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Shashikumar SA, Chopra Z, Buxbaum JD, Joynt Maddox KE, Ryan AM. Physician Group Practices Accrued Large Bonuses Under Medicare's Bundled Payment Model, 2018-20. Health Aff (Millwood) 2024; 43:623-631. [PMID: 38709974 DOI: 10.1377/hlthaff.2023.00915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
The Bundled Payments for Care Improvement Advanced Model (BPCI-A), a voluntary Alternative Payment Model for Medicare, incentivizes hospitals and physician group practices to reduce spending for patient care episodes below preset target prices. The experience of physician groups in BPCI-A is not well understood. We found that physician groups earned $421 million in incentive payments during BPCI-A's first four performance periods (2018-20). Target prices were positively associated with bonuses, with a mean reconciliation payment of $139 per episode in the lowest decile of target prices and $2,775 in the highest decile. In the first year of the COVID-19 pandemic, mean bonuses increased from $815 per episode to $2,736 per episode. These findings suggest that further policy changes, such as improving target price accuracy and refining participation rules, will be important as the Centers for Medicare and Medicaid Services continues to expand BPCI-A and develop other bundled payment models.
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Affiliation(s)
| | - Zoey Chopra
- Zoey Chopra, University of Michigan, Ann Arbor, Michigan
| | | | | | - Andrew M Ryan
- Andrew M. Ryan , Brown University, Providence, Rhode Island
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Sankaran R, Gulseren B, Prescott HC, Langa KM, Nguyen T, Ryan AM. Identifying Sources of Inter-hospital Variation in Episode Spending for Sepsis Care. Med Care 2024:00005650-990000000-00225. [PMID: 38625015 DOI: 10.1097/mlr.0000000000002000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
OBJECTIVE To evaluate inter-hospital variation in 90-day total episode spending for sepsis, estimate the relative contributions of each component of spending, and identify drivers of spending across the distribution of episode spending on sepsis care. DATA SOURCES/STUDY SETTING Medicare fee-for-service claims for beneficiaries (n=324,694) discharged from acute care hospitals for sepsis, defined by MS-DRG, between October 2014 and September 2018. RESEARCH DESIGN Multiple linear regression with hospital-level fixed effects was used to identify average hospital differences in 90-day episode spending. Separate multiple linear regression and quantile regression models were used to evaluate drivers of spending across the episode spending distribution. RESULTS The mean total episode spending among hospitals in the most expensive quartile was $30,500 compared with $23,150 for the least expensive hospitals (P<0.001). Postacute care spending among the most expensive hospitals was almost double that of least expensive hospitals ($7,045 vs. $3,742), accounting for 51% of the total difference in episode spending between the most expensive and least expensive hospitals. Female patients, patients with more comorbidities, urban hospitals, and BPCI-A-participating hospitals were associated with significantly increased episode spending, with the effect increasing at the right tail of the spending distribution. CONCLUSION Inter-hospital variation in 90-day episode spending on sepsis care is driven primarily by differences in post-acute care spending.
