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Rice HJ, Fernandes MB, Punia V, Rubinos C, Sivaraju A, Zafar SF. Predictors of follow-up care for critically-ill patients with seizures and epileptiform abnormalities on EEG monitoring. Clin Neurol Neurosurg 2024; 241:108275. [PMID: 38640778 DOI: 10.1016/j.clineuro.2024.108275] [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: 02/12/2024] [Revised: 03/20/2024] [Accepted: 04/04/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE Post-hospitalization follow-up visits are crucial for preventing long-term complications. Patients with electrographic epileptiform abnormalities (EA) including seizures and periodic and rhythmic patterns are especially in need of follow-up for long-term seizure risk stratification and medication management. We sought to identify predictors of follow-up. METHODS This is a retrospective cohort study of all patients (age ≥ 18 years) admitted to intensive care units that underwent continuous EEG (cEEG) monitoring at a single center between 01/2016-12/2019. Patients with EAs were included. Clinical and demographic variables were recorded. Follow-up status was determined using visit records 6-month post discharge, and visits were stratified as outpatient follow-up, neurology follow-up, and inpatient readmission. Lasso feature selection analysis was performed. RESULTS 723 patients (53 % female, mean (std) age of 62.3 (16.4) years) were identified from cEEG records with 575 (79 %) surviving to discharge. Of those discharged, 450 (78 %) had outpatient follow-up, 316 (55 %) had a neurology follow-up, and 288 (50 %) were readmitted during the 6-month period. Discharge on antiseizure medications (ASM), younger age, admission to neurosurgery, and proximity to the hospital were predictors of neurology follow-up visits. Discharge on ASMs, along with longer length of stay, younger age, emergency admissions, and higher illness severity were predictors of readmission. SIGNIFICANCE ASMs at discharge, demographics (age, address), hospital care teams, and illness severity determine probability of follow-up. Parameters identified in this study may help healthcare systems develop interventions to improve care transitions for critically-ill patients with seizures and other EA.
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Affiliation(s)
- Hunter J Rice
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States; Center for Value-based Health Care and Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Marta Bento Fernandes
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States; Center for Value-based Health Care and Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Vineet Punia
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Clio Rubinos
- University of North Carolina, Chapel Hill, NC, United States
| | - Adithya Sivaraju
- Department of Neurology, Yale New Haven Hospital, Yale University, New Haven, CT, United States
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States; Center for Value-based Health Care and Sciences, Massachusetts General Hospital, Boston, MA, United States.
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Bess S, Line BG, Nunley P, Ames C, Burton D, Mundis G, Eastlack R, Hart R, Gupta M, Klineberg E, Kim HJ, Kelly M, Hostin R, Kebaish K, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Postoperative Discharge to Acute Rehabilitation or Skilled Nursing Facility Compared With Home Does Not Reduce Hospital Readmissions, Return to Surgery, or Improve Outcomes Following Adult Spine Deformity Surgery. Spine (Phila Pa 1976) 2024; 49:E117-E127. [PMID: 37694516 DOI: 10.1097/brs.0000000000004825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/01/2023] [Indexed: 09/12/2023]
Abstract
STUDY DESIGN Retrospective review of a prospective multicenter adult spinal deformity (ASD) study. OBJECTIVE The aim of this study was to evaluate 30-day readmissions, 90-day return to surgery, postoperative complications, and patient-reported outcomes (PROs) for matched ASD patients receiving nonhome discharge (NON), including acute rehabilitation (REHAB), and skilled nursing facility (SNF), or home (HOME) discharge following ASD surgery. SUMMARY OF BACKGROUND DATA Postoperative disposition following ASD surgery frequently involves nonhome discharge. Little data exists for longer term outcomes for ASD patients receiving nonhome discharge versus patients discharged to home. MATERIALS AND METHODS Surgically treated ASD patients prospectively enrolled into a multicenter study were assessed for NON or HOME disposition following hospital discharge. NON was further divided into REHAB or SNF. Propensity score matching was used to match for patient age, frailty, spine deformity, levels fused, and osteotomies performed at surgery. Thirty-day hospital readmissions, 90-day return to surgery, postoperative complications, and 1-year and minimum 2-year postoperative PROs were evaluated. RESULTS A total of 241 of 374 patients were eligible for the study. NON patients were identified and matched to HOME patients. Following matching, 158 patients remained for evaluation; NON and HOME had similar preoperative age, frailty, spine deformity magnitude, surgery performed, and duration of hospital stay ( P >0.05). Thirty-day readmissions, 90-day return to surgery, and postoperative complications were similar for NON versus HOME and similar for REHAB (N=64) versus SNF (N=42) versus HOME ( P >0.05). At 1-year and minimum 2-year follow-up, HOME demonstrated similar to better PRO scores including Oswestry Disability Index, Short-Form 36v2 questionnaire Mental Component Score and Physical Component Score, and Scoliosis Research Society scores versus NON, REHAB, and SNF ( P <0.05). CONCLUSIONS Acute needs must be considered following ASD surgery, however, matched analysis comparing 30-day hospital readmissions, 90-day return to surgery, postoperative complications, and PROs demonstrated minimal benefit for NON, REHAB, or SNF versus HOME at 1- and 2-year follow-up, questioning the risk and cost/benefits of routine use of nonhome discharge. LEVEL OF EVIDENCE Level III-prognostic.
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Affiliation(s)
- Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Breton G Line
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Pierce Nunley
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas School of Medicine, Kansas City, KS
| | | | | | | | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael Kelly
- Department of Orthopedic Surgery, San Diego Children's Hospital, San Diego, CA
| | | | - Khaled Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Virgine Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Frank Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA
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Klein S, Eaton KP, Bodnar BE, Keller SC, Helgerson P, Parsons AS. Transforming Health Care from Volume to Value: Leveraging Care Coordination Across the Continuum. Am J Med 2023; 136:985-990. [PMID: 37481020 DOI: 10.1016/j.amjmed.2023.06.023] [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] [Received: 06/15/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Sharon Klein
- Department of Medicine, New York University Langone Health, New York
| | - Kevin P Eaton
- Department of Medicine, New York University Langone Health, Brooklyn
| | - Benjamin E Bodnar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Sara C Keller
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Paul Helgerson
- Department of Medicine, University of Virginia School of Medicine, Charlottesville
| | - Andrew S Parsons
- Department of Medicine, University of Virginia School of Medicine, Charlottesville.
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Kalata S, Howard R, Diaz A, Nuliyahu U, Ibrahim AM, Nathan H. Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending. JAMA Netw Open 2023; 6:e230140. [PMID: 36808240 PMCID: PMC9941887 DOI: 10.1001/jamanetworkopen.2023.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
IMPORTANCE Health care mergers and acquisitions have increased vertical integration of skilled nursing facilities (SNFs) in health care networks. While vertical integration may result in improved care coordination and quality, it may also lead to excess utilization, as SNFs are paid a per diem rate. OBJECTIVE To determine the association of vertical integration of SNFs within hospital networks with SNF utilization, readmissions, and spending for Medicare beneficiaries undergoing elective hip replacement. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals performing at least 10 elective hip replacements during the study period. Fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent elective hip replacement between January 1, 2016, and December 31, 2017, with continuous Medicare coverage for 3 months before and 6 months after surgery were included. Data were analyzed from February 2 to August 8, 2022. EXPOSURES Treatment at a hospital within a network that also owns at least 1 SNF based on the 2017 American Hospital Association survey. MAIN OUTCOMES AND MEASURES Rates of SNF utilization, 30-day readmissions, and price-standardized 30-day episode payments. Hierarchical multivariable logistic and linear regression clustered at hospitals was performed with adjusting for patient, hospital, and network characteristics. RESULTS A total of 150 788 patients (61.4% women; mean [SD] age, 74.3 [6.4] years) underwent hip replacement. After risk adjustment, vertical SNF integration was associated with a higher rate of SNF utilization (21.7% [95% CI, 20.4%-23.0%] vs 19.7% [95% CI, 18.7%-20.7%]; adjusted odds ratio [aOR], 1.15 [95% CI, 1.03-1.29]; P = .01) and lower 30-day readmission rate (5.6% [95% CI, 5.4%-5.8%] vs 5.9% [95% CI, 5.7%-6.1%]; aOR, 0.94 [95% CI, 0.89-0.99]; P = .03). Despite higher SNF utilization, the total adjusted 30-day episode payments were slightly lower ($20 230 [95% CI, $20 035-$20 425] vs $20 487 [95% CI, $20 314-$20 660]; difference, -$275 [95% CI, -$15 to -$498]; P = .04) driven by lower postacute payments and shorter SNF length of stays. Adjusted readmission rates were particularly low for patients not sent to an SNF (3.6% [95% CI, 3.4%-3.7%]; P < .001) but were significantly higher for patients with an SNF length of stay less than 5 days (41.3% [95% CI, 39.2%-43.3%]; P < .001). CONCLUSIONS AND RELEVANCE In this cross-sectional study of Medicare beneficiaries undergoing elective hip replacements, vertical integration of SNFs in a hospital network was associated with higher rates of SNF utilization and lower rates of readmissions without evidence of higher overall episode payments. These findings support the purported value of integrating SNFs into hospital networks but also suggest that there is room for improving the postoperative care of patients in SNFs early in their stay.
