Possible consequences of regionally based bundled payments for diabetic amputations for safety net hospitals in Texas

Newhall, Karina; Stone, David H.; Svoboda, Ryan M; Goodney, Philip P.

doi:10.1016/j.jvs.2016.06.098

Cited by 6 publications

(3 citation statements)

References 30 publications

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“…Trends such as these are important to identify as adult reconstruction surgery moves toward bundled payment programs, particularly while considering that lower socioecomic status is associated with an increased risk of undergoing GRA. For example, in a study of diabetes-related amputations, Newhall et al 27 found that these procedures were over 50% more common at safety net hospitals. Based on our findings, similar trends might be suspected regarding GRA.…”

Section: Discussionmentioning

confidence: 99%

Socioeconomic Status Is Associated With the Risk of Girdlestone Resection Arthroplasty After Periprosthetic Infection of the Hip

Kirchner

Lieber

Kim

et al. 2021

J Am Acad Orthop Surg

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Introduction: Girdlestone resection arthroplasty (GRA) is a radical but sometimes necessary treatment of periprosthetic joint infection (PJI) of the hip. The purpose of this of this study was to identify the independent risk factors for GRA after PJI of the hip. Methods: This is a retrospective, cross-sectional analysis of the National (Nationwide) Inpatient Sample from 2010 to 2014. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) was used to identify 27,404 patients with PJI of the hip, including 889 patients who underwent GRA (ICD-9-CM 80.05). A multivariate model was created to examine the association between GRA and patient characteristics such as age, sex, race, primary payer, median household income, and location and teaching status of the hospital where the procedure was performed. Furthermore, the model controlled for patient comorbidities, including diabetes, anemias, hypertension, congestive heart failure, chronic pulmonary disease, peripheral vascular disease, and drug abuse. Results: The strongest independent risk factor for GRA was Medicare insurance (odds ratio [OR], 1.859, 95% confidence interval [CI], 1.500 to 2.304). Medicaid insurance was also associated with GRA (OR, 1.662, CI, 1.243 to 2.223). Compared with the wealthiest quartile for household income, patients in the poorest quartile (OR, 1.299, CI, 1.046 to 1.614) and second poorest quartile (OR, 1.269, CI, 1.027 to 1.567) were significantly more likely to have a GRA. Furthermore, patients older than 80 years old were at a higher risk of GRA than all other age groups (P < 0.05). No statistical differences were seen regarding patient race or sex. Conclusions: This study demonstrates that poorer patients, patients with government health insurance plans, and elderly patients are each at independently heightened risk of undergoing a GRA for the treatment of PJI of the hip. Level of Evidence: III, retrospective cohort study.

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Section: Discussionmentioning

confidence: 99%

Socioeconomic Status Is Associated With the Risk of Girdlestone Resection Arthroplasty After Periprosthetic Infection of the Hip

Kirchner

Lieber

Kim

et al. 2021

J Am Acad Orthop Surg

View full text Add to dashboard Cite

show abstract

“…Secondary outcomes included other diabetes-related conditions and procedures (tissue and bone debridement, peripheral vascular disease, and diabetic foot ulcer) commonly considered to be direct precursors or alternatives to LEA. Codes for all outcome definitions were informed through prior literature [20][21][22][23][24][25][26][27][28][29][30] and clinical guidance (Table S2). For secondary analyses, we excluded patients with baseline history of any outcome.…”

Section: Outcome Definitionsmentioning

confidence: 99%

Sodium‐glucose co‐transporter‐2 inhibitor use and risk of lower‐extremity amputation: Evolving questions, evolving answers