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Affiliation(s)
- Roshun Sankaran
- Department of Radiology, University of California San Diego, San Diego, CA
| | - Baris Gulseren
- Department of Health Management and Policy, University of Michigan School of Public Health
- Center for Evaluation Health Reform, University of Michigan
| | | | - Kenneth M Langa
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Thuy Nguyen
- Department of Health Management and Policy, University of Michigan School of Public Health
- Center for Evaluation Health Reform, University of Michigan
| | - Andrew M Ryan
- Department of Health Services, Policy, and Practice, Center for Health Policy, Brown University, Providence, RI
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Donato DP, Simpson AM, Willcockson J, Veith J, King BW, Agarwal JP. Associations with Discharge to Post-Acute Care Facilities Among Patients Undergoing Open Reduction Internal Fixation of Distal Radius Fractures. Plast Surg (Oakv) 2024; 32:40-46. [PMID: 38433790 PMCID: PMC10902480 DOI: 10.1177/22925503221085082] [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: 03/05/2024] Open
Abstract
Introduction: Distal radius fractures are a common injury of the hand and wrist that often require intensive rehabilitation. We sought to identify risk factors associated with discharge to a post-acute care facility following distal radius fracture repair. Methods: The 2011 to 2016 National Surgical Quality Improvement Program® (NSQIP) database was queried for all Current Procedural Terminology (CPT) codes that corresponded with open distal radius fracture repair. Patients with concomitant traumatic injuries were excluded. Patient demographics, comorbidities, perioperative factors, laboratory data, and surgical details were collected. Our primary outcome was to determine postoperative discharge destination: home versus a post-acute care facility, and to identify factors that predict discharge to post-acute care facility. Secondary outcomes included unplanned readmission, reoperation, and complications. Results: Between 2011 and 2016, a total of 12,001 patients underwent open distal radius fracture repair and had complete information for their discharge. Of these analyzed patients, 3.24% (n = 389) were discharged to rehabilitation facilities. The following factors were identified on multivariate analysis to have an association with discharge to a post-acute care facility: 65 years or older, White race, underweight, using steroids preoperatively, American Society of Anesthesiologists (ASA) classification > 2, admitted from a nursing home or already hospitalized, anemic, undergoing bilateral surgery, wound classification other than clean, and complications prior to discharge. Conclusion: Factors identified by our study to have associations with discharge to post-acute care facilities following distal radius fracture repair can help in appropriate patient counseling and triage from the hospital to home versus a post-acute care facility.
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Affiliation(s)
- Daniel P Donato
- Division of Plastic and Reconstructive Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Andrew M Simpson
- Division of Plastic Surgery, Western University, London, ON, Canada
| | - James Willcockson
- Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob Veith
- Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Brody W King
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jayant P Agarwal
- Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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Alexander GL, Liu J. Assessing Associations Between Health Information Technology Maturity and Nursing Home Survey Deficiencies. J Gerontol Nurs 2024; 50:8-14. [PMID: 38170463 DOI: 10.3928/00989134-20231211-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
One in three nursing home (NH) residents experience adverse events. One strategy for safer NH care is health information technology (HIT). Two national NH surveys measuring HIT maturity were administered in 2020 (N = 719) and 2021 (N = 312). Quarterly NH survey deficiencies from the same years were linked to HIT maturity surveys. Descriptive statistics and logistic regression were used in analysis. NHs were of similar size and location, with more for-profit facilities. Most (67.5% and 61.9%, respectively) NH administrators reported having capabilities to share data internally within their facility, and not externally. Mean HIT maturity scores increased from Year 1 to Year 2. Over 2 years, 5,406 deficiencies were reported, mostly (31.3%) for nutrition and dietary deficiencies. There were negative associations between HIT maturity and deficiency scope. With a 1-unit increase in HIT maturity, relative risk of widespread scope decreased by 14%. Among covariates, bed size, staffing, and year were significant factors associated with deficiency scope. [Journal of Gerontological Nursing, 50(1), 8-14.].
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Sznol JA, Becher R, Maung AA, Bhattacharya B, Davis K, Schuster KM. Routine post-operative labs and healthcare system burden in acute appendicitis. Am J Surg 2023; 226:571-577. [PMID: 37291012 DOI: 10.1016/j.amjsurg.2023.06.005] [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: 03/20/2023] [Revised: 05/16/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Data from the National Health Expenditure Accounts have shown a steady increase in healthcare cost paralleled by availability of laboratory tests. Resource utilization is a top priority for reducing health care costs. We hypothesized that routine post-operative laboratory utilization unnecessarily increases costs and healthcare system burden in acute appendicitis (AA) management. METHODS A retrospective cohort of patients with uncomplicated AA 2016-2020 were identified. Clinical variables, demographics, lab usage, interventions, and costs were collected. RESULTS A total of 3711 patients with uncomplicated AA were identified. Total costs of labs ($289,505, 99.56%) and repletions ($1287.63, 0.44%) were $290,792.63. Increased LOS was associated with lab utilization in multivariable modeling, increasing costs by $837,602 or 472.12 per patient. CONCLUSIONS In our patient population, post-operative labs resulted in increased costs without discernible impact on clinical course. Routine post-operative laboratory testing should be re-evaluated in patients with minimal comorbidities as this likely increases cost without adding value.
