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Cichocki M, O'Meara R, Kang I, Kittrell Z, Rao P, Weise L, Babrowski T, Soult M, Blecha M. Socioeconomic Disadvantage is a Leading Variable in Risk Score for Major Amputation Following Emergent Infra-Inguinal Arterial Bypass Surgery. J Vasc Surg 2024:S0741-5214(24)01247-3. [PMID: 38851469 DOI: 10.1016/j.jvs.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/29/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024]
Abstract
OBJECTIVE The purpose of this study is to identify patients at particularly high risk for major amputation following emergent infra-inguinal bypass to help tailor postoperative and long-term patient management. METHODS In the Vascular Quality Initiative, we identified 2126 patients who underwent emergent infra-inguinal artery bypass. Two primary outcomes were investigated : major ipsilateral amputation above the ankle level during index hospitalization and major amputation above the ankle at any time after emergent infra-inguinal bypass surgery (perioperative and post discharge combined). Binary logistic regression analysis was performed for each outcome utilizing variables which achieved a univariable P value < .10. We then determined which variables have a multivariable association for the outcomes as defined by a regression P value of .05 or less. A risk score was then created for the outcome of amputation after emergent infra-inguinal bypass using weighted beta-coefficient. Variables with a multivariable P-value < .05 were included in the risks score and weighted based on their respective regression beta-coefficient in a point scale. RESULTS Overall, 17.1% (368/2126) of patients experienced major amputation at some point in follow up after emergent infra-inguinal artery bypass. Mean follow up duration on the amputation variable was 261 days with end point being time of amputation or time of last follow up data on the amputation variable. Variables with a significant multivariable association (P<.05) with major amputation at any point after emergent infra-inguinal arterial bypass were : home status in top 10% (most deprived) of area deprivation index; prior infra-inguinal ipsilateral arterial bypass; prior ipsilateral endovascular arterial intervention; prosthetic bypass conduit; postoperative skin/soft tissue infection; and postoperative need to revise or thrombectomize bypass. Pertinent negatives on multivariable analysis included all baseline co-morbidities, insurance status, race, and gender. There is steep progression in amputation rate ranging from 5% at scores of 0 and 1 to over 60% for scores in excess of 10. AUC analysis revealed a value of .706. CONCLUSIONS Patients living in the most disadvantaged socioeconomic neighborhoods have an increased risk of amputation following emergent infra-inguinal arterial bypass independent of baseline co-morbidities and perioperative events. Baseline co-morbidities are not impactful regarding amputation rates after emergent infra-inguinal bypass surgery. The need for bypass revision or thrombectomy during index hospitalization is the most impactful factor towards amputation after emergency bypass. A risk score with quality accuracy has been developed to help identify patients at particularly high likelihood of limb loss which may aid in counseling regarding heightened vigilance in postoperative and long term follow up care.
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Affiliation(s)
- Meghan Cichocki
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy
| | - Rylie O'Meara
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy
| | - Ian Kang
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy
| | - Zach Kittrell
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy
| | - Priya Rao
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy
| | - Lorela Weise
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy
| | - Trissa Babrowski
- University of Chicago Medical Center, Section of Vascular Surgery and Endovascular Therapy
| | - Michael Soult
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy
| | - Matthew Blecha
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy.
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Li Z, Ho V, Merrell MA, Hung P. Trends in patient perceptions of care toward rural and urban hospitals in the United States: 2014-2019. J Rural Health 2024; 40:565-573. [PMID: 38031505 DOI: 10.1111/jrh.12813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/26/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE Understanding rural-urban disparities in patient satisfaction is critical to identify gaps for improvement in patient-centered care and tailor interventions to specific patient needs, especially those in the Frontier and Remote areas (FAR). This study aimed to examine disparities in patient perceptions of care between urban, rural non-FAR, and FAR hospitals between 2014 and 2019. METHODS This is a retrospective longitudinal study using 2014-2019 Hospital Consumer Assessment of Healthcare Providers and Systems data linked to American Hospital Annual Survey data (3,524 hospitals in 2014 and 3,440 hospitals in 2019). Multivariable linear regression models were used to identify differential trends in patient perceptions of care by hospital rurality over 2014-2019, adjusting hospital- and county-level characteristics. FINDINGS In 2014, patients at rural non-FAR and FAR hospitals had lower percentages of willingness to definitely recommend these hospitals than urban hospitals (average percentage difference, 95% CI: -4.0% [-4.5%, -3.5%]; -2.0% [-2.8%, -1.2%]); yet, over the study period, rural hospitals experienced steeper increases in patient willingness to recommend (0.2% [0.07%, 0.4%]; 0.4% [0.08%, 0.7%]). FAR hospitals also showed improvements in patient experience in a clean environment, communication with nurses, communication about medicines, and responsiveness of staff. Communication with doctors showed slight decreases across hospital locations. CONCLUSIONS Patient perceptions of care were generally improved in all US hospitals from 2014 to 2019, except communications with doctors. These findings highlight the potential for enhancing patient satisfaction and experience in urban hospitals and suggest the need to improve patient willingness to recommend in rural FAR hospitals.
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Affiliation(s)
- Zhong Li
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
- Rural & Minority Health Research Center, University of South Carolina, Columbia, South Carolina, USA
| | - Vivian Ho
- Rural & Minority Health Research Center, University of South Carolina, Columbia, South Carolina, USA
| | - Melinda A Merrell
- Rural & Minority Health Research Center, University of South Carolina, Columbia, South Carolina, USA
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Peiyin Hung
- Rural & Minority Health Research Center, University of South Carolina, Columbia, South Carolina, USA
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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Nash KA, Tolliver DG, Foster AA. Accountability to Quality and Equity of Care for Children With Acute Agitation in the Emergency Department. Hosp Pediatr 2024; 14:390-393. [PMID: 38618650 DOI: 10.1542/hpeds.2024-007776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Katherine A Nash
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Destiny G Tolliver
- Department of Pediatrics, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Ashley A Foster
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California
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Quesada O, Crousillat D, Rodriguez F, Bravo-Jaimes K, Briller J, Ogunniyi MO, Mattina DJ, Aggarwal NR, Rodriguez CJ, De Oliveira GMM, Velarde G. Cardiovascular Disease in Hispanic Women: JACC Review Topic of the Week. J Am Coll Cardiol 2024; 83:1702-1712. [PMID: 38658109 DOI: 10.1016/j.jacc.2024.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/29/2024] [Accepted: 02/05/2024] [Indexed: 04/26/2024]
Abstract
Cardiovascular disease affects 37% of Hispanic women and is the leading cause of death among Hispanic women in the United States. Hispanic women have a higher burden of cardiovascular risk factors, are disproportionally affected by social determinants of health, and face additional barriers related to immigration, such as discrimination, language proficiency, and acculturation. Despite this, Hispanic women show lower rates of cardiovascular disease and mortality compared with non-Hispanic White women. However, this "Hispanic paradox" is challenged by recent studies that account for the diversity in culture, race, genetic background, country of origin, and social determinants of health within Hispanic subpopulations. This review provides a comprehensive overview of the cardiovascular risk factors in Hispanic women, emphasizing the role of social determinants, and proposes a multipronged approach for equitable care.
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Affiliation(s)
- Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA; The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA.
| | - Daniela Crousillat
- Division of Cardiovascular Sciences, Department of Medicine, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Katia Bravo-Jaimes
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Joan Briller
- Division of Cardiology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois, USA; Department of Obstetrics and Gynecology, University of Illinois Chicago, Chicago, Illinois, USA
| | - Modele O Ogunniyi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA; Grady Health System, Atlanta, Georgia, USA
| | - Deirdre J Mattina
- Department of Cardiovascular Medicine, Cleveland Clinic, Beachwood, Ohio, USA
| | - Niti R Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Gladys Velarde
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
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Liu M, Sandhu S, Joynt Maddox KE, Wadhera RK. Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program. JAMA 2024; 331:1387-1396. [PMID: 38536161 PMCID: PMC10974683 DOI: 10.1001/jama.2024.2440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/13/2024] [Indexed: 04/24/2024]
Abstract
Importance Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. Objective To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. Design, Setting, and Participants This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Exposures Hospital Value-Based Purchasing program HEA. Main Outcomes and Measures Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Results Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Conclusions and Relevance Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.
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Affiliation(s)
- Michael Liu
- Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Karen E. Joynt Maddox
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Associate Editor, JAMA
| | - Rishi K. Wadhera
- Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Faloye AO, Houston BT, Milam AJ. Racial and Ethnic Disparities in Cardiovascular Care. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00244-1. [PMID: 38876812 DOI: 10.1053/j.jvca.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 06/16/2024]
Affiliation(s)
| | - Bobby T Houston
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
| | - Adam J Milam
- Department of Anesthesiology and Perioperative Medicine; Mayo Clinic; Phoenix, AZ
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Wadhera RK, Secemsky EA, Xu J, Yeh RW, Song Y, Goldhaber SZ. Community Socioeconomic Status, Acute Cardiovascular Hospitalizations, and Mortality in Medicare, 2003 to 2019. Circ Cardiovasc Qual Outcomes 2024; 17:e010090. [PMID: 38597091 DOI: 10.1161/circoutcomes.123.010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 01/31/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades. METHODS Medicare files were linked with the Centers for Disease Control and Prevention's social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries. RESULTS A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990-650 per 100 000) and nondisadvantaged communities (950-570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02-1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13-1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063-1559 per 100 000) and nondisadvantaged communities (1767-1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146-184 per 100 000) and nondisadvantaged communities (153-184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01-1.20]). CONCLUSIONS Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.
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Affiliation(s)
- Rishi K Wadhera
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Eric A Secemsky
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Jiaman Xu
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Yang Song
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.Z.G.)
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Wadhera RK, Joynt Maddox KE. Policy Strategies to Advance Cardiovascular Health in the United States-Building on a Century of Progress. Circ Cardiovasc Qual Outcomes 2024; 17:e010149. [PMID: 38626057 DOI: 10.1161/circoutcomes.123.010149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Affiliation(s)
- Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA (R.K.W.)
- Harvard Medical School, Boston, MA (R.K.W.)
| | - Karen E Joynt Maddox
- Cardiovascular Division, John T. Milliken Department of Internal Medicine and Center for Advancing Health Services, Policy & Economics Research, Washington University School of Medicine in St. Louis, MO (K.E.J.M.)
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Milam AJ, Ogunniyi MO, Faloye AO, Castellanos LR, Verdiner RE, Stewart JW, Chukumerije M, Okoh AK, Bradley S, Roswell RO, Douglass PL, Oyetunji SO, Iribarne A, Furr-Holden D, Ramakrishna H, Hayes SN. Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:530-545. [PMID: 38267114 DOI: 10.1016/j.jacc.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/08/2023] [Indexed: 01/26/2024]
Abstract
There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.
