BACKGROUND:The association between insurance status and survival among critically injured patients has been shown to be profound, yet the impact of the Affordable Care Act (ACA) on trauma outcomes remains unclear. We evaluated the association between ACA implementation and changes in insurance status, discharge disposition, and in-hospital mortality among trauma patients. STUDY DESIGN:We conducted a retrospective analysis of adult trauma patients admitted to Level I and II trauma centers in the National Trauma Data Bank. The pre-ACA period was defined as 2007 to 2013, with 2014 as a washout year and 2015 to 2019 as the post-ACA period. Bivariate and multivariable analyses compared insurance status, in-hospital mortality, and discharge disposition. RESULTS:Among 3,171,236 patients, uninsured rates declined (28.9% to 20.1%, p < 0.001) and Medicaid coverage increased (15.4% to 25.4%, p < 0.001) post-ACA. Odds of discharge to postacute care (odds ratio [OR] 1.16; 95% CI 1.15 to 1.17) and home with services were also increased (OR 1.47; 95% CI 1.45 to 1.49; p < 0.001). Although unadjusted mortality decreased slightly (2.7% to 2.6%, p < 0.001), adjusted mortality was higher post-ACA (OR 1.13; 95% CI 1.11 to 1.15, p < 0.001). Patients treated at Level II centers (34.0% to 38.2%, p < 0.001) and nonteaching centers (9.6% to 12.0%, p < 0.001) increased, but transfers to Level I centers (24.5% to 23.9%, p < 0.001) decreased post-ACA. Insurance status was independently associated with higher odds of mortality post-ACA (Medicaid: OR 1.12; 95% CI 1.09 to 1.16; uninsured: OR 2.17; 95% CI 2.10 to 2.24 compared with private insurance). CONCLUSIONS:Despite improved insurance coverage, mortality increased post-ACA. Our findings suggest evolving trauma care patterns in the post-ACA era, including greater reliance on Level II centers and fewer transfers, underscoring the importance of developing a national trauma system under changing policy conditions.

BACKGROUND:Critically injured trauma patients often require prolonged mechanical ventilation and intensive care. Tracheostomy facilitates ventilator weaning and transition to chronic care, yet timing varies widely. We compared trauma patients undergoing early versus late tracheostomy and examined clinical outcomes. METHODS:The National Trauma Data Bank (2017-2023) was queried for adult patients undergoing tracheostomy. Exclusions included burn patients, missing timing data, emergency department deaths, and transfers. Early tracheostomy was defined as ≤7 days from admission. Patient characteristics were compared. Outcomes included prolonged intensive care unit stay (≥20 days), prolonged mechanical ventilation (≥16 days), prolonged ventilator weaning (>7 days), ventilator-associated pneumonia, discharge home, and mortality. Multivariable logistic regression and propensity score-matched sensitivity analyses were performed. RESULTS:Among 61,555 eligible trauma patients undergoing tracheostomy, 20,080 (32.6%) underwent early tracheostomy. Early tracheostomy patients were younger (median age, 39 vs 50 years; P < .001), more often male (80.6% vs 76.4%, P < .001), had lower injury severity, and fewer comorbidities. After adjustment, early tracheostomy was associated with shorter intensive care unit stay (odds ratio, 0.18; 95% confidence interval, 0.17-0.19; P < .001), fewer ventilator days (odds ratio, 0.20; 95% confidence interval, 0.19-0.21; P < .001), lower odds of prolonged ventilator weaning (odds ratio, 0.79; 95% confidence interval, 0.76-0.83; P < .001), less ventilator-associated pneumonia (odds ratio, 0.51; 95% confidence interval, 0.48-0.55), and higher odds of discharge home (odds ratio, 2.27; 95% confidence interval, 2.14-2.40), but increased mortality (odds ratio, 1.36; 95% confidence interval, 1.25-1.49; P < .001). Propensity-matched analysis demonstrated a persistent 2.0% absolute mortality difference. CONCLUSION:Early tracheostomy was associated with improved intensive care unit and ventilator efficiency and greater likelihood of discharge home, despite modestly higher mortality, underscoring the complexity of timing decisions.