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Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Adrian Diaz
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, The Ohio State University, Columbus
| | - Usha Nuliyahu
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew M. Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
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Lai CK, Towe CW, Patel NJ, Brown LR, Claridge JA, Ho VP. Re-Admission in Patients with Necrotizing Soft Tissue Infections: Continuity of Care Matters. Surg Infect (Larchmt) 2022; 23:866-872. [PMID: 36394462 PMCID: PMC9784599 DOI: 10.1089/sur.2022.243] [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: 11/19/2022] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressive infections with high mortality and complication rates. The incidence of NSTIs has been increasing steadily whereas mortality has decreased; survivors have a high risk of re-hospitalization. We hypothesized that re-admission to the index hospital where the first admission occurred would be associated with better clinical outcomes compared with re-admission to a non-index hospital. Patients and Methods: We identified patients from the 2017 Nationwide Readmissions Database with an index admission for NSTIs and examined all-cause re-admissions within 90 days of discharge. We noted whether re-admission occurred at the index or a non-index hospital. Survey-weighted logistic regression identified factors associated with death at the first re-admission and re-admission to index hospital. We also compared patient outcomes between patients admitted to index versus non-index hospitals. Results: We identified 27,051 NSTI survivors, of whom 6,954 (25.7%) had an unplanned re-admission within 90 days. A large proportion of re-admission occurred at non-index hospitals (28.3%; n = 1,966). Factors associated with non-index re-admission included prolonged index length of stay, discharge to short-term hospital, and leaving against medical advice. Patients re-admitted to index hospitals had a lower mortality rate (4.7% vs. 6.7%; p = 0.003), lower admission costs (in $1000; 45 [23-88] vs. 50 [24-104]; p = 0.004) and higher discharge rate to home (55.7% vs. 48.6%; p < 0.001). Conclusions: More than one-quarter of re-admissions among NSTI survivors were to non-index hospitals. Continuity of care is important because re-admission to the index hospital was associated with better patient outcomes.
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Affiliation(s)
- Clara K.N. Lai
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Christopher W. Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nimitt J. Patel
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | | | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Cleveland, Ohio, USA
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Zogg CK, Metcalfe D, Judge A, Perry DC, Costa ML, Gabbe BJ, Schoenfeld AJ, Davis KA, Cooper Z, Lichtman JH. Learning From England's Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Hip Fracture Outcomes. Ann Surg 2022; 275:506-514. [PMID: 33491982 PMCID: PMC9233527 DOI: 10.1097/sla.0000000000004305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate England's Best Practice Tariff (BPT) and consider potential implications for Medicare patients should the US adopt a similar plan. SUMMARY BACKGROUND DATA Since the beginning of the Affordable Care Act, Medicare has renewed efforts to improve the outcomes of older adults through introduction of an expanding set of alternative-payment models. Among trauma patients, recommended arrangements met with mixed success given concerns about the heterogeneous nature of trauma patients and resulting outcome variation. A novel approach taken for hip fractures in England could offer a viable alternative. METHODS Linear regression, interrupted time-series, difference-in-difference, and counterfactual models of 2000 to 2016 Medicare (US), HES-APC (England) death certificate-linked claims (≥65 years) were used to: track US hip fracture trends, look at changes in English hip fracture trends before-and-after BPT implementation, compare changes in US-versus-English mortality, and estimate total/theoretical lives saved. RESULTS A total of 806,036 English and 3,221,109 US hospitalizations were included. After BPT implementation, England's 30-day mortality decreased by 2.6 percentage-points (95%CI: 1.7-3.5) from a baseline of 9.9% (relative reduction 26.3%). 90- and 365-day mortality decreased by 5.6 and 5.4 percentage-points. 30/90/365-day readmissions also declined with a concurrent shortening of hospital length-of-stay. From 2000 to 2016, US outcomes were stagnant (P > 0.05), resulting in an inversion of the countries' mortality and >38,000 potential annual US lives saved. CONCLUSIONS Process measure pay-for-performance led to significant improvements in English hip fracture outcomes. As efforts to improve US older adult health continue to increase, there are important lessons to be learned from a successful initiative like the BPT.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, Connecticut
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Yale School of Public Health, New Haven, Connecticut
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Daniel C. Perry
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Belinda J. Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew J. Schoenfeld
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Boston, Massachusetts
| | | | - Zara Cooper
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Sood N, Shier V, Huckfeldt PJ, Weissblum L, Escarce JJ. The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities. Health Serv Res 2021; 56:828-838. [PMID: 33969480 PMCID: PMC8522568 DOI: 10.1111/1475-6773.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes. DATA SOURCES Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014. STUDY DESIGN We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions. DATA EXTRACTION METHODS We identified Medicare beneficiaries discharged from a hospital to IRF. PRINCIPAL FINDINGS In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals. CONCLUSIONS Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.
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Affiliation(s)
- Neeraj Sood
- Leonard D. Schaeffer Center for Health Policy and Economics, Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Victoria Shier
- Leonard D. Schaeffer Center for Health Policy and Economics, Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Peter J. Huckfeldt
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | | | - José J. Escarce
- David Geffen School of Medicine at UCLACaliforniaLos AngelesUSA
- UCLA Fielding School of Public Health, Los AngelesCaliforniaUSA
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Chudgar NP, Zhu R, Gray KD, Chiu R, Carrera AD, Lang SJ, Avgerinos DV, Mack CA. Implementing a High Value Care Discharge Protocol in Patients Undergoing CABG Reduces Readmission. Ann Thorac Surg 2021; 113:1112-1118. [PMID: 34403692 DOI: 10.1016/j.athoracsur.2021.07.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/19/2021] [Accepted: 07/07/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Readmission after coronary artery bypass grafting (CABG) is associated with adverse outcomes and increased cost. We evaluated the impact of a high value care discharge protocol on readmission, length of stay (LOS) and discharge destination in patients undergoing isolated CABG. METHODS In 2016, a comprehensive, patient-centered discharge protocol was implemented. A nurse practitioner was the fulcrum of this program, which focused on improving health literacy, disease management and rigorous follow-up. All patients undergoing isolated CABG between 2012-2019 were retrospectively analyzed with regard to 30-day readmission, LOS, and discharge disposition. Differences were analyzed by Mann-Whitney, chi-squared and t-tests. Analyses were repeated using propensity matching. RESULTS A total of 910 consecutive patients undergoing isolated CABG were included in the analyses - 353 pre-protocol and 557 post-protocol. Pre-protocol patients had a readmission rate of 14.4% (n=51), compared to 6.8% (n=38) in the post-protocol patients (p<0.001). Median postoperative LOS prior to implementation was 6 days (interquartile range 5-8) compared to 5 days (interquartile range 4-6) post-implementation (p<0.001). Post-implementation, a higher proportion of patients were discharged to home compared to a skilled nursing facility (82.7% [n=461] vs 73.9% [n=261], p=0.002). Following propensity matching, 298 well-balanced patients were included for analysis and these significant reductions in LOS, readmission and discharge destination persisted. CONCLUSIONS Implementation of a new discharge protocol was significantly associated with reduced readmission and LOS, along with higher rates of discharge to home in isolated CABG patients. Importantly, the results were sustainable and did not require additional resources, delivering high value care.