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Affiliation(s)
- Adam J Milam
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA.
| | - Modele O Ogunniyi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA; Grady Health System, Atlanta, Georgia, USA
| | - Abimbola O Faloye
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA. https://twitter.com/bfaloyeMD
| | - Luis R Castellanos
- Division of Cardiovascular Medicine, Department of Medicine, University of California-San Diego, La Jolla, California, USA. https://twitter.com/lrcastel
| | - Ricardo E Verdiner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA. https://twitter.com/VerdinerMD
| | - James W Stewart
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA. https://twitter.com/stewartwjames
| | - Merije Chukumerije
- Department of Cardiovascular Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA. https://twitter.com/DrMerije
| | - Alexis K Okoh
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. https://twitter.com/OkohMD
| | - Steven Bradley
- Department of Anesthesia and Critical Care, Moffitt Cancer Center, Tampa, Florida, USA. https://twitter.com/stevenbradleyMD
| | - Robert O Roswell
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York, USA. https://twitter.com/DrRobRoswell
| | - Paul L Douglass
- Center for Cardiovascular Care, Wellstar Atlanta Medical Center, Atlanta, Georgia, USA
| | - Shakirat O Oyetunji
- Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington, USA. https://twitter.com/LaraOyetunji
| | - Alexander Iribarne
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Debra Furr-Holden
- Department of Epidemiology, School of Global Public Health, New York University, New York, New York, USA. https://twitter.com/DrDebFurrHolden
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/SharonneHayes
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Nash KA, Weerahandi H, Yu H, Venkatesh AK, Holaday LW, Herrin J, Lin Z, Horwitz LI, Ross JS, Bernheim SM. Measuring Equity in Readmission as a Distinct Assessment of Hospital Performance. JAMA 2024; 331:111-123. [PMID: 38193960 PMCID: PMC10777266 DOI: 10.1001/jama.2023.24874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/13/2023] [Indexed: 01/10/2024]
Abstract
Importance Equity is an essential domain of health care quality. The Centers for Medicare & Medicaid Services (CMS) developed 2 Disparity Methods that together assess equity in clinical outcomes. Objectives To define a measure of equitable readmissions; identify hospitals with equitable readmissions by insurance (dual eligible vs non-dual eligible) or patient race (Black vs White); and compare hospitals with and without equitable readmissions by hospital characteristics and performance on accountability measures (quality, cost, and value). Design, Setting, and Participants Cross-sectional study of US hospitals eligible for the CMS Hospital-Wide Readmission measure using Medicare data from July 2018 through June 2019. Main Outcomes and Measures We created a definition of equitable readmissions using CMS Disparity Methods, which evaluate hospitals on 2 methods: outcomes for populations at risk for disparities (across-hospital method); and disparities in care within hospitals' patient populations (within-a-single-hospital method). Exposures Hospital patient demographics; hospital characteristics; and 3 measures of hospital performance-quality, cost, and value (quality relative to cost). Results Of 4638 hospitals, 74% served a sufficient number of dual-eligible patients, and 42% served a sufficient number of Black patients to apply CMS Disparity Methods by insurance and race. Of eligible hospitals, 17% had equitable readmission rates by insurance and 30% by race. Hospitals with equitable readmissions by insurance or race cared for a lower percentage of Black patients (insurance, 1.9% [IQR, 0.2%-8.8%] vs 3.3% [IQR, 0.7%-10.8%], P < .01; race, 7.6% [IQR, 3.2%-16.6%] vs 9.3% [IQR, 4.0%-19.0%], P = .01), and differed from nonequitable hospitals in multiple domains (teaching status, geography, size; P < .01). In examining equity by insurance, hospitals with low costs were more likely to have equitable readmissions (odds ratio, 1.57 [95% CI, 1.38-1.77), and there was no relationship between quality and value, and equity. In examining equity by race, hospitals with high overall quality were more likely to have equitable readmissions (odds ratio, 1.14 [95% CI, 1.03-1.26]), and there was no relationship between cost and value, and equity. Conclusion and Relevance A minority of hospitals achieved equitable readmissions. Notably, hospitals with equitable readmissions were characteristically different from those without. For example, hospitals with equitable readmissions served fewer Black patients, reinforcing the role of structural racism in hospital-level inequities. Implementation of an equitable readmission measure must consider unequal distribution of at-risk patients among hospitals.
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Affiliation(s)
- Katherine A. Nash
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Himali Weerahandi
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Huihui Yu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Louisa W. Holaday
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeph Herrin
- Flying Buttress Associates, Charlottesville, Virginia
- Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Leora I. Horwitz
- Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, New York
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Division of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Deputy Editor, JAMA
| | - Susannah M. Bernheim
- Division of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Now with Centers for Medicaid and Medicare Services, Baltimore, Maryland
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Kyalwazi AN, Narasimmaraj P, Xu J, Song Y, Wadhera RK. Medicare's Value-Based Purchasing And 30-Day Mortality At Hospitals Caring For High Proportions Of Black Adults. Health Aff (Millwood) 2024; 43:118-124. [PMID: 38190594 DOI: 10.1377/hlthaff.2023.00740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
The care of Black adults is highly concentrated at a limited set of US hospitals that often have limited resources. In 2011, the Medicare Hospital Value-Based Purchasing (VBP) Program began financially penalizing or rewarding hospitals based on thirty-day mortality rates for target conditions (myocardial infarction, heart failure, and pneumonia). Because the VBP Program has disproportionately penalized resource-constrained hospitals caring for high proportions of Black adults since its implementation in 2011, clinicians, health system leaders, and policy makers have worried that the program may unintentionally be widening racial disparities in health outcomes. Using Medicare claims for beneficiaries ages sixty-five and older who were hospitalized for three target conditions at 2,908 US hospitals participating in the VBP Program, we found that thirty-day mortality rates were consistently higher for two of three conditions at hospitals with high proportions of Black adults compared with other hospitals. There was no evidence of a differential change in thirty-day mortality among all Medicare beneficiaries with targeted conditions at high-proportion Black hospitals versus other hospitals seven years after the implementation of the VBP Program. However, gaps in mortality between these sites did widen in the subgroup of Black adults with pneumonia. These findings highlight that important concerns remain about the regressive nature and equity implications of national pay-for-performance programs.
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Affiliation(s)
| | | | - Jiaman Xu
- Jiaman Xu, Beth Israel Deaconess Medical Center
| | - Yang Song
- Yang Song, Beth Israel Deaconess Medical Center
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12
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Secemsky EA, Kirksey L, Quiroga E, King CM, Martinson M, Hasegawa JT, West NEJ, Wadhera RK. Impact of Intensity of Vascular Care Preceding Major Amputation Among Patients With Chronic Limb-Threatening Ischemia. Circ Cardiovasc Interv 2024; 17:e012798. [PMID: 38152880 DOI: 10.1161/circinterventions.122.012798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 09/22/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Lower-limb amputation rates in patients with chronic limb-threatening ischemia vary across the United States, with marked disparities in amputation rates by gender, race, and income status. We evaluated the association of patient, hospital, and geographic characteristics with the intensity of vascular care received the year before a major lower-limb amputation and how intensity of care associates with outcomes after amputation. METHODS Using Medicare claims data (2016-2019), beneficiaries diagnosed with chronic limb-threatening ischemia who underwent a major lower-limb amputation were identified. We examined patient, hospital, and geographic characteristics associated with the intensity of vascular care received the year before amputation. Secondary objectives evaluated all-cause mortality and adverse events following amputation. RESULTS Of 33 036 total Medicare beneficiaries undergoing major amputation, 7885 (23.9%) were due to chronic limb-threatening ischemia; of these, 4988 (63.3%) received low-intensity and 2897 (36.7%) received high-intensity vascular care. Mean age, 76.6 years; women, 38.9%; Black adults, 24.5%; and of low income, 35.2%. After multivariable adjustment, those of low income (odds ratio, 0.65 [95% CI, 0.58-0.72]; P<0.001), and to a lesser extent, men (odds ratio, 0.89 [95% CI, 0.81-0.98]; P=0.019), and those who received care at a safety-net hospital (odds ratio, 0.87 [95% CI, 0.78-0.97]; P=0.012) were most likely to receive low intensity of care before amputation. High-intensity care was associated with a lower risk of all-cause mortality 2 years following amputation (hazard ratio, 0.79 [95% CI, 0.74-0.85]; P<0.001). CONCLUSIONS Patients who were of low-income status, and to a lesser extent, men, or those cared for at safety-net hospitals were most likely to receive low-intensity vascular care. Low-intensity care was associated with worse long-term event-free survival. These data emphasize the continued disparities that exist in contemporary vascular practice.
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Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S., R.K.W.)
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, OH (L.K.)
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle (E.Q.)
| | - Claire M King
- Abbott Vascular, Santa Clara, CA (C.M.K., J.T.H., N.E.J.W.)
| | | | | | - Nick E J West
- Abbott Vascular, Santa Clara, CA (C.M.K., J.T.H., N.E.J.W.)
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S., R.K.W.)
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13
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Thai NH, Post B, Young GJ. Hospital-physician Integration and Value-based Payment: Early Results From MIPS. Med Care 2023; 61:822-828. [PMID: 37737738 DOI: 10.1097/mlr.0000000000001923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND Hospital-physician integration is often justified as a driver of clinical quality improvement due to joint resources covering a broad spectrum of care. Value-based programs, such as the Medicare Merit-Based Incentive Payment System (MIPS), are intended to tie financial incentives to clinical quality, which may confer an advantage on such integrated practices. OBJECTIVES We assessed the relationship between hospital-physician integration and MIPS performance by comparing hospital-integrated practices and independent practices. RESEARCH DESIGN This was a cross-sectional study using data from the Quality Payment Program for the performance year 2020. SUBJECTS Physician practices with a valid MIPS composite score in performance year 2020. MEASURES Hospital integration was based on whether at least 75% of a practice's physicians either billed most of their services using hospital outpatient department codes or billed through a hospital tax identifier. The primary outcome was the MIPS quality category score, and the secondary outcomes were the specific quality measures reported by practice groups. RESULTS Of the 20 most frequently reported measures, 14 were common in both groups. No difference was observed in the quality category score between hospital-integrated practices and independent practices in either unadjusted comparisons or after adjusting for practice characteristics, including practice size, geography, specialty mix, and case mix. In the secondary outcome models for specific quality measures, hospital-integrated practices achieved higher scores on most overlap measures but not all. CONCLUSIONS The findings on quality category score suggest that hospital integration does not confer much advantage in the context of MIPS quality performance.
