All Publications

  • Out-of-Pocket Costs and Provider Payments in Cleft Lip and Palate Repair. Annals of plastic surgery Rochlin, D. H., Ma, L. W., Sheckter, C. C., Lorenz, H. P. 2022


    BACKGROUND: As healthcare spending within the United States grows, payers have attempted to curb spending through higher cost sharing for patients. For families attempting to balance financial obligations with their children's surgical needs, high cost sharing could place families in difficult situations, deciding between life-altering surgery and bankruptcy. We aim to investigate trends in patient cost sharing and provider payments for cleft lip and palate repair.METHODS: The IBM MarketScan Commercial Database was queried to extract patients younger than 18 years who underwent primary or secondary cleft lip and/or palate repair from 2007 to 2016. Financial variables included gross payments to the provider (facility and/or physician), net payment as reported by the carrier, coordination of benefits and other savings, and the beneficiary contribution, which consisted of patients' coinsurance, copay, and deductible payments. Linear regression was used to evaluate trends in payments over time. Poisson regression was used to trend the proportion of patients with a nonzero beneficiary contribution. All financial values were adjusted to 2016 dollars per the consumer price index to account for inflation.RESULTS: The sample included 6268 cleft lip and 9118 cleft palate repair episodes. Total provider payments increased significantly from 2007 to 2016 for patients undergoing cleft lip (median, $2527.33 vs $5116.30, P 0.008) and palate ($1766.13 vs $3511.70, P < 0.001) repair. Beneficiary contribution also increased significantly for both cleft lip ($155.75 vs $193.31, P < 0.001) and palate ($124.37 vs $183.22, P < 0.001) repair, driven by an increase in deductibles (P < 0.002). The proportion of cleft palate patients with a nonzero beneficiary contribution increased yearly by 1.6% (P = 0.002). Higher provider payments and beneficiary contributions were found in the Northeast (P < 0.001) and South (P < 0.011), respectively, for both cleft lip and palate repair.CONCLUSIONS: The US national data demonstrate that for commercially insured patients with cleft lip and/or palate, there has been a trend toward higher patient cost sharing, most pronounced in the South. This suggests that patients are bearing an increased cost burden while provider payments are simultaneously accelerating. Additional studies are needed to understand the impact of increased cost sharing on parents' decision to pursue cleft lip and/or palate repair for their children.

    View details for DOI 10.1097/SAP.0000000000003081

    View details for PubMedID 35180754

  • Differences Between Center-level Outcomes in Emergency and Elective General Surgery Hatchimonji, J. S., Ma, L. W., Kaufman, E. J., Dowzicky, P. M., Scantling, D. R., Yang, W., Holena, D. N. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2021: 1-9


    Center-level outcome metrics have long been tracked in elective surgery (ELS). Despite recent interest in measuring emergency general surgery (EGS) quality, centers are often compared based on elective or combined outcomes. Therefore, quality of care for emergency surgery specifically is unknown.We extracted data on EGS and ELS patients from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Centers that performed >100 ELS and EGS operations were included. Risk-adjusted mortality, complication, and failure to rescue (FTR, death after complication) rates were calculated and observed-to-expected ratios were calculated by center for ELS and EGS patients. Centers were determined to be high or low outliers if the 90% CI for the observed: expected ratio excluded 1. We calculated the frequency with which centers demonstrated a different performance status between EGS and ELS. Kendall's tau values were calculated to assess for correlation between EGS and ELS status.A total of 204 centers with 45,500 EGS cases and 49,380 ELS cases met inclusion criteria. Overall mortality, complication, and FTR rates were 1.7%, 8.0%, and 14.5% respectively. There was no significant correlation between mortality performance in EGS and ELS, with 36 centers in a different performance category (high outlier, low outlier, as expected) in EGS than in ELS. The correlation for complication rates was 0.20, with 60 centers in different categories for EGS and ELS. For FTR rates, there was no correlation, with 16 centers changing category.There was minimal correlation between outcomes for ELS and EGS. High performers in one category were rarely high performers in the other. There may be important differences between the processes of care that are important for EGS and ELS outcomes that may yield meaningful opportunities for quality improvement.

