Search Results (389)

Introduction: The costs associated with ambulance services are varied and poorly understood, which may contribute to financial burden and barriers to care for patients. Methods: We describe differences in ambulance service costs, comparing public versus private companies, by using the Centers for Medicare and Medicaid Services public use files. We determined the two largest public and two largest private ambulance companies in each state and calculated the average miles traveled per ambulance ride, number of trips by company, adjusted cost, and CPT code usage. We compared these variables between 2019 and 2021, across nine geographic divisions of the US. Results: In both 2019 and 2021, the average costs (adjusted for total service) of public companies were higher than the average costs of private companies. In both years, public companies had fewer average miles traveled compared to private companies. The distribution of CPT codes used was significantly different in public and private companies. The CPT code used most frequently by public companies was more expensive than the CPT code used most often by private companies. Conclusions: Differences in ambulance billing practices may contribute to financial uncertainty for patients. This study underscores the need for further investigation into the factors driving these disparities to inform policy decisions and improve cost transparency for patients. Full article

Background: National guidelines recommend adjuvant chemotherapy (AC) following resection for all stages of pancreatic cancer (PDAC), but the benefit of AC in Stage IA disease remains unclear. The objective of this study was to identify a subgroup of patients with Stage IA PDAC that could possibly forego AC. Study Design: The National Cancer Database (NCDB) was queried to identify all patients with Stage IA PDAC diagnosed from 2010 to 2021. Patients who received AC were compared to those who did not. Multivariable analysis was conducted to identify risk factors associated with overall survival (OS). Results: There were 1421 patients eligible for analysis. On multivariable analysis, we found nine factors associated with worse overall OS: advanced age (p = 0.0414), lower median income (p = 0.0148), Medicare (p = 0.0180), higher-grade tumor histology (p = 0.0182), LVI (p = 0.0028), positive surgical margins (p = 0.0027), examination of fewer than 12 lymph nodes (p = 0.0395), and a length of stay greater than 7 days (p < 0.0001). OS was negatively correlated with an increased number of risk factors. Improved OS was observed following AC in patients with three (∆OS = +54 months; p = 0.0016) or four or more risk factors (∆OS = +11.4 months; p = 0.0250). However, patients with fewer than three risk factors did not experience improvement in OS following AC. Conclusions: AC does not appear to benefit Stage IA PDAC patients with fewer than three risk factors indicating that it may be safe to omit AC in these individuals. Full article

Ambient fine particulate matter (PM2.5) is associated with increased mortality at concentrations below current regulatory standards. Studies of low-level exposure often rely on large administrative cohorts whose geographic and demographic composition may influence observed associations. In a prior analysis, we observed an association between long-term PM2.5 and all-cause mortality among Native American Medicare beneficiaries living in zip codes within the lowest decile of PM2.5 exposure. The present study, a case–control analysis of 1,713,399 low-PM2.5-exposed beneficiaries enrolled in traditional Medicare during 2015–2016, evaluated whether this association could be explained by geographic context, socioeconomic position (SEP), or baseline health status. We used principal components analysis to summarize area-level SEP indicators and beneficiary-level chronic disease diagnoses. In fully adjusted pooled models, PM2.5 was more strongly associated with mortality among Native American beneficiaries (odds ratio, OR = 1.12 per ug/m³; 95% CI 1.06–1.18) than among non-Native American beneficiaries (OR = 1.01 per ug/m³; 95% CI 1.001–1.02). Sequential adjustment among Native Americans showed that state-level geographic clustering accounted for most attenuation of the PM2.5 coefficient, with additional modest attenuation after adjustment for SEP and chronic disease patterns. These findings suggest that PM2.5–mortality associations observed in low-exposure populations may partly reflect geographic composition and underlying health differences within these large cohorts. Full article

Studies that have sought to describe and account for pre-diagnosed depressive symptoms on BC treatment choice, delay in initiating treatment, and mortality have been inconsistent. The purpose of the study is to examine the association between pre-diagnosed depressive symptoms and their impact on breast cancer (BC) treatment, treatment delays, and mortality. We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results–Medicare Health Outcomes Survey (SEER-MHOS) dataset among women aged 65 years and older diagnosed with BC. Among 3840 eligible patients, 28.1% had pre-diagnosed depressive symptoms. Patients with pre-diagnosed depressive symptoms who were diagnosed with early-stage BC were significantly more likely (OR = 1.52; 95% CI: 1.26–1.84) to undergo mastectomy or receive breast-conserving surgery (BCS) alone rather than BCS plus radiation therapy (RT) compared to patients who were not pre-diagnosed with depressive symptoms. Among patients with advanced-stage BC, pre-diagnosed depressive symptoms were not significantly associated with treatment type. Among Hispanic patients, pre-diagnosed depressive symptoms were associated with treatment delays. Overall, patients with pre-diagnosed depressive symptoms had a 16% increased adjusted risk of BC-related mortality compared to those who were not pre-diagnosed with depressive symptoms, and those with advanced-stage cancer had an 18% higher adjusted risk of death than early-stage BC. Conclusions: Overlooking depressive symptoms management prior to a breast cancer diagnosis may result in poorer survival outcomes. Early detection and consistent management of depression are critical for improving patient survival. Full article

