Using Appendiceal Perforation Rates to Measure Impact of a Disaster on Healthcare System Effectiveness
ABSTRACT To understand baseline inequities in appendiceal perforation rates and the impact of hurricane destruction on the healthcare system with respect to perforation rates and racial disparities.
We used claims data extracted from Medicaid Analytic Extract files to identify appendicitis diagnoses in children and adolescents based on International Classification of Diseases-9 codes and appendectomy procedures based on Current Procedural Terminology codes in the hurricane-affected states of Mississippi and Louisiana. County-level summary data obtained from 2005 Area Resource Files were used to determine high and low hurricane-affected areas. We estimated logistic regression models, mutually adjusting for race, sex, and age, to examine disparities and mixed logistic regression models to determine whether county-level effects contributed to perforation rates.
There were nine counties in the high-impact area and 133 counties in the low-impact area. Living in the high- or low-impact area was not associated with a statistically different rate of perforation before or after Hurricane Katrina; however, living in the high-impact area was associated with a change from a lower risk (odds ratio [OR] 0.62) of perforation prehurricane to a higher risk (OR 1.14) posthurricane compared with those living in the low-impact areas. African Americans had statistically higher perforation rates than whites in the high-impact areas both before (OR 1.46) and after (OR 1.71) Hurricane Katrina.
Health professionals and hospital systems were able to maintain effective levels of care before and after Hurricane Katrina; however, perforation rates in African Americans suggest ongoing racial disparities during disasters.
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ABSTRACT: The Centers for Medicare and Medicaid Services (CMS) now make data from the Medicaid and Medicare programs available for research. Prior research has identified important issues in Medicaid data obtained from a commercial vendor. To perform exploratory analyses of Medicaid and Medicare data obtained through CMS. We obtained data from 1999 to 2000 for 5 large Medicaid programs (California, Florida, New York, Ohio, and Pennsylvania), together with the corresponding Medicare data for dual eligibles. We first plotted the number of prescription claims per month. We next plotted the frequency of hospitalization by age group, first using Medicaid data alone, then supplemented with Medicare data. We next plotted the frequency of claims with a diagnosis of complications of pregnancy and childbirth, and of prostate cancers, stratified by sex. The number of prescription claims per month was very stable. Because of cocoverage by Medicare, Medicaid data seemed to miss a substantial number of hospitalizations in those age 45 years and older. Diagnoses of complications of pregnancy and childbirth were uncommon in men and in women older than 60 years, and prostate cancer diagnoses were uncommon in women. In contrast to Medicaid data previously obtained from a commercial vendor, we found no evidence that prescription Medicaid data from CMS were incomplete. We were also reassured by the infrequency of gross diagnostic miscoding. Researchers using Medicaid data to study hospital outcomes should obtain supplemental Medicare data on dual eligibles for studies of persons aged 45 years and older.Medical Care 01/2008; 45(12):1216-20. DOI:10.1097/MLR.0b013e318148435a · 2.94 Impact Factor
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ABSTRACT: To assess the effects of Hurricane Katrina on mortality, morbidity, disease prevalence, and service utilization during 1 year in a cohort of 20,612 older adults who were living in New Orleans, Louisiana, before the disaster and who were enrolled in a managed care organization (MCO). Observational study comparing mortality, morbidity, and service use for 1 year before and after Hurricane Katrina, augmented by a stratified random sample of 303 enrollees who participated in a telephone survey after Hurricane Katrina. Sources of data for health and service use were MCO claims. Mortality was based on reports to the MCO from the Centers for Medicare & Medicaid Services; morbidity was measured using adjusted clinical groups case-mix methods derived from diagnoses in ambulatory and hospital claims data. Mortality in the year following Hurricane Katrina was not significantly elevated (4.3% before vs 4.9% after the hurricane). However, overall morbidity increased by 12.6% (P <.001) compared with a 3.4% increase among a national sample of Medicare managed care enrollees. Nonwhite subjects from Orleans Parish experienced a morbidity increase of 15.9% (P <.001). The prevalence of numerous treated medical conditions increased, and emergency department visits and hospitalizations remained significantly elevated during the year. The enormous health burden experienced by older individuals and the disruptions in service utilization reveal the long-term effects of Hurricane Katrina on this vulnerable population. Although quick rebuilding of the provider network may have attenuated more severe health outcomes for this managed care population, new policies must be introduced to deal with the health consequences of a major disaster.The American journal of managed care 01/2009; 15(1):13-22. · 2.17 Impact Factor
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ABSTRACT: The authors relate prehospital delay and in-hospital delay to the incidence of perforation of appendicitis. Quality assurance studies use perforation rate as an index of quality of care. This is based on the assumption commonly presented in retrospective reports that in-hospital delay to surgery influences the incidence of perforation. Only one limited study prospectively found that prehospital delay increased the perforation rate. During a 6-month period, 95 consecutive adults undergoing appendectomies at Foothills Hospital in Calgary, Alberta, were questioned as to onset and type of first symptom (i.e., epigastric discomfort, anorexia nervosa, vomiting, and abdominal pain). Time of emergency room (ER) arrival, surgery consultation, and operating room start were taken from the chart. Surgical and pathology reports were used to identify status of appendix (normal, inflamed, suppurative, gangrenous, perforated) and presence of abscess cavity. The status of appendix was related to prehospital and in-hospital delay to establish significance. There were 13 (14%) normal, 67 (70%) inflamed, and 15 (16%) perforated appendices. Patients with perforated appendices waited 2.5 times longer before reporting to the ER, compared with patients with inflamed appendices (57 hours vs. 22 hours, p < 0.007). Once in the hospital, patients with perforated appendices were identified and treated faster than those with inflamed appendices (7 vs. 9 hours, p < 0.039). Analysis by ER physician was 3 hours whether the appendix was normal, inflamed, or perforated. Analysis by the surgeon was significantly shorter in patients with perforated appendices than patients with inflamed appendices (4 vs. 6 hours, p < 0.039). This prospective study identifies that delay in presentation accounts for the majority of perforated appendices. Clinical evaluation is effective for identifying patients with more advanced disease. Indiscriminate appendectomy as an attempt to decrease perforation is not supported by these data. Hospital perforation rates likely reflect patient factors, illness attitude, and access to medical care.Annals of Surgery 03/1995; 221(3):278-81. DOI:10.1097/00000658-199503000-00010 · 7.19 Impact Factor