IntroductionAnnually, 300,000 operations are performed for adhesive small bowel obstruction (aSBO). Previous hysterectomy is thought to be a common etiology for aSBO in female patients. However, there are few data that characterize clinical outcomes of patients with prior hysterectomy and aSBO.MethodsThe National Inpatient Sample (2010-2019) was utilized to identify adults admitted with aSBO as the primary diagnosis. We compared women with a prior history of hysterectomy to male patients with aSBO. The primary outcomes were successful nonoperative management and complicated aSBO, defined as the need for bowel resection or ostomy formation. Secondary outcomes included hospital mortality and length of stay (LOS). Multivariate logistic regression models adjusted for patient characteristics.ResultsAmong 72,055 aSBO patients, 16.3% had prior hysterectomy. Nonoperative management was more frequently successful in women with hysterectomy (62.3% vs 53.6%, P < 0.001), with higher adjusted odds of nonoperative success (OR 1.11, 95% CI 1.06-1.16, P < 0.001). Among operative patients (n = 32,417), bowel resection rates were higher in patients with prior hysterectomy (40.3% vs 33.6%, P < 0.001). There was no significant difference in time to surgical intervention (P = 0.905). Patients with prior hysterectomy had lower mortality (0.94% vs 2.09%, P < 0.001), and shorter LOS (6.7 vs 7.9 days, P < 0.001).ConclusionPrior hysterectomy is associated with higher rates of successful nonoperative management for aSBO. However, when operative intervention is required, prior hysterectomy is associated with higher rates of bowel resection. Despite this, overall mortality and length of stay are significantly lower in this population.

BackgroundCholecystectomy is the most common surgical intervention performed in the United States with over 300,000 annual cases. We aim to describe risk factors for complications and prolonged stay after cholecystectomy in a 20-year analysis of a national database.MethodsThe Nationwide Inpatient Sample (NIS) was queried for years 2000-2019 for patients who underwent cholecystectomy within 7 days of admission. Complicated stay was defined as postoperative stay longer than 3 days or an ICU admission. Outcomes were postoperative complications, hospital length of stay, hospital charges, and mortality.ResultsThere were 901,205 patients who underwent laparoscopic cholecystectomy. Mean age was 50 ± 19 years, 68% were female. Complicated stay was identified in 13% of patients. These patients were older (61 ± 19 vs 49 ± 19), more likely to be male (47% vs 32%), and to have Medicare insurance (51% vs 26%). Acute presentation as indication for surgery (acute cholecystitis, choledocholithiasis, and pancreatitis) were more common in complicated stays compared to chronic cholecystitis or cholelithiasis only. They were more likely to undergo subtotal cholecystectomy (1.2% vs 0.54%) or conversion to open surgery (0.98% vs 0.08%), to suffer common bile duct injury (0.54% vs 0.04%), and have higher mortality (2.4% vs 0.06%). On multivariate regression, the strongest predictors for complicated stay were CBDI (OR 12.9), conversion to open (OR 11.4), and subtotal cholecystectomy (OR 1.8).ConclusionOpen or subtotal cholecystectomy, older age, pancreatitis, and delayed operation from admission were associated with complicated course. This data highlights careful preoperative risk stratification and early operative intervention to reduce complications.

