Income and Geographic Disparities in in‐Hospital Mortality Following Cardiovascular Procedures: Evidence From the National Inpatient Sample, 2016–2022

Health Services Research · 2026-04-01

OBJECTIVE: To examine whether income- and geography-related disparities in in-hospital mortality after major cardiovascular procedures arise from differences in patient acuity, hospital characteristics, or inequities within hospitals. STUDY SETTING AND DESIGN: This observational study analyzed national data on eight major cardiovascular procedures performed between 2016 and 2022. We used multivariable logistic regression with progressive adjustment for demographics, clinical severity (All Patient Refined Diagnosis Related Groups [APR-DRG] risk and severity scores), and hospital characteristics. DATA SOURCES AND ANALYTIC SAMPLE: We analyzed secondary data from the National Inpatient Sample including 1,120,235 discharges (weighted N = 5,906,795) representing adults undergoing percutaneous coronary intervention, coronary artery bypass grafting, carotid endarterectomy/stenting, surgical valve replacement, transcatheter valve procedures, non-carotid endarterectomy, aneurysm repair, or peripheral bypass. Patient income was proxied using ZIP code-level median household income quartiles. Geographic location was classified as large metropolitan (≥ 1 million population), smaller metropolitan (50,000-999,999), or non-metropolitan. PRINCIPAL FINDINGS: Lowest-income patients presented with mean APR-DRG risk scores 0.15-0.25 points higher than highest-income patients. After full adjustment with hospital fixed effects, in-hospital mortality was 0.67% points higher (95% CI: 0.08-1.26) among lowest-income patients. Geographic patterns were complex: after adjusting for hospital characteristics, non-metropolitan location was associated with 0.48% points higher mortality, though this was not statistically significant (95% CI: -0.01 to 0.97), and smaller metropolitan areas with 1.03% points higher mortality (95% CI: 0.30-1.76). Between-hospital differences explained 11.6% of mortality variance. CONCLUSIONS: Socioeconomic and geographic disparities in mortality following major cardiovascular procedures persist after adjustment for clinical and hospital factors. These disparities remain, with slightly larger point estimates, in within-hospital analyses, suggesting that hospital-level differences alone do not account for observed inequities. Interventions should address both social determinants and intra-hospital inequities. Multilevel interventions targeting both social determinants and within-hospital processes may be needed.

Inpatient to Outpatient Shifts in Surgical Care: Persistence of COVID-19 Era Changes and Socioeconomic Variations

Medical Care Research and Review · 2025-12-06 · 1 citations

The COVID-19 pandemic disrupted surgical care delivery, yet the extent to which shifts from inpatient to outpatient settings have persisted remains unclear. Using medical claims data from Independence Blue Cross (2018-2022), we examined changes in surgery settings across 102 procedures before the pandemic and during the 2 years following the suspension of elective surgeries. After 2 years, inpatient volumes decreased for 9 of the 20 most common pre-pandemic inpatient procedures, with corresponding increases in outpatient utilization. Hip and knee replacements experienced the most pronounced shifts, with inpatient shares falling by more than 40 percentage points. Patients from lower-income census tracts saw greater declines in overall procedure volumes (-6.0%) compared to those from higher-income areas (+5.2%). Total allowed amounts decreased for procedures with outpatient migration, while out-of-pocket costs remained stable. These findings suggest durable, post-pandemic shifts in surgical care delivery patterns, with potential implications for access, costs, and equity.

Characterizing industry payments for FDA-approved AI medical devices

Health Affairs Scholar · 2025-11-07

Introduction: Artificial intelligence-enabled medical devices (AIMDs) are increasing in use, but this growth has raised concerns about inequities in access across well-resourced and under-resourced settings. Little is known about industry-clinician partnerships in the AIMD ecosystem. Methods: We examined the value, specialty distribution, market concentration, and institutional profile of payments made by industry to clinicians for Food and Drug Administration-approved AIMDs using the Open Payments Database. We linked payments to the affiliated hospital of the clinician using the Medicare Provider Data catalog. We performed a regression to explain the association of payments with hospital and county-level factors. Results: We found $59.3 million was spent on payments to 46 315 clinicians for AIMDs between 2017 and 2023, representing an increasing share of total medical device payments over time. We saw high payment concentration in technologically intensive medical specialties and among clinicians affiliated with large, urban teaching hospitals. Conclusion: Industry payments for AIMDs are increasing and concentrated among technology-intensive specialties. Payments are more likely to flow to clinicians affiliated with teaching hospitals that are larger and in non-rural areas. This may reflect or mediate increased AI utilization in these settings. Continued monitoring of payments, transparent reporting, and targeted resource support may be needed to promote equitable access to AIMDs.

