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Background: Studies have shown that Black patients die more frequently following coronary artery bypass grafting than their White counterparts for reasons not fully explained by disease severity or comorbidity. To examine whether provider care team segregation within hospitals contributes to this inequity, we analyzed national Medicare data. Methods: Using national Medicare data, we identified beneficiaries who underwent coronary artery bypass grafting at hospitals where this procedure was performed on at least 10 Black and 10 White patients between 2008 and 2014 (n=12 646). After determining the providers who participated in their perioperative care, we examined the extent to which Black and White patients were cared for by unique networks of provider care teams within the same hospital. We then evaluated whether a lack of overlap in composition of the provider care teams treating Black versus White patients (ie, high segregation) was associated with higher 90-day operative mortality among Black patients. Results: The median level of provider care team segregation was high (0.89) but varied across hospitals (interquartile range, 0.85–0.90). On multivariable analysis, after controlling for patient-, hospital-, and community-level differences, mortality rates for White patients were comparable at hospitals with high and low levels of provider care segregation (5.4% [95% CI, 4.7%–6.1%] versus 5.8% [95% CI, 4.7%–7.0%], respectively; P =0.601), while Black patients treated at high-segregation hospitals had significantly higher mortality than those treated at low-segregation hospitals (8.3% [95% CI, 5.4%–12.4%] versus 3.3% [95% CI, 2.0%–5.4%], respectively; P =0.017). The difference in mortality rates for Black and White patients treated at low-segregation hospitals was nonsignificant (−2.5%; P =0.098). Conclusions: Black patients who undergo coronary artery bypass grafting at a hospital with a higher level of provider care team segregation die more frequently after surgery than Black patients treated at a hospital with a lower level.

INTRODUCTION:Studies suggest that nonsteroidal anti-inflammatory drugs (NSAID) may contribute to inflammatory bowel disease (IBD) exacerbations. We examined whether variation in the likelihood of IBD exacerbations is attributable to NSAID.METHODS:In a cohort of patients with IBD (2004–2015), we used 3 analytic methods to examine the likelihood of an exacerbation after an NSAID exposure. First, we matched patients by propensity for NSAID use and examined the association between NSAID exposure and IBD exacerbation using an adjusted Cox proportional hazards model. To assess for residual confounding, we estimated a previous event rate ratio and used a self-controlled case series analysis to further explore the relationship between NSAID and IBD exacerbations.RESULTS:We identified 15,705 (44.8%) and 19,326 (55.2%) IBD patients with and without an NSAID exposure, respectively. Findings from the Cox proportional hazards model suggested an association between NSAID and IBD exacerbation (hazard ratio 1.24; 95% confidence interval 1.16–1.33). However, the likelihood of an IBD exacerbation in the NSAID-exposed arm preceding NSAID exposure was similar (hazard ratio 1.30; 95% confidence interval 1.21–1.39). A self-controlled case series analysis of 3,968 patients who had both an NSAID exposure and IBD exacerbation demonstrated similar exacerbation rates in the 1 year preceding exposure, 2–6 weeks postexposure, and 6 weeks to 6 months postexposure, but a higher incidence in 0–2 weeks postexposure, suggesting potential confounding by reverse causality.DISCUSSION:While we see an association between NSAID and IBD exacerbations using traditional methods, further analysis suggests this may be secondary to residual bias. These findings may reassure patients and clinicians considering NSAID as a nonopioid pain management option.

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