IntroductionThis study assesses the impact of the Affordable Care Act (ACA) on lung cancer stage at diagnosis and cancer-specific survival, focusing on whether increased access to care for minorities and low-income individuals improves detection and outcomes.MethodologyA retrospective analysis of SEER database data (2007-2020) compared lung cancer cases in pre-ACA (2007-2013) and post-ACA (2014-2020) periods. California, a Medicaid expansion state, and Texas, a non-expansion state, were analyzed. Patients aged 18-64 years were followed for up to 6 years. Difference-in-differences and multinomial logistic regression were used to evaluate the ACA Medicaid expansion impact on disease stage and cancer-specific mortality.ResultsAmong 104,415 lung cancer patients, 59,825 (57.3%) were diagnosed pre-ACA, and 44,590 (42.7%) post-ACA. The cohort was predominantly White (63.7%) and male (52.9%), with an average age of 56.8 years. In California, ACA implementation led to a 1.2 percentage point increase in localized disease (95% CI: 0.2%-2.2%, P < 0.001) and a 2.8 percentage point reduction in metastatic disease (95% CI: -4.1% to -1.4%, P < 0.001) compared to Texas. Cancer-specific mortality in California decreased by 15.9% (95% CI: -23.9% to -7.8%, P < 0.001) vs Texas.ConclusionACA Medicaid expansion in California resulted in earlier lung cancer detection, reduced metastatic disease, and lower cancer-specific mortality compared to Texas. These improvements spanned all racial and ethnic groups, underscoring the benefits of Medicaid expansion in improving cancer outcomes.

BackgroundSurgical society membership and meeting attendance are critical for academic success. Studies demonstrate an association between society membership and greater publication numbers, NIH grants, and departmental leadership positions. Despite this, another study revealed a 68% lapse in membership status by faculty respondents due to costs. Understanding these costs is essential to structuring institutional investments in faculty development.MethodsMembership dues, meeting registration fees, and meeting attendance costs for 23 national, regional, and subspecialty societies from 2022 to 2024 were analyzed. Meeting costs were estimated assuming a 3-day attendance model. Membership dues and meeting registration fees were trended over a 3-year period.ResultsSubspecialty and national societies had the highest meeting attendance cost ($2638 and $2492, respectively). Regional societies had the lowest cost ($2252). Overall average membership dues were the highest for subspecialty societies ($474) and lowest for regional societies ($327). National societies' average membership dues were $431 and had the highest average increase over the 3-year period ($47). Subspecialty societies had the highest average meeting registration fees ($684) and the highest increases in fees over the study ($61). National societies' meeting registration averaged $581 with an average increase of $49. Regional societies had the lowest registration fees ($445) with no increases.DiscussionSubspecialty societies have the highest overall costs and had the greatest increases in meeting registration fees. National societies had the greatest increases in membership dues. Regional society costs are lowest and remained unchanged. An understanding of how faculty and departments finance these costs is needed.

Introduction We aim to examine the professional outcomes of graduates from a Historically Black College and University (HBCU) surgery residency program since inception. Materials and Methods A retrospective analysis using records of 378 graduates from a single HBCU general surgery residency program was queried from 1938 to 2025. Educational outcomes were captured and trends evaluated by univariable and multivariable analyses. Results Overall, there were 300 (87%) Black, 78 (21%) female, 234 (62%) Black males, 293 (79.0%) male, and 12 (3.5%) Hispanic surgical graduates. Comparing early to late cohorts, we found that decreased Black graduates (122 (90%) versus 96 (80%), P = 0.029), decreased Black male graduates (100 (70%) versus 58 (47%), P < 0.001), increased female graduates (22 (16%) versus 48 (39%), P < 0.001), increased Hispanic graduates (1 (1%) versus 6 (5%), P = 0.045), increased graduates pursuing fellowships (65 (54%) versus 91 (77%), P < 0.001), increased maintenance of board certification (96 (76%) versus 113 (91%), P = 0.001), increased fellowship of the American College of Surgeons distinction (58 (46%) versus 74 (60%), P = 0.026), and increased age at graduation (33 y old versus 34 y old, P = 0.0325). On multivariable analyses, the odds of board certification (adjusted odds ratio [aOR] = 3.75, P = 0.008), fellowship (aOR = 2.00, P = 0.028), and female sex (aOR = 4.15, P < 0.001) were significantly associated with the late versus early group of graduates, whereas fellowship of the American College of Surgeons designation, pursuance of an academic position, US medical graduate, Black Race, and Hispanic Ethnicity were not. Conclusions Trends for surgical graduates of this HBCU program appear to mirror national trends. Such programs contribute to the diversification of surgeons, while maintaining excellent educational outcomes.

