•We present a new, transparent and replicable model-driven method to predict the onset of food crises across the world.•We apply the model to Malawi, a country with persistent chronic and acute food ...security problems.•Leveraging readily available data, our model substantially improves over the status quo global methods of prediction.•Our best forecasts predict the out-of-sample food security status for between 65 and 88 percent of village clusters.•Our analysis and results demonstrate the potential gains to real-time food security modeling.
Globally, over 800 million people are food insecure. Current methods for identifying food insecurity crises are not based on statistical models and fail to systematically incorporate readily available data on prices, weather, and demographics. As a result, policymakers cannot rapidly identify food insecure populations. These problems delay responses to mitigate hunger. We develop a replicable, near real-time model incorporating spatially and temporally granular market data, remotely-sensed rainfall and geographic data, and demographic characteristics. We train the model on 2010–2011 data from Malawi and forecast 2013 food security. Our model correctly identifies the food security status of 83 to 99% of the most food insecure village clusters in 2013, depending on the food security measure, while the prevailing approach correctly identifies between 0 and 10%. Our results show the power of modeling food insecurity to provide early warning and suggest model-driven approaches could dramatically improve food insecurity crisis response.
We use an innovative approach to improve the effectiveness of smallholder afforestation programs by psychometrically segmenting a population based on preferences for the market and non-market values ...of trees.
202 randomly selected smallholders in Nicaragua were presented with nine discrete choice experiments of possible afforestation contracts with varying attribute levels of market and non-market values and were asked in which program they would choose to participate.
We estimate unobservable smallholder-specific preferences for afforestation program attributes as a function of observable socio-demographic variables using conditional distributions from a random coefficient logit model. Cluster analysis was used to segment the population based on these preferences and socio-demographic characteristics.
Smallholder preferences for non-market values are found to increase with distance to market and to be more important than market values in afforestation decisions. Two well-defined smallholder segments are identified. The first is characterized as market-oriented, placing less importance on non-market values. The second is characterized as unwilling to participate in afforestation programs without non-market values. These findings cast doubt on the reliance of market values as the primary determinant of smallholders' afforestation decisions and imply that programs could be designed more cost effectively by bundling different attributes for different segments of the population.
•The importance of non-market values on smallholders' afforestation decisions is assessed.•Smallholder-specific estimates for non-market values are derived.•Non market values are found to be important to smallholders' afforestation decisions.•Two well-defined smallholder segments are identified based on preferences to non-market values.
The safety of bilateral total knee arthroplasties (BTKAs) during the same hospitalization remains controversial. The authors sought to study differences in perioperative outcomes between unilateral ...and BTKA and to further compare BTKAs performed during the same versus different operations during the same hospitalization.
Nationwide Inpatient Sample data from 1998 to 2006 were analyzed. Entries for unilateral and BTKA procedures performed on the same day (simultaneous) and separate days (staged) during the same hospitalization were identified. Patient and healthcare system-related demographics were determined. The incidences of in-hospital mortality and procedure-related complications were estimated and compared between groups. Multivariate regression was used to identify independent risk factors for morbidity and mortality.
Despite younger average age and lower comorbidity burden, procedure-related complications and in-hospital mortality were more frequent after BTKA than after unilateral procedures (9.45% vs. 7.07% and 0.30% vs. 0.14%; P < 0.0001 each). An increased rate of complications was associated with a staged versus simultaneous approach with no difference in mortality (10.30% vs. 9.15%; P < 0.0001 and 0.29% vs. 0.26%; P = 0.2875). Independent predictors for in-hospital mortality included BTKA (simultaneous: odds ratio, 2.23 95% confidence interval, 1.69-2.95; P < 0.0001; staged: odds ratio, 2.01 confidence interval, 1.28-3.41; P = 0.0031), male sex (odds ratio, 2.02 confidence interval, 1.75-2.34; P < 0.0001), age older than 75 yr (odds ratio, 3.96 confidence interval, 2.77-5.66; P < 0.0001), and the presence of a number of comorbidities and complications.