    View details for DOI 10.1016/j.jss.2020.11.086

    View details for Web of Science ID 000635161100001

    View details for PubMedID 33387728

  • The Impact of Socially Stigmatized Preexisting Conditions on Outcomes After Injury JOURNAL OF SURGICAL RESEARCH Ma, L. W., Kaufman, E. J., Hatchimonji, J. S., Xiong, R., Scantling, D. R., Stoecker, J. B., Holena, D. N. 2021; 257: 511-518


    Socially stigmatized preexisting conditions (SSPECs), including alcohol use disorder (AUD), drug use disorder (DUD), and major psychiatric illness, may lead to provider minimization of patient symptoms and have been associated with negative outcomes. However, the impact of SSPECs on failure to rescue (FTR) has not been evaluated. We hypothesized that SSPEC patients would have increased probability of complications, mortality, and FTR.We performed a retrospective analysis of the 2015 National Trauma Data Bank, including patients aged ≥18 y and excluding burn victims, patients with Injury Severity Score <9, and non-SSPEC patients with drug or alcohol withdrawal. We defined SSPECs using the National Trauma Data Bank's comorbidity recording codes for AUD, DUD, and major psychiatric illnesses. We built multivariable logistic regression models to determine the relationships between SSPECs and complications, mortality, and FTR.We included 365,801 patients (62% male, 76% White, median age 56 y [interquartile range 35-74], median Injury Severity Score 10 [interquartile range 9-17]). After adjusting for patient and injury characteristics, SSPEC patients were more likely to have complications (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.70-1.79), less likely to die (OR 0.43, CI 0.38-0.48), and less likely to have FTR (OR 0.34, CI 0.26-0.43). SSPEC patients had a significantly higher complication rate (12.4% versus 7.2%; P < 0.001). After excluding drug or alcohol withdrawal, the complication rate remained significantly higher for SSPEC patients (9.3% versus 7.2%; P < 0.001).Although SSPEC patients have lower odds of mortality and FTR, they are at higher probability of complications after injury. Further investigation into the causality behind the higher complications despite lower mortality and FTR is warranted.

    View details for DOI 10.1016/j.jss.2020.08.005

    View details for Web of Science ID 000599097100055

    View details for PubMedID 32916504

  • Enterocutaneous fistula after emergency general surgery: Mortality, readmission, and financial burden Hatchimonji, J. S., Passman, J., Kaufman, E. J., Sharoky, C. E., Ma, L. W., Scantling, D., Xiong, R., Holena, D. N. LIPPINCOTT WILLIAMS & WILKINS. 2020: 167-172


    The burden of enterocutaneous fistula (ECF) after emergency general surgery (EGS) has not been rigorously characterized. We hypothesized that ECF would be associated with higher rates of postdischarge mortality and readmissions.Using the 2016 National Readmission Database, we conducted a retrospective study of adults presenting for gastrointestinal (GI) surgery. Cases were defined as emergent if they were nonelective admissions with an operation occurring on hospital day 0 or 1. We used International Classification of Diseases, 10th Revision, code K63.2 (fistula of intestine) to identify postoperative fistula. We measured mortality rates and 30- and 90-day readmission rates censuring discharges occurring in December or from October to December, respectively.A total of 135,595 patients underwent emergency surgery; 1,470 (1.1%) developed ECF. Mortality was higher in EGS patients with ECF than in those without (10.1% vs. 5.4%; odds ratio [OR], 1.99; 95% confidence interval [CI], 1.67-2.36) among patients who survived the index admission. Readmission rates were higher for EGS patients with ECF than without at 30 days (31.0% vs. 12.6%; OR, 3.12; 95% CI, 2.76-3.54) and at 90 days (51.1% vs. 20.1%; OR, 4.15; 95% CI, 3.67-4.70). Similar increases were shown in elective GI surgery.Enterocutaneous fistula after GI EGS is associated with significantly increased odds of mortality and readmission, with rates continuing to climb out to at least 90 days. Processes of care designed to mitigate risk in this high-risk cohort should be developed.Prognostic and Epidemiological Study, Level III.

    View details for DOI 10.1097/TA.0000000000002673

    View details for Web of Science ID 000547897300027

    View details for PubMedID 32176165

    View details for PubMedCentralID PMC7802884

  • A 'weekend effect' in operative emergency general surgery Hatchimonji, J. S., Kaufman, E. J., Sharoky, C. E., Ma, L. W., Holena, D. N. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2020: 237-239


    Evidence of a "weekend effect" is limited in emergency general surgery (EGS). We hypothesized that there are increased rates of complications, death, and failure-to-rescue (FTR) in patients undergoing weekend EGS operations.National Inpatient Sample (NIS) data, January 2014-September 2015 were used. Operative EGS patients were identified by ICD-9 procedure code and timing to operation. Complications were defined by ICD-9 code. We performed survey-weighted multivariable regression analyses.Of 438,110 EGS patients, 103,450 underwent weekend operation. There was no association between weekend operation and FTR (OR 1.17; 95%CI 0.95-1.45) or complications (OR 1.04; 95%CI 0.97-1.13). There was a weekend effect on mortality (OR 1.22; 95%CI 1.02-1.46) and an interactive effect between weekend operation and teaching status on complications (teaching OR 1.22; 95%CI 1.15-1.29; interaction OR 1.13; 95%CI 1.03-1.25).There is evidence for a "weekend effect" on mortality, but not complications or FTR, in this cohort.