BACKGROUND:There are approximately 100,000 patients with sickle cell disease (SCD) in America with 134,000 SCD-related admissions annually costing $1.1 billion. Cholecystectomy is the most common procedure in those patients. We evaluate the impact of socioeconomic factors on peri-operative outcomes. STUDY DESIGN:The Nationwide Inpatient Sample was queried for patients with SCD and gallbladder disease between 2006 and 2015. Patients were stratified by insurance and hospital type. Outcomes included perioperative vaso-occlusive crisis (VOC), post-operative morbidity, and mortality. RESULTS:A total of 1779 patients were included. Most patients had Medicaid (49 ​%), then Private insurance (29 ​%). Urban-Teaching hospitals cared for 75 ​% of patients. Complications were lowest with private insurance. On logistic regression, odds of VOC were 1.57 [1.05-2.33] with Medicare and 1.51 [1.13-2.01] with Medicaid. CONCLUSION:Majority of patients with SCD undergoing cholecystectomy have Medicaid and receive care in urban teaching hospitals. Perioperative VOC was lowest with private insurance and significantly higher with Medicare and Medicaid.

Background: The passage of the Affordable Care Act (ACA) in 2010 marked a pivotal moment in American health care policy, significantly expanding access to health care services. This study aims to explore the relationship between the ACA and the utilization and outcomes of Roux-en-Y Gastric Bypass (RYGB) surgery. Methods: Using data from the National Inpatient Sample (NIS) Database, this retrospective study compares the pre-ACA period (2007-2009) with the post-ACA period (2017-2019), encompassing patients who had RYGB. Multivariable logistic analysis was done accounting for patient's characteristics, comorbidities, and hospital type. Results: In the combined periods, there were 158 186 RYGB procedures performed, with 30.0% transpiring in pre-ACA and 70.0% in the post-ACA. Post-ACA, the proportion of uninsured patients decreased from 4.8% to 3.6% (P < .05), while Black patients increased from 12.5% to 18.5% (P < .05). Medicaid-insured patients increased from 6.8% to 18.1% (P < .05), and patients in the poorest income quartile increased from 20% to 26% (P < .05). Patients in the post-ACA period were less likely to have longer hospital stays (OR = .16: 95% CI .16-.17, P < .01), in-hospital mortality (OR = .29: 95% CI .18-.46, P < .01), surgical site infection (OR = .25: 95% CI .21-.29, P < .01), postop hemorrhage (OR = .24: 95% CI .21-.28, P < .01), and anastomotic leak (OR = .14: 95% CI .10-.18, P < .01) than those in the pre-ACA period. Discussion: Following the implementation of the ACA, utilization of bariatric surgery significantly increased, especially among Black patients, Medicaid beneficiaries, and low-income patients. Moreover, despite the inclusion of more high-risk surgical patients in the post-ACA period, there were better outcomes after surgery.