Background: Population genetic screening (PGS) serves an essential role in identifying individuals at higher risk for hereditary cancer and cardiovascular disease. Nevertheless, the current lack of insurance coverage for screening costs might pose a barrier to its adoption. Health systems might contemplate covering these test expenses, but individuals covered by Medicaid and Medicare may not qualify for cost-free screening due to constraints related to the Beneficiary Inducement Statute. Methods: A cross-sectional online survey was administered to 602 US adults in January 2023. Andersen’s model guided variable selection. An ordered probit model was deployed to explore the association between insurance type and willingness to pay (WTP) for PGS, controlling for demographic and healthcare characteristics. Results: Among the 602 respondents, 524 (87%) were included in our analysis. Over 70% (n = 373) of participants expressed WTP for genetic testing. A similar proportion of respondents with Medicare and Medicaid expressed WTP for screening (68%, and 70%, respectively). Insurance type was not significantly associated with WTP for genetic testing. Notably, lower trust levels and absence of family cancer history were associated with a lower probability of expressing high WTP compared to the reference categories (high levels of trust and having a family cancer history). Conclusions: WTP for genetic testing was not significantly associated with insurance type. Almost 30% of our sample were unwilling to pay for PGS, suggesting variability in WTP for PGS and adding to the limited literature on how individuals value genomic screening tests. Full article

Background/Objectives: Breast cancer (BC) represents a major public health problem that is influenced by social and systemic factors. This study evaluates disparities in the BC care continuum based on health insurance type and determines whether these patterns differ according to neighborhood-level deprivation. Methods: Using the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database, we conducted a retrospective cohort study of women aged ≥18 years and diagnosed with BC in Puerto Rico between 2012 and 2016. The main outcomes were diagnostic delay (>60 days) and six-year mortality. Insurance type (private, Medicare, Medicaid, and dual enrollment in Medicare and Medicaid) was the main predictor, with neighborhood deprivation as a modifier. Logistic and Cox models assessed delay and survival, adjusting for key covariates. Results: Disparities in diagnostic delays and risk of death across insurance types were most evident in areas with low to average deprivation, whereas, in neighborhoods with above-average to highest deprivation, these differences diminished for diagnostic delay and disappeared for risk of death. Conclusions: These findings reveal that neighborhood environment, an intermediary social determinant of health, may affect the timeliness and quality of care provided to women diagnosed with BC. Full article

Background: Diabetic foot infections (DFIs) are a major cause of hospitalization, limb loss, and mortality among patients with diabetic foot ulcers (DFUs). This study evaluated the risk of developing DFIs among patients with newly diagnosed DFUs across insurance categories. Methods: Adults ≥18 years with a new DFU diagnosis were identified in the PearlDiver insurance claims database (2010–2020) using validated ICD-9/10 codes. Insurance status at the index DFU was categorized as Medicaid, Medicare, commercial, or self-pay. Propensity score matching (1:3) based on age, sex, Charlson Comorbidity Index, and major comorbidities was used to compare Medicaid vs. non-Medicaid patients. Results: Among 258,122 patients with new DFUs, 20,638 (8.0%) were Medicaid beneficiaries. Medicaid patients were younger (50.1 ± 10.2 vs. 60.6 ± 12.1 years, p < 0.001) but had similar comorbidity burden compared with commercially insured and Medicare patients. In matched analysis post-matching, Medicaid insurance was independently associated with higher odds of DFI-related hospitalization within 12 months (aOR 1.18, 95% CI 1.14–1.24) and major amputation at 3 years (aOR 1.72, 95% CI 1.39–2.13). Higher CCI, chronic kidney disease, congestive heart failure, COPD, and peripheral vascular disease also predicted adverse outcomes. Conclusions: Medicaid insurance was independently associated with increased risks of DFI and major amputation among patients with newly diagnosed DFUs. These findings highlight infection as a potentially modifiable pathway driving limb loss and emphasize the need to improve early ulcer evaluation and infection management for Medicaid beneficiaries. Full article

