Private equity firms have increased their participation in the US health care system, raising questions about incentive alignment and downstream effects on patients. However, there is a lack of systematic characterization of private equity acquisition of short-term acute care hospitals. We present an overview of the scope of private equity-backed hospital acquisitions over the course of 2003-17, comparing the financial and operational differences between those hospitals and hospitals that remained unacquired through 2017. A total of 42 private equity deals occurred, involving 282 unique hospitals across 36 states. In unadjusted analyses, hospitals that were acquired had larger bed sizes, more discharges, and more full-time-equivalent staff positions in 2003 relative to nonacquired hospitals; private equity-acquired hospitals also had higher charge-to-cost ratios and higher operating margins, and this gap widened during our study period. These findings motivate evaluations by policy makers and researchers on the impact, if any, of private equity acquisition on health care access, spending, and risk-adjusted outcomes.
Preclinical evidence has demonstrated anti-tumorigenic effects of metformin. The effects of metformin following pancreatic cancer, however, remain undefined. We sought to assess the association between metformin use and survival using a large, nationally representative sample of patients undergoing surgery for pancreatic cancer. Patients undergoing a pancreatic resection between January 01, 2010, and December 31, 2012, were identified using the Truven Health MarketScan database. Clinical data, including history of metformin use, as well as operative details and information on long-term outcomes were collected. Multivariable Cox proportional hazards regression analysis was performed to assess the effect of metformin use on overall survival (OS). A total of 3393 patients were identified. The mean age of patients was 54.2 years (SD = 9.1 years). Roughly one half of patients were female (n = 1735, 51.1 %); 49.1 % (n = 1665) presented with a Charlson comorbidity index of 3 or greater (CCI ≥3); and 19.6 % (n = 664) had diabetes. At the time of surgery, 60.0 % (n = 2034) of patients underwent a pancreaticoduodenectomy, 35.7 % (n = 1212) a partial/distal pancreatectomy, while 4.3 % (n = 147) had a total pancreatectomy. On pathology, 1057 (31.2 %) had lymph node metastasis. Metformin use was identified in 456 patients (13.4 %) and was more commonly administered among patients without locally advanced disease (14.3 vs. 11.6 %, p = 0.038). While OS was comparable between patients within the first year of surgery (OS at 1 year 65.4 % [95 % confidence interval (CI) 63.4-67.3 %] vs. 69.2 % [95 % CI 64.2-73.4 %]), patients who received metformin demonstrated an improved OS beginning at 18 months following surgery. On multivariable analysis adjusting for patient and clinicopathologic characteristics, metformin use was independently associated with a decreased risk of mortality (hazard ratio [HR] = 0.79, 95 % CI 0.67-0.93, p = 0.005). Metformin use was associated with an improved overall survival among patients undergoing pancreatic surgery for pancreatic cancer. Further work is necessary to better understand its role in modifying cancer-specific and overall health outcomes.
BACKGROUND: All-cause readmission rates in patients undergoing ileostomy formation are as high as 20–30%. Dehydration is a leading cause. No predictive model for dehydration readmission has been described. OBJECTIVE: To develop and validate the Dehydration Readmission after Ileostomy Prediction (DRIP) scoring system to predict risk of readmission for dehydration after ileostomy formation. DESIGN: Patients who underwent ileostomy formation were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset (2012–2015). Predictors for dehydration were identified using multivariable logistic regression analysis and translated into point scoring system based on corresponding β coefficients using 2012–2014 data (derivation). Model discrimination was assessed with receiver operating characteristic curves using 2015 data (validation). SETTINGS: This study used the ACS-NSQIP. PATIENTS: A total of 8064 patients (derivation) and 3467 patients (validation) were included from the ACS-NSQIP. MAIN OUTCOME MEASURES: Dehydration readmission within 30 days of operation RESULTS: A total of 8064 patients were in the derivation sample, with 2.9% (20.1% overall) readmitted for dehydration. Twenty-five variables were queried, and seven predictors were identified with points assigned: ASA Class III (4 points), female gender (5 points), ileal pouch anal anastomosis (4 points), age ≥65 years (5 points), shortened length of stay (5 points), ASA Class I-II with inflammatory bowel disease (7 points), and hypertension (9 points). A 39-point, 5-tier risk category scoring system was developed. The model performed well in derivation (AUC=0.71) and validation (AUC=0.74) samples and passed the Hosmer-Lemeshow goodness-of-fit test. LIMITATIONS: Limitations of this study pertained to those of the ACS-NSQIP including: lack of generalizability, lack of ileostomy-specific variables, and inability to capture multiple readmission ICD-9/10 codes. CONCLUSIONS: The DRIP score is a validated scoring system that identifies patients at risk for dehydration readmission after ileostomy formation. It is a specific approach to optimize patient factors, implement interventions, and prevent readmissions. See Video Abstract at http://links.lww.com/DCR/Axxx.
The 5-item mFI is significantly associated with 30-day morbidity in patients undergoing combined colorectal and liver resections. It is a tool that can guide surgeons preoperatively in assessing morbidity risk in patients undergoing concomitant resections.
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