Access to Mental Health and Substance Use Treatment in Comprehensive Primary Care Plus

JAMA Network Open · 2024-04-26 · 5 citations

Importance: To meet increasing demand for mental health and substance use services, the Centers for Medicare & Medicaid Services launched the 5-year Comprehensive Primary Care Plus (CPC+) demonstration in 2017, requiring primary care practices to integrate behavioral health services. Objective: To examine the association of CPC+ with access to mental health and substance use treatment before and during the COVID-19 pandemic. Design, Setting, and Participants: Using difference-in-differences analyses, this retrospective cohort study compared adults attributed to CPC+ and non-CPC+ practices, from January 1, 2018, to June 30, 2022. The study included adults aged 19 to 64 years who had depression, anxiety, or opioid use disorder (OUD) and were enrolled with a private health insurer in Pennsylvania. Data were analyzed from January to June 2023. Exposure: Receipt of care at a practice participating in CPC+. Main Outcomes and Measures: Total cost of care and the number of primary care visits for evaluation and management, community mental health center visits, psychiatric hospitalizations, substance use treatment visits (residential and nonresidential), and prescriptions filled for antidepressants, anxiolytics, buprenorphine, naltrexone, or methadone. Results: The 188 770 individuals in the sample included 102 733 adults (mean [SD] age, 49.5 [5.6] years; 57 531 women [56.4%]) attributed to 152 CPC+ practices and 86 037 adults (mean [SD] age, 51.6 [6.6] years; 47 321 women [54.9%]) attributed to 317 non-CPC+ practices. Among patients diagnosed with OUD, compared with patients attributed to non-CPC+ practices, attribution to a CPC+ practice was associated with filling more prescriptions for buprenorphine (0.117 [95% CI, 0.037 to 0.196] prescriptions per patient per quarter) and anxiolytics (0.162 [95% CI, 0.005 to 0.319] prescriptions per patient per quarter). Among patients diagnosed with depression or anxiety, attribution to a CPC+ practice was associated with more prescriptions for buprenorphine (0.024 [95% CI, 0.006 to 0.041] prescriptions per patient per quarter). Conclusions and Relevance: Findings of this cohort study suggest that individuals with an OUD who received care at a CPC+ practice filled more buprenorphine and anxiolytics prescriptions compared with patients who received care at a non-CPC+ practice. As the Centers for Medicare & Medicaid Innovation invests in advanced primary care demonstrations, it is critical to understand whether these models are associated with indicators of high-quality primary care.

Limited Access to Aortic Valve Procedures in Socioeconomically Disadvantaged Areas

Journal of the American Heart Association · 2024-01-13 · 10 citations

Background To explore how differences in local socioeconomic deprivation impact access to aortic valve procedures and the treatment of aortic valve disease, in comparison to other open and minimally invasive surgical procedures. Methods and Results Procedure volume data were obtained from the Healthcare Cost and Utilization Project from 18 states from 2016 to 2019 and merged with area deprivation index data, an index of zip code‐level socioeconomic distress. We estimate the relationship between local deprivation ranking and differences in volumes of aortic valve replacement, which include transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), versus coronary artery bypass graft surgery and laparoscopic colectomy (LC). All regressions control for state and year fixed effects and an array of zip code‐level characteristics. TAVR procedures have increased over time across all zip codes. The rate of increase is negatively correlated with deprivation ranking, regardless of the higher share of hospitalizations per population in high deprivation areas. Distributional analysis further supports these findings, showing that lower area deprivation index areas account for a disproportionately large share of SAVR, TAVR, and LC procedures in our sample relative to their share of all hospitalizations in our sample. By comparison, the cumulative distribution of coronary artery bypass graft procedures was nearly identical to that of total hospitalizations, suggesting that this procedure is equitably distributed. Regressions show high area deprivation index areas have lower prevalence of SAVR ( β =−15.1%, [95% CI, −26.8 to −3.5]), TAVR ( β =−9.1%, [95% CI, −18.0 to −0.2]), and LC ( β =−19.9%, [95% CI, −35.4 to −4.4]), with no statistical difference in the prevalence of coronary artery bypass graft ( β =−2.5%, [95% CI, −12.7 to 7.6]), a widespread and commonly performed procedure. In the population aged ≥80 years, results show high area deprivation index areas have a lower prevalence of TAVR ( β =−11.9%, [95% CI, −18.7 to −5.2]) but not SAVR ( β =−0.8%, [95% CI, 8.1 to 6.3]), LC ( β =−3.5%, [95% CI, −13.4 to −6.4]), or coronary artery bypass graft ( β =5.2%, [95% CI, −1.1 to 1.1]). Conclusions People living in high deprivation areas have less access to life‐saving technologies, such as SAVR, and even moreso to device‐intensive minimally invasive procedures such as TAVR and LC.