Background/Objectives: The relationship between clinical volume and academic performance in orthopedic surgery remains understudied. The purpose of this study is to explore the characteristics of high-achieving academic orthopedic surgeons in an attempt to extrapolate patterns and trends that govern the relationship between clinical performance and academia in orthopedic surgery. Methods: The 2023 National Plan and Provider Enumeration System and Medicare claims data (2021–2022) databases were used to include all active orthopedic surgeons of different subspecialties. A publication score, based on publication volume, journal impact, and authorship position, was calculated for each included surgeon, and surgeons who scored in the top 5% were deemed high-achieving academic orthopedic surgeons. Additional data pertaining to demographic characteristics, clinical volume, relative value units (RVUs), and Healthgrades ratings were recorded and analyzed. Results: A total of 23,403 orthopedic surgeons were included in our study, with 1169 considered top researchers. There were significant disparities in multiple parameters according to gender. Moreover, there were geographic variations among orthopedic surgeons with regard to mean publication scores, clinical volume, and RVUs. The top researcher cohort had a higher mean publication score (p < 0.001) and a higher mean clinical volume (p < 0.001) when compared to the total surgeon cohort. Mean RVUs were higher in the total surgeon cohort, although not reaching significance. Hip and knee, as well as shoulder and elbow surgeons, had significantly greater clinical volumes in the top researcher cohort than in the total surgeon cohort (p < 0.001). Despite differences in clinical and research metrics, there were no significant differences in mean Healthgrades ratings and the mean number of Healthgrades ratings between the top researcher sample and the non-top researcher sample. Conclusions: Higher research productivity was not associated with lower clinical productivity, as high-achieving academic orthopedic surgeons demonstrated high academic performance while remaining clinically active. Full article

Introduction: As spine surgery volume continues to grow, ensuring patient safety and minimizing complications are increasingly critical. Disruptive bleeding—defined as hemorrhagic events requiring clinical intervention—is a significant perioperative challenge. This study aimed to: (1) quantify disruptive bleeding incidence; (2) evaluate associations between patient demographics, Elixhauser Comorbidity Index (ECI), and bleeding risk; and (3) assess the impact of disruptive bleeding on mortality, ventilator use, length of inpatient stay, 90-day readmissions, and inpatient costs. Methods: A nationwide healthcare database was used to identify patients who underwent spine surgery in 2019. Patients were subdivided by the Elixhauser Comorbidity Index (ECI) from 0 to ≥6, and multivariate logistic regression was employed to analyze for potential association with disruptive bleeding. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated for each ECI classification. After controlling for baseline demographics, generalized linear models were used to evaluate how disruptive bleeding influenced hospital mortality, ventilator use, 90-day readmission rates, lengths of inpatient stay, and inpatient costs. Results: Among 165,461 patients undergoing spine surgery, 15,337 (9.3%) experienced disruptive bleeding. Women and Medicare coverage were associated with higher bleeding risk (p < 0.05). Disruptive bleeding odds increased with comorbidity burden, ranging from OR = 2.31 (95% CI 1.92–2.77) for ECI = 5 to OR = 3.32 (95% CI 2.73–4.06) for ECI ≥ 6. Disruptive bleeding was associated with increased ventilator use (18.4 versus 8.2% for ECI ≥ 6; p < 0.001) and inpatient mortality (3.0 versus 0.7% for ECI ≥ 6; p < 0.001). Hospital stays were significantly prolonged (10.4 versus 6.6 days for ECI ≥ 6; p < 0.001), 90-day readmission rates were higher (19.8 versus 14.7%; p < 0.001), and inpatient costs increased substantially ($68,000 versus $37,500; p < 0.001). Conclusions: Disruptive bleeding in spine surgery is more frequent among patients with elevated comorbidity burdens and is linked to greater mortality, ventilator dependence, and healthcare resource use. These findings highlight the importance of proactive risk stratification and targeted perioperative management strategies for high-risk patients undergoing spine surgery. Full article