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Affiliation(s)
- Ngoc H Thai
- Bouve College of Health Sciences, Northeastern University
- Center for Health Policy and Healthcare Research, Northeastern University
| | - Brady Post
- Center for Health Policy and Healthcare Research, Northeastern University
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University
| | - Gary J Young
- Center for Health Policy and Healthcare Research, Northeastern University
- D'Amore McKim School of Business, Northeastern University, Boston, MA
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Lin SC, Hammond G, Esposito M, Majewski C, Foraker RE, Joynt Maddox KE. Segregated Patterns of Hospital Care Delivery and Health Outcomes. JAMA HEALTH FORUM 2023; 4:e234172. [PMID: 37991783 PMCID: PMC10665978 DOI: 10.1001/jamahealthforum.2023.4172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/29/2023] [Indexed: 11/23/2023] Open
Abstract
Importance Residential segregation has been shown to be a root cause of racial inequities in health outcomes, yet little is known about current patterns of racial segregation in where patients receive hospital care or whether hospital segregation is associated with health outcomes. Filling this knowledge gap is critical to implementing policies that improve racial equity in health care. Objective To characterize contemporary patterns of racial segregation in hospital care delivery, identify market-level correlates, and determine the association between hospital segregation and health outcomes. Design, Setting, and Participants This cross-sectional study of US hospital referral regions (HRRs) used 2018 Medicare claims, American Community Survey, and Agency for Healthcare Research and Quality Social Determinants of Health data. Hospitalization patterns for all non-Hispanic Black or non-Hispanic White Medicare fee-for-service beneficiaries with at least 1 inpatient hospitalization in an eligible hospital were evaluated for hospital segregation and associated health outcomes at the HRR level. The data analysis was performed between August 10, 2022, and September 6, 2023. Exposures Dissimilarity index and isolation index for HRRs. Main Outcomes and Measures Health outcomes were measured using Prevention Quality Indicator (PQI) acute and chronic composites per 100 000 Medicare beneficiaries, and total deaths related to heart disease and stroke per 100 000 residents were calculated for individuals aged 74 years or younger. Correlation coefficients were used to compare residential and hospital dissimilarity and residential and hospital isolation. Linear regression was used to examine the association between hospital segregation and health outcomes. Results This study included 280 HRRs containing data for 4386 short-term acute care and critical access hospitals. Black and White patients tended to receive care at different hospitals, with a mean (SD) dissimilarity index of 23 (11) and mean (SD) isolation index of 13 (13), indicating substantial variation in segregation across HRRs. Hospital segregation was correlated with residential segregation (correlation coefficients, 0.58 and 0.90 for dissimilarity and isolation, respectively). For Black patients, a 1-SD increase in the hospital isolation index was associated with 204 (95% CI, 154-254) more acute PQI hospitalizations per 100 000 Medicare beneficiaries (28% increase from the median), 684 (95% CI, 488-880) more chronic PQI hospitalizations per 100 000 Medicare beneficiaries (15% increase), and 6 (95% CI, 2-9) additional deaths per 100 000 residents (6% increase) compared with 68 (95% CI, 24-113; 6% increase), 202 (95% CI, 131-274; 8% increase), and 2 (95% CI, 0 to 4; 3% increase), respectively, for White patients. Conclusions and Relevance This cross-sectional study found that higher segregation of hospital care was associated with poorer health outcomes for both Black and White Medicare beneficiaries, with significantly greater negative health outcomes for Black populations, supporting racial segregation as a root cause of health disparities. Policymakers and clinical leaders could address this important public health issue through payment reform efforts and expansion of health insurance coverage, in addition to supporting upstream efforts to reduce racial segregation in hospital care and residential settings.
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Affiliation(s)
- Sunny C. Lin
- Division of General Medical Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
- Institute for Public Health, Washington University in St Louis, St Louis, Missouri
| | - Gmerice Hammond
- Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
| | | | - Cassandra Majewski
- Division of General Medical Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Randi E. Foraker
- Division of General Medical Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | - Karen E. Joynt Maddox
- Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
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15
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Byrd JN, Cichocki MN, Chung KC. Plastic Surgeons and Equity: Are Merit-Based Incentive Payment System Scores Impacted by Minority Patient Caseload? Plast Reconstr Surg 2023; 152:534e-539e. [PMID: 36917743 DOI: 10.1097/prs.0000000000010406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services introduced the Merit-based Incentive Payment System (MIPS) in 2017 to extend value-based payment to outpatient physicians. The authors hypothesized that the MIPS scores for plastic surgeons are impacted by the existing measures of patient disadvantage, minority patient caseload, and dual eligibility. METHODS The authors conducted a retrospective cohort study of plastic surgeons participating in Medicare and MIPS using the Physician Compare national downloadable file and MIPS scores. Minority patient caseload was defined as nonwhite patient caseload. The authors evaluated the characteristics of participating plastic surgeons, their patient caseloads, and their scores. RESULTS Of 4539 plastic surgeons participating in Medicare, 1257 participated in MIPS in the first year of scoring. The average patient caseload is 85% white, with racial/ethnicity data available for 73% of participating surgeons. In multivariable regression, higher minority patient caseload is associated with a lower MIPS score. CONCLUSIONS As minority patient caseload increases, MIPS scores decrease for otherwise similar caseloads. The Centers for Medicare and Medicaid Services must consider existing and additional measures of patient disadvantage to ensure equitable surgeon scoring.
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Affiliation(s)
- Jacqueline N Byrd
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
- Center for Health Outcomes and Policy, University of Michigan
- Department of Surgery, University of Texas Southwestern Medical School
| | - Meghan N Cichocki
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Kevin C Chung
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
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McLaughlin CC, Boscoe FP. The geography of Medicare's hospital value-based purchasing in relation to market demographics. Health Serv Res 2023; 58:844-852. [PMID: 36755373 PMCID: PMC10315389 DOI: 10.1111/1475-6773.14141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVE To illustrate the association between the sociodemographic characteristics of hospital markets and the geographic patterns of Medicare hospital value-based purchasing (HVBP) scores. DATA SOURCES AND STUDY SETTING This is a secondary analysis of United States hospitals with a HVBP Total Performance Score (TPS) for 2019 in the Centers for Medicare and Medicaid Services (CMS) Hospital Compare database (4/2021 release) and American Community Survey (ACS) data for 2015-2019. STUDY DESIGN This is a cross-sectional study using spatial multivariable autoregressive models with HVBP TPS and component domain scores as dependent variables and hospital market demographics as the independent variables. DATA COLLECTION/EXTRACTION METHODS We calculated hospital market demographics using ZIP code level data from the ACS, weighted the 2019 CMS inpatient Hospital Service Area file. PRINCIPAL FINDINGS Spatial autoregressive models using eight nearest neighbors with diversity index, race and ethnicity distribution, families in poverty, unemployment, and lack of health insurance among residents ages 19-64 years provided the best model fit. Diversity index had the highest statistically significant contribution to lower TPS (ß = -12.79, p < 0.0001), followed by the percent of the population coded to "non-Hispanic, some other race" (ß = -2.59, p < 0.0023), and the percent of families in poverty (ß = -0.26, p < 0.0001). Percent of the population was non-Hispanic American Indian/Alaskan Native (ß = 0.35, p < 0.0001) and percent non-Hispanic Asian (ß = 0.12, p < 0.02071) were associated with higher TPS. Lower predicted TPS was observed in large urban cities throughout the US as well as in states throughout the Southeastern US. Similar geographic patterns were observed for the predicted Patient Safety, Person and Community Engagement, and Efficiency and Cost Reduction domain scores but are not for predicted Clinical Outcomes scores. CONCLUSIONS The lower predicted scores seen in cities and in the Southeastern region potentially reflect an inherent-that is, structural-association between market sociodemographics and HVBP scores.
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Affiliation(s)
- Colleen C. McLaughlin
- Department of Population Health SciencesAlbany College of Pharmacy and Health SciencesAlbanyNew YorkUSA
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17
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Frego N, D'Andrea V, Labban M, Trinh QD. An ecological framework for racial and ethnic disparities in surgery. Curr Probl Surg 2023; 60:101335. [PMID: 37316107 DOI: 10.1016/j.cpsurg.2023.101335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Nicola Frego
- Department of Urology, Istituto Clinico Humanitas IRCCS, Milan, Italy
| | - Vincent D'Andrea
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA
| | - Muhieddine Labban
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA; Brigham and Women's Faulkner Hospital, Jamaica Plain, MA.
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18
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Diamond J, Ayodele I, Fonarow GC, Joynt-Maddox KE, Yeh RW, Hammond G, Allen LA, Greene SJ, Chiswell K, DeVore AD, Yancy C, Wadhera RK. Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults: Get With The Guidelines-Heart Failure Registry. JAMA Cardiol 2023; 8:545-553. [PMID: 37074702 PMCID: PMC10116383 DOI: 10.1001/jamacardio.2023.0695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/26/2023] [Indexed: 04/20/2023]
Abstract
Importance Black adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown. Objective To compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals. Design, Setting, and Participants Patients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022. Exposures Hospitals caring for high proportions of Black patients. Main Outcomes and Measures Quality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients. Results This study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based β-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02). Conclusions and Relevance Quality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.
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Affiliation(s)
- Jamie Diamond
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
| | - Karen E. Joynt-Maddox
- Center for Health Economics and Policy, Cardiovascular Division, Washington University School of Medicine, Washington University, St Louis, Missouri
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Gmerice Hammond
- Center for Health Economics and Policy, Cardiovascular Division, Washington University School of Medicine, Washington University, St Louis, Missouri
| | - Larry A. Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Stephen J. Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D. DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Clyde Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Velarde G, Bravo‐Jaimes K, Brandt EJ, Wang D, Douglass P, Castellanos LR, Rodriguez F, Palaniappan L, Ibebuogu U, Bond R, Ferdinand K, Lundberg G, Thamman R, Vijayaraghavan K, Watson K. Locking the Revolving Door: Racial Disparities in Cardiovascular Disease. J Am Heart Assoc 2023; 12:e025271. [PMID: 36942617 PMCID: PMC10227271 DOI: 10.1161/jaha.122.025271] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Racial disparities in cardiovascular disease are unjust, systematic, and preventable. Social determinants are a primary cause of health disparities, and these include factors such as structural and overt racism. Despite a number of efforts implemented over the past several decades, disparities in cardiovascular disease care and outcomes persist, pervading more the outpatient rather than the inpatient setting, thus putting racial and ethnic minority groups at risk for hospital readmissions. In this article, we discuss differences in care and outcomes of racial and ethnic minority groups in both of these settings through a review of registries. Furthermore, we explore potential factors that connote a revolving door phenomenon for those whose adverse outpatient environment puts them at risk for hospital readmissions. Additionally, we review promising strategies, as well as actionable items at the policy, clinical, and educational levels aimed at locking this revolving door.