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Affiliation(s)
- Neel P Chudgar
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Roger Zhu
- Department of Surgery, New York Presbyterian/Queens, Flushing, NY, USA
| | - Katherine D Gray
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Ryan Chiu
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - Samuel J Lang
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - Charles A Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
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Toraih E, Hussein M, Tatum D, Reisner A, Kandil E, Killackey M, Duchesne J, Taghavi S. The burden of readmission after discharge from necrotizing soft tissue infection. J Trauma Acute Care Surg 2021; 91:154-163. [PMID: 33755642 DOI: 10.1097/ta.0000000000003169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The need for extensive surgical debridement with necrotizing soft tissue infections (NSTIs) may put patients at high risk for unplanned readmission. However, there is a paucity of data on the burden of readmission in patients afflicted with NSTI. We hypothesized that unplanned readmission would significantly contribute to the burden of disease after discharge from initial hospitalization. METHODS The Nationwide Readmission Database was used to identify adults undergoing debridement for NSTI hospitalizations from 2010 to 2017. Risk factors for 90-day readmission were assessed by Cox proportional hazards regression. RESULTS There were a total of 82,738 NSTI admissions during the study period, of which 25,076 (30.3%) underwent 90-day readmissions. Median time to readmission was 25 days (interquartile range, 9-49 days). Fragmentation of care, longer length of index stay (>2 weeks), and Medicaid status were independent risk factors for readmission. Median cost of a readmission was US $10,543. Readmission added 174,640 hospital days to episodes of care over the study period, resulting in an estimated financial burden of US $1.4 billion. CONCLUSION Unplanned readmission caused by NSTIs is common and costly. Interventions that target patients at risk for readmission may help decrease the burden of disease. LEVEL OF EVIDENCE Economic/Epidemiological, level IV.
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Affiliation(s)
- Eman Toraih
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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Gu J, Huckfeldt P, Sood N. The Effects of Accountable Care Organizations Forming Preferred Skilled Nursing Facility Networks on Market Share, Patient Composition, and Outcomes. Med Care 2021; 59:354-361. [PMID: 33704104 PMCID: PMC7959004 DOI: 10.1097/mlr.0000000000001493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Through participation in payment reforms such as bundled payment and accountable care organizations (ACOs), hospitals are increasingly financially responsible for health care use and adverse health events occurring after hospital discharge. To improve management and coordination of postdischarge care, ACO hospitals are establishing a closer relationship with skilled nursing facilities (SNFs) through the formation of preferred SNF networks. RESEARCH DESIGN We evaluated the effects of preferred SNF network formation on care patterns and outcomes. We included 10 ACOs that established preferred SNF networks between 2014 and 2015 in the sample. We first investigated whether hospitals "steer" patients to preferred SNFs by examining the percentage of patients sent to preferred SNFs within each hospital before and after network formation. We then used a difference-in-difference model with SNF fixed effects to evaluate the changes in patient composition and outcomes of preferred SNF patients from ACO hospitals after network formation relative to patients from other hospitals. RESULTS We found that preferred network formation was not associated with higher market share or better outcomes for preferred SNF patients from ACO hospitals. However, we found a small increase in the average number of Elixhauser comorbidities for patients from ACO hospitals after network formation, relative to patients from non-ACO hospitals. CONCLUSIONS After preferred SNF network formation, there is some evidence that ACO hospitals sent more complex patients to preferred SNFs, but there was no change in the volume of patients received by these SNFs. Furthermore, preferred network formation was not associated with improvement in patient outcomes.
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Affiliation(s)
- Jing Gu
- School of Pharmacy, University of Southern California, Los Angeles, CA
| | - Peter Huckfeldt
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA
| | - Neeraj Sood
- School of Public Health, University of Minnesota, Minneapolis, MN
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Huckfeldt PJ, Gu J, Escarce JJ, Karaca-Mandic P, Sood N. The association of vertically integrated care with health care use and outcomes. Health Serv Res 2021; 56:817-827. [PMID: 33728678 DOI: 10.1111/1475-6773.13642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes. DATA SOURCES Medicare provider, beneficiary, and claims data from 2012 to 2014. STUDY DESIGN We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs. Among patients admitted to integrated SNFs, we estimated differences in health care use and outcomes for patients originating from the parent hospital (ie, receiving vertically integrated care) versus other hospitals using linear regressions that included SNF fixed effects. We estimated bounds for our main estimates that incorporated potential omitted variables bias. DATA EXTRACTION METHODS We identified hospital-based SNFs based on provider data. We defined virtually integrated SNFs based on patient flows between hospitals and SNFs. We identified SNF episodes, preceding hospital stays, patient characteristics, health care use, and patient outcomes using Medicare data. PRINCIPAL FINDINGS Consistent with prior research, integrated SNFs performed better on quality measures and health care use relative to nonintegrated SNFs (eg, hospital-based SNFs had 11-day shorter stays compared with nonintegrated SNFs adjusting for patient characteristics, P < .001). Stroke patients admitted to hospital-based SNFs from the parent hospital had shorter preceding hospital stays (adjusted difference: -1.2 days, P = .001) and shorter initial SNF stays (adjusted difference: -2.7 days, P = .049); estimates were attenuated but still robust accounting for potential omitted variables bias. For stroke patients, associations between vertically integrated care and other outcomes were either statistically insignificant or not robust to accounting for potential omitted variables bias. CONCLUSIONS Vertically integrated hospital and SNF care was associated with shorter hospital and SNF stays. However, there were few beneficial associations with other outcomes, suggesting limited coordination benefits from vertical integration.
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Affiliation(s)
- Peter J Huckfeldt
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jing Gu
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - José J Escarce
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Pinar Karaca-Mandic
- Carlson School of Management, University of Minnesota, Minneapolis, Minnesota, USA
| | - Neeraj Sood
- Schaeffer Center for Health Policy and Economics, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
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County-Level Social Vulnerability is Associated with Worse Surgical Outcomes Especially Among Minority Patients. Ann Surg 2020; 274:881-891. [PMID: 33351455 DOI: 10.1097/sla.0000000000004691] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to characterize the association between patient county-level vulnerability with postoperative outcomes. SUMMARY BACKGROUND DATA While the impact of demographic-, clinical- and hospital-level factors on outcomes following surgery have been examined, little is known about the effect of a patient's community of residence on surgical outcomes. METHODS Individuals who underwent colon resection, coronary artery bypass graft (CABG), lung resection, or lower extremity joint replacement (LEJR) were identified in the 2016-2017 Medicare database, which was merged with CDC vulnerability index (SVI) dataset at the beneficiary level of residence. Logistic regression models were utilized to estimate the probability of postoperative complications, mortality, readmission, and expenditures. RESULTS Among 299,583 Medicare beneficiary beneficiaries who underwent a colectomy (n = 88,778, 29.6%), CABG (n = 109,564, 36.6%), lung resection (n = 30,401, 10.1%), or LEJR (n = 70,840, 23.6%).Mean SVI score was 50.2 (SD: (25.2); minority patients were more likely to reside in highly vulnerable communities (low SVI: n = 3,531, 5.8% vs. high SVI: n = 7,895, 13.3%; p < 0.001). After controlling for competing risk factors, the risk-adjusted probability of a serious complication among patients from a high versus low SVI county was 10-20% higher following colectomy (OR 1.1 95%CI 1.1-1.2) or CABG (OR 1.2 95%CI 1.1-1.3), yet there no association of SVI with risk of serious complications following lung resection (OR 1.2 95%CI 1.0-1.3) or LEJR (OR 1.0 95%CI 0.93-1.2). The risk-adjusted probability of 30-day mortality was incrementally higher among patients from high SVI counties following colectomy (OR 1.1 95%CI 1.1-1.3), CABG (OR 1.4, 95%CI 1.2-1.5), and lung resection (OR 1.4 (95%CI 1.1-1.8), yet not LEJR (OR 0.95 95%CI 0.72-1.2). Black/minority patients undergoing a colectomy, CABG, or lung resection who lived in highly socially vulnerable counties had an estimate 28-68% increased odds of a serious complication and a 58-60% increased odds of 30-day mortality compared with a black/minority patient from a low socially vulnerable county, as well as a markedly higher risk than white patients (all p > 0.05). CONCLUSION Patients residing in vulnerable communities characterized by a high SVI generally had worse postoperative outcomes. The impact of social vulnerability was most pronounced among black/minority patients, rather than white individuals. Efforts to ensure equitable surgical outcomes need to focus on both patient-level, as well as community-specific factors.
