Incorporating Present-on-Admission Indicators in Medicare Claims to Inform Hospital Quality Measure Risk Adjustment Models

Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition

Importance

The effects of private equity acquisitions of US hospitals on the clinical quality of inpatient care and patient outcomes remain largely unknown.

Objective

To examine changes in hospital-acquired adverse events and hospitalization outcomes associated with private equity acquisitions of US hospitals.

Design, Setting, and Participants

Data from 100% Medicare Part A claims for 662 095 hospitalizations at 51 private equity-acquired hospitals were compared with data for 4 160 720 hospitalizations at 259 matched control hospitals (not acquired by private equity) for hospital stays between 2009 and 2019. An event study, difference-in-differences design was used to assess hospitalizations from 3 years before to 3 years after private equity acquisition using a linear model that was adjusted for patient and hospital attributes.

Main Outcomes and Measures

Hospital-acquired adverse events (synonymous with hospital-acquired conditions; the individual conditions were defined by the US Centers for Medicare & Medicaid Services as falls, infections, and other adverse events), patient mix, and hospitalization outcomes (including mortality, discharge disposition, length of stay, and readmissions).

Results

Hospital-acquired adverse events (or conditions) were observed within 10 091 hospitalizations. After private equity acquisition, Medicare beneficiaries admitted to private equity hospitals experienced a 25.4% increase in hospital-acquired conditions compared with those treated at control hospitals (4.6 [95% CI, 2.0-7.2] additional hospital-acquired conditions per 10 000 hospitalizations, P = .004). This increase in hospital-acquired conditions was driven by a 27.3% increase in falls (P = .02) and a 37.7% increase in central line-associated bloodstream infections (P = .04) at private equity hospitals, despite placing 16.2% fewer central lines. Surgical site infections doubled from 10.8 to 21.6 per 10 000 hospitalizations at private equity hospitals despite an 8.1% reduction in surgical volume; meanwhile, such infections decreased at control hospitals, though statistical precision of the between-group comparison was limited by the smaller sample size of surgical hospitalizations. Compared with Medicare beneficiaries treated at control hospitals, those treated at private equity hospitals were modestly younger, less likely to be dually eligible for Medicare and Medicaid, and more often transferred to other acute care hospitals after shorter lengths of stay. In-hospital mortality (n = 162 652 in the population or 3.4% on average) decreased slightly at private equity hospitals compared with the control hospitals; there was no differential change in mortality by 30 days after hospital discharge.

Conclusions and Relevance

Private equity acquisition was associated with increased hospital-acquired adverse events, including falls and central line-associated bloodstream infections, along with a larger but less statistically precise increase in surgical site infections. Shifts in patient mix toward younger and fewer dually eligible beneficiaries admitted and increased transfers to other hospitals may explain the small decrease in in-hospital mortality at private equity hospitals relative to the control hospitals, which was no longer evident 30 days after discharge. These findings heighten concerns about the implications of private equity on health care delivery.

The Usefulness of Present-on-Admission Data as an Indicator of Healthcare Quality Evaluation Using the Korean National Hospital Discharge in-Depth Injury Survey Data from 2006 to 2019

Purpose

Comorbidities of a principal diagnosis have varying impacts on disease and require different management depending on the onset timing. This study investigated the usefulness of present-on-admission (POA), specifically focusing on decubitus ulcers, delirium, and hypokalemia, as an indicator of healthcare quality.

Patients and Methods

We analyzed patient discharge data for 14 years from 2006 to 2019 using Korean National Hospital Discharge In-Depth Injury Survey (KNHDIS).

Results

Out of 3,231,731 discharged patients, 19,871 had secondary diagnosis codes for decubitus ulcers (n=10,390, 52.3%), delirium (n=6103, 30.7%), or hypokalemia (n=3378, 17.0%). Analysis of patients with secondary diagnoses of decubitus ulcers, delirium, or hypokalemia revealed notable differences in demographics, including gender distribution, mean age, admission route, insurance type, surgical intervention rates, mortality rates, and length of stay (LOS). Among patients with one of the top 20 principal diagnoses, those with secondary diagnoses of decubitus ulcers, delirium, or hypokalemia exhibited higher odds of surgery, increased mortality risks, and longer LOS compared to those without these secondary diagnoses.

Conclusion

All three of these diseases commonly occur postoperatively or during treatment and thus should be designated as potentially preventable complications that require special attention, and should also be considered as quality-of-care indicators.

Using Potentially Preventable Severe Maternal Morbidity to Monitor Hospital Performance

BACKGROUND

The Centers for Disease Control and Prevention (CDC) measure of severe maternal morbidity (SMM) quantifies the burden of SMM but is not restricted to potentially preventable SMM. The authors adapted the CDC SMM measure for this purpose and evaluated it for use as a hospital performance measure.