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Affiliation(s)
- Gladys Velarde
- Department of CardiologyUniversity of FloridaJacksonvilleFL
| | | | | | - Daniel Wang
- Division of CardiologyUniversity of CaliforniaLos AngelesCA
| | - Paul Douglass
- Division of CardiologyWellstar Atlanta Medical CenterAtlantaGA
| | | | - Fatima Rodriguez
- Division of Cardiology and the Cardiovascular InstituteStanford University School of MedicinePalo AltoCA
| | | | - Uzoma Ibebuogu
- Division of CardiologyUniversity of Tennessee Health Science CenterMemphisTN
| | - Rachel Bond
- Division of CardiologyDignity HealthGilbertAZ
- Division Cardiology, Department of Internal MedicineCreighton University School of MedicineOmahaNE
| | - Keith Ferdinand
- Division of CardiologyTulane School of MedicineNew OrleansLA
| | | | - Ritu Thamman
- Division of CardiologyUniversity of PittsburghPittsburghPA
| | | | - Karol Watson
- Division of CardiologyUniversity of CaliforniaLos AngelesCA
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20
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Mentias A, Peterson ED, Keshvani N, Kumbhani DJ, Yancy C, Morris A, Allen L, Girotra S, Fonarow GC, Starling R, Alvarez P, Desai M, Cram P, Pandey A. Achieving Equity in Hospital Performance Assessments Using Composite Race-Specific Measures of Risk-Standardized Readmission and Mortality Rates for Heart Failure. Circulation 2023; 147:1121-1133. [PMID: 37036906 PMCID: PMC10765408 DOI: 10.1161/circulationaha.122.061995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 01/23/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND The contemporary measures of hospital performance for heart failure hospitalization and 30-day risk-standardized readmission rate (RSRR) and risk-standardized mortality rate (RSMR) are estimated using the same risk adjustment model and overall event rate for all patients. Thus, these measures are mainly driven by the care quality and outcomes for the majority racial and ethnic group, and may not adequately represent the hospital performance for patients of Black and other races. METHODS Fee-for-service Medicare beneficiaries from January 2014 to December 2019 hospitalized with heart failure were identified. Hospital-level 30-day RSRR and RSMR were estimated using the traditional race-agnostic models and the race-specific approach. The composite race-specific performance metric was calculated as the average of the RSRR/RMSR measures derived separately for each race and ethnicity group. Correlation and concordance in hospital performance for all patients and patients of Black and other races were assessed using the composite race-specific and race-agnostic metrics. RESULTS The study included 1 903 232 patients (75.7% White [n=1 439 958]; 14.5% Black [n=276 684]; and 9.8% other races [n=186 590]) with heart failure from 1860 hospitals. There was a modest correlation between hospital-level 30-day performance metrics for patients of White versus Black race (Pearson correlation coefficient: RSRR=0.42; RSMR=0.26). Compared with the race-agnostic RSRR and RSMR, composite race-specific metrics for all patients demonstrated stronger correlation with RSRR (correlation coefficient: 0.60 versus 0.74) and RSMR (correlation coefficient: 0.44 versus 0.51) for Black patients. Concordance in hospital performance for all patients and patients of Black race was also higher with race-specific (versus race-agnostic) metrics (RSRR=64% versus 53% concordantly high-performing; 61% versus 51% concordantly low-performing). Race-specific RSRR and RSMR metrics (versus race-agnostic) led to reclassification in performance ranking of 35.8% and 39.2% of hospitals, respectively, with better 30-day and 1-year outcomes for patients of all race groups at hospitals reclassified as high-performing. CONCLUSIONS Among patients hospitalized with heart failure, race-specific 30-day RSMR and RSRR are more equitable in representing hospital performance for patients of Black and other races.
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Affiliation(s)
- Amgad Mentias
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Eric D. Peterson
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Dharam J. Kumbhani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Clyde Yancy
- Division of Cardiology, Northwestern University School of Medicine, Chicago, IL
| | - Alanna Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Larry Allen
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Denver, CO
| | - Saket Girotra
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Gregg C. Fonarow
- Ahmanson Cardiomyopathy Center, UCLA School of Medicine, Los Angeles, CA
| | - Randall Starling
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Paulino Alvarez
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Milind Desai
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Peter Cram
- Department of Internal Medicine, UT Medical Branch, Galveston, TX
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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21
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Oseran AS, Wadhera RK, Orav EJ, Figueroa JF. Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings. Ann Intern Med 2023; 176:480-488. [PMID: 36972544 DOI: 10.7326/m22-3165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown. OBJECTIVE To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures. DESIGN Cross-sectional. SETTING Population-based. PARTICIPANTS Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. MEASUREMENTS Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated. RESULTS Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings. LIMITATION Hospital performance measurement and risk adjustment differed slightly from those used by Medicare. CONCLUSION Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. PRIMARY FUNDING SOURCE Laura and John Arnold Foundation.
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Affiliation(s)
- Andrew S Oseran
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts (A.S.O.)
| | - Rishi K Wadhera
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.K.W.)
| | - E John Orav
- Harvard T.H. Chan School of Public Health and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (E.J.O., J.F.F.)
| | - Jose F Figueroa
- Harvard T.H. Chan School of Public Health and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (E.J.O., J.F.F.)
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Powers BW, Figueroa JF, Canterberry M, Gondi S, Franklin SM, Shrank WH, Joynt Maddox KE. Association Between Community-Level Social Risk and Spending Among Medicare Beneficiaries: Implications for Social Risk Adjustment and Health Equity. JAMA HEALTH FORUM 2023; 4:e230266. [PMID: 37000433 PMCID: PMC10066453 DOI: 10.1001/jamahealthforum.2023.0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/03/2023] [Indexed: 04/01/2023] Open
Abstract
Importance Payers are increasingly using approaches to risk adjustment that incorporate community-level measures of social risk with the goal of better aligning value-based payment models with improvements in health equity. Objective To examine the association between community-level social risk and health care spending and explore how incorporating community-level social risk influences risk adjustment for Medicare beneficiaries. Design, Setting, and Participants Using data from a Medicare Advantage plan linked with survey data on self-reported social needs, this cross-sectional study estimated health care spending health care spending was estimated as a function of demographics and clinical characteristics, with and without the inclusion of Area Deprivation Index (ADI), a measure of community-level social risk. The study period was January to December 2019. All analyses were conducted from December 2021 to August 2022. Exposures Census block group-level ADI. Main Outcomes and Measures Regression models estimated total health care spending in 2019 and approximated different approaches to social risk adjustment. Model performance was assessed with overall model calibration (adjusted R2) and predictive accuracy (ratio of predicted to actual spending) for subgroups of potentially vulnerable beneficiaries. Results Among a final study population of 61 469 beneficiaries (mean [SD] age, 70.7 [8.9] years; 35 801 [58.2%] female; 48 514 [78.9%] White; 6680 [10.9%] with Medicare-Medicaid dual eligibility; median [IQR] ADI, 61 [42-79]), ADI was weakly correlated with self-reported social needs (r = 0.16) and explained only 0.02% of the observed variation in spending. Conditional on demographic and clinical characteristics, every percentile increase in the ADI (ie, more disadvantage) was associated with a $11.08 decrease in annual spending. Directly incorporating ADI into a risk-adjustment model that used demographics and clinical characteristics did not meaningfully improve model calibration (adjusted R2 = 7.90% vs 7.93%) and did not significantly reduce payment inequities for rural beneficiaries and those with a high burden of self-reported social needs. A postestimation adjustment of predicted spending for dual-eligible beneficiaries residing in high ADI areas also did not significantly reduce payment inequities for rural beneficiaries or beneficiaries with self-reported social needs. Conclusions and Relevance In this cross-sectional study of Medicare beneficiaries, the ADI explained little variation in health care spending, was negatively correlated with spending conditional on demographic and clinical characteristics, and was poorly correlated with self-reported social risk factors. This prompts caution and nuance when using community-level measures of social risk such as the ADI for social risk adjustment within Medicare value-based payment programs.
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Affiliation(s)
- Brian W. Powers
- Tufts University School of Medicine, Boston, Massachusetts
- MassGeneral Brigham, Boston, Massachusetts
- Humana Inc, Louisville, Kentucky
| | - Jose F. Figueroa
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Suhas Gondi
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
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Patel TA, Jain B, Parikh RB. The Enhancing Oncology Model: Leveraging improvement science to increase health equity in value-based care. J Natl Cancer Inst 2023; 115:125-130. [PMID: 36245086 PMCID: PMC9905958 DOI: 10.1093/jnci/djac194] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/27/2022] [Accepted: 10/06/2022] [Indexed: 11/12/2022] Open
Abstract
The Oncology Care Model (OCM), launched in 2016 by the Centers for Medicare and Medicaid Services, was the first demonstration of value-based payment in oncology. Although the OCM delivered mixed results in terms of quality of care and total episode costs, the model had no statistically significant impact on remediating racial, ethnic, and socioeconomic disparities among beneficiaries. These deficits have been prominent in other aspects of US healthcare, and as a result, the Institute for Healthcare Improvement has advocated for stakeholders to leverage improvement science, an applied science that focuses on implementing rapid cycles for change, to identify and overcome barriers to health equity. With the announcement of the new Enhancing Oncology Model, a continuation of the OCM's efforts in introducing value to cancer care for episodes surrounding chemotherapy administration, both policymakers and providers must apply tenets of improvement science and make eliminating disparities in alternative payment models a forefront objective. In this commentary, we discuss previous inequities in alternative payment models, the role that improvement science plays in addressing health-care disparities, and steps that stakeholders can take to maximize equitable outcomes in the Enhancing Oncology Model.
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Affiliation(s)
- Tej A Patel
- Department of Health Care Management, University of Pennsylvania, Philadelphia, PA, USA
| | - Bhav Jain
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ravi B Parikh
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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Were hospitals with sustained high performance more successful at reducing mortality during the pandemic's second wave? Health Care Manage Rev 2023; 48:70-79. [PMID: 36413651 DOI: 10.1097/hmr.0000000000000354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In 2019, the COVID-19 pandemic emerged. Variation in COVID-19 patient outcomes between hospitals was later reported. PURPOSE This study aims to determine whether sustainers-hospitals with sustained high performance on Hospital Value-Based Purchasing Total Performance Score (HVBP-TPS)-more effectively responded to the pandemic and therefore had better patient outcomes. METHODOLOGY We calculated hospital-specific risk-standardized event rates using deidentified patient-level data from the UnitedHealth Group Clinical Discovery Database. HVBP-TPS from 2016 to 2019 were obtained from Centers for Medicare & Medicaid Services. Hospital characteristics were obtained from the American Hospital Association Annual Survey Database (2019), and county-level predictors were obtained from the Area Health Resource File. We use a repeated-measures regression model assuming an AR(1) type correlation structure to test whether sustainers had lower mortality rates than nonsustainers during the first wave (spring 2020) and the second wave (October to December 2020) of the pandemic. RESULTS Sustainers did not have significantly lower COVID-19 mortality rates during the first wave of the pandemic, but they had lower COVID-19 mortality rates during the second wave compared to nonsustainers. Larger hospitals, teaching hospitals, and hospitals with higher occupancy rates had higher mortality rates. CONCLUSION During the first wave of the pandemic, mortality rates did not differ between sustainers and nonsustainers. However, sustainers had lower mortality rates than nonsustainers in the second wave, most likely because of their knowledge management capabilities and existing structures and resources that enable them to develop new processes and routines to care for patients in times of crisis. Therefore, a consistently high level of performance over the years on HVBP-TPS is associated with high levels of performance on COVID-19 patient outcomes. PRACTICE IMPLICATIONS Investing in identifying the knowledge, processes, and resources that foster the dynamic capabilities needed to achieve superior performance in HVBP might enable hospitals to utilize these capabilities to adapt more effectively to future changes and uncertainty.