Yang

Wang

Pate

et al. 2019

Diabetes Obesity Metabolism

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Aim To examine whether sodium‐glucose co‐transporter‐2 (SGLT2) inhibitors are associated with a higher risk of lower‐extremity amputation than dipeptidyl‐peptidase‐4 (DPP‐4) inhibitors and sulphonylureas. Methods We conducted a retrospective cohort study, using the MarketScan Commercial Claims and Encounters Database (2013‐2015), to compare the incidence of lower‐extremity amputation (LEA) between initiators of SGLT2 inhibitors and initiators of two second‐line drugs, DPP‐4 inhibitors and sulphonylureas (SUs). We estimated crude incidence rates (IRs) and adjusted hazard ratios (aHR), with 95% confidence intervals (CIs), before and after propensity‐score weighting. We additionally conducted sensitivity analyses using a comparator group of all non‐metformin, non‐SGLT2 inhibitor glucose‐lowering drugs, as previous studies used this approach. Results In a cohort of 328 150 individuals aged 18 to 64 years, the IR of LEA ranged from 1.5 to 2.4 per 1000 person‐years. In as‐treated analysis, the estimated hazard of LEA was increased among SGLT2 inhibitor initiators compared to DPP‐4 inhibitor initiators (aHR 1.69, 95% CI 1.20‐2.38), but not compared to SU initiators (aHR 1.02, 95% CI 0.67‐1.55) or non‐metformin, non‐SGLT2 inhibitor initiators (aHR 1.02, 95% CI 0.54‐1.93). Results were consistent in intention‐to‐treat analysis and across a number of sensitivity analyses. Conclusions Among commercially insured patients in the United States, our results suggest that initiation of SGLT2 inhibitors may increase the risk of LEA compared to initiation of DPP‐4 inhibitors. Contrasting results when comparing SGLT2 inhibitor initiators to DPP‐4 inhibitor and SU initiators highlight the importance of choosing appropriate comparator drugs when addressing comparative effectiveness and safety questions that can inform clinical decision‐making.

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“…To increase outcome specificity, we required FG diagnoses to either occur in an inpatient setting or be followed by a hospitalization within 7 days, and be additionally accompanied by systemic antibiotic, debridement, or related surgical procedure4 within 7 days (primary outcome definition). Codes were informed through prior literature15–25 and clinical guidance.…”

Section: Methodsmentioning

confidence: 99%

Real-world evidence on sodium-glucose cotransporter-2 inhibitor use and risk of Fournier’s gangrene

Yang

Wang

Pate

et al. 2020

BMJ Open Diab Res Care

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BackgroundSodium-glucose cotransporter-2 inhibitors (SGLT2i) have been associated with increased occurrence of Fournier’s gangrene (FG), a rare but serious form of necrotizing fasciitis, leading to a warning from the Food and Drug Administration. Real-world evidence on FG is needed to validate this warning.MethodsWe used data from IBM MarketScan (2013–2017) to compare the incidence of FG among adult patients who initiated either SGLT2i, a dipeptidyl peptidase-4 inhibitor (DPP4i), or any non-SGLT2i antihyperglycemic medication. FG was defined using inpatient International Classification of Diseases, Ninth Edition and Tenth Edition diagnosis codes 608.83 and N49.3, respectively, combined with procedure codes for debridement, surgery, or systemic antibiotics. We estimated crude incidence rates (IRs) using Poisson regression, and crude and adjusted HRs (aHR) and 95% CIs using standardized mortality ratio-weighted Cox proportional hazards models. Sensitivity analyses examined the impact of alternative outcome definitions.ResultsWe identified 211 671 initiators of SGLT2i (n=93 197) and DPP4i (n=118 474), and 305 329 initiators of SGLT2i (n=32 868) and non-SGLT2i (n=272 461). Crude FG IR ranged from 3.2 to 3.8 cases per 100 000 person-years during a median follow-up of 0.51–0.58 years. Compared with DPP4i, SGLT2i initiation was not associated with increased risk of FG for any outcome definition, with aHR estimates ranging from 0.25 (0.04–1.74) to 1.14 (0.86–1.51). In the non-SGLT2i comparison, we observed an increased risk of FG for SGLT2i initiators when using FG diagnosis codes alone, using all diagnosis settings (aHR 1.80; 0.53–6.11) and inpatient diagnoses only (aHR 4.58; 0.99–21.21).ConclusionsNo evidence of increased risk of FG associated with SGLT2i was observed compared with DPP4i, arguably the most relevant clinical comparison. However, uncertainty remains based on potentially higher risk in the broader comparison with all non-SGLT2i antihyperglycemic agents and the rarity of FG.Trial registration numberEUPAS Register Number 30018.

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Possible consequences of regionally based bundled payments for diabetic amputations for safety net hospitals in Texas

Abstract: Regions with a high proportion of safety net hospitals perform almost half of the diabetic amputations in Texas. Changes to traditional payment models should account for the disproportionate burden of high-risk procedures performed by these hospitals.

Cited by 6 publications

References 30 publications

Socioeconomic Status Is Associated With the Risk of Girdlestone Resection Arthroplasty After Periprosthetic Infection of the Hip

Socioeconomic Status Is Associated With the Risk of Girdlestone Resection Arthroplasty After Periprosthetic Infection of the Hip

Sodium‐glucose co‐transporter‐2 inhibitor use and risk of lower‐extremity amputation: Evolving questions, evolving answers

Real-world evidence on sodium-glucose cotransporter-2 inhibitor use and risk of Fournier’s gangrene

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