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Affiliation(s)
- Joshua A Sznol
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Robert Becher
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Adrian A Maung
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Bishwajit Bhattacharya
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kimberly Davis
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kevin M Schuster
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
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Riveros C, Ranganathan S, Shah YB, Huang E, Xu J, Geng M, Melchiode Z, Hu S, Miles BJ, Esnaola N, Kaushik D, Jerath A, Wallis CJD, Satkunasivam R. Postoperative Discharge Destination Impacts 30-Day Outcomes: A National Surgical Quality Improvement Program Multi-Specialty Surgical Cohort Analysis. J Clin Med 2023; 12:6784. [PMID: 37959249 PMCID: PMC10650337 DOI: 10.3390/jcm12216784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Surgical patients can be discharged to a variety of facilities which vary widely in intensity of care. Postoperative readmissions have been found to be more strongly associated with post-discharge events than pre-discharge complications, indicating the importance of discharge destination. We sought to evaluate the association between discharge destination and 30-day outcomes. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were dichotomized based on discharge destination: home versus non-home. The main outcome of interest was 30-day unplanned readmission. The secondary outcomes included post-discharge pulmonary, infectious, thromboembolic, and bleeding complications, as well as death. In this cohort study of over 1.5 million patients undergoing common surgical procedures across eight surgical specialties, we found non-home discharge to be associated with adverse 30-day post-operative outcomes, namely, unplanned readmissions, post-discharge pulmonary, infectious, thromboembolic, and bleeding complications, as well as death. Non-home discharge is associated with worse 30-day outcomes among patients undergoing common surgical procedures. Patients and caregivers should be counseled regarding discharge destination, as non-home discharge is associated with adverse post-operative outcomes.
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Affiliation(s)
- Carlos Riveros
- Department of Urology, Houston Methodist Hospital, Houston, TX 77030, USA; (C.R.); (S.R.); (E.H.); (Z.M.); (S.H.); (B.J.M.); (D.K.)
| | - Sanjana Ranganathan
- Department of Urology, Houston Methodist Hospital, Houston, TX 77030, USA; (C.R.); (S.R.); (E.H.); (Z.M.); (S.H.); (B.J.M.); (D.K.)
| | - Yash B. Shah
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Emily Huang
- Department of Urology, Houston Methodist Hospital, Houston, TX 77030, USA; (C.R.); (S.R.); (E.H.); (Z.M.); (S.H.); (B.J.M.); (D.K.)
| | - Jiaqiong Xu
- Center for Health Data Science and Analytics, Houston Methodist Research Institute, Houston, TX 77030, USA;
| | - Michael Geng
- School of Engineering Medicine, Texas A&M University, Houston, TX 77030, USA;
| | - Zachary Melchiode
- Department of Urology, Houston Methodist Hospital, Houston, TX 77030, USA; (C.R.); (S.R.); (E.H.); (Z.M.); (S.H.); (B.J.M.); (D.K.)
| | - Siqi Hu
- Department of Urology, Houston Methodist Hospital, Houston, TX 77030, USA; (C.R.); (S.R.); (E.H.); (Z.M.); (S.H.); (B.J.M.); (D.K.)
| | - Brian J. Miles
- Department of Urology, Houston Methodist Hospital, Houston, TX 77030, USA; (C.R.); (S.R.); (E.H.); (Z.M.); (S.H.); (B.J.M.); (D.K.)
| | - Nestor Esnaola
- Department of Surgery, Houston Methodist Hospital, Houston, TX 77030, USA;
| | - Dharam Kaushik
- Department of Urology, Houston Methodist Hospital, Houston, TX 77030, USA; (C.R.); (S.R.); (E.H.); (Z.M.); (S.H.); (B.J.M.); (D.K.)
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Center, Toronto, ON M4N 3M5, Canada;
| | - Christopher J. D. Wallis
- Division of Urology and Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5R 0A3, Canada;
- Division of Urology, University of Toronto, Toronto, ON M5R 0A3, Canada
- Division of Urology, Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, TX 77030, USA; (C.R.); (S.R.); (E.H.); (Z.M.); (S.H.); (B.J.M.); (D.K.)
