Publications

OBJECTIVE: To compare the effectiveness of a modified surface gelatin sponge to a plain collagen sponge for hemostasis of parenchymal hepatic bleeding.

STUDY DESIGN: Prospective, randomized trial of two hemostatic agents.

ANIMALS: A total of 45 dogs undergoing elective liver surgery were randomly allocated into two groups: 22 in the adhesive gelatin (AG) group and 23 in the plain collagen (PC) group. A total of 20 patients per group underwent liver biopsy to create a uniformly sized bleeding surface, with the remaining patients (AG = 2, PC = 3) undergoing liver lobectomy.

METHODS: Evaluation of hemostatic effectiveness and tissue adhesion of each sponge type was performed by the operating surgeon using structured scoring systems. Hemostatic parameters were primarily evaluated at the liver biopsy site to maintain homogeneity of bleeding surface size.

RESULTS: For the liver biopsy group (n = 40), 5 min after hemostatic sponge application, 10/20 dogs were bleeding in the PC group, compared to 2/20 in AG group (p = .0138). The PC bleeding was significantly higher than AG across the 3 to 6 min evaluation period (p < .001). When surgeons tested the adhesion of the sponge across the whole cohort (n = 45), AG scored 2 (of 3) against 1 for PC (p < .001). In group PC, 5/23 sponges dislodged during abdominal lavage and preparations for closure and had to be replaced due to recurrence of bleeding, compared with no AG sponges dislodging (p = .042). There were no further complications related to the use of either sponge.

CONCLUSION: In the dogs with hepatic parenchymal incision, use of an adhesive gelatin sponge improved intraoperative attachment and haemostatic effectiveness, compared to a collagen sponge.

CLINICAL SIGNIFICANCE: Based on our clinical experience in these cases, adhesive gelatin sponges could be considered an effective option when selecting a hemostatic agent for liver surgery in dogs.

Enrollment in Medicare Advantage (MA) plans rose to over 50% of eligible Medicare patients in 2023. Payments to MA plans incorporate risk scores that are largely based on patient diagnoses from the prior year, which incentivizes MA plans to code diagnoses more intensively. We estimated coding inflation rates for individual MA contracts using a method that allows for differential selection into contracts based on patient health. We illustrate the method using data on MA risk scores and health conditions from the most recent year available, 2014. This approach could also be used beginning in 2022, when Medicare transitioned to MA risk scores based on MA Encounter records. Several existing methods assess coding intensity, but this study's approach is novel in its use of plan-level mortality rates to infer plan-level coding intensity. We found an enrollment-weighted mean coding inflation rate of 8.4%, with rates ranging from 3.4% to 12.7% for the largest 8 MA insurers and from 1.1% to 22.2% for the largest 20 MA contracts in 2014. We found higher coding intensity for health plans that were HMOs, provider-owned, large, older, or had high star ratings. Approximately 68.1% of MA enrollees were in contracts with coding inflation rates larger than Medicare's coding intensity adjustment.

BACKGROUND: Medicare Advantage (MA) includes incentives to reduce health care spending and insures over half of Medicare eligible adults. Substance use disorders (SUD) are common in this population.

OBJECTIVE: To compare clinical outcomes between MA and traditional Medicare beneficiaries hospitalized with SUD.

DESIGN: Retrospective cohort.

PATIENTS: Medicare beneficiaries hospitalized for alcohol withdrawal or opioid overdose from 2016 to 2021.

MEASURES: Primary outcomes included mortality and all-cause readmissions within 30 days of discharge. Secondary outcomes included use of SUD medications.

RESULTS: Of 104,833 beneficiaries hospitalized for alcohol withdrawal (mean age 62.1 [SD 11.5] years, 71.8% male) and 75,463 hospitalized for opioid overdose (mean age 64.5 [SD 12.5] years, 40.8% male), 36.4% and 37.3% were enrolled in MA, respectively. Adjusted rates of 30-day mortality were lower in MA for alcohol withdrawal (unadjusted 2.5% in MA vs 2.4% in traditional Medicare; adjusted difference -0.27 pp [95% CI -0.47, -0.08]) but similar for opioid overdose (7.8% in MA vs 7.9% in traditional Medicare; adjusted difference -0.13 pp [-0.54, 0.27]). Rates of 30-day readmissions were lower in MA for both alcohol withdrawal (12.3% in MA vs 13.7% in traditional Medicare; adjusted difference -1.01 pp [95% CI -1.44, -0.59]) and opioid overdose (14.8% in MA vs 17.6% in traditional Medicare; adjusted difference -1.93 pp [95% CI -2.49, -1.37]). Enrollment in MA was associated with lower use of medications for alcohol use disorder (unadjusted 9.6% in MA vs 11.3% in traditional Medicare; adjusted difference -1.66 pp [95% CI -2.72, -0.60]) but higher use of medications for opioid use disorder (unadjusted 4.9% in MA vs 4.2% in traditional Medicare; adjusted difference, 0.82 pp [95% CI 0.08, 1.57]).

CONCLUSIONS: Compared to traditional Medicare, MA was associated with modestly lower 30-day mortality after alcohol withdrawal, lower 30-day readmission rates after alcohol withdrawal and opioid overdose hospitalizations, and mixed findings on medication use.