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Narasimmaraj PR, Wadhera RK. Heart Failure Readmissions: A Measure of Quality or Social Vulnerability? JACC. HEART FAILURE 2023; 11:124-125. [PMID: 36599539 DOI: 10.1016/j.jchf.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Prihatha R Narasimmaraj
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rishi K Wadhera
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
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26
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Trends in Medicare Reimbursement for the Top 20 Surgical Procedures in Craniofacial Trauma. J Craniofac Surg 2023; 34:247-249. [PMID: 36608102 DOI: 10.1097/scs.0000000000008840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Research regarding financial trends in craniofacial trauma surgery is limited. Understanding these trends is important to the evolvement of suitable reimbursement models in craniofacial plastic surgery. The purpose of this study was to evaluate the trends in Medicare reimbursement rates for the top 20 most utilized surgical procedures for facial trauma. METHODS The 20 most commonly utilized Current Procedural Terminology (CPT) codes for facial trauma repairs in 2018 were queried from The National Summary Data File from the Centers for Medicare & Medicaid Services (CMS). Reimbursement data for each procedure was then extracted from The Physician Fee Schedule Lookup Tool. Changes to the United States consumer price index (CPI) were used to adjust all gathered data for inflation to 2021 US dollars (USD). The average annual and the total percent change in reimbursement were calculated for the included procedures based on the adjusted trends from the years 2000 to 2021. RESULTS From 2000 to 2021, the average reimbursement for all procedures decreased by 16.6% after adjusting for inflation. Closed treatment of temporomandibular joint dislocation and closed treatment of nasal bone fractures without manipulation demonstrated the greatest decrease in mean adjusted reimbursement at -48.7% and -48.3%, respectively, while closed treatment of nasal bone fractures without stabilization demonstrated the smallest mean decrease at -1.4% during the study period. Open treatment of nasal septal fractures with or without stabilization demonstrated the greatest increase in mean adjusted reimbursement at 18.9%, while closed treatment of nasal septal fractures with or without stabilization demonstrated the smallest increase at 1.2%. The average reimbursement for all closed procedures in the top 20 decreased by 19.3%, while that for all open procedures decreased by 15.5%. The adjusted reimbursement rate for all top 20 procedures decreased by an average of 0.8% each year. CONCLUSIONS To the best of our knowledge, this is the first study to comprehensively evaluate trends in Medicare reimbursement for facial trauma surgical repairs. Adjusting for inflation, Medicare reimbursement for the top 20 most commonly utilized procedures has largely decreased from 2000 to 2021. Consideration of these trends by surgeons, hospital systems, and policymakers will be important to assure continued access to meaningful surgical facial trauma care in the United States.
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Glance LG, Joynt Maddox KE, Mazzefi M, Knight PW, Eaton MP, Feng C, Kertai MD, Albernathy J, Wu IY, Wyrobek JA, Cevasco M, Desai N, Dick AW. Racial and Ethnic Disparities in Access to Minimally Invasive Mitral Valve Surgery. JAMA Netw Open 2022; 5:e2247968. [PMID: 36542380 PMCID: PMC9857175 DOI: 10.1001/jamanetworkopen.2022.47968] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Whether people from racial and ethnic minority groups experience disparities in access to minimally invasive mitral valve surgery (MIMVS) is not known. OBJECTIVE To investigate racial and ethnic disparities in the utilization of MIMVS. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the Society of Thoracic Surgeons Database for patients who underwent mitral valve surgery between 2014 and 2019. Statistical analysis was performed from January 24 to August 11, 2022. EXPOSURES Patients were categorized as non-Hispanic White, non-Hispanic Black, and Hispanic individuals. MAIN OUTCOMES AND MEASURES The association between MIMVS (vs full sternotomy) and race and ethnicity were evaluated using logistic regression. RESULTS Among the 103 753 patients undergoing mitral valve surgery (mean [SD] age, 62 [13] years; 47 886 female individuals [46.2%]), 10 404 (10.0%) were non-Hispanic Black individuals, 89 013 (85.8%) were non-Hispanic White individuals, and 4336 (4.2%) were Hispanic individuals. Non-Hispanic Black individuals were more likely to have Medicaid insurance (odds ratio [OR], 2.21; 95% CI, 1.64-2.98; P < .001) and to receive care from a low-volume surgeon (OR, 4.45; 95% CI, 4.01-4.93; P < .001) compared with non-Hispanic White individuals. Non-Hispanic Black individuals were less likely to undergo MIMVS (OR, 0.65; 95% CI, 0.58-0.73; P < .001), whereas Hispanic individuals were not less likely to undergo MIMVS compared with non-Hispanic White individuals (OR, 1.08; 95% CI, 0.67-1.75; P = .74). Patients with commercial insurance had 2.35-fold higher odds of undergoing MIMVS (OR, 2.35; 95% CI, 2.06-2.68; P < .001) than those with Medicaid insurance. Patients operated by very-high volume surgeons (300 or more cases) had 20.7-fold higher odds (OR, 20.70; 95% CI, 12.7-33.9; P < .001) of undergoing MIMVS compared with patients treated by low-volume surgeons (less than 20 cases). After adjusting for patient risk, non-Hispanic Black individuals were still less likely to undergo MIMVS (adjusted OR [aOR], 0.88; 95% CI, 0.78-0.99; P = .04) and were more likely to die or experience a major complication (aOR, 1.25; 95% CI, 1.16-1.35; P < .001) compared with non-Hispanic White individuals. CONCLUSIONS AND RELEVANCE In this cross-sectional study, non-Hispanic Black patients were less likely to undergo MIMVS and more likely to die or experience a major complication than non-Hispanic White patients. These findings suggest that efforts to reduce inequity in cardiovascular medicine may need to include increasing access to private insurance and high-volume surgeons.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St Louis, St Louis, Missouri
| | - Michael Mazzefi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville
| | - Peter W. Knight
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - Michael P. Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Changyong Feng
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine, Rochester, New York
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Albernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins, Baltimore, Maryland
| | - Isaac Y. Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Julie A. Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Marisa Cevasco
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Nimesh Desai
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
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Sabbatini AK, Joynt-Maddox KE, Liao J, Basu A, Parrish C, Kreuter W, Wright B. Accounting for the Growth of Observation Stays in the Assessment of Medicare's Hospital Readmissions Reduction Program. JAMA Netw Open 2022; 5:e2242587. [PMID: 36394872 PMCID: PMC9672971 DOI: 10.1001/jamanetworkopen.2022.42587] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Decreases in 30-day readmissions following the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP) have occurred against the backdrop of increasing hospital observation stay use, yet observation stays are not captured in readmission measures. OBJECTIVE To examine whether the HRRP was associated with decreases in 30-day readmissions after accounting for observation stays. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included a 20% sample of inpatient admissions and observation stays among Medicare fee-for-service beneficiaries from January 1, 2009, to December 31, 2015. Data analysis was performed from November 2021 to June 2022. A differences-in-differences analysis assessed changes in 30-day readmissions after the announcement of the HRRP and implementation of penalties for target conditions (heart failure, acute myocardial infarction, and pneumonia) vs nontarget conditions under scenarios that excluded and included observation stays. MAIN OUTCOMES AND MEASURES Thirty-day inpatient admissions and observation stays. RESULTS The study included 8 944 295 hospitalizations (mean [SD] age, 78.7 [8.2] years; 58.6% were female; 1.3% Asian; 10.0% Black; 2.0% Hispanic; 0.5% North American Native; 85.0% White; and 1.2% other or unknown). Observation stays increased from 2.3% to 4.4% (91.3% relative increase) of index hospitalizations among target conditions and 14.1% to 21.3% (51.1% relative increase) of index hospitalizations for nontarget conditions. Readmission rates decreased significantly after the announcement of the HRRP and returned to baseline by the time penalties were implemented for both target and nontarget conditions regardless of whether observation stays were included. When only inpatient hospitalizations were counted, decreasing readmissions accrued into a -1.48 percentage point (95% CI, -1.65 to -1.31 percentage points) absolute reduction in readmission rates by the postpenalty period for target conditions and -1.13 percentage point (95% CI, -1.30 to -0.96 percentage points) absolute reduction in readmission rates by the postpenalty period for nontarget conditions. This reduction corresponded to a statistically significant differential change of -0.35 percentage points (95% CI, -0.59 to -0.11 percentage points). Accounting for observation stays more than halved the absolute decrease in readmission rates for target conditions (-0.66 percentage points; 95% CI, -0.83 to -0.49 percentage points). Nontarget conditions showed an overall greater decrease during the same period (-0.76 percentage points; 95% CI, -0.92 to -0.59 percentage points), corresponding to a differential change in readmission rates of 0.10 percentage points (95% CI, -0.14 to 0.33 percentage points) that was not statistically significant. CONCLUSIONS AND RELEVANCE The findings of this study suggest that the reduction of readmissions associated with the implementation of the HRRP was smaller than originally reported. More than half of the decrease in readmissions for target conditions appears to be attributable to the reclassification of inpatient admission to observation stays.
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Affiliation(s)
- Amber K. Sabbatini
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle
| | - Karen E. Joynt-Maddox
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Josh Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
- Value System Science Lab, Department of Medicine, University of Washington, Seattle
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics Institute, University of Washington School of Pharmacy, Seattle
| | - Canada Parrish
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle
| | - William Kreuter
- The Comparative Health Outcomes, Policy, and Economics Institute, University of Washington School of Pharmacy, Seattle
| | - Brad Wright
- Department of Health Services, Policy and Management University of South Carolina School of Public Health, Columbia
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Shashikumar SA, Gulseren B, Berlin NL, Hollingsworth JM, Joynt Maddox KE, Ryan AM. Association of Hospital Participation in Bundled Payments for Care Improvement Advanced With Medicare Spending and Hospital Incentive Payments. JAMA 2022; 328:1616-1623. [PMID: 36282256 PMCID: PMC9597389 DOI: 10.1001/jama.2022.18529] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/20/2022] [Indexed: 11/14/2022]
Abstract
Importance Bundled Payments for Care Improvement Advanced (BPCI-A) is a Centers for Medicare & Medicaid Services (CMS) initiative that aims to produce financial savings by incentivizing decreases in clinical spending. Incentives consist of financial bonuses from CMS to hospitals or penalties paid by hospitals to CMS. Objective To investigate the association of hospital participation in BPCI-A with spending, and to characterize hospitals receiving financial bonuses vs penalties. Design, Setting, and Participants Difference-in-differences and cross-sectional analyses of 4 754 139 patient episodes using 2013-2019 US Medicare claims at 694 participating and 2852 nonparticipating hospitals merged with hospital and market characteristics. Exposures BPCI-A model years 1 and 2 (October 1, 2018, through December 31, 2019). Main Outcomes and Measures Hospitals' per-episode spending, CMS gross and net spending, and the incentive allocated to each hospital. Results The study identified 694 participating hospitals. The analysis observed a -$175 change in mean per-episode spending (95% CI, -$378 to $28) and an aggregate spending change of -$75.1 million (95% CI, -$162.1 million to $12.0 million) across the 428 670 episodes in BPCI-A model years 1 and 2. However, CMS disbursed $354.3 million (95% CI, $212.0 million to $496.0 million) more in bonuses than it received in penalties. Hospital participation in BPCI-A was associated with a net loss to CMS of $279.2 million (95% CI, $135.0 million to $423.0 million). Hospitals in the lowest quartile of Medicaid days received a mean penalty of $0.41 million; (95% CI, $0.09 million to $0.72 million), while those in the highest quartile received a mean bonus of $1.57 million; (95% CI, $1.09 million to $2.08 million). Similar patterns were observed for hospitals across increasing quartiles of Disproportionate Share Hospital percentage and of patients from racial and ethnic minority groups. Conclusions and Relevance Among US hospitals measured between 2013 and 2019, participation in BPCI-A was significantly associated with an increase in net CMS spending. Bonuses accrued disproportionately to hospitals providing care for marginalized communities.
