95% CI, 0.79-1.23; P = .89]; IRR for change in slope, 1.00 [95% CI, 0.97-1.03; P = .80]). Before program implementation, infection rates were statistically significantly higher for safety-net than for non-safety-net hospitals for CLABSI (IRR, 1.23; 95% CI, 1.07-1.42; P = .004), CAUTI (IRR, 1.38; 95% CI, 1.16-1.64; P < .001), and SSI after colon surgical procedure (odds ratio [OR], 1.26; 95% CI, 1.06-1.50; P = .009). The disparity persisted over time when comparing the last year of the study with the first year (CLABSI: ratio of ratios [ROR], 0.93 [95% CI, 0.77-1.13; P = .48]; CAUTI: ROR, 0.90 [95% CI, 0.73-1.10; P = .31]; SSI after colon surgical procedures: ROR, 0.96 [95% CI, 0.78-1.20; P = .75]). Rates of SSI after abdominal hysterectomy procedure were similar in safety-net and non-safety-net hospitals before implementation (OR, 1.13; 95% CI, 0.91-1.40; P = .27) but higher after implementation (OR, 1.43; 95% CI, 1.11-1.83; P = .006), although this change was not significant (ROR, 1.20; 95% CI, 0.91-1.59; P = .20).Conclusions and relevanceThis study found that HACRP and HVBP implementation was not associated with any improvements in targeted health care-associated infections among safety-net or non-safety-net hospitals or with changes in disparities in infection rates. Given the persistent health care-associated infection rate disparities, these programs appear to function as a disproportionate penalty system for safety-net hospitals that offer no measurable benefits for patients.
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Project description:The aim of this study was to determine sustained effectiveness in reducing depression symptoms and improving depression care 1 year following intervention completion.Of 387 low-income, predominantly Hispanic diabetes patients with major depression symptoms randomized to 12-month socioculturally adapted collaborative care (psychotherapy and/or antidepressants, telephone symptom monitoring/relapse prevention) or enhanced usual care, 264 patients completed 2-year follow-up. Depression symptoms (Symptom Checklist-20 [SCL-20], Patient Health Questionnaire-9 [PHQ-9]), treatment receipt, diabetes symptoms and quality of life were assessed 24 months postenrollment using intent-to-treat analyses.At 24 months, more intervention patients received ongoing antidepressant treatment (38% vs. 25%, ?(2)=5.11, df=1, P=.02); sustained depression symptom improvement [SCL-20 <0.5 (adjusted odds ratio=2.06, 95% confidence interval=1.09-3.90, P=.03), SCL-20 score (adjusted mean difference -0.22, P=.001) and PHQ-9 ?50% reduction (adjusted odds ratio=1.87, 95% confidence interval =1.05-3.32, P=.03)]. Over 2 years, improved effects were found in significant study group by time interaction for Short Form-12 mental health, Sheehan Disability Scale (SDS) functional impairment, diabetes symptoms, anxiety and socioeconomic stressors (P=.02 for SDS; P<.0001 for all others); however, group differences narrowed over time and were no longer significant at 24 months.Socioculturally tailored collaborative care that included maintenance antidepressant medication, ongoing symptom monitoring and behavioral activation relapse prevention was associated with depression improvement over 24 months for predominantly Hispanic patients in primary safety net care.
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Project description:PurposeNewly enacted policies at the state and federal level in the United States require acute care hospitals to engage in sepsis quality improvement. However, responding to these policies requires considerable resources and may disproportionately burden safety-net hospitals. To better understand this issue, we analyzed the relationship between hospital safety-net status and performance on Medicare's SEP-1 quality measure.Materials and methodsWe linked multiple publicly-available datasets with information on SEP-1 performance, structural hospital characteristics, hospital financial case mix, and health system affiliation. We analyzed the relationship between hospital safety-net status and SEP-1 performance, as well as whether hospital characteristics moderated that relationship.ResultsWe analyzed data from 2827 hospitals, defining safety-net hospitals using financial case mix data. The 703 safety-net hospitals performed worse on Medicare's SEP-1 quality measure (adjusted difference 2.3% compliance, 95% CI -4.0%--0.6%). This association was most evident in hospitals not affiliated with health systems, in which the difference between safety-net and non-safety-net hospitals was 6.8% compliance (95% CI -10.4%--3.3%).ConclusionsExisting sepsis policies may harm safety-net hospitals and widen health disparities. Our findings suggest that strategies to promote collaboration among hospitals may be an avenue for sepsis performance improvement in safety-net hospitals.