BTKAs carry increased risk of perioperative morbidity and mortality compared with unilateral procedures. Staging BTKA procedures during the same hospitalization offers no mortality benefit and may even expose patients to increased morbidity.
Population-based database analysis.
To analyze trends in patient- and healthcare-system-related characteristics, utilization and outcomes associated with anterior cervical spine fusions.
Anterior ...cervical decompression and spine fusion (ACDF) is one of the most commonly performed surgical procedures of the spine. However, few data analyzing trends in patient- and healthcare-system-related characteristics, utilization and outcomes exist.
Data from 1990 to 2004 collected in the National Hospital Discharge Survey were accessed. ACDF procedures were identified. Five-year periods of interest (POI) were created for temporal analysis and changes in the prevalence and utilization of this procedure as well as in patient- and healthcare-system-related variables were examined. The changes in the occurrence of procedure-related complications were evaluated.
An estimated total of 771,932 discharges after ACDF were identified. Temporally, an almost 8-fold increase in total prevalence was accompanied by a similar increase in utilization (23/100.000 civilians/POI to 157/100.000/civilians/POI). The highest increase in utilization was observed in those > or =65 years (28-fold). Average age increased from 47.2 years to 50.5 years over time. Length of hospital stay decreased from 5.17 days to 2.38 days. Overall procedure-related complication rates decreased from 4.6% to 3.03%. The prevalence of hypertension, diabetes mellitus, hypercholesterolemia, obesity, pulmonary, and coronary artery increased over time among patients undergoing ACDF.
Despite limitations inherent to secondary analysis of large databases, we identified a number of significant changes in the utilization, demographics, and outcomes associated with ACDF, which can be used to assess the effect of changes in medical care, direct health care resources, and future research. The effect of the increased prevalence of comorbidities on medical practice remains to be evaluated. Further studies are necessary to evaluate causal relationships.
Background
Coronary artery bypass grafting (CABG) surgery is the gold standard treatment for complex coronary artery disease. Social determinants of health, including primary payer status, are ...disproportionately associated with adverse outcomes following surgical operations. We sought to examine associations between insurance status, in particular having Medicaid public insurance, and postoperative outcomes following isolated CABG surgeries.
Methods
A retrospective review was performed using Florida, California, New York, Maryland, and Kentucky State Inpatient Databases (2007–2014) for isolated CABG patients ≥ 18 years. Multivariate regression for postsurgical inpatient mortality, postsurgical complications, 30- and 90-day readmission rates, total charges, and length of stay yielded adjusted odds ratios (ORs) reported for outcomes by insurance status.
Results
Among 312,018 individuals, patients with Medicaid insurance and those designated as Uninsured incurred increased adjusted ORs of postsurgical inpatient mortality (56 and 64%, respectively) compared to Private Insurance. Additionally, Medicaid had the highest adjusted OR for 30-day readmission (OR 1.52, 95% CI 1.45–1.59), 90-day readmission (OR 1.53, 95% CI 1.47–1.59), postsurgical complications (OR 1.10, 95% CI 1.07–1.14) including pulmonary and infectious complications, postoperative length of stay, and total hospital charges (2016 dollars).
Conclusions
Medicaid insurance, compared to Private Insurance, is significantly associated with worse outcomes after isolated CABG. Our results demonstrate that Medicaid as a patient’s primary insurance payer is an independent predictor of perioperative risks. Further research may help explain the reasons for the differences in payer groups.
Colectomies are one of the most common surgeries in the United States with about 275,000 performed annually. Studies have shown that insurance status is an independent risk factor for worse surgical ...outcomes. This study aims to analyze the effect of insurance on health outcomes of patients undergoing colectomy procedures.
We examined hospital discharge data from the State Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, from 2009 to 2014 in California, Florida, New York, Maryland, and Kentucky. The primary outcome was in-hospital mortality. Secondary outcomes included complications, length of stay (LOS), total hospital charges, and 30- and 90-d readmissions.