Hospitals are energy- and waste-intensive systems. Inpatient buildings dominate the sector’s electricity and gas consumption, and healthcare waste streams—especially device-associated disposables—increase environmental burdens. AI-enabled predictive maintenance (PdM) offers a dual lever: (1) reducing energy use by keeping assets operating at efficient points, and (2) preventing avoidable waste by extending component life, reducing emergency spares, and avoiding device-induced clinical workflow disruptions. In this study, an end-to-end architecture is developed by integrating multi-modal sensing (electrical, thermal, acoustic, vibration), computerized maintenance management systems (CMMS), risk-based maintenance under International Electrotechnical Commission (IEC)/International Organization for Standardization standards (ISO 60601, 62353/62304, 81001-5-1), and learning pipelines (self-supervised anomaly detection, remaining useful life estimators, and carbon-aware work order scheduling). Using representative hospital archetypes and equipment classes (imaging, patient monitoring, laboratory analyzers, sterilizers, and pumps), energy, downtime, and waste avoidance are simulated under baseline preventive maintenance (PM) versus PdM with alternate equipment management. Results showed that 10–22% site electricity reduction was achieved, attributable to equipment efficiency and optimized duty-cycling, 18–35% fewer unplanned failures, and a 12–28% reduction in associated consumable waste and emergency part scrappage across scenarios, while maintaining compliance with Joint Commission/Centers for Medicare & Medicaid Services and IEC safety testing intervals. We discuss cybersecurity (IEC 81001-5-1) and the trustworthiness of AI, present a governance model linking CMMS events to carbon telemetry, and provide an implementation roadmap. Full article

Background: Secondary pulmonary hypertension (SPH) predicts poor outcomes in obstructive sleep apnea (OSA) patients. This study examines sex/racial disparities, predictors, and inpatient mortality in SPH-related OSA hospitalizations. Methods: We used the National Inpatient Sample (2019) and ICD-10 codes to identify OSA-related hospitalizations with SPH. The burden of SPH and disparities by sex/race were assessed. We also compared the odds and predictors of in-hospital mortality in OSA patients with vs. without SPH. Results: Of total adult OSA hospitalizations (n = 2,317,136, median age of 66 [56–74] years, and males: 57.2%), 9.4% (218,795/2,317,136) had SPH. Females vs. males (11.3% vs. 8.1%) and Blacks vs. other race groups (13.5%) with OSA had a higher prevalence of SPH. The SPH cohort often consisted of females (51 vs. 41.9%), Blacks (20.9 vs. 14.0%), Medicare-insured (73.4 vs. 60.6%), and non-elective admissions (89.2 vs. 74.4%) vs. the non-SPH cohort. The SPH cohort also had a higher burden of complicated HTN (52.9 vs. 36.3%), DM with complications (42.7 vs. 32.4%), COPD (52.5 vs. 36.9%), history of prior MI (11.4 vs. 9.6%), and venous thromboembolism (10.4 vs. 8.4%). However, in-hospital mortality was more likely to be in males (OR 1.12; 95%CI 1.00–1.25, p = 0.048) vs. females, and OSA patients with metastatic cancer (OR 2.73; 95%CI 2.04–3.65) and solid non-metastatic tumors (OR 1.65; 95%CI 1.26–2.15) (p < 0.001). Conclusions: The prevalence of SPH with OSA was greater in females and Blacks, whereas males and Whites had higher subsequent inpatient mortality. More prospective studies are needed to understand the role of comorbidities on survival outcomes. Full article

Background: Chronic kidney disease (CKD) is traditionally viewed as a condition marked by a progressive reduction in kidney function leading to the need for kidney dialysis or transplantation. The estimated prevalence of CKD in adults in Puerto Rico is ~20% higher than that of the overall United States (US). To address the disproportionately high rate of CKD in Puerto Rico, we created a multidisciplinary chronic disease management (CDM) program targeting CKD and diabetes mellitus (DM), the leading CKD risk factor. Methods: Over 7200 eligible enrollees in a Puerto Rico-Managed Medicare Program participated in a CDM program targeting individuals with CKD or DM as determined by administrative review. Evaluations were conducted on 4068 program participants with baseline glomerular filtration rate (eGFR) and codifying CKD stage by eGFR. A dietitian/nurse team provided dietary and lifestyle recommendations to the patient/family and a nephrologist/endocrinologist made diabetes and CKD recommendations to the primary care provider. Findings on 2095 participants with Stages 1–3 CKD with follow-up eGFR at least 6 months but less than 2 years after baseline are presented. Results: At baseline, the mean age was 74 years (range 30–101), 59% of patients were female and mean duration of follow-up from initial evaluation to second evaluation was 407 days (±159 days SD). Most participants had Stage 2 CKD (34.8%), followed by CKD Stage 1 and 3 (33.5 and 31.7%). During the follow-up period, 55.9% of participants with Stage 1 CKD remained in Stage 1, 84.9% of patients with Stage 2 remained in Stage 2 or regressed to Stage 1, while 96.1% of patients with Stage 3 remained in Stage 3 or regressed to Stage 2. Only 15.1% of patients in Stage 2 progressed to Stage 3 and 3.9% of patients in Stage 3 progressed to Stage 4 or 5. A secondary analysis comparing all 665 CDM Stage 3 participants to 117,249 historical controls found CDM participants demonstrated a higher rate of regression (20.3% vs. 15.2%; absolute difference +5.1 percentage points; p = <0.01) and a lower rate of progression (3.9% vs. 15.3%; absolute difference −11.4 percentage points; p < 0.001). Conclusions: Early findings of a multidisciplinary CDM intervention indicate that 79% of participants with CKD Stages 1–3 by eGFR had stabilized or improved CKD status. Comparison to a randomized control group to better assess for causality and longer-term CDM program follow-up on CKD status and clinical outcomes is warranted. Full article