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Nonhome Discharge as an Independent Risk Factor for Adverse Events and Readmission in Patients Undergoing Anterior Cervical Discectomy and Fusion. Clin Spine Surg 2020; 33:E454-E459. [PMID: 32101991 DOI: 10.1097/bsd.0000000000000961] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
STUDY DESIGN A retrospective study of a prospectively collected cohort. OBJECTIVE To characterize a cohort of patients who underwent anterior cervical discectomy and fusion (ACDF) and examine whether nonhome discharge (NHD) is associated with postdischarge adverse events (AEs) and readmission. SUMMARY OF THE BACKGROUND DATA Predictors of NHD have been elucidated in the spine surgery literature, and NHD has been tied to poor outcomes in the joint arthroplasty literature, but no such analysis exists for patients undergoing ACDF. MATERIALS AND METHODS All patients who underwent ACDF from 2012 to 2015 in the National Surgical Quality Improvement Program were identified. Those who underwent concomitant posterior cervical operations were excluded. Patients who were discharged to home were compared with those discharged to nonhome destinations on the basis of demographics and outcomes. Multivariable models were created to assess whether NHD was an independent risk factor for postdischarge AEs and readmission. RESULTS NHD patients were significantly older (63.96 vs. 53.57 y; P<0.0001), more functionally dependent (13.87% vs. 1.09%; P<0.0001), more likely to have body mass index >40 (9.38% vs. 7.51%; P=0.004), and more likely to have ASA Class >2 (77.89% vs. 39.57%; P<0.0001). Patients who underwent NHD were significantly more likely to suffer severe AEs (14.44% vs. 0.93%; P<0.0001), minor AEs (7.22% vs. 0.24%; P<0.0001), and infectious complications (3.58% vs. 0.13%; P<0.0001) before discharge. When examining AEs after discharge, patients who underwent NHD were more likely to suffer severe AEs (6.37% vs. 1.34%; P<0.0001), minor AEs (4.09% vs. 0.74%; P<0.0001), death (1.25% vs. 0.07%; P<0.0001), and unplanned readmission (10.12% vs. 3.06%; P<0.0001). In adjusted analysis, NHD was found to independently predict severe AEs after discharge (odds ratio, 2.40; 95% confidence interval, 1.87-3.07; P<0.0001) and readmission (odds ratio, 1.77; 95% confidence interval, 1.46-2.14; P<0.0001). CONCLUSIONS NHD patients were significantly sicker than those discharged home. In addition, NHD is associated with higher rates of postdischarge complications.
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White EM, Kosar CM, Rahman M, Mor V. Trends In Hospitals And Skilled Nursing Facilities Sharing Medical Providers, 2008-16. Health Aff (Millwood) 2020; 39:1312-1320. [PMID: 32744938 DOI: 10.1377/hlthaff.2019.01502] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hospitals and skilled nursing facilities (SNFs) face increasing pressure to improve care coordination and reduce unnecessary readmissions. One strategy to accomplish this is to share physicians and advanced practice clinicians, so that the same providers see patients in both settings. Using 2008-16 Medicare claims, we found that as SNFs moved increasingly toward using SNF specialists, there was a steady decline in the number of facilities sharing medical providers and in the proportion of SNF primary care delivered by provider practices with both hospital and SNF clinicians (hospital-SNF practices). In SNF fixed effects analyses, we found that SNFs that increased primary care visits by hospital-SNF practices had slightly fewer readmissions, shorter lengths-of-stay, and increased successful community discharges. These findings suggest that SNFs that share medical providers with hospitals may see some benefit from that linkage, although the magnitude of the benefit may be small.
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Affiliation(s)
- Elizabeth M White
- Elizabeth M. White is an investigator in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Cyrus M Kosar
- Cyrus M. Kosar is a doctoral candidate in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
| | - Momotazur Rahman
- Momotazur Rahman is an associate professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
| | - Vincent Mor
- Vincent Mor is a professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
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15
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Abstract
Following the Affordable Care Act (ACA), more hospitals vertically integrated into skilled nursing facilities (SNFs). Hospitals are now being penalized for avoidable readmissions, creating a greater demand for better coordination of care between hospitals and SNF. We created a longitudinal panel data set by merging data from the American Hospital Association's Annual Survey, CMS' Hospital Compare, and the Rural Urban Commuting Area data. Hospital and year fixed-effects models were used to examine the relationship between hospital vertical integration into SNF and 30-day pneumonia and heart failure (HF) readmission rates between 2008 and 2011. Our primary analyses modeled the impact of hospital vertical integration into SNF on 30-day readmissions for both pneumonia and HF using hospital and year fixed effects. Our secondary analyses examined whether hospital vertical integration into SNF was associated with a change in readmissions rates among different types of hospitals. Our results indicate that hospitals that vertically integrated into SNF were associated with a reduction in hospital 30-day pneumonia readmission rates (β = -0.233, p = .039). Vertical integration into SNF was not significantly associated with 30-day HF readmissions. Our secondary analyses found variation in the impact of vertical integration on readmission rates among different hospital organizational types.
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16
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Opportunities for Collaboration: Refining Postoperative Readmission Risk for Skilled Nursing Facility Patients. J Am Med Dir Assoc 2019; 20:1060-1062. [PMID: 31455507 DOI: 10.1016/j.jamda.2019.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 11/20/2022]
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17
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Paredes AZ, Malik AT, Cluse M, Strassels SA, Santry HP, Eiferman D, Jones C, Vazquez D. Discharge disposition to skilled nursing facility after emergent general surgery predicts a poor prognosis. Surgery 2019; 166:489-495. [PMID: 31326186 DOI: 10.1016/j.surg.2019.04.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 03/26/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Emergency general surgery can have a profound impact on the functional status of even previously independent patients. The role and influence of discharging a patient to a skilled nursing facility, however, remains largely unknown. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program for community-dwelling adults who underwent 1 of 7 emergency general surgery procedures and were discharged home or to a skilled nursing facility from 2012 to 2016. Propensity score matching and multivariable regression analyses were performed to determine the relationship between discharge disposition and outcomes. RESULTS Overall, 140,922 patients met the inclusion criteria. The majority were discharged home (95.9%). After applying 1:1 propensity score matching, in comparison to patients discharged home, individuals discharged to a skilled nursing facility had a greater odds of respiratory (odds ratio 2.32; 95% confidence interval, 1.59-3.38) and septic complications (odds ratio 1.63, 95% confidence interval 1.12-2.36) after discharge. Furthermore, following surgery, individuals discharged to a skilled nursing facility had a greater odds of 30-day readmission (odds ratio 1.14; 95% confidence interval, 1.01-1.29), and death within 30 days of the procedure (odds ratio 2.07; 95% confidence interval, 1.65-2.61). CONCLUSION After accounting for patient severity and perioperative course, discharge to a skilled nursing facility is an independent risk factor for death, readmission, and postdischarge complications.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Wexner Medical Center, Columbus.
| | - Azeem T Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus
| | - Marcus Cluse
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Wexner Medical Center, Columbus
| | - Scott A Strassels
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Wexner Medical Center, Columbus
| | - Heena P Santry
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Wexner Medical Center, Columbus
| | - Daniel Eiferman
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Wexner Medical Center, Columbus
| | - Christian Jones
- Department of Surgery, Division of Acute Care Surgery, Johns Hopkins Medicine, Baltimore, MD
| | - Daniel Vazquez
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Wexner Medical Center, Columbus
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18
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Paredes AZ, Hyer JM, Beal EW, Bagante F, Merath K, Mehta R, White S, Pawlik TM. Impact of skilled nursing facility quality on postoperative outcomes after pancreatic surgery. Surgery 2019; 166:1-7. [DOI: 10.1016/j.surg.2018.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 01/06/2023]
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19
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Zhu JM, Navathe A, Yuan Y, Dykstra S, Werner RM. Medicare's bundled payment model did not change skilled nursing facility discharge patterns. THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:329-334. [PMID: 31318505 PMCID: PMC6788623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate whether participation in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) model was associated with changes in discharge referral patterns to skilled nursing facilities (SNFs), specifically number of SNF partners and discharge concentration. STUDY DESIGN Retrospective observational study using difference-in-differences analysis. METHODS We used Medicare claims data from 2010 to 2015 to identify admissions for lower joint replacement surgery and the following medical conditions: congestive heart failure, renal failure, sepsis, pneumonia, urinary tract and kidney infections, chronic obstructive pulmonary disease, and stroke. We used difference-in-differences analyses to assess changes in discharge patterns among BPCI-participating hospitals compared with matched control hospitals. RESULTS Our analytic sample included 3078 acute care hospitals and 14,866 Medicare-certified SNFs in the United States, encompassing more than 47 million hospital discharges. Of these hospitals, 416 participated in BPCI, with the majority selecting into joint replacement episodes (n = 295). BPCI participation was not associated with any change in number of SNF partners (increase by 0.8 SNFs among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -0.2 to 1.9; P = .11) or in discharge concentration (increase in Herfindahl-Hirschman Index of 0.2 among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -68.7 to 69.1; P = .36). Results did not vary across clinical conditions and were robust across duration of BPCI participation and with different comparison groups. CONCLUSIONS Hospital participation in BPCI was not associated with changes in the number of SNF partners or in discharge concentration relative to non-BPCI hospitals. More research is needed to understand how hospitals are responding to bundled payment incentives and specific practices that contribute to improvements in cost and quality.