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Affiliation(s)
- Sukruth A Shashikumar
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Baris Gulseren
- School of Public Health, University of Michigan, Ann Arbor
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor
| | - Nicholas L Berlin
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor
| | | | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Associate Editor, JAMA
| | - Andrew M Ryan
- School of Public Health, Brown University, Providence, Rhode Island
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Kim H, Mahmood A, Hammarlund NE, Chang CF. Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives. Front Public Health 2022; 10:882715. [PMID: 36299751 PMCID: PMC9589294 DOI: 10.3389/fpubh.2022.882715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/12/2022] [Indexed: 01/21/2023] Open
Abstract
Beginning in the early 2010s, an array of Value-Based Purchasing (VBP) programs has been developed in the United States (U.S.) to contain costs and improve health care quality. Despite documented successes in these efforts in some instances, there have been growing concerns about the programs' unintended consequences for health care disparities due to their built-in biases against health care organizations that serve a disproportionate share of disadvantaged patient populations. We explore the effects of three Medicare hospital VBP programs on health and health care disparities in the U.S. by reviewing their designs, implementation history, and evidence on health care disparities. The available empirical evidence thus far suggests varied impacts of hospital VBP programs on health care disparities. Most of the reviewed studies in this paper demonstrate that hospital VBP programs have the tendency to exacerbate health care disparities, while a few others found evidence of little or no worsening impacts on disparities. We discuss several policy options and recommendations which include various reform approaches and specific programs ranging from those addressing upstream structural barriers to health care access, to health care delivery strategies that target service utilization and health outcomes of vulnerable populations under the VBP programs. Future studies are needed to produce more explicit, conclusive, and consistent evidence on the impacts of hospital VBP programs on disparities.
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Affiliation(s)
- Hyunmin Kim
- School of Health Professions, The University of Southern Mississippi, Hattiesburg, MS, United States
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, United States
| | - Asos Mahmood
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, United States
- Center for Health System Improvement, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Medicine-General Internal Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Noah E. Hammarlund
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, United States
| | - Cyril F. Chang
- Department of Economics, Fogelman College of Business and Economics, The University of Memphis, Memphis, TN, United States
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Chen A, Ghosh A, Gwynn KB, Newby C, Henry TL, Pearce J, Fleurant M, Schmidt S, Bracey J, Jacobs EA. Society of General Internal Medicine Position Statement on Social Risk and Equity in Medicare's Mandatory Value-Based Payment Programs. J Gen Intern Med 2022; 37:3178-3187. [PMID: 35768676 PMCID: PMC9485310 DOI: 10.1007/s11606-022-07698-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/02/2022] [Indexed: 11/30/2022]
Abstract
The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major mandatory pay-for-performance programs have been implemented since 2012 with increasing positive and negative payment adjustments over time. A growing body of evidence indicates that these programs are inequitable and financially penalize safety-net systems and systems that care for a higher proportion of racial and ethnic minority patients. Payments from penalized systems are often redistributed to those with higher performance scores, which are predominantly better-financed, large, urban systems that serve less vulnerable patient populations - a "Reverse Robin Hood" effect. This inequity may be diminished by adjusting for social risk factors in payment policy. In this position statement, we review the literature evaluating equity across Medicare value-based payment programs, major policy reports evaluating the use of social risk data, and provide recommendations on behalf of the Society of General Internal Medicine regarding how to address social risk and unmet health-related social needs in these programs. Immediate recommendations include implementing peer grouping (stratification of healthcare systems by proportion of dual eligible Medicare/Medicaid patients served, and evaluation of performance and subsequent payment adjustments within strata) until optimal methods for accounting for social risk are defined. Short-term recommendations include using census-based, area-level indices to account for neighborhood-level social risk, and developing standardized approaches to collecting individual socioeconomic data in a robust but sensitive way. Long-term recommendations include implementing a research agenda to evaluate best practices for accounting for social risk, developing validated health equity specific measures of care, and creating policies to better integrate healthcare and social services.
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Affiliation(s)
- Anders Chen
- Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Arnab Ghosh
- Department of Medicine, Weill Cornell Medical College of Columbia University, New York, NY, USA
| | - Kendrick B Gwynn
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Celeste Newby
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tracey L Henry
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Jackson Pearce
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Stacie Schmidt
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Jennifer Bracey
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Oseran AS, Wadhera RK. Improving Quality Improvement-From Aspiration Toward Empiricism. JAMA Cardiol 2022; 7:912-913. [PMID: 35947368 DOI: 10.1001/jamacardio.2022.2493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andrew S Oseran
- Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Division of Cardiology, Massachusetts General Hospital, Boston
| | - Rishi K Wadhera
- Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Khullar D, Tian W, Wadhera RK. High-Performing and Low-Performing Hospitals Across Medicare Value-Based Payment Programs. JAMA HEALTH FORUM 2022; 3:e221864. [PMID: 35977223 PMCID: PMC9308053 DOI: 10.1001/jamahealthforum.2022.1864] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/28/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Dhruv Khullar
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Wei Tian
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Rishi K. Wadhera
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Gondi S, Joynt Maddox K, Wadhera RK. "REACHing" for Equity - Moving from Regressive toward Progressive Value-Based Payment. N Engl J Med 2022; 387:97-99. [PMID: 35801977 DOI: 10.1056/nejmp2204749] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Suhas Gondi
- From the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (S.G., R.K.W.), and Brigham and Women's Hospital (S.G.) - both in Boston; and the Cardiovascular Division, John T. Milliken Department of Medicine, School of Medicine, and the Center for Health Economics and Policy, Washington University in St. Louis, St. Louis (K.J.M.)
| | - Karen Joynt Maddox
- From the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (S.G., R.K.W.), and Brigham and Women's Hospital (S.G.) - both in Boston; and the Cardiovascular Division, John T. Milliken Department of Medicine, School of Medicine, and the Center for Health Economics and Policy, Washington University in St. Louis, St. Louis (K.J.M.)
| | - Rishi K Wadhera
- From the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (S.G., R.K.W.), and Brigham and Women's Hospital (S.G.) - both in Boston; and the Cardiovascular Division, John T. Milliken Department of Medicine, School of Medicine, and the Center for Health Economics and Policy, Washington University in St. Louis, St. Louis (K.J.M.)
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Chiu N, Aggarwal R, Song Y, Wadhera RK. Association of the Medicare Value-Based Purchasing Program With Changes in Patient Care Experience at Safety-net vs Non–Safety-net Hospitals. JAMA HEALTH FORUM 2022; 3:e221956. [PMID: 35977225 PMCID: PMC9270698 DOI: 10.1001/jamahealthforum.2022.1956] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/12/2022] [Indexed: 11/26/2022] Open
Abstract
Question Is the Centers for Medicare & Medicaid Services Hospital Value-Based Purchasing (VBP) program associated with changes in patient-reported experience in safety-net vs non–safety-net Hospitals? Findings In this cohort study of 2266 US hospitals, safety-net hospitals had lower performance than non–safety-net hospitals across all measures of patient experience and satisfaction from 2008 through 2019. The VBP program implementation was not associated with improvement in measures of patient experience in safety-net vs non–safety-net hospitals. Meaning Findings of this study suggest that the VBP program was not associated with improved patient experience at safety-net vs non–safety-net hospitals; policy makers may need to explore strategies beyond pay-for-performance programs to address the differences in patient-reported experience at these hospitals. Importance Safety-net hospitals, which have limited financial resources and care for disadvantaged populations, have lower performance on measures of patient experience than non–safety-net hospitals. In 2011, the Centers for Medicare & Medicaid Services Hospital Value-Based Purchasing (VBP) program began tying hospital payments to patient-reported experience scores, but whether implementation of this program narrowed differences in scores between safety-net and non–safety-net hospitals is unknown. Objective To evaluate whether the VBP program’s implementation was associated with changes in measures of patient-reported experience at safety-net hospitals compared with non–safety-net hospitals between 2008 and 2019. Design, Setting, and Participants This cohort study evaluated 2266 US hospitals that participated in the VBP program between 2008 and 2019. Safety-net hospitals were defined as those in the highest quartile of the disproportionate share hospital index. Data were analyzed from December 2021 to February 2022. Main Outcomes and Measures The primary outcomes were the Hospital Consumer Assessment of Healthcare Providers and Systems global measures of patient-reported experience and satisfaction, including a patient’s overall rating of a hospital and willingness to recommend a hospital. Secondary outcomes included the 7 other Hospital Consumer Assessment of Healthcare Providers and Systems measures encompassing communication ratings, clinical processes ratings, and hospital environment ratings. Piecewise linear mixed regression models were used to assess annual trends in performance on each patient experience measure by hospital safety-net status before (July 1, 2007-June 30, 2011) and after (July 1, 2011-June 30, 2019) implementation of the VBP program. Results Of 2266 US hospitals, 549 (24.2%) were safety-net hospitals. Safety-net hospitals were more likely than non–safety-net hospitals to be nonteaching (67.6% [371 of 549] vs 53.1% [912 of 1717]; P < .001) and urban (82.5% [453 of 549] vs 77.4% [1329 of 1717]; P = .01). Safety-net hospitals consistently had lower patient experience scores than non–safety-net hospitals across all measures from 2008 to 2019. The percentage of patients rating safety-net hospitals as a 9 or 10 out of 10 increased during the pre-VBP program period (annual percentage change, 1.84%; 95% CI, 1.73%-1.96%) and at a slower rate after VBP program implementation (annual percentage change, 0.49%; 95% CI, 0.45%-0.53%) at safety-net hospitals. Similar patterns were observed at non–safety-net hospitals (pre-VBP program annual percentage change, 1.84% [95% CI, 1.77%-1.90%] and post-VBP program annual percentage change, 0.42% [95% CI, 0.41%-0.45%]). There was no differential change in performance between these sites after the VBP program implementation (adjusted differential change, 0.07% [95% CI, −0.08% to 0.23%]; P = .36). These patterns were similar for the global measure that assessed whether patients would definitely recommend a hospital. There was also no differential change in performance between safety-net and non–safety-net hospitals under the VBP program across measures of communication, including doctor (adjusted differential change, −0.09% [95% CI, −0.19% to 0.01%]; P = .08) and nurse (adjusted differential change, −0.01% [95% CI, −0.12% to 0.10%]; P = .86) communication as well as clinical process measures (staff responsiveness adjusted differential change, 0.13% [95% CI, −0.03% to 0.29%]; P = .11; and discharge instructions adjusted differential change, −0.02% [95% CI, −0.12% to 0.07%]; P = .62). Conclusions and Relevance This cohort study of 2266 US hospitals found that the VBP program was not associated with improved patient experience at safety-net hospitals vs non–safety-net hospitals during an 8-year period. Policy makers may need to explore other strategies to address ongoing differences in patient experience and satisfaction, including additional support for safety-net hospitals.