Measuring hospital inpatient Procedure Access Inequality in the United States

Health Affairs Scholar · 2024-10-29 · 2 citations

Geographic disparities in access to inpatient procedures are a significant issue within the US healthcare system. This study introduces the Procedure Access Inequality (PAI) index, a standardized metric to quantify these disparities while adjusting for disease prevalence. Using data from the Healthcare Cost and Utilization Project State Inpatient Databases, we analyzed inpatient procedure data from 18 states between 2016 and 2019. The PAI index reveals notable variability in access inequality across different procedures, with minimally invasive and newer procedures exhibiting higher inequality. Key findings indicate that procedures such as skin grafts and minimally invasive gastrectomy have the highest PAI scores, while cesarean sections and percutaneous coronary interventions have the lowest. The study highlights that higher inequality is associated with greater market concentration and in particular, fewer hospitals offering these procedures. These findings emphasize the need for targeted policy interventions to address procedural access disparities to promote more equitable healthcare delivery across the United States.

“I Quit”: Schedule Volatility as a Driver of Voluntary Employee Turnover

Manufacturing & Service Operations Management · 2023-03-15 · 28 citations

Problem definition: Employers across many sectors of the economy have been fast to adopt variable work scheduling policies. The cost of this flexibility for employers is usually borne by employees, for whom unstable work schedules create several disruptions. In the context of home healthcare, we examine how employer-driven volatility in nurses’ schedules impacts their decision to voluntarily leave their job. Methodology/results: Using an instrumental variables approach, we causally identify the effect of schedule volatility on nurses’ voluntary turnover. We begin by constructing an operational measure of schedule volatility using time-stamped work log data from one of the largest home health agencies in the United States. Because this measure may be endogenous to the worker’s decision to quit, we instrument for schedule volatility using paid days off taken by other nurses in the same branch. We find that higher levels of schedule volatility substantially increase a worker’s likelihood of quitting. Specifically, a one-standard-deviation increase in schedule volatility increases the average worker’s propensity to quit on a given day by more than threefold. Translated into yearly terms, 30 days of high schedule volatility over the course of the year increases the average worker’s probability of quitting that year by 20%. Our policy simulations of counterfactual scheduling policies suggest that excess schedule volatility can explain a significant portion of voluntary turnover, and some interventions have the potential to substantially reduce workers’ daily propensity to quit. Managerial implications: This work contributes to the understanding of the extent to which employees value control over their own work schedules and are averse to volatile work schedules that are dictated by employers. Especially in the current environment where there is a growing emphasis on work-life balance and employee-driven flexibility, finding a way to support stable schedules could be important for employers to attract and retain workers. Funding: This work was supported by the National Research Service Award Postdoctoral Fellowship, the Wharton Dean's Research Fund, the Agency for Healthcare Research and Quality [T32 Grant 5T32HS26116], and the Claude Marion Endowed Faculty Scholar Award. Supplemental Material: The e-companion is available at https://doi.org/10.1287/msom.2023.1205 .

The Relationship Between Scope of Practice Laws for Task Delegation and Nurse Turnover in Home Health

Journal of the American Medical Directors Association · 2023-08-24 · 4 citations

Lobbying Physicians: Payments from Industry and Hospital Procurement of Medical Devices

SSRN Electronic Journal · 2022-01-01 · 4 citations