title: Care of patients undergoing vascular surgery at safety net public hospitals is associated with higher cost but similar mortality to nonsafety net hospitals.
abstract: OBJECTIVE
  This study compared in-hospital mortality and resource utilization among vascular surgical patients at safety net public hospitals (SNPHs) with those at nonsafety net public hospitals (nSNPHs).
  
  
  METHODS
  The National Inpatient Sample (2003-2011) was queried to identify surgical patients with peripheral arterial disease (PAD), carotid stenosis, or nonruptured abdominal aorta aneurysm based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. The cohort was then divided into SNPH and nSNPH groups according to the definition of SNPH used by the National Association of Public Hospitals. Clinical characteristics, length of stay, in-hospital mortality, and hospital charges were compared between groups. Advanced PAD was defined as that associated with rest pain or tissue loss. Statistical methods included bivariate χ(2) tests for categoric variables, t-tests for continuous variables, and multivariable linear and logistic regression to adjust for confounding variables (in-hospital mortality).
  
  
  RESULTS
  We identified 306,438 patients operated on for PAD, carotid stenosis, and abdominal aortic aneurysm. Patients at SNPHs were younger, the percentage of female and minority patients was higher, and patients had a higher Elixhauser comorbidity index (P < .001). Nonelective admissions were more common among SNPH patients who presented with more advanced PAD (P > .05) and symptomatic carotid stenosis (P < .05). Patients at SNPHs had a significantly longer length of stay, higher hospital charges, and higher in-hospital mortality (P < .05 for all variables). Crude odds of mortality at SNPHs were 1.28 higher than at nSNPHs (95% confidence interval, 1.13-1.46; P < .001), but adjusted analyses revealed no statistically significant difference between the odds of in-hospital mortality at both hospital groups.
  
  
  CONCLUSIONS
  Patients undergoing vascular surgery at SNPHs, despite being younger, had higher comorbidities, presented more urgently with more advanced disease, and incurred higher costs than the SNPH cohort despite similar adjusted odds of in-hospital mortality. Delayed presentation and higher comorbidities are most likely related to poor access to routine and preventive health care for the SNPH patients.
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass. Electronic address: mohammad.eslami@bmc.org.
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Eslami
authors.affiliation: Department of Biostatistics, Boston University School of Public Health, Boston, Mass.
authors.forename: Denis
authors.initials: D
authors.lastname: Rybin
authors.affiliation: Department of Biostatistics, Boston University School of Public Health, Boston, Mass.
authors.forename: Gheorghe
authors.initials: G
authors.lastname: Doros
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass.
authors.forename: Alik
authors.initials: A
authors.lastname: Farber
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000191:economics / Q000401:mortality / Q000601:surgery; D016893:Carotid Stenosis / Q000191:economics / Q000401:mortality / Q000601:surgery; D016009:Chi-Square Distribution; D015897:Comorbidity; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000191:economics / Q000401:mortality; D005260:Female; D006295:Health Resources / Q000191:economics* / Q000706:statistics & numerical data; D017721:Hospital Costs; D017052:Hospital Mortality; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume / Q000191:economics; D006779:Hospitals, Public / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care / Q000191:economics*; D058729:Peripheral Arterial Disease / Q000191:economics / Q000401:mortality / Q000601:surgery; D019984:Quality Indicators, Health Care / Q000191:economics*; D012189:Retrospective Studies; D012307:Risk Factors; D064876:Safety-net Providers / Q000191:economics* / Q000706:statistics & numerical data; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics* / Q000401:mortality* / Q000706:statistics & numerical data