Objective To examine the growth and evolution of the home health agency (HHA) market and to compare quality performance across HHA ownership categories. Data Source Agency characteristics were extracted from Medicare cost reports and Provider of Services file. Quality of care and patient characteristics were extracted from Quality of Patient Care Star Ratings and HHA Public Use File. Study Design Agency‐ and state‐level analyses were conducted to describe HHA market trends. Patient characteristics and quality measures were compared across ownership categories of interest. Data Collection/Extraction Methods All Medicare‐certified HHAs in operation, 2005‐2018. Principal Findings Over the study period, the HHA sector grew substantially, increasing from 7899 to 10 818 agencies, and chain‐owned HHAs doubled in number from 903 (11.4% of all agencies) to 1841 (17.0%). In 2018, across agency types, for‐profit nonchain agencies were the largest category both in the number of agencies (67.8%) and the number of Medicare enrollees served (40.7%). Additionally, for‐profit nonchain agencies grew most in total number, from 4293 (54.3%) to 7337 (67.8%), while for‐profit chain agencies grew most in the number of Medicare enrollees served, from 439 998 (12.9%) to 1 082 385 (28.3%). Regarding patient composition, for‐profit nonchain agencies served the highest proportion of dual eligible beneficiaries (42.2%) and African‐Americans (27.9%) among all agency types. Regarding quality performance, a higher star rating is significantly (P < .01) associated with chain agency status. Moreover, chain HHAs performed better on self‐reported process measures, and risk‐adjusted self‐reported outcome measures; however, they performed worse on risk‐adjusted claims‐based outcome measures. These results were similar across for‐profit and nonprofit chain agencies. Conclusion Chains play a growing role in the home health sector. Substantial differences in geographic distribution, patient composition, and quality performance were observed between chain‐ and nonchain HHAs. Examining the growth and performance of multi‐agency chains can help inform quality reporting and monitoring, assess payment adequacy, and facilitate greater transparency and accountability within the HHA marketplace.
Operative classification of ventral abdominal hernias: new and practical classification. Yasser Selim. From the Ministry of Health.Background: Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system for ventral hernias. One of the more accepted classification systems is that of the European Hernia Society (EHS). Its limitation is that it does not include individual patient risk factors and wound classification. The aim of this work was to find out the basic principles of hernia etiology and pathogenesis, clarify the factors that are important in treatment of ventral hernias, and categorize hernia patients according to those factors. Methods: This retrospective study included 238 patients who presented to our surgery department between 2010 and 2020. A full description of ventral hernias was made, including their type according to the EHS. In addition, abdominal wall components were assessed, including strength of rectus muscles, lateral abdominal muscles, and abdominal fascia, namely the linea alba. Patients with spontaneous hernias were grouped according to the size of the defect and the condition of the rectus abdominis muscles, the fascia and other abdominal muscles. Results: Patients were put into 6 clinical categories: type 1A, type 1B, type 2, type 3, type 4, and type 5. The grouping of patients was done according to the factors we believed affect the choice of surgical procedure and the prognosis of repair. Patients with types 1 and 2 have normal abdominal muscles, whereas those with types 3 and 4 have weak muscles and weak stretched fascia (linea alba). Type 5 includes incisional hernias. Conclusion: The primary purpose of any classification should be to improve the possibility of comparing different studies and their results. By describing hernias in a standardized way, different patient populations can be compared. Numerous classifications for groin and ventral hernias have been proposed over the past 5-6 decades. For primary abdominal wall hernias, there was agreement with EHS classification on the use of localization and size as classification variables.
Pancreatic ductal adenocarcinoma (PDAC) is a high fatality cancer with one of the worst prognoses in solid tumors. Most patients present with late stage, metastatic disease and are not eligible for potentially curative surgery. Despite complete resection, the majority of surgical patients will recur within the first two years following surgery. Postoperative immunosuppression has been described in different digestive cancers. While the underlying mechanism is not fully understood, there is compelling evidence to link surgery with disease progression and cancer metastasis in the postoperative period. However, the idea of surgery-induced immunosuppression as a facilitator of recurrence and metastatic spread has not been explored in the context of pancreatic cancer. By surveying the existing literature on surgical stress in mostly digestive cancers, we propose a novel practice-changing paradigm: alleviate surgery-induced immunosuppression and improve oncological outcome in PDAC surgical patients by administering oncolytic virotherapy in the perioperative period.
Gastrosplenic fistula is a rare and potentially fatal clinical entity unknown to most healthcare providers. Its diagnosis and management are challenging; and addressing it too late can have devastating consequences for patients. To increase awareness about this pathology, we hereby present a case of asymptomatic gastrosplenic fistula arising from a diffuse large B cell lymphoma in a 60-year-old Caucasian man with no significant medical history. The patient was successfully treated with open en-bloc splenectomy and partial gastrectomy. The patient was discharged from the hospital 3 days after the surgery. At 1-month postoperatively, the patient was asymptomatic and presented no complication of the surgery. He went on to finish six cycles of chemotherapy (R-EPOCH, rituximab, etoposide phosphate, prednisone, vincristine sulfate, cyclophosphamide, doxorubicin hydrochloride) and achieved complete metabolic response. At 2 years after the surgery, the patient remains asymptomatic and presents no sign of disease recurrence.
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