    View details for DOI 10.1016/j.amjsurg.2019.11.024

    View details for Web of Science ID 000545562900048

    View details for PubMedID 31744597

  • Complications and Failure to Rescue After Abdominal Surgery for Trauma in Obese Patients Kaufman, E. J., Hatchimonji, J. S., Ma, L. W., Passman, J., Holena, D. N. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2020: 211-219


    Although obesity is considered an epidemic in the United States, there is mixed evidence regarding the impact of obesity on outcomes after traumatic injury and major surgery. We hypothesized that obese patients undergoing trauma laparotomy would be at increased risk of failure to rescue (FTR), defined as death after a complication.We analyzed trauma registry data for adult patients who underwent abdominal exploration for trauma at all 30 level I and II Pennsylvania trauma centers, 2011-2014. We used competing risks regression to identify significant risk factors for complications. We used multivariable logistic regression to identify significant risk factors for FTR.Of 95,806 admitted patients, 15,253 (15.9%) were categorized as obese. Overall, 3228 (3.4%) underwent laparotomy, including 2681 (83.1%) nonobese and 547 (17.0%) obese patients. Among obese patients, 47.2% had at least one complication and 28.7% had two or more complications, compared with 33.5% and 18.7% of nonobese patients, respectively. The most common complication was pneumonia (15.0% of obese and 10.5% of nonobese patients; P = 0.003), followed by sepsis (8.8% versus 4.2%; P < 0.001) and deep vein thrombosis (8.4% versus 5.9%; P < 0.001). Obesity was independently associated with complications (hazard ratio, 1.4; 95% confidence interval, 1.2-1.6). In multivariable analysis, obesity was not associated with FTR (odds ratio, 1.3; 95% confidence interval, 0.9-2.0).Obesity is a risk factor for complications after traumatic injury but not for FTR. The increased risk of complications may reflect processes of care that are not attuned to the needs of this population, offering opportunities for improvement in care.

    View details for DOI 10.1016/j.jss.2020.01.026

    View details for Web of Science ID 000536920900028

    View details for PubMedID 32171135

  • Trauma video review utilization: A survey of practice in the United States Dumas, R. P., Vella, M. A., Hatchimonji, J. S., Ma, L., Maher, Z., Holena, D. N. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2020: 49-53


    Trauma video review (TVR) for quality improvement and education in the United States has been described for nearly three decades. The most recent information on this practice indicated a declining prevalence. We hypothesized that TVR utilization has increased since most recent estimates.We conducted a survey of TVR practices at level I and level II US trauma centers. We distributed an electronic survey covering past, current, and future TVR utilization to the Eastern Association for the Surgery of Trauma membership.45.0% of US level I and level II trauma centers completed surveys. 71/249 centers (28.5%) had active TVR programs. The use of TVR did not differ between level I and level II centers (28.8% vs. 27.8%, p = 0.87). Respondents using TVR were overwhelmingly positive about its perception (median score 8, [IQR 6-9]; 10 = 'best') at their institutions.TVR use at Level I centers has increased over the past decade. Increased TVR utilization may form the basis for multicenter studies comparing processes of care during trauma resuscitation.

    View details for DOI 10.1016/j.amjsurg.2019.08.025

    View details for Web of Science ID 000502608300009

    View details for PubMedID 31537325

    View details for PubMedCentralID PMC8428979

  • Failure to rescue in surgical patients: A review for acute care surgeons JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Hatchimonji, J. S., Kaufman, E. J., Sharoky, C. E., Ma, L., Whitlock, A., Holena, D. N. 2019; 87 (3): 699-706


    The Failure to Rescue (FTR) rate is defined as the mortality rate among patients who experience one or more complications. It has been used as an outcome metric for approximately 25 years, primarily in elective surgery populations, and has been shown to be associated with factors that are modifiable on the institutional level. Although the FTR metric was derived in elective surgical populations, modifications have been made in attempts to refine the metric and apply it to broader populations, including medical patients and non-elective surgical patients. However, study among emergency general surgery patients has been limited. In this review, we summarize the current knowledge surrounding FTR, including established risk factors and potential limitations of the metric in emergency general surgery (EGS) populations. We then discuss a conceptual model for FTR events and review strategies to minimize rates. Finally, we provide a brief overview of current areas of study and potential future directions in acute care surgery.

    View details for DOI 10.1097/TA.0000000000002365

    View details for Web of Science ID 000483829500030

    View details for PubMedID 31090684

    View details for PubMedCentralID PMC6711800