| S-EPMC6901718 | biostudies-literature
Project description:PurposeWe evaluated the efficacy and safety of pembrolizumab in patients with recurrent gynecologic cancers in real-world practice.Materials and methodsWe conducted a retrospective, single-institution study of patients with recurrent gynecologic malignancies treated with pembrolizumab. The primary endpoints were the objective response rate (ORR) and safety.ResultsThirty-one patients treated with pembrolizumab were included. The primary disease sites were the uterine cervix (n=18), ovaries (n=8), and uterine corpus (n=5). Fifteen of the 31 patients (48%) had an Eastern Cooperative Oncology Group performance status of ≥2. The median number of prior chemotherapy lines was 2 (range, 1-6), and 14 of 31 patients (45%) had received ≥ 3 prior lines of chemotherapy. The overall ORR was 22.6%: specifically, 22.3% (4 of 18 patients), 12.5% (1 of 8 patients), and 40% (2 of 5 patients) for cervical, ovarian, and endometrial cancers, respectively. During a median follow-up of 4.7 months (range, 0.2-35.3), the median time to response was 1.9 months (range, 1.4-5.7). The median duration of response was not reached (range, 8.8-not reached). The median progression-free survival was 2.5 months (95% confidence interval, 1.7-not reached). Adverse events occurred in 20 patients (64.5%), and only 3 (9.7%) were grade ≥3. There was one case of suspicious treatment-related mortality, apart from which most adverse events were manageable.ConclusionIn real-world practice, pembrolizumab was feasible and effective in heavily treated recurrent gynecologic cancer patients with poor performance status who may not be eligible for enrollment in clinical trials.
| S-EPMC7515778 | biostudies-literature
Project description:BACKGROUND:Because of residential segregation and a lack of health insurance, minorities often receive care in different facilities than whites. Massachusetts (MA) health reform provided insurance to previously uninsured patients, which enabled them to potentially shift inpatient care to nonminority-serving or nonsafety-net hospitals. OBJECTIVES:Examine whether MA health reform affected hospitals' racial mix of patients, and individual patients' use of safety-net hospitals. RESEARCH DESIGN:Difference-in-differences analysis of 2004-2009 inpatient discharge data from MA, compared with New York (NY), and New Jersey (NJ), to identify postreform changes, adjusting for secular changes. SUBJECTS:(1) Hospital-level analysis (discharges): 345 MA, NY, and NJ hospitals; (2) patient-level analysis (patients): 39,921 patients with ?2 hospitalizations at a safety-net hospital in the prereform period. MEASURES:Prereform to postreform changes in percentage of discharges that are minority (black and Hispanic) at minority-serving hospitals; adjusted odds of patient movement from safety-net hospitals (prereform) to nonsafety-net hospitals (postreform) by age group and state. RESULTS:Treating NJ as the comparison state, MA reform was associated with an increase of 5.8% (95% CI, 1.4%-10.3%) in the percentage of minority discharges at MA minority-serving hospitals; with NY as the comparison state, the change was 2.1% (95% CI, -0.04% to 4.3%). Patient movement from safety-net to nonsafety-net hospitals was greater in MA than comparison states (difference-in-differences adjusted OR=1.3; 95% CI, 1.0-1.7; P=0.04). CONCLUSIONS:Following MA health reform, the safety-net remains an important component of the health care system.
| S-EPMC4989238 | biostudies-literature
Project description:ImportanceMedical patients discharged from safety-net hospitals (SNHs) experience higher readmission rates compared with those discharged from non-SNHs. However, little is known about whether this association persists for surgical patients.ObjectivesTo examine differences in readmission rates between SNHs and non-SNHs among surgical patients after discharge and determine whether hospital characteristics might account for some of the variation.Design, setting, and participantsThis observational retrospective study linked the Healthcare Cost and Utilization Project State Inpatient Databases of the Agency for Healthcare Research and Quality from January 1, 2011, through December 31, 2014, for 4 states (New York, Florida, Iowa, and Washington) with data from the 2014 American Hospital Association annual survey. After identifying surgical discharges, SNHs were defined as those with the top quartile of inpatient stays paid by Medicaid or self-paid. Hospital-level risk-standardized readmission rates (RSRRs) for surgical discharges were calculated. The association between hospital RSRRs and hospital characteristics was evaluated with bivariate analyses. An estimated multivariable hierarchical linear regression model was used to examine variation in hospital RSRRs, adjusting for hospital characteristics, state, year, and SNH status. Data were analyzed from June 1, 2017, through March 1, 2018.ExposuresSurgical care at an SNH.Main outcomes and measuresReadmission after an index surgical admission.ResultsA total of 1 252 505 patients across all 4 years and states were included in the analysis (51.7% women; mean [SD] age, 52.7 [18.1] years). Bivariate analyses found that SNHs had higher mean (SD) surgical RSRRs compared with non-SNHs; significant differences were found for New York (9.6 [0.1] vs 10.9 [0.1]; P < .001) and Florida (11.6 [0.1] vs 12.1 [0.1]; P = .001). The SNHs also had higher RSRRs in these 2 states when stratified by hospital funding (nonfederal government SNHs in New York, 11.9 [0.2]; for-profit, private SNHs in Florida, 13.1 [0.2]; P < .001 for both); however, bed size was a significant factor for higher mean (SD) RSRRs only for New York (200 to 399 beds, 12.0 [0.4]; P = .006). Similar results were found for multivariable linear regression models; RSRRs were 1.02% higher for SNHs compared with non-SNHs (95% CI, 0.75%-1.29%; P < .001). Increased RSRRs were observed for hospitals in New York and Florida, teaching hospitals, and investor-owned hospitals. Factors associated with reduced RSRRs included presence of an ambulatory surgery center, cardiac catheterization capabilities, and high surgical volume.Conclusions and relevanceAccording to results of this study, surgical patients treated at SNHs experienced slightly higher RSRRs compared with those treated at non-SNHs. This association persisted after adjusting for year, state, and hospital factors, including teaching status, hospital bed size, and hospital volume.
| S-EPMC6537916 | biostudies-literature