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Leland NE, Rouch SA, Prusynski RA, Shore AD, Kaufman H, Hoover LP, Mroz TM, Freburger JK, Saliba D. Implementation of US Post-Acute Care Payment Reform and COVID-19 Policies: Examining Experiences of Health System Leaders, Staff, Patients, and Family Caregivers-A Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6959. [PMID: 37887697 PMCID: PMC10606322 DOI: 10.3390/ijerph20206959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023]
Abstract
In fiscal year 2020, new national Medicare payment models were implemented in the two most common post-acute care settings (i.e., skilled nursing facilities (SNFs) and home health agencies (HHAs)), which were followed by the emergence of COVID-19. Given concerns about the unintended consequence of these events, this study protocol will examine how organizations responded to these policies and whether there were changes in SNF and HHA access, care delivery, and outcomes from the perspectives of leadership, staff, patients, and families. We will conduct a two-phase multiple case study guided by the Institute of Medicine's Model of Healthcare Systems. Phase I will include three cases for each setting and a maximum of fifty administrators per case. Phase II will include a subset of Phase I organizations, which are grouped into three setting-specific cases. Each Phase II case will include a maximum of four organizations. Semi-structured interviews will explore the perspectives of frontline staff, patients, and family caregivers (Phase II). Thematic analysis will be used to examine the impact of payment policy and COVID-19 on organizational operations, care delivery, and patient outcomes. The results of this study intend to develop evidence addressing concerns about the unintended consequences of the PAC payment policy during the COVID-19 pandemic.
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Affiliation(s)
- Natalie E. Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA 15219, USA; (S.A.R.); (A.D.S.)
| | - Stephanie A. Rouch
- Department of Occupational Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA 15219, USA; (S.A.R.); (A.D.S.)
- The Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Rachel A. Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98195, USA; (R.A.P.); (H.K.); (T.M.M.)
| | - Amanda D. Shore
- Department of Occupational Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA 15219, USA; (S.A.R.); (A.D.S.)
| | - Hannah Kaufman
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98195, USA; (R.A.P.); (H.K.); (T.M.M.)
| | - Lorelei P. Hoover
- Department of Occupational Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA 15219, USA; (S.A.R.); (A.D.S.)
| | - Tracy M. Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98195, USA; (R.A.P.); (H.K.); (T.M.M.)
| | - Janet K. Freburger
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA 15219, USA;
| | - Debra Saliba
- Veterans Affairs (VA) Greater Los Angeles Geriatrics Research Education and Clinical Center (GRECC), Los Angeles, CA 90095, USA;
- Borun Center, University of California, Los Angeles, CA 90095, USA
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Burke LG, Burke RC, Duggan CE, Figueroa JF, John Orav E, Marcantonio ER. Trends in healthy days at home for Medicare beneficiaries using the emergency department. J Am Geriatr Soc 2023; 71:3122-3133. [PMID: 37300394 PMCID: PMC10592590 DOI: 10.1111/jgs.18464] [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] [Received: 02/07/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status. METHODS We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status. RESULTS We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD. CONCLUSIONS Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - E. John Orav
- Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
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Li CY, Kim H, Downer B, Lee MJ, Ottenbacher K, Kuo YF. Addressing non-response data for standardized post-acute functional items. BMC Health Serv Res 2023; 23:955. [PMID: 37674152 PMCID: PMC10481609 DOI: 10.1186/s12913-023-09982-8] [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] [Received: 02/09/2023] [Accepted: 08/29/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND The post-acute patient standardized functional items (Section GG) include non-response options such as refuse, not attempt and not applicable. We examined non-response patterns and compared four methods to address non-response functional data in Section GG at nation-wide inpatient rehabilitation facilities (IRF). METHODS We characterized non-response patterns using 100% Medicare 2018 data. We applied four methods to generate imputed values for each non-response functional item of each patient: Monte Carlo Markov Chains multiple imputations (MCMC), Fully Conditional Specification multiple imputations (FCS), Pattern-mixture model (PMM) multiple imputations and the Centers for Medicare