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Affiliation(s)
- Jane M Zhu
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
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20
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Andriotti T, Goralnick E, Jarman M, Chaudhary MA, Nguyen LL, Learn PA, Haider AH, Schoenfeld AJ. The Optimal Length of Stay Associated With the Lowest Readmission Risk Following Surgery. J Surg Res 2019; 239:292-299. [DOI: 10.1016/j.jss.2019.02.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/12/2019] [Accepted: 02/19/2019] [Indexed: 01/11/2023]
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Zhu JM, Patel V, Shea JA, Neuman MD, Werner RM. Hospitals Using Bundled Payment Report Reducing Skilled Nursing Facility Use And Improving Care Integration. Health Aff (Millwood) 2019; 37:1282-1289. [PMID: 30080469 DOI: 10.1377/hlthaff.2018.0257] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A goal of Medicare's bundled payment models is to improve quality and control costs after hospital discharge. Little is known about how participating hospitals are focusing their efforts to achieve these objectives, particularly around the use of skilled nursing facilities (SNFs). To understand hospitals' approaches, we conducted semistructured interviews with an executive or administrator in each of twenty-two hospitals and health systems participating in Medicare's Comprehensive Care for Joint Replacement model or its Bundled Payments for Care Improvement initiative for lower extremity joint replacement episodes. We identified two major organizational responses. One principal strategy was to reduce SNF referrals, using risk-stratification tools, patient education, home care supports, and linkages with home health agencies to facilitate discharges to home. Another was to enhance integration with SNFs: fifteen hospitals or health systems in our sample had formed networks of preferred SNFs to exert influence over SNF quality and costs. Common coordination strategies included sharing access to electronic medical records, embedding providers across facilities, hiring dedicated care coordination staff, and creating platforms for data sharing. As hospitals presumably move toward home-based care and more selective SNF referrals, more evidence is needed to understand how these discharge practices affect the quality of care and patient outcomes.
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Affiliation(s)
- Jane M Zhu
- Jane M. Zhu ( ) is a National Clinician Scholar and fellow in the Division of General Internal Medicine at the Perelman School of Medicine and an associate fellow at the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania, in Philadelphia
| | - Viren Patel
- Viren Patel is a medical student at the Perelman School of Medicine, University of Pennsylvania
| | - Judy A Shea
- Judy A. Shea is a professor in the Division of General Internal Medicine at the Perelman School of Medicine, University of Pennsylvania
| | - Mark D Neuman
- Mark D. Neuman is an associate professor in the Department of Anesthesia and Critical Care at the Perelman School of Medicine and a senior fellow at the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania
| | - Rachel M Werner
- Rachel M. Werner is a professor of medicine in the Division of General Internal Medicine at the Perelman School of Medicine and a professor of health care management at the Wharton School of Business, both at the University of Pennsylvania, and core faculty at the Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, in Philadelphia
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22
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Hoffman AF, Pink GH, Kirk DA, Randolph RK, Holmes GM. What Characteristics Influence Whether Rural Beneficiaries Receiving Care From Urban Hospitals Return Home for Skilled Nursing Care? J Rural Health 2019; 36:94-103. [PMID: 30951228 DOI: 10.1111/jrh.12365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Skilled nursing care (SNC) provides Medicare beneficiaries short-term rehabilitation from an acute event. The purpose of this study is to assess beneficiary, market, and hospital factors associated with beneficiaries receiving care near home. METHODS The population includes Medicare beneficiaries who live in a rural area and received acute care from an urban facility in 2013. "Near home" was defined 3 different ways based on distances from the beneficiary's home to the nearest source of SNC. Results include unadjusted means and odds ratios from logistic regression. FINDINGS About 69% of rural beneficiaries receiving acute care in an urban location returned near home for SNC. Beneficiaries returning home were white (odds ratio [OR] black: 0.69; other race: 0.79); male (OR: 1.07); older (OR age 85+ [vs 65-69]: 1.14); farther from SNC (OR: 1.01 per mile); closer to acute care (OR: 0.28, logged miles); and received acute care from hospitals that did not own a skilled nursing facility (owned OR: 0.77) and hospitals with: no swing bed (swing bed OR: 0.47), high case mix (OR: 3.04), and nonprofit status (for-profit OR: 0.85). Results varied somewhat across definitions of "near home." CONCLUSIONS Rural Medicare beneficiaries who received acute care far from home were more likely to receive SNC far from home. Because Medicare beneficiaries have the choice of where to receive SNC, policy makers may consider ensuring that new payment models do not incentivize provision of SNC away from home.
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Affiliation(s)
- Abby F Hoffman
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - George H Pink
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Denise A Kirk
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Randy K Randolph
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - George M Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Post-acute Care: Current State and Future Directions. J Am Med Dir Assoc 2019; 20:392-395. [DOI: 10.1016/j.jamda.2019.02.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 01/16/2023]
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Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Post-Acute Care After Joint Replacement in Medicare's Bundled Payments for Care Improvement Initiative. J Am Geriatr Soc 2019; 67:1027-1035. [PMID: 30802938 DOI: 10.1111/jgs.15803] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 11/27/2022]
Abstract
IMPORTANCE Bundled payments, in which services provided around a care episode are linked together, are being tested under Medicare's Bundled Payments for Care Improvement (BPCI) program. Reducing post-acute care (PAC) is critical under bundled payment, but little is known about whether this is done through provider selection or consolidation, and whether particular patterns of changes in PAC are associated with success under the program. OBJECTIVE To characterize patterns of change in PAC under lower-extremity joint replacement episodes in BPCI. DESIGN Retrospective difference-in-differences study. SETTING US Medicare, 2013 to 2015. PARTICIPANTS A total of 264 US hospitals participating in BPCI for lower-extremity joint replacement and matched controls. EXPOSURES Participation in BPCI. MEASUREMENTS Use and duration of institutional PAC (proportion discharged to a skilled nursing facility, an inpatient rehabilitation facility, and a long-term care hospital), dispersion of PAC (proportion of discharges to commonly used providers), and quality of PAC (Star Ratings, readmission rates, length of stay, and nurse staffing); part A Medicare payments. RESULTS BPCI participants decreased the use and duration of institutional PAC compared to controls: overall institutional PAC declined 4.4% in BPCI hospitals vs 2.1% in non-BPCI hospitals (difference = -2.2%; P = .033), and duration decreased by 1.6 days in BPCI hospitals compared to 0.0 days in non-BPCI hospitals (difference in differences = -1.5 days; P < .001). However, BPCI participants did not change their PAC referral patterns to reduce dispersion or refer patients to higher-quality PAC providers. Hospitals that were more successful in reducing Medicare payments started with higher payments and higher use of institutional PAC settings and demonstrated greater drops in use and duration of institutional PAC, but no differences in dispersion or referral to high-quality providers. CONCLUSIONS AND RELEVANCE Reductions in spending under BPCI were driven by a shift from higher- to lower-cost discharge settings, and by shortening the duration of institutional PAC. Hospitals that reduced payments the most had the highest spending at baseline. J Am Geriatr Soc 67:1027-1035, 2019.
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Affiliation(s)
| | - E John Orav
- Brigham and Women's Hospital, Boston, Massachusetts.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jie Zheng
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Arnold M Epstein
- Brigham and Women's Hospital, Boston, Massachusetts.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Arrighi-Allisan AE, Neifert SN, Gal JS, Deutsch BC, Caridi JM. Discharge Destination as a Predictor of Postoperative Outcomes and Readmission Following Posterior Lumbar Fusion. World Neurosurg 2019; 122:e139-e146. [DOI: 10.1016/j.wneu.2018.09.147] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 01/17/2023]
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Stoicea N, Magal S, Kim JK, Bai M, Rogers B, Bergese SD. Post-acute Transitional Journey: Caring for Orthopedic Surgery Patients in the United States. Front Med (Lausanne) 2018; 5:342. [PMID: 30581817 PMCID: PMC6292951 DOI: 10.3389/fmed.2018.00342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/21/2018] [Indexed: 02/03/2023] Open
Abstract
As the geriatric population in the United States continues to age, there will be an increased demand for total hip and total knee arthroplasties (THAs and TKAs). Older patients tend to have more comorbidities and poorer health, and will require post-acute care (PAC) following discharge. The most utilized PAC facilities following THA and TKA are skilled nursing facilities (SNFs), in-patient rehabilitation facilities (IRFs), and home with home health care (HHC). Coordination of care between hospitals and PACs, including the complete transfer of patient information, continues to be a challenge which impacts the quality of care provided by the PACs. The increased demand of hospital resources and PACs by the geriatric population necessitates an improvement in this transition of care process. This review aims to examine the transition of care process currently utilized in the United States for orthopedic surgery patients, and discuss methods for improvement. Employing these approaches will play a key role in improving patient outcomes, decreasing preventable hospital readmissions, and reducing mortality following THA and TKA. The extensive nature of this topic and the ramification of different types of healthcare systems in different countries were the determinant factors limiting our work.