METHODS

Guidelines for defining performance SMM (pSMM) were (1) exclusion of preexisting conditions from outcome; (2) exclusion of inconsistently documented outcomes; and (3) risk adjustment for conditions that preceded hospitalization. California maternal hospital discharge data from 2016 to 2017 were used for model development, and 2018 data were used for model testing and evaluation of hospital performance. Separate models were developed for hospital types (Community, Teaching, Integrated Delivery System [IDS], and IDS Teaching), generating model-based expected pSMM values. Observed-to-expected (O/E) ratios were calculated for hospitals and used to categorize them as overperforming, average performing, or underperforming using 95% confidence intervals. Performance categories were compared for pSMM vs. CDC SMM (excluding blood transfusion).

RESULTS

The overall 2016-2018 pSMM rate was 0.44%. All hospital types had over- and underperformers, and the proportions of Community, Teaching, IDS, and IDS Teaching hospitals whose performance differed from their performance on the CDC SMM measure were 12.1%, 25.0%, 38.9%, and 66.7%, respectively.

CONCLUSION

The rate of potentially preventable SMM as defined by pSMM (0.44%) was less than half the previously published rate of CDC SMM (1.03%). pSMM identified differences in performance across hospitals, and pSMM and CDC SMM classified hospitals' performances differently. pSMM may be suitable for hospital comparisons because it identifies potentially preventable, hospital-acquired SMM that should be responsive to quality improvement activities.

Severe Maternal Morbidity in California Hospitals: Performance Based on a Validated Multivariable Prediction Model

BACKGROUND

Severe maternal morbidity (SMM) is under development as a quality indicator for maternal health care. The aim of this study is to evaluate California hospital performance based on a standardized SMM measure.

METHODS

California maternal hospital delivery discharge data from 2016 to 2017 were used to develop logistic regression models for SMM, adjusted for clinical risk factors at admission. Data from 2018 were used to test the models and evaluate hospital performance. SMM was defined per the Centers for Disease Control and Prevention, including (excluding) blood transfusion. Independent models were developed for each hospital type: community, teaching, integrated delivery system (IDS), and IDS teaching. Within each type, model-based expected SMM values and observed-to-expected (O/E) ratios were calculated for each hospital. For each hospital type, hospitals were ranked by O/E ratio, and over- and underperforming hospitals were identified using 95% confidence intervals.

RESULTS

Rates of SMM including (excluding) transfusion by hospital type were 1.7% (0.9%) for community, 2.7% (1.5%) for teaching, 2.3% (1.2%) for IDS, and 3.0% (1.6%) for IDS teaching hospitals. In higher-volume community hospitals (≥ 500 births/year), the proportion of underperformers including (excluding) transfusion was 20.7% (11.0%). Summing over all hospital types, 25.3% (14.9%) of hospitals were identified as underperformers in that they experienced significantly more SMM events than expected including (excluding) transfusion.

CONCLUSION

California hospital discharge data demonstrated significant hospital variation in standardized childbirth SMM. These data suggest that a standardized SMM measure may help guide and monitor statewide quality improvement efforts.

Association of Socioeconomic Disadvantage With Mortality and Readmissions Among Older Adults Hospitalized for Pulmonary Embolism in the United States

Background In the United States, hospitalizations for pulmonary embolism (PE) are increasing among older adults insured by Medicare. Although efforts to reduce health disparities have intensified, it remains unclear whether clinical outcomes differ between socioeconomically disadvantaged and nondisadvantaged Medicare beneficiaries hospitalized with PE. Methods and Results In this study, there were 53 386 Medicare fee-for-service beneficiaries age ≥65 years hospitalized for PE between October 2015 and January 2017. Of these, 5494 (10.3%) were socioeconomically disadvantaged and 47 892 (89.7%) were nondisadvantaged. Socioeconomically disadvantaged adults were of similar age as nondisadvantaged adults (77.1 versus 77.0), more likely to be female (68.5% versus 54.2%), and less likely to receive advanced therapies (11.0% versus 12.1%). After adjustment for demographics, 90-day all-cause mortality rates were similar between disadvantaged and nondisadvantaged adults. In contrast, 1-year mortality rates were higher among socioeconomically disadvantaged adults (hazard ratio [HR], 1.16; 95% CI, 1.10-1.22), although these differences were partially attenuated after additional adjustments for comorbidities and PE severity (HR, 1.09; 95% CI, 1.02-1.16). Risk-adjusted 30-day and 90-day all-cause readmission rates were substantially higher among socioeconomically disadvantaged patients (30-day HR, 1.14 [95% CI, 1.06-1.22]; 90-day HR, 1.18 [95% CI, 1.12-1.25]). In addition, 90-day readmissions attributed to PE, deep vein thrombosis, and/or bleeding were higher among socioeconomically disadvantaged patients (HR, 1.16; 95% CI, 1.02-1.32). Conclusions Socioeconomically disadvantaged older adults hospitalized with PE have higher 1-year mortality rates compared with their nondisadvantaged counterparts. Nearly 1 in 3 socioeconomically disadvantaged older adults was readmitted within 90 days of a hospitalization for PE. Targeted strategies are needed to improve transitional and ambulatory care for this vulnerable population.