A total of 444,877 patients were included in the analysis. Bivariate analysis showed that open surgeries were more common in Medicaid patients (50.5%), whereas robotic and laparoscopic surgeries were more common in private insurance holders (50.4% and 21.7%, respectively). In the adjusted multivariate models, when compared with private insurance patients, Medicaid patients had the highest odds ratio (OR) for mortality (OR, 1.96; 95% confidence interval CI, 1.78-2.15), complication rates (OR, 1.43; 95% CI, 1.38-1.49), 30-d readmission (OR, 1.47; 95% CI, 1.40-1.55), 90-d readmission (OR, 1.44; 95% CI, 1.37-1.51), longer LOS (coefficient, 1.26; 95% CI, 1.24-1.28), and higher total hospital charges (coefficient, 1.15; 95% CI, 1.13-1.17).
We identified Medicaid insurance status as a predictor of open colectomies and of higher mortality, LOS, complications, readmission rates, and charges after colectomy. Further research and initiatives are necessary to meet the specific needs of patients with different payer types.
Discharge against medical advice (DAMA) is associated with greater risk of hospital readmission and higher morbidity, mortality, and costs, but with a rapidly increasing elderly inpatient population, ...there is a lack of national data on DAMA in this subgroup. The National Inpatient Sample (2003–2013 for trends, 2013 for multivariable analysis, n = 29,290,852) was used to describe trends in DAMA in elderly inpatients, to study diagnosis codes associated with admission, and to assess factors associated with DAMA using multivariable logistic regression. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported for risk factors of interest. Although DAMA rates in individuals aged 65 and older were one fourth of those found in individuals aged 18 to 64, an increasing trend was found in both groups. From 2003 to 2013, rates increased in individuals aged 18 to 64 (from 1.44% to 1.78%) and in those aged 65 and older (from 0.37% to 0.42% (both P < .001). In both age groups, individuals admitted for mental illness had the highest risk of DAMA. Factors associated with higher adjusted odds of DAMA were generally similar between age groups, although risk of DAMA was higher in elderly adults than in those aged 18 to 64 for blacks (OR 1.65, 95% CI 1.49–1.82 vs OR 1.16, 95% CI 1.12–1.20), Hispanics (OR 1.58, 95% CI 1.41–1.77 vs OR 0.83, 95% CI 0.79–0.87), and those in the lowest income quartile (OR 1.57, 95% CI 1.43–1.72 vs OR 1.12, 95% CI 1.08–1.17), suggesting that race/ethnicity and poverty are more pronounced as risk factors for DAMA in elderly inpatients.
Abstract
Objective
The aim of this study was to examine the association of preexisting opioid use disorder and postoperative outcomes in patients undergoing total hip or knee arthroplasty (THA and ...TKA, respectively) in the overall population and in the Medicare-only population.
Methods
This retrospective cohort study examined data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for the years 2007–2014 from California, Florida, New York, Maryland, and Kentucky. We compared patients with and without opioid use disorders on unadjusted rates and calculated adjusted odds ratios (aORs) of in-hospital mortality, postoperative complications, length of stay, and 30-day and 90-day readmission status; analyses were repeated in a subgroup of Medicare insurance patients only.
Subjects
After applying our exclusion criteria, our study included 1,422,210 adult patients undergoing lower extremity arthroplasties, including 818,931 Medicare insurance patients. In our study, 0.4% of THA patients and 0.3% of TKA patients had present-on-admission opioid use disorder.
Results
Opioid use disorder patients were at higher risk for in-hospital mortality (aOR = 3.10), 30- and 90-day readmissions (aORs = 1.81, 1.81), and pulmonary and infectious complications (aORs = 1.25, 1.96).