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Affiliation(s)
- Nicoleta Stoicea
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Samarchitha Magal
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - January K Kim
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Michael Bai
- College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Barbara Rogers
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Sergio Daniel Bergese
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States.,Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
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Zuckerman RB, Wu S, Chen LM, Joynt Maddox KE, Sheingold SH, Epstein AM. The Five-Star Skilled Nursing Facility Rating System and Care of Disadvantaged Populations. J Am Geriatr Soc 2018; 67:108-114. [DOI: 10.1111/jgs.15629] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/31/2018] [Accepted: 08/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Rachael B. Zuckerman
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
| | - Shannon Wu
- Department of Health Policy and Management; Bloomberg School of Public Health, Johns Hopkins University; Baltimore Maryland
| | - Lena M. Chen
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
- Department of Internal Medicine, Institute for Healthcare Policy and Innovation; University of Michigan Health System, Center for Healthcare Outcomes and Policy, University of Michigan; Ann Arbor Michigan
| | - Karen E. Joynt Maddox
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
- Cardiovascular Division, Department of Medicine; School of Medicine, Washington University; St. Louis Missouri
| | - Steven H. Sheingold
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
| | - Arnold M. Epstein
- Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University; Department of Medicine, Brigham and Women's Hospital; Boston Massachusetts
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Graham C, Ross L, Bueno EB, Harrington C. Assessing the Quality of Nursing Homes in Managed Care Organizations: Integrating LTSS for Dually Eligible Beneficiaries. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018800090. [PMID: 30222018 PMCID: PMC6144495 DOI: 10.1177/0046958018800090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is known about the quality of nursing homes in managed care organizations (MCOs) networks. This study (1) described decision-making criteria for selecting nursing home networks and (2) compared selected quality indicators of network and nonnetwork nursing homes. The sample was 17 MCOs participating in a California demonstration that provided integrated long-term services and supports to dually eligible enrollees in 2017. The findings showed that the MCOs established a broad network of nursing homes, with only limited attention to using quality criteria. Network nursing homes (602) scored significantly lower on 6 selected quality measures than nonnetwork (117) nursing homes. Low registered nurse and total nurse staffing were strong predictors of network nursing homes controlling for facility characteristics. Managed care organizations should consider greater transparency about the quality of their nursing homes and use specific quality criteria to improve the quality of their networks.
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Affiliation(s)
- Carrie Graham
- 1 Center for the Advanced Study of Aging Services, Berkeley, CA, USA
| | - Leslie Ross
- 2 University of California, San Francisco, USA
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Mendu ML, Michaelidis CI, Chu MC, Sahota J, Hauser L, Fay E, Smith A, Huether MA, Dobija J, Yurkofsky M, Pu CT, Britton K. Implementation of a skilled nursing facility readmission review process. BMJ Open Qual 2018; 7:e000245. [PMID: 30094344 PMCID: PMC6069909 DOI: 10.1136/bmjoq-2017-000245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 05/28/2018] [Accepted: 06/30/2018] [Indexed: 11/03/2022] Open
Abstract
30-day readmissions for patients at skilled nursing facilities (SNF) are common and preventable. We implemented a readmission review process for patients readmitted from two SNFs, involving an electronic review tool and monthly conferences. The electronic review tool captures information related to preventability and factors contributing to readmission. The study included 128 patients, readmitted within 30 days from 1 October 2015 through 1 May 2017, at a tertiary care academic medical centre in Boston, MA, and two partnering SNFs. There was a discrepancy in preventability rating between SNF and hospital reviewers, with 79.7% of cases rated not preventable by the SNF, and 58.6% by the hospital. There was moderate positive correlation between the hospital's and SNFs' preventability ratings (rs=0.652, p<0.001). In most cases, the SNF reviewers felt that no factors contributed (57.8%), and hospital reviewers felt that issues with end-of-life planning (14.1%) and medical complexity (12.5%) were major factors. Despite the lack of strong correlation between SNF and hospital responses, several cross-continuum quality improvement projects were developed. We found that implementation of a SNF readmission review process employing bidirectional review by SNF and hospital was feasible, and facilitated systems-based improvement in the transition from hospital to postacute care.
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Affiliation(s)
- Mallika L Mendu
- Department of Quality and Safety, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Constantinos I Michaelidis
- Internal Medicine Residency Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michele C Chu
- Department of Quality and Safety, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jasdeep Sahota
- Brigham and Women's Physician's Organization, Brookline, Massachusetts, USA
| | - Lauren Hauser
- Brigham and Women's Physician's Organization, Brookline, Massachusetts, USA
| | - Emily Fay
- Brigham and Women's Physician's Organization, Brookline, Massachusetts, USA
| | - Aimee Smith
- Hebrew Rehabilitation Center in Boston, Boston, Massachusetts, USA
| | - Mary Ann Huether
- Hebrew Rehabilitation Center in Boston, Boston, Massachusetts, USA
| | - John Dobija
- Spaulding Nursing and Therapy Center West Roxbury, Boston, Massachusetts, USA
| | - Mark Yurkofsky
- Spaulding Nursing and Therapy Center West Roxbury, Boston, Massachusetts, USA
| | - Charles T Pu
- Partners Healthcare Center for Population Health Management, Boston, Massachusetts, USA
| | - Kathryn Britton
- Department of Quality and Safety, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Rahman M, Gadbois EA, Tyler DA, Mor V. Hospital-Skilled Nursing Facility Collaboration: A Mixed-Methods Approach to Understanding the Effect of Linkage Strategies. Health Serv Res 2018; 53:4808-4828. [PMID: 30079445 DOI: 10.1111/1475-6773.13016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To characterize the nature and degree of hospitals' efforts to collaborate with skilled nursing facilities (SNFs) and associated patient outcomes. DATA SOURCES/STUDY SETTING Qualitative data were collected through 138 interviews with staff in 16 hospitals and 25 SNFs in eight markets across the United States in 2015. Quantitative data include Medicare claims data for the 290,603 patients discharged from those 16 hospitals between 2008 and 2015. STUDY DESIGN/DATA COLLECTION Semi-structured interviews with hospital and SNF staff were coded and used to classify hospitals' collaboration efforts with SNFs into high versus low collaboration hospitals, and risk-adjusted, claims-based hospital readmission rates from SNF were compared. PRINCIPAL FINDINGS Hospital collaboration efforts were defined as establishing SNF partners, transition management initiatives, and hospital staff visits to SNFs. High collaboration hospitals were more likely to send patients to SNFs (as opposed to home, home with home health, or other PAC settings), sent a higher share of patients to high quality SNFs, and had fewer hospital readmissions from SNF sooner than did low collaboration hospitals. CONCLUSIONS Although collaboration with SNF requires significant administrative and clinical time investment, it is associated with positive patient outcomes.
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Affiliation(s)
- Momotazur Rahman
- Center for Gerontology and Healthcare Research, Brown University, Providence, RI
| | - Emily A Gadbois
- Center for Gerontology and Healthcare Research, Brown University, Providence, RI
| | - Denise A Tyler
- Aging, Disability& Long-Term Care, RTI International, Waltham, MA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University, Providence, RI
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Tyler DA, Gadbois EA, McHugh JP, Shield RR, Winblad U, Mor V. Patients Are Not Given Quality-Of-Care Data About Skilled Nursing Facilities When Discharged From Hospitals. Health Aff (Millwood) 2018; 36:1385-1391. [PMID: 28784730 DOI: 10.1377/hlthaff.2017.0155] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hospitals are now being held at least partly accountable for Medicare patients' care after discharge, as a result of regulations and incentives imposed by the Affordable Care Act. However, little is known about how patients select a postacute care facility. We used a multiple case study approach to explore both how patients requiring postacute care decide which skilled nursing facility to select and the role of hospital staff members in this decision. We interviewed 138 staff members of sixteen hospitals and twenty-five skilled nursing facilities and 98 patients in fourteen of the skilled nursing facilities. Most patients described receiving only lists of skilled nursing facilities from hospital staff members, while staff members reported not sharing data about facilities' quality with patients because they believed that patient choice regulations precluded them from doing so. Consequently, patients' choices were rarely based on readily available quality data. Proposed changes to the Medicare conditions of participation for hospitals that pertain to discharge planning could rectify this problem. In addition, less strict interpretations of choice requirements would give hospitals flexibility in the discharge planning process and allow them to refer patients to higher-quality facilities.