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Affiliation(s)
- Nicholas Chiu
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Chan AK, Shahrestani S, Ballatori AM, Orrico KO, Manley GT, Tarapore PE, Huang M, Dhall SS, Chou D, Mummaneni PV, DiGiorgio AM. Is the Centers for Medicare and Medicaid Services Hierarchical Condition Category Risk Adjustment Model Satisfactory for Quantifying Risk After Spine Surgery? Neurosurgery 2022; 91:123-131. [PMID: 35550453 PMCID: PMC9514755 DOI: 10.1227/neu.0000000000001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) hierarchical condition category (HCC) coding is a risk adjustment model that allows for the estimation of risk-and cost-associated with health care provision. Current models may not include key factors that fully delineate the risk associated with spine surgery. OBJECTIVE To augment CMS HCC risk adjustment methodology with socioeconomic data to improve its predictive capabilities for spine surgery. METHODS The National Inpatient Sample was queried for spinal fusion, and the data was merged with county-level coverage and socioeconomic status variables obtained from the Brookings Institute. We predicted outcomes (death, nonroutine discharge, length of stay [LOS], total charges, and perioperative complication) with pairs of hierarchical, mixed effects logistic regression models-one using CMS HCC score alone and another augmenting CMS HCC scores with demographic and socioeconomic status variables. Models were compared using receiver operating characteristic curves. Variable importance was assessed in conjunction with Wald testing for model optimization. RESULTS We analyzed 653 815 patients. Expanded models outperformed models using CMS HCC score alone for mortality, nonroutine discharge, LOS, total charges, and complications. For expanded models, variable importance analyses demonstrated that CMS HCC score was of chief importance for models of mortality, LOS, total charges, and complications. For the model of nonroutine discharge, age was the most important variable. For the model of total charges, unemployment rate was nearly as important as CMS HCC score. CONCLUSION The addition of key demographic and socioeconomic characteristics substantially improves the CMS HCC risk-adjustment models when modeling spinal fusion outcomes. This finding may have important implications for payers, hospitals, and policymakers.
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Affiliation(s)
- Andrew K. Chan
- Department of Neurological Surgery, University of California, San Francisco, California, USA
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Shane Shahrestani
- Department of Medical Engineering, California Institute of Technology, Pasadena, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alexander M. Ballatori
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Katie O. Orrico
- American Association of Neurological Surgeons/Congress of Neurological Surgeons Washington Office, Washington, District of Columbia, USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Michael Huang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Sanjay S. Dhall
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Bryan AF, Nair-Desai S, Tsai TC. The Need for a Better-Quality Reporting System for Ambulatory and Outpatient Surgery-Surgical Quality Without Walls. JAMA Surg 2022; 157:753-754. [PMID: 35767275 DOI: 10.1001/jamasurg.2022.0680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ava Ferguson Bryan
- Department of Surgery, University of Chicago, Chicago, Illinois.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Thomas C Tsai
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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DiGiorgio AM, Tantry EK. Commentary: Loss to Follow-up and Unplanned Readmission After Emergent Surgery for Acute Subdural Hematoma. Neurosurgery 2022; 91:e79-e80. [DOI: 10.1227/neu.0000000000002060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/10/2022] [Indexed: 11/18/2022] Open
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Hermes Z, Joynt Maddox KE, Yeh RW, Zhao Y, Shen C, Wadhera RK. Neighborhood Socioeconomic Disadvantage and Mortality Among Medicare Beneficiaries Hospitalized for Acute Myocardial Infarction, Heart Failure, and Pneumonia. J Gen Intern Med 2022; 37:1894-1901. [PMID: 34505979 PMCID: PMC9198133 DOI: 10.1007/s11606-021-07090-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services' Hospital Value-Based Purchasing program uses 30-day mortality rates for acute myocardial infarction, heart failure, and pneumonia to evaluate US hospitals, but does not account for neighborhood socioeconomic disadvantage when comparing their performance. OBJECTIVE To determine if neighborhood socioeconomic disadvantage is associated with worse 30-day mortality rates after a hospitalization for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in the USA, as well as within the subset of counties with a high proportion of Black individuals. DESIGN AND PARTICIPANTS This retrospective, population-based study included all Medicare fee-for-service beneficiaries aged 65 years or older hospitalized for acute myocardial infarction, heart failure, or pneumonia between 2012 and 2015. EXPOSURE Residence in most socioeconomically disadvantaged vs. less socioeconomically disadvantaged neighborhoods as measured by the area deprivation index (ADI). MAIN MEASURE(S) All-cause mortality within 30 days of admission. KEY RESULTS The study included 3,471,592 Medicare patients. Of these patients, 333,472 resided in most disadvantaged neighborhoods and 3,138,120 in less disadvantaged neighborhoods. Patients living in the most disadvantaged neighborhoods were younger (78.4 vs. 80.0 years) and more likely to be Black adults (24.6% vs. 7.5%) and dually enrolled in Medicaid (39.4% vs. 21.8%). After adjustment for demographics (age, sex, race/ethnicity), poverty, and clinical comorbidities, 30-day mortality was higher among beneficiaries residing in most disadvantaged neighborhoods for AMI (adjusted odds ratio 1.08, 95% CI 1.06-1.11) and pneumonia (aOR 1.05, 1.03-1.07), but not for HF (aOR 1.02, 1.00-1.04). These patterns were similar within the subset of US counties with a high proportion of Black adults (AMI, aOR 1.07, 1.03-1.11; HF 1.02, 0.99-1.05; pneumonia 1.03, 1.00-1.07). CONCLUSIONS Neighborhood socioeconomic disadvantage is associated with higher 30-day mortality for some conditions targeted by value-based programs, even after accounting for individual-level demographics, clinical comorbidities, and poverty. These findings may have implications as policymakers weigh strategies to advance health equity under value-based programs.
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Affiliation(s)
- Zachary Hermes
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, MA, Boston, USA
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Karen E Joynt Maddox
- Center for Health Economics and Policy, Washington University Institute for Public Health and Cardiovascular Division, Washington University School of Medicine, Saint Louis, MO, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, MA, Boston, USA
| | - Yuansong Zhao
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, MA, Boston, USA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, MA, Boston, USA
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, MA, Boston, USA.
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Morris A, Shah KS, Enciso JS, Hsich E, Ibrahim NE, Page R, Yancy C. HFSA Position Statement The Impact of Healthcare Disparities on Patients with Heart Failure. J Card Fail 2022; 28:1169-1184. [PMID: 35595161 DOI: 10.1016/j.cardfail.2022.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 01/17/2023]
Abstract
Heart Failure (HF) remains a condition associated with high morbidity, mortality, and associated costs. Although the number of medical and device-based therapies available to treat HF are expanding at a remarkable rate, disparities in the risk for incident HF and treatments delivered to patients are also of growing concern. These disparities span across racial and ethnic groups, socioeconomic status, and apply across the spectrum of HF from Stage A to Stage D. The complexity of HF risk and treatment is further impacted by the number of patients who experience the downstream impact of social determinants of health. The purpose of this document is to highlight the known healthcare disparities that exist in the care of patients with HF, and to provide a context for how clinicians and researchers should assess both biologic and social determinants of HF risk in vulnerable populations. Furthermore, this document will provide a framework for future steps that can be utilized to help diminish inequalities in access and clinical outcomes over time, and offer solutions to help reduce disparities within HF care.
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Affiliation(s)
| | | | | | | | | | - Robert Page
- 1462 Clifton Road Suite 504, Atlanta GA 30322
| | - Clyde Yancy
- 1462 Clifton Road Suite 504, Atlanta GA 30322
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Inferior Clinical Outcomes for Patients with Medicaid Insurance following Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients. World Neurosurg 2022; 164:e1024-e1033. [DOI: 10.1016/j.wneu.2022.05.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022]
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Rosenbaum L. Reassessing Quality Assessment - The Flawed System for Fixing a Flawed System. N Engl J Med 2022; 386:1663-1667. [PMID: 35417632 DOI: 10.1056/nejmms2200976] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Lisa Rosenbaum
- Dr. Rosenbaum is a national correspondent for the Journal
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Patel KV, Keshvani N, Pandey A, Vaduganathan M, Holmes DN, Matsouaka RA, DeVore AD, Allen LA, Yancy CW, Fonarow GC. Association of readmission penalty amount with subsequent 30-day risk standardized readmission and mortality rates among patients hospitalized with heart failure: An analysis of get with the guidelines - heart failure participating centers. Am Heart J 2022; 246:1-11. [PMID: 34973189 DOI: 10.1016/j.ahj.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 12/04/2021] [Accepted: 12/27/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Hospital Readmissions Reduction Program penalizes hospitals with excess 30-day risk-standardized readmission rates (RSRR) for heart failure (HF). The association of financial penalty amount with subsequent short-term clinical outcomes is unknown. METHODS Patients admitted to American Heart Association Get With The Guidelines-HF registry participating centers from October 1, 2012 through December 1, 2015 who had Medicare-linked data were included. October 2012 hospital-specific penalty amounts were calculated based on diagnosis-related group payments and excess readmission ratios. Adjusted Cox models were created to evaluate the association of penalty amount categories (non-penalized: 0%; low-penalized: >0%-<0.50%; mid-penalized ≥0.50%-<0.99%; high-penalized ≥0.99%) with subsequent 30-day RSRR and risk-standardized mortality rates (RSMR). Trends in post-discharge 30-day RSRR and RSMR from 2012 to 2015 were analyzed across hospitals stratified by penalty amount categories. RESULTS The present study included 61,329 patients who were admitted across 262 hospitals. Compared with patients admitted to non-penalized hospitals (36.3%), those admitted to increasingly penalized hospitals were more likely to have higher 30-day RSRR (low-penalized [43.9%]: HR, 1.10 [95% CI, 1.04-1.16]; mid-penalized [12.0%]: HR, 1.07 [95% CI, 0.99-1.16]; high-penalized [7.9%]: HR, 1.23 [95% CI, 1.12-1.35]) but not 30-day RSMR. Over time, 30-day RSRR and RSMR did not meaningfully change across penalized versus non-penalized hospitals. CONCLUSIONS Financial penalties based on 30-day RSRR are not associated with declines in 30-day RSRR or RSMR from 2012 to 2015 among patients hospitalized with HF. Financially penalizing hospitals based on current Hospital Readmissions Reduction Program metrics may not incentivize improvements in short-term clinical outcomes for HF.
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Shashikumar SA, Waken RJ, Aggarwal R, Wadhera RK, Joynt Maddox KE. Three-Year Impact Of Stratification In The Medicare Hospital Readmissions Reduction Program. Health Aff (Millwood) 2022; 41:375-382. [PMID: 35254934 DOI: 10.1377/hlthaff.2021.01448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with high readmission rates. In fiscal year 2019 the program was changed to account for the association between social risk and high readmission rates. The new approach stratifies hospitals into five groups by hospitals' proportion of patients dually enrolled in Medicare and Medicaid, and it evaluates performance within each stratum instead of within the national cohort. Its impact on hospitals caring for vulnerable populations has not been studied. We calculated the change in average annual penalty percentage, before and after stratification, for safety-net hospitals, rural hospitals, and hospitals caring for a high share of Black and Hispanic or Latino patients. We found that stratification by proportion of dual enrollees was associated with a decrease in penalties by -0.09 percentage points at hospitals with the highest proportion of dual enrollees, -0.08 percentage points at rural hospitals, and -0.06 percentage points at hospitals with a large share of Black and Hispanic or Latino patients. Fully adjusted analyses suggest that these patterns were driven by penalty reductions at rural hospitals and hospitals disproportionately serving Black and Hispanic or Latino patients. Given the allocation of fewer penalties to these hospitals, we conclude that the stratification mandate was a modest step toward equity within the HRRP.