BACKGROUND:The 2014 Kidney Allocation System (KAS) revision aimed to enhance equity in organ allocation and improve patient outcomes. This study assesses the impacts of the KAS revision on renal transplantation demographics and outcomes in the United States.METHODS:We conducted a retrospective study utilizing the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) database from 1998 to 2022. We compared recipient and donor characteristics, and outcomes (graft failure and recipient survival) pre- and post-KAS revision.RESULTS:Post-KAS, recipients were significantly older (53 vs 48, P < .001) with an increase in Medicaid beneficiaries (7.3% vs 5.5%, P < .001). Despite increased graft survival, HR = .91 (95% CI 0.80-.92, P < .001), overall recipient survival decreased, HR = 1.06 (95% CI 1.04-1.09, P < .001). KAS revision led to greater racial diversity among recipients and donors, enhancing equity in organ allocation. However, disparities persist in graft failure rates and recipient survival across racial groups.DISCUSSION:The 2014 Kidney Allocation System revision has led to important changes in the renal transplantation landscape. While progress has been made towards increasing racial equity in organ allocation, further refinements are needed to address ongoing disparities. Recognizing the changing patient profiles and socio-economic factors will be crucial in shaping future policy modifications.

BACKGROUND:Up to 85% of patients with sickle cell disease (SCD) will develop gallstones by their third decade. Cholecystectomy is the most commonly performed procedure in these patients. Cholecystectomy is recommended for patients with SCD with symptomatic cholelithiasis and leads to lower morbidity. No contemporary large studies have evaluated this recommendation or associated clinical outcomes. This study evaluates clinical outcomes after cholecystectomy in patients with SCD and cholelithiasis with specific advanced clinical presentations.STUDY DESIGN:The Nationwide Inpatient Sample was queried for patients with SCD and gallbladder disease between 2006 and 2015. Patients were divided into groups based on their disease presentation, including uncomplicated cholelithiasis, acute and chronic cholecystitis, and gallstone pancreatitis. Clinical outcomes associated with disease presentation were analyzed. Statistical analysis was performed using the Student's t -test, chi-square test, ANOVA, and logistic regression.RESULTS:There were 6,662 patients with SCD who presented with cholelithiasis. Median age was 20 (interquartile range 16 to 34) years and 54% were female patients. Cholecystectomy was performed in 1,779 patients with SCD with the most common indication being chronic cholecystitis (44%), followed by uncomplicated cholelithiasis (27%), acute cholecystitis (21%), and choledocholithiasis or gallstone pancreatitis (8%). On multivariable regression, advanced clinical presentation was the strongest predictor of perioperative vaso-occlusive crisis, which was the most common complication. Patients undergoing cholecystectomy for uncomplicated cholelithiasis were at lower risk than those with acute cholecystitis (odds ratio [OR] 2.37; 95% CI 1.64 to 3.41), chronic cholecystitis (OR 1.74; 95% CI 1.26 to 2.4), and choledocholithiasis or gallstone pancreatitis (OR 2.24; 95% CI 1.41 to 3.57).CONCLUSIONS:Seventy-three percent of patients with SCD have advanced clinical presentation at the time of their cholecystectomy. After cholecystectomy, perioperative vaso-occlusive events were significantly increased in patients with advanced clinical presentation. These data support screening abdominal ultrasounds and early cholecystectomy for cholelithiasis in patients with SCD.

Background: This study investigates the association between neighborhood socioeconomic status, measured by the Distressed Communities Index (DCI), and short-term outcomes following colon resection. Methods: Utilizing the Maryland State Inpatient Sample database (SID 2018-2020), we determined the association between DCI and post-op outcomes following colon resection including length of stay, readmissions, 30-day inhospital mortality, and non-routine discharges. Multivariate regression analysis was performed to control for potential confounding factors. Results: Of the 13,839 patients studied, median age was 63, with 54.3 % female and 64.5 % elective admissions. Laparoscopic surgery was performed in 36.9 % cases, with a median hospital stay of 5 days. Patients in distressed communities faced higher risks of emergency admission (OR: 1.31), prolonged hospitalization (OR: 1.29), nonroutine discharges (OR: 1.36), and readmission (OR: 1.33). Black patients had longer stays than White patients (OR: 1.3). Despite adjustments, in-hospital mortality did not significantly differ among neighborhoods. Conclusion: Our study reveals that patients residing in distressed neighborhoods face a higher risk of prolonged hospitalization, non-routine discharges, and readmission rate after colon resection.