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Affiliation(s)
- Denise A Tyler
- Denise A. Tyler is a senior research health policy analyst in the Aging Disability and Long Term Care program at RTI International in Waltham, Massachusetts, and an adjunct assistant professor in the Center for Gerontology and Healthcare Research, Brown University School of Public Health, in Providence, Rhode Island
| | - Emily A Gadbois
- Emily A. Gadbois is a project director in the Center for Gerontology and Healthcare Research, Brown University School of Public Health
| | - John P McHugh
- John P. McHugh is an assistant professor in the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, in New York City
| | - Renée R Shield
- Renée R. Shield is a professor in the Center for Gerontology and Healthcare Research, Brown University School of Public Health
| | - Ulrika Winblad
- Ulrika Winblad was a Harkness Fellow in 2014-15 at the Center for Gerontology and Healthcare Research, Brown University School of Public Health. She is an associate professor in the Department of Public Health and Caring Sciences, Uppsala University, in Sweden
| | - Vincent Mor
- Vincent Mor is a professor of health services, policy, and practice at the Brown University School of Public Health and a health scientist at the Providence Veterans Affairs Medical Center
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Coronary artery bypass graft readmission rates and risk factors - A retrospective cohort study. Int J Surg 2018; 54:7-17. [PMID: 29678620 DOI: 10.1016/j.ijsu.2018.04.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 01/23/2018] [Accepted: 04/12/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hospital readmissions contribute substantially to the overall healthcare cost. Coronary artery bypass graft (CABG) is of particular interest due to its relatively high short-term readmission rates and mean hospital charges. METHODS A retrospective review was performed on 2007-2011 data from California, Florida, and New York from the State Inpatient Databases, Healthcare Cost and Utilization Project. All patients ≥18 years of age who underwent isolated CABG and met inclusion/exclusion criteria were included. Insurance status was categorized by Medicaid, Medicare, Private Insurance, Uninsured, and Other. Primary outcomes were unadjusted rates and adjusted odds of readmission at 30- and 90-days. Secondary outcomes included diagnosis at readmission. RESULTS A total of 177,229 were included in the analyses after assessing for exclusion criteria. Overall 30-day readmission rate was 16.1%; rates were highest within Medicare (18.4%) and Medicaid (20.2%) groups and lowest in the private insurance group (11.7%; p < 0.0001). Similarly, 90-day rates were highest in Medicare (27.3%) and Medicaid (29.8%) groups and lowest in the private insurance group (17.6%), with an overall 90-day rate of 24.0% (p < 0.0001). The most common 30-day readmission diagnoses were atrial fibrillation (26.7%), pleural effusion (22.5%), and wound infection (17.7%). Medicare patients had the highest proportion of readmissions with atrial fibrillation (31.7%) and pleural effusions (23.3%), while Medicaid patients had the highest proportion of readmissions with wound infections (21.8%). Similar results were found at 90 days. Risk factors for readmission included non-private insurance, age, female sex, non-white race, low median household income, non-routine discharge, length of stay, and certain comorbidities and complications. CONCLUSIONS CABG readmission rates remain high and are associated with insurance status and racial and socioeconomic markers. Further investigation is necessary to better delineate the underlying factors that relate racial and socioeconomic disparities to CABG readmissions. Understanding these factors will be key to improving healthcare outcomes and expenditure.
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Rosen BT, Halbert RJ, Hart K, Diniz MA, Isonaka S, Black JT. The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities. J Hosp Med 2018; 13:229-236. [PMID: 29069115 DOI: 10.12788/jhm.2852] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients. OBJECTIVE Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs. DESIGN An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015. SETTING A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs. PATIENTS All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation. INTERVENTION The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff. MEASUREMENT Thirty-day readmission rate for ECP patients compared to patients not enrolled in ECP. RESULTS The average unadjusted, 30-day readmission rate for ECP patients over the 18-month study period was 17.2% compared to 23.0% among patients not enrolled in ECP (P < 0.001). After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P < 0.001). These effects were robust to stratified analyses, analyses adjusted for clustering, and balancing of covariates using propensity weighting. CONCLUSIONS A coordinated, interdisciplinary team caring for SNF patients can reduce 30-day hospital readmissions.
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Affiliation(s)
- Bradley T Rosen
- Cedars-Sinai Health System, Los Angeles, California, USA.
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Ronald J Halbert
- Cedars-Sinai Health System, Los Angeles, California, USA
- Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
| | - Kelley Hart
- Cedars-Sinai Health System, Los Angeles, California, USA
| | - Marcio A Diniz
- Cedars-Sinai Health System, Los Angeles, California, USA
| | - Sharon Isonaka
- Cedars-Sinai Health System, Los Angeles, California, USA
| | - Jeanne T Black
- Cedars-Sinai Health System, Los Angeles, California, USA
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Feder SL, Britton MC, Chaudhry SI. "They Need to Have an Understanding of Why They're Coming Here and What the Outcomes Might Be." Clinician Perspectives on Goals of Care for Patients Discharged From Hospitals to Skilled Nursing Facilities. J Pain Symptom Manage 2018; 55:930-937. [PMID: 29097273 DOI: 10.1016/j.jpainsymman.2017.10.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 10/23/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT The number of patients discharged from acute care hospitals to skilled nursing facilities (SNFs) is rising. These patients have increasingly complex needs and many experience poor outcomes while under SNF care, including hospital readmissions. Patients' goals of care (GoC) are viewed as a factor contributing to unplanned hospital readmissions from SNFs. However, clinicians' perspectives of GoC for hospitalized patients discharged to SNFs are not well-described. OBJECTIVES To explore how clinicians view GoC for hospitalized patients discharged to SNFs. METHODS Qualitative study using semi-structured interviews and thematic analysis. RESULTS Forty-one clinicians from one acute care hospital and two SNFs completed interviews ranging in length from 14 to 52 minutes (mean = 32 minutes). Of the sample, 22% were nurses, 20% physicians, 15% were from care management, and 15% were from social services. Respondents viewed patients' GoC for continuing treatment at the SNF as important, but acknowledged that they were infrequently discussed during hospitalization. Many respondents felt that patients and families had unrealistic GoC for SNF care. Factors that contributed to unrealistic GoC included patients' limited knowledge of disease processes, prognosis, and treatment options; and inconsistent or insufficient communication of GoC among hospital and SNF clinicians, the patient, and family members. Respondents associated a lack of GoC or unrealistic GoC with patients' dissatisfaction with SNF care, unplanned transitions to hospice, and hospital readmissions. CONCLUSIONS Respondents reported that GoC conversations infrequently occurred during hospitalization, contributing to unrealistic patient and family expectations for SNF care and poor patient outcomes. Interventions are needed that facilitate timely, accurate, and consistent GoC discussions across care continuums.
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Affiliation(s)
| | - Meredith Campbell Britton
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sarwat I Chaudhry
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Meyers DJ, Mor V, Rahman M. Medicare Advantage Enrollees More Likely To Enter Lower-Quality Nursing Homes Compared To Fee-For-Service Enrollees. Health Aff (Millwood) 2018; 37:78-85. [PMID: 29309215 PMCID: PMC5822393 DOI: 10.1377/hlthaff.2017.0714] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Unlike fee-for-service (FFS) Medicare, most Medicare Advantage (MA) plans have a preferred network of care providers that serve most of a plan's enrollees. Little is known about how the quality of care MA enrollees receive differs from that of FFS Medicare enrollees. This article evaluates the differences in the quality of skilled nursing facilities (SNFs) that Medicare Advantage and FFS beneficiaries entered in the period 2012-14. After we controlled for patients' clinical, demographic, and residential neighborhood effects, we found that FFS Medicare patients have substantially higher probabilities of entering higher-quality SNFs (those rated four or five stars by Nursing Home Compare) and those with lower readmission rates, compared to MA enrollees. The difference between MA and FFS Medicare SNF selections was less for enrollees in higher-quality MA plans than those in lower-quality plans, but Medicare Advantage still guided patients to lower-quality facilities.