and Medicaid Services (CMS) approach. We compared changes of Spearman correlations and weighted kappa between Section GG and the site-specific functional items across impairments before and after applying four methods. RESULTS One hundred fifty-nine thousand six hundred ninety-one Medicare fee-for-services beneficiaries admitted to IRFs with stroke, brain dysfunction, neurologic condition, orthopedic disorders, and debility. At discharge, 3.9% (self-care) and 61.6% (mobility) of IRF patients had at least one non-response answer in Section GG. Patients tended to have non-response data due to refused at discharge than at admission. Patients with non-response data tended to have worse function, especially in mobility; also improved less functionally compared to patients without non-response data. Overall, patients coded as 'refused' were more functionally independent in self-care and patients coded as 'not applicable' were more functionally independent in transfer and mobility, compared to other non-response answers. Four methods showed similar changes in correlations and agreements between Section GG and the site-specific functional items, but variations exist across impairments between multiple imputations and the CMS approach. CONCLUSIONS The different reasons for non-response answers are correlated with varied functional status. The high proportion of patients with non-response data for mobility items raised a concern of biased IRF quality reporting. Our findings have potential implications for improving patient care, outcomes, quality reporting, and payment across post-acute settings.
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Affiliation(s)
- Chih -Ying Li
- Department of Occupational Therapy, School of Health Professions, University of Texas Medical Branch, Rm 3.906, 301 University Blvd., Galveston, TX, 77555-1142, USA.
- Department of Population Health and Health Disparities, School of Public and Population Health, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Hyunkyoung Kim
- Office of Biostatistics, Department of Preventive Medicine & Public Health, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-1148, USA
| | - Brian Downer
- Department of Population Health and Health Disparities, School of Public and Population Health, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA
| | - Mi Jung Lee
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA
| | - Kenneth Ottenbacher
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA
| | - Yong-Fang Kuo
- Office of Biostatistics, Department of Preventive Medicine & Public Health, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-1148, USA
- Sealy Center On Aging, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0177, USA
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10
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Zhu Y, Stearns SC. Hospital safety-net status and postdischarge outcomes: The impact of socioeconomic status and Medicare post-acute care types. J Eval Clin Pract 2023; 29:955-963. [PMID: 36807665 DOI: 10.1111/jep.13815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/19/2023] [Accepted: 01/29/2023] [Indexed: 02/21/2023]
Abstract
AIM To examine the impact of socioeconomic status (SES) and postacute care (PAC) locations on the association between hospital safety-net status and 30-day postdischarge outcomes (readmission, hospice use, or death). METHOD Medicare Current Beneficiary Survey (MCBS) participants during 2006-2011 who were Medicare Fee-for-Service beneficiaries aged 65.5 years or older were included. The associations between hospital safety-net status and 30-day post-discharge outcomes were evaluated by comparing the models with and without PAC and SES adjustments. Safety-net hospital status was defined as being in the top 20% of hospitals ranked by hospital-level percent of total Medicare patient days. SES was measured using individual-level SES (dual eligibility, income, and education) and the Area Deprivation Index (ADI). RESULTS This study identified 13,173 index hospitalizations for 6,825 patients; 1,428 hospitalizations (11.8%) were in safety-net hospitals. The average unadjusted 30-day hospital readmission rate was 22.6% in safety-net hospitals versus 18.8% in nonsafety-net hospitals. Regardless of whether patient SES status was controlled or not, safety-net hospitals had higher estimated probabilities of 30-day readmission (ranging from 0.217 to 0.222 vs. 0.184 to 0.189), and lower probabilities for having neither readmission nor hospice/death (0.750-0.763 vs. 0.780-0.785); for models additionally adjusted for PAC types, safety-net patients had lower rates of hospice use or death (0.019-0.027 vs. 0.030-0.031). CONCLUSIONS The results suggested that safety-net hospitals had lower hospice/death rates but higher readmission rates relative to outcomes at nonsafety-net hospitals. Readmission rate differences were similar regardless of patients' SES status. However, the rate