Conclusions
Present-on-admission opioid use disorder was a risk factor for worse postoperative outcomes and increased health care utilization in the lower extremity arthroplasty population. Opioid use disorder is a potentially modifiable risk factor for mortality, postoperative complications, and health care utilization, especially in the at-risk Medicare population.
Analysis of population-based national hospital discharge data collected for the National Inpatient Sample.
To examine demographics of patients undergoing primary anterior spine fusion (ASF), ...posterior spine fusion (PSF), and anterior/posterior spine fusion (APSF) of the noncervical spine, assess the incidence of perioperative morbidity and mortality, and determine independent risk factors for in-hospital death.
The utilization of surgical fusion has been increasing dramatically. Despite this trend, a paucity of literature addressing perioperative outcomes exists.
Data collected for each year between 1998 and 2006 for the National Inpatient Sample were analyzed. Discharges with a procedure code for primary noncervical spine fusion were included in the sample. The prevalence of patient as well as health care system-related demographics were evaluated by procedure type (ASF, PSF, and APSF). Frequencies of procedure-related complications and in-hospital mortality were analyzed. Independent predictors for in-hospital mortality were determined.
We identified 261,256 entries representing an estimated 1,273,228 hospitalizations for primary spine fusion. Patients undergoing ASF and APSF were significantly younger (44.8 ± 0.08 and 44.22 ± 0.11 years) and had lower average comorbidity indeces (0.30 ± 0.002 and 0.31 ± 0.004) than those undergoing PSF (52.12 ± 0.04 years and 0.41 ± 0.002) (P < 0.0001). The incidence of procedure-related complications was 18.68% among ASF, 15.72% in PSF, and 23.81% in APSF patients (P < 0.0001). In-hospital mortality rates after APSF were approximately twice those of PSF (0.51 ± 0.038 vs. 0.26 ± 0.012) (P < 0.0001). Adjusted risk factors for in-hospital mortality included the following: APSF and ASF compared to PSF, male gender, increasing age, and increasing comorbidity burden. Several comorbidities and complications independently increased the risk for perioperative death, as did underlying spinal pathology.
Despite being performed in generally younger and healthier patients, APSF and ASF are associated with increased morbidity and mortality. Our findings can be used for the purposes of risk stratification, accurate patient consultation, and hypothesis formation for future research.
Abstract Objective We sought to determine the rate of postoperative supraventricular tachycardia (POSVT) in patients undergoing pulmonary lobectomy, and its association with adverse outcomes. Methods ...Using the State Inpatient Database, from the Healthcare Cost and Utilization Project, we reviewed lobectomies performed (2009-2011) in California, Florida, and New York, to determine POSVT incidence. Patients were grouped by presence or absence of POSVT, with or without other complications. Stroke rates were analyzed independently from other complications. Multivariable regression analysis was used to determine factors associated with POSVT. Results Among 20,695 lobectomies performed, 2449 (11.8%) patients had POSVT, including 1116 (5.4%) with isolated POSVT and 1333 (6.4%) with POSVT with other complications. Clinical predictors of POSVT included age ≥75 years, male gender, white race, chronic obstructive pulmonary disease, congestive heart failure, thoracotomy surgical approach, and pulmonary complications. POSVT was associated with an increase of: stroke (odds ratio OR 1.74; 95% confidence interval CI 1.03-2.94); in-hospital death (OR 1.85; 95% CI 1.45-2.35); LOS (OR 1.33; 95% CI 1.29-1.37); and readmission (OR 1.29; 95% CI 1.04-1.60). The stroke rate was <1% in patients who had isolated POSVT, and 1.5% in patients with POSVT with other complications. Patients with isolated POSVT had increased readmission and LOS, and a marginal increase in stroke rate, compared with patients with an uncomplicated course. Conclusions POSVT is common in patients undergoing pulmonary lobectomy and is associated with adverse outcomes. Comparative studies are needed to determine whether strict adherence to recently published guidelines will decrease the rate of stroke, readmission, and death after POSVT in thoracic surgical patients.
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