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Affiliation(s)
- David J Meyers
- David J. Meyers ( ) is a doctoral student in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Vincent Mor
- Vincent Mor is a professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health, and a health scientist at the Providence Veterans Affairs Medical Center
| | - Momotazur Rahman
- Momotazur Rahman is an assistant professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health
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Stoicea N, You T, Eiterman A, Hartwell C, Davila V, Marjoribanks S, Florescu C, Bergese SD, Rogers B. Perspectives of Post-Acute Transition of Care for Cardiac Surgery Patients. Front Cardiovasc Med 2017; 4:70. [PMID: 29230400 PMCID: PMC5712014 DOI: 10.3389/fcvm.2017.00070] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 10/25/2017] [Indexed: 12/20/2022] Open
Abstract
Post-acute care (PAC) facilities improve patient recovery, as measured by activities of daily living, rehabilitation, hospital readmission, and survival rates. Seamless transitions between discharge and PAC settings continue to be challenges that hamper patient outcomes, specifically problems with effective communication and coordination between hospitals and PAC facilities at patient discharge, patient adherence and access to cardiac rehabilitation (CR) services, caregiver burden, and the financial impact of care. The objective of this review is to examine existing models of cardiac transitional care, identify major challenges and social factors that affect PAC, and analyze the impact of current transitional care efforts and strategies implemented to improve health outcomes in this patient population. We intend to discuss successful methods to address the following aspects: hospital-PAC linkages, improved discharge planning, caregiver burden, and CR access and utilization through patient-centered programs. Regular home visits by healthcare providers result in decreased hospital readmission rates for patients utilizing home healthcare while improved hospital-PAC linkages reduced hospital readmissions by 25%. We conclude that widespread adoption of improvements in transitional care will play a key role in patient recovery and decrease hospital readmission, morbidity, and mortality.
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Affiliation(s)
- Nicoleta Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Tian You
- The Ohio State University College of Medicine, Columbus, OH, United States
| | - Andrew Eiterman
- The Ohio State University College of Medicine, Columbus, OH, United States
| | - Clifton Hartwell
- The Ohio State University College of Medicine, Columbus, OH, United States
| | - Victor Davila
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Stephen Marjoribanks
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | | | - Sergio Daniel Bergese
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States.,Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Barbara Rogers
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Improving transitions of care across the spectrum of healthcare delivery: A multidisciplinary approach to understanding variability in outcomes across hospitals and skilled nursing facilities. Am J Surg 2017; 213:910-914. [PMID: 28396033 DOI: 10.1016/j.amjsurg.2017.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/31/2017] [Accepted: 04/04/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Improving coordination during transitions of care from the hospital to Skilled Nursing Facilities (SNF)s is critical for improving healthcare quality. In 2014, we formed (Improving Nursing Facility Outcomes using Real-Time Metrics, INFORM) to improve transitions of care by identifying structural and process factors that lead to poor clinical outcomes and hospital readmission. METHODS Stakeholders from 10 SNFs and 4 hospitals collaborated to assess the current hospital and system-level challenges to safe transitions of care and identify targets for interventions. RESULTS The INFORM collaborative identified areas for improvement including improving accuracy and timeliness of discharge information, facilitating congruent medication reconciliation, and developing care plans to support functional improvement. DISCUSSION Hospital and SNF stakeholder engagement prioritized the challenges in patient transitions from inpatient to skilled nursing facility settings. Innovative solutions that address barriers to safe and effective transitions of care are critical to improving clinical outcomes, decreasing adverse events and avoiding readmission.
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Ali AM, Gibbons CER. Predictors of 30-day hospital readmission after hip fracture: a systematic review. Injury 2017; 48:243-252. [PMID: 28063674 DOI: 10.1016/j.injury.2017.01.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/26/2016] [Accepted: 01/01/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Early readmission to hospital after hip fracture is associated with increased mortality and significant costs to the healthcare system. There is growing interest in the use of 30-day readmission rates as a metric of hospital performance. Identifying patients at increased risk of readmission after hip fracture may enable pre-emptive action to mitigate this risk and the development of effective methods of risk-adjustment to allow readmission to be used as a reliable measure of hospital performance. METHODS We conducted a systematic review of bibliographic databases and reference lists up to July 2016 to identify primary research papers assessing the effect of patient- and hospital-related risk factors for 30-day readmission to hospital after hip fracture. RESULTS 495 papers were found through electronic and reference search. 65 full papers were assessed for eligibility. 22 met inclusion criteria and were included in the final review. Medical causes of readmission were significantly more common than surgical causes, with pneumonia consistently being cited as the most common readmission diagnosis. Age, pre-existing pulmonary disease and neurological disorders were strong independent predictors of readmission. ASA grade and functional status were more robust predictors of readmission than the Charlson score or individual co-morbidities. Hospital-related risk factors including initial length of stay, hospital size and volume, time to surgery and type of anaesthesia did not have a consistent effect on readmission risk. Discharge location and the strength of hospital-discharge facility linkage were important determinants of risk. CONCLUSIONS Patient-related risk factors such as age, co-morbidities and functional status are stronger predictors of 30-day readmission risk after hip fracture than hospital-related factors. Rates of 30-day readmission may not be a valid reflection of hospital performance unless a clear distinction can be made between modifiable and non-modifiable risk factors. We identify a number of deficiencies in the existing literature and highlight key areas for future research.
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Affiliation(s)
- Adam M Ali
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
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Rahman M, Norton EC, Grabowski DC. Do hospital-owned skilled nursing facilities provide better post-acute care quality? JOURNAL OF HEALTH ECONOMICS 2016; 50:36-46. [PMID: 27661738 PMCID: PMC5127756 DOI: 10.1016/j.jhealeco.2016.08.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 05/23/2023]
Abstract
As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.
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Affiliation(s)
| | - Edward C Norton
- University of Michigan, Ann Arbor, MI 48109, USA; NBER, Cambridge, MA 02138, USA
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40
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Rahman M, Grabowski DC, Mor V, Norton EC. Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure? Health Serv Res 2016. [PMID: 27766639 DOI: 10.1111/1475‐6773.12603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity. SETTINGS Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization. STUDY DESIGN We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV. PRINCIPAL FINDINGS The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013. CONCLUSIONS Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Vincent Mor
- Department of Health Services Policy and Practice, Brown University, Providence, RI.,Health Services Research Program, Providence Veterans Administration Medical Center, Providence, RI
| | - Edward C Norton
- Department of Health Management and Policy and Department of Economics, University of Michigan, Ann Arbor, MI.,National Bureau of Economic Research, Cambridge, MA
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Rahman M, Grabowski DC, Mor V, Norton EC. Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure? Health Serv Res 2016; 51:2158-2175. [PMID: 27766639 DOI: 10.1111/1475-6773.12603] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity. SETTINGS Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization. STUDY DESIGN We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV. PRINCIPAL FINDINGS The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013. CONCLUSIONS Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Vincent Mor
- Department of Health Services Policy and Practice, Brown University, Providence, RI.,Health Services Research Program, Providence Veterans Administration Medical Center, Providence, RI
| | - Edward C Norton
- Department of Health Management and Policy and Department of Economics, University of Michigan, Ann Arbor, MI.,National Bureau of Economic Research, Cambridge, MA
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Rahman M, McHugh J, Gozalo PL, Ackerly DC, Mor V. The Contribution of Skilled Nursing Facilities to Hospitals' Readmission Rate. Health Serv Res 2016; 52:656-675. [PMID: 27193697 DOI: 10.1111/1475-6773.12507] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30-day rehospitalization. DATA SOURCES/SETTINGS Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization. STUDY DESIGN We ranked hospitals and SNFs into quartiles based on previous years' adjusted rehospitalization rates (ARRs) and examined how rehospitalizations from a given hospital vary depending upon the admitting SNF ARR quartile. We examined whether the availability of SNFs with low rehospitalization rates influenced hospitals' SNF readmission rates and whether changes in a hospital's ARR over 3 years is associated with changes in the SNFs to which they discharge. PRINCIPAL FINDINGS Hospital readmission rates from SNFs varied 5 percentage points between patients discharged to SNFs in the lowest and the highest rehospitalization quartiles. Low rehospitalization rate hospitals sent a larger fraction of their patients to the lowest rehospitalization SNFs available in the area. A 10 percent increase in hospital's share of discharges to the lowest rehospitalization quartile SNFs is associated with a 1 percentage point reduction in hospital's ARR. CONCLUSIONS The SNF rehospitalization rate has greater influence on patients' risk of rehospitalization than the discharging hospital. Identifying high-performing SNFs may be a powerful strategy for hospitals to reduce rehospitalizations.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | - John McHugh
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | - Pedro L Gozalo
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | | | - Vincent Mor
- Department of Health Services Policy and Practice, Brown University, Providence, RI.,Providence Veterans Administration Medical Center, Health Services Research Program, Providence, RI
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Jacobs DO. Comment: Hospital to specific skilled nursing facility linkages-More may be better. Surgery 2016; 159:1469-70. [PMID: 26994484 DOI: 10.1016/j.surg.2016.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/03/2016] [Indexed: 11/27/2022]
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