Objectives: This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents’ knowledge, cross-cultural care, skills, and beliefs. Background: Cross-cultural training of providers may reduce health care outcome disparities, but its effectiveness in surgical trainees is unknown. Methods: PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group (“Early”) received PACTS between periods 1 and 2, while the Delayed group (“Delayed”) received PACTS between periods 2 and 3. Residents were assessed preintervention and postintervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. χ2 and Fisher exact tests were conducted to evaluate within-intervention and between-intervention group differences. Results: Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents’ Cross-Cultural Care (79.6%–88.2%, P<0.0001), Self-Assessed Skills (74.5%––85.0%, P<0.0001), and Beliefs (89.6%–92.4%, P=0.0028) improved after PACTS; knowledge scores (71.3%–74.3%, P=0.0661) were unchanged. Delayed resident scores pre-PACTS to post-PACTS showed minimal improvements in all domains. When comparing the 2 groups in period 2, Early residents had modest improvement in all 4 assessment areas, with a statistically significant increase in Beliefs (92.4% vs 89.9%, P=0.0199). Conclusions: The PACTS curriculum is a comprehensive tool that improved surgical residents’ knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations.

Firearms are a leading cause of injury and death among children in the United States. Most gun violence studies highlight mortality, but few have examined the morbidity in disfiguring injuries suffered by children. Using National Trauma Data Bank 2007-2015, children who suffered gunshot injuries and underwent procedures with lasting physical disfigurement formed the cohort of this study. We identified 28 593 children as victims of firearm injuries. Most were aged 13-18 (84%). There was a preponderance of male gender (86%) and black race/ethnicity (57%). Total mortality was 3774 (13%), and 1500 (5.4%) were identified with one or more disfigurements: 220 amputations, 191 craniectomy, 100 enucleation, 533 ileostomy/colostomy, and 557 tracheostomies. This report highlights the large toll firearm injuries take on American children, specifically in non-concealable disfigurements. These injuries are very impactful to their education and overall socialization and therefore must be a part of the discussion of gun violence in the United States.

Previous studies suggest that median household income is a major determinant of the likelihood of amputation versus revascularization on a national level. It has recently been postulated that it is not primarily income but overall socioeconomic deprivation that influences this disparity. We undertook this study to determine the effect of socioeconomic deprivation on the likelihood of revascularization versus amputation on a statewide level.

BACKGROUND:The objective of this study was to identify predictors of mortality among patients presenting to the emergency department (ED) with attempted suicides.METHODS:We analyzed data on emergency department (ED) visits for attempted suicides from the Nationwide Emergency Department Sample (NEDS) database from January 2010 to December 2017. The predictors of mortality were determined in multivariate analysis including age, sex, insurance, annual income, region of the country, mechanism of injury, mental health conditions (schizophrenia; depression; and anxiety, bipolar, and personality disorders), chronic illnesses (hypertension, diabetes, obesity, and dementia), and social risk factors such as alcohol addiction, smoking, and substance abuse.RESULTS:From 2010 to 2017, there were 979,383 ED visits for attempted suicides in the NEDS database. Among these patients, 10,301 (1.1%) died. Of these completed suicides, 73.9% were male with the median age of 43 years (IQR, 30) while the unsuccessful suicide attempt group had a median age of 30 years (IQR, 24) and were 42.7% male. The most common mechanisms of suicide attempt were poisoning (58.8%) and cut injury (25.6%). Gunshot was the most lethal mechanism accounting 40.3% of the completed suicides despite representing 1.3% of the attempts who came to ED. After controlling for common risk factors for attempted suicide, significant predictors of completed suicide include higher income status, uninsured status, male sex, and higher age.DISCUSSION:Among US patients presenting to the ED following attempted suicide, factors associated with suicide completion include increasing age, male sex, higher income, gunshot injuries, and uninsured status.