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Affiliation(s)
| | - R J Waken
- R. J. Waken, Washington University in St. Louis
| | - Rahul Aggarwal
- Rahul Aggarwal, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Rishi K Wadhera
- Rishi K. Wadhera, Beth Israel Deaconess Medical Center and Harvard Medical School
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45
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Liu M, Figueroa JF, Song Y, Wadhera RK. Mortality and Postdischarge Acute Care Utilization for Cardiovascular Conditions at Safety-Net Versus Non-Safety-Net Hospitals. J Am Coll Cardiol 2022; 79:83-87. [PMID: 34763956 PMCID: PMC8741642 DOI: 10.1016/j.jacc.2021.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 01/07/2023]
Affiliation(s)
- Michael Liu
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Javed Z, Haisum Maqsood M, Yahya T, Amin Z, Acquah I, Valero-Elizondo J, Andrieni J, Dubey P, Jackson RK, Daffin MA, Cainzos-Achirica M, Hyder AA, Nasir K. Race, Racism, and Cardiovascular Health: Applying a Social Determinants of Health Framework to Racial/Ethnic Disparities in Cardiovascular Disease. Circ Cardiovasc Qual Outcomes 2022; 15:e007917. [PMID: 35041484 DOI: 10.1161/circoutcomes.121.007917] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Health care in the United States has seen many great innovations and successes in the past decades. However, to this day, the color of a person's skin determines-to a considerable degree-his/her prospects of wellness; risk of disease, and death; and the quality of care received. Disparities in cardiovascular disease (CVD)-the leading cause of morbidity and mortality globally-are one of the starkest reminders of social injustices, and racial inequities, which continue to plague our society. People of color-including Black, Hispanic, American Indian, Asian, and others-experience varying degrees of social disadvantage that puts these groups at increased risk of CVD and poor disease outcomes, including mortality. Racial/ethnic disparities in CVD, while documented extensively, have not been examined from a broad, upstream, social determinants of health lens. In this review, we apply a comprehensive social determinants of health framework to better understand how structural racism increases individual and cumulative social determinants of health burden for historically underserved racial and ethnic groups, and increases their risk of CVD. We analyze the link between race, racism, and CVD, including major pathways and structural barriers to cardiovascular health, using 5 distinct social determinants of health domains: economic stability; neighborhood and physical environment; education; community and social context; and healthcare system. We conclude with a set of research and policy recommendations to inform future work in the field, and move a step closer to health equity.
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Affiliation(s)
- Zulqarnain Javed
- Division of Health Equity & Disparities Research, Center for Outcomes Research, Houston Methodist, TX (Z.J., M.C.-A., K.N.)
| | | | - Tamer Yahya
- Center for Outcomes Research, Houston Methodist, TX (T.Y., I.A., J.V.-E., M.C.-A., K.N.)
| | | | - Isaac Acquah
- Center for Outcomes Research, Houston Methodist, TX (T.Y., I.A., J.V.-E., M.C.-A., K.N.)
| | - Javier Valero-Elizondo
- Center for Outcomes Research, Houston Methodist, TX (T.Y., I.A., J.V.-E., M.C.-A., K.N.).,Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, TX (J.V.-E., M.C.-A., K.N.).,Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist, TX (J.V.-E., M.C.-A., K.N.)
| | - Julia Andrieni
- Population Health and Primary Care (J.A.), Houston Methodist Hospital, TX
| | - Prachi Dubey
- Houston Methodist Hospital, Houston Methodist Research Institute, TX (P.D.)
| | - Ryane K Jackson
- Office of Community Benefits (R.K.J.), Houston Methodist Hospital, TX
| | - Mary A Daffin
- Barrett Daffin Frappier Turner & Engel, L.L.P., Houston, TX (M.A.D.)
| | - Miguel Cainzos-Achirica
- Division of Health Equity & Disparities Research, Center for Outcomes Research, Houston Methodist, TX (Z.J., M.C.-A., K.N.).,Center for Outcomes Research, Houston Methodist, TX (T.Y., I.A., J.V.-E., M.C.-A., K.N.).,Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, TX (J.V.-E., M.C.-A., K.N.).,Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist, TX (J.V.-E., M.C.-A., K.N.)
| | - Adnan A Hyder
- Milken Institute School of Public Health, George Washington University, DC (A.A.H.)
| | - Khurram Nasir
- Division of Health Equity & Disparities Research, Center for Outcomes Research, Houston Methodist, TX (Z.J., M.C.-A., K.N.).,Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, TX (J.V.-E., M.C.-A., K.N.).,Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist, TX (J.V.-E., M.C.-A., K.N.)
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47
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Piña IL, Jimenez S, Lewis EF, Morris AA, Onwuanyi A, Tam E, Ventura HO. Race and Ethnicity in Heart Failure: JACC Focus Seminar 8/9. J Am Coll Cardiol 2021; 78:2589-2598. [PMID: 34887145 DOI: 10.1016/j.jacc.2021.06.058] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022]
Abstract
Heart failure (HF) affects >6 million Americans, with variations in incidence, prevalence, and clinical outcomes by race/ethnicity. Black adults have the highest risk for HF, with earlier age of onset and the highest risk of death and hospitalizations. The risk of hospitalizations for Hispanic patients is higher than White patients. Data on HF in Asian individuals are more limited. However, the higher burden of traditional cardiovascular risk factors, particularly among South Asian adults, is associated with increased risk of HF. The role of environmental, socioeconomic, and other social determinants of health, more likely for Black and Hispanic patients, are increasingly recognized as independent risk factors for HF and worse outcomes. Structural racism and implicit bias are drivers of health care disparities in the United States. This paper will review the clinical, physiological, and social determinants of HF risk, unique for race/ethnic minorities, and offer solutions to address systems of inequality that need to be recognized and dismantled/eradicated.
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Affiliation(s)
| | | | | | - Alanna A Morris
- Emory University, Atlanta, Georgia, USA. https://twitter.com/morrismd
| | | | - Edlira Tam
- Montefiore Medical Center, Bronx, New York, USA
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Murali S, Shay A, Lai LY, Breathett K, Nallamothu BK, Hollingsworth JM. Within-Hospital Racial Disparities in Operative Mortality Following Coronary Artery Bypass Grafting. Surg Innov 2021; 29:684-686. [PMID: 34784821 DOI: 10.1177/15533506211059902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sitara Murali
- Dow Division of Health Services Research, 21614Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Addison Shay
- Dow Division of Health Services Research, 21614Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Lillian Y Lai
- Dow Division of Health Services Research, 21614Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Khadijah Breathett
- Division of Cardiology, 12216College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John M Hollingsworth
- Dow Division of Health Services Research, 21614Department of Urology, University of Michigan, Ann Arbor, MI, USA
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49
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Khan SU, Javed Z, Lone AN, Dani SS, Amin Z, Al-Kindi SG, Virani SS, Sharma G, Blankstein R, Blaha MJ, Cainzos-Achirica M, Nasir K. Social Vulnerability and Premature Cardiovascular Mortality Among US Counties, 2014 to 2018. Circulation 2021; 144:1272-1279. [PMID: 34662161 DOI: 10.1161/circulationaha.121.054516] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Substantial differences exist between United States counties with regards to premature (<65 years of age) cardiovascular disease (CVD) mortality. Whether underlying social vulnerabilities of counties influence premature CVD mortality is uncertain. METHODS In this cross-sectional study (2014-2018), we linked county-level CDC/ATSDR SVI (Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index) data with county-level CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiological Research) mortality data. We calculated scores for overall SVI and its 4 subcomponents (ie, socioeconomic status; household composition and disability; minority status and language; and housing type and transportation) using 15 social attributes. Scores were presented as percentile rankings by county, further classified as quartiles on the basis of their distribution among all US counties (1st [least vulnerable] = 0 to 0.25; 4th [most vulnerable = 0.75 to 1.00]). We grouped age-adjusted mortality rates per 100 000 person-years for overall CVD and its subtypes (ischemic heart disease, stroke, hypertension, and heart failure) for nonelderly (<65 years of age) adults across SVI quartiles. RESULTS Overall, the age-adjusted CVD mortality rate per 100 000 person-years was 47.0 (ischemic heart disease, 28.3; stroke, 7.9; hypertension, 8.4; and heart failure, 2.4). The largest concentration of counties with more social vulnerabilities and CVD mortality were clustered across the southwestern and southeastern parts of the United States. The age-adjusted CVD mortality rates increased in a stepwise manner from 1st to 4th SVI quartiles. Counties in the 4th SVI quartile had significantly higher mortality for CVD (rate ratio, 1.84 [95% CI, 1.43-2.36]), ischemic heart disease (1.52 [1.09-2.13]), stroke (2.03 [1.12-3.70]), hypertension (2.71 [1.54-4.75]), and heart failure (3.38 [1.32-8.61]) than those in the 1st SVI quartile. The relative risks varied considerably by demographic characteristics. For example, among all ethnicities/races, non-Hispanic Black adults in the 4th SVI quartile versus the 1st SVI quartile exclusively had significantly higher relative risks of stroke (1.65 [1.07-2.54]) and heart failure (2.42 [1.29-4.55]) mortality. Rural counties with more social vulnerabilities had 2- to 5-fold higher mortality attributable to CVD and subtypes. CONCLUSIONS In this analysis, US counties with more social vulnerabilities had higher premature CVD mortality, varied by demographic characteristics and rurality. Focused public health interventions should address the socioeconomic disparities faced by underserved communities to curb the growing burden of premature CVD.
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Affiliation(s)
| | - Zulqarnain Javed
- Division of Health Equity and Disparities Research, Center for Outcomes Research (Z.J., M.C-A., K.N.), Houston Methodist, TX
| | - Ahmad N Lone
- Department of Cardiology, Guthrie Health System/Robert Packer Hospital, Sayre, PA (A.N.L.)
| | - Sourbha S Dani
- Division of Cardiology, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA (S.S.D.)
| | | | - Sadeer G Al-Kindi
- Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH (S.G.A-K.). Michael E. DeBakey Veterans Affairs Medical Center
| | - Salim S Virani
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX (S.S.V.)
| | - Garima Sharma
- Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (G.S., M.J.B.)
| | - Ron Blankstein
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.)
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (G.S., M.J.B.)
| | - Miguel Cainzos-Achirica
- Cardiovascular Prevention and Wellness (M.C-A., K.N.), DeBakey Heart and Vascular Center.,Division of Health Equity and Disparities Research, Center for Outcomes Research (Z.J., M.C-A., K.N.), Houston Methodist, TX
| | - Khurram Nasir
- Cardiovascular Prevention and Wellness (M.C-A., K.N.), DeBakey Heart and Vascular Center.,Division of Health Equity and Disparities Research, Center for Outcomes Research (Z.J., M.C-A., K.N.), Houston Methodist, TX.,Center for Computational Health and Precision Medicine (C3-PH) (K.N.), Houston Methodist, TX
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50
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Oseran AS, Wadhera RK. Promise and Pitfalls of Paying-for-Performance: Learning From the Polish Experience. Circ Cardiovasc Qual Outcomes 2021; 14:e008273. [PMID: 34380329 DOI: 10.1161/circoutcomes.121.008273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew S Oseran
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA (A.S.O., R.W.).,Division of Cardiology, Massachusetts General Hospital, Boston (A.S.O.)
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA (A.S.O., R.W.)
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