Chronic wounds, including diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), and pressure injuries, remain a major global health burden and contribute substantially to Medicare spending. Because traditional wound dressings fail to address the dynamic microenvironment of chronic wounds, bioactive materials that modulate inflammation and support tissue regeneration are needed. In this study, we evaluated the tissue response to our borate-based bioactive glass fiber matrix (BBGFM) designed to overcome limitations of existing fibrous wound dressings. Two Sus scrofa domesticus underwent creation of twelve 5 × 5 cm subcutaneous pockets each, which were treated with BBGFM at three thicknesses (25%, 50%, and 100%) or left untreated as controls. One animal was euthanized at three weeks and the other at six weeks for gross and histopathological evaluation of all wound sites. BBGFM-treated pockets demonstrated a dose-dependent increase in inflammation at three weeks that diminished by six weeks. Enhanced neovascularization and collagen matrix deposition were also seen at both time points. Collagen maturity increased across all groups by six weeks, and residual BBGFM correlated with initial implant thickness. These findings indicate that BBGFM promotes a controlled inflammatory response and supports neovascularization and matrix remodeling in a dose-dependent manner, suggesting its potential as an effective bioactive wound matrix. Full article

This study explores how hospital location (rural/non-rural) may moderate the nurse staffing ratio’s impact on three hospital-acquired infections. This study used data from 2022 to 2024 on nurse staffing and hospital characteristics from the American Hospital Association Annual Survey and data on hospital-acquired infection rates from the Medicare Care Compare dataset provided by the Centers for Medicare and Medicaid Services. After removing missing values, the final dataset included 7997 hospital-year observations across the US. Independent variables include rural hospital designation, nursing hours per patient day, and RN FTE per adjusted day. The dependent variables included infection rates of Central Line-Associated Bloodstream Infection, Catheter-Associated Urinary Tract Infection, and Methicillin-Resistant Staphylococcus aureus. Multiple regression was performed in Stata 18. Our research found that across all three infection types, an increase in nursing hours per patient day is significantly associated with a decrease in the infection rate, and that impact was not moderated by hospital rurality. Extra time spent with patients in either a rural or non-rural hospital decreased hospital-acquired infection rates. While RN FTEs were included in the model, total nursing hours per patient day emerged as the more consistent predictor of lower hospital-acquired infection rates. Full article

Background: Financial sustainability remains a central challenge for U.S. hospitals as rising operating costs, shifting federal reimbursement, and policy uncertainty intensify economic pressures. This study estimates the prevalence and recent changes in financial distress among U.S. short-term acute care hospitals. Methods: We conducted a national longitudinal analysis of all U.S. short-term acute care hospitals from 2021 to 2023 using financial and operational data from Medicare cost reports linked with community-level data from the American Community Survey. Financial distress was measured using the Altman Z-score, with severe distress defined as Z ≤ 1.8. Logistic regression models were used to identify organizational, operational, and market characteristics associated with distress. Results: The proportion of hospitals classified as severely financially distressed increased from 18.6% in 2021 to 22.0% in 2023. Operating margins and returns on assets declined significantly over the study period, while mean Z-scores showed a modest but non-significant downward trend. In adjusted models, urban hospitals had higher odds of distress (OR 1.27, 95% CI 1.15–1.40, p < 0.001), as did hospitals with longer average lengths of stay (OR 1.07 per day, 95% CI 1.04–1.09, p < 0.001) and higher debt-to-equity ratios (OR 1.05 per unit, 95% CI 1.05–1.06, p < 0.001). Higher occupancy rates were protective (OR 0.31, 95% CI 0.25–0.40, p < 0.001). Larger market population was also associated with increased distress risk (OR 1.61, 95% CI 1.21–2.14, p = 0.001), while other market characteristics were not significant. Conclusions: Financial distress remains widespread and appears to be increasing among U.S. acute care hospitals. Operational efficiency, capital structure, and local market scale are key drivers of financial vulnerability, highlighting the need for targeted strategies to strengthen hospital resilience and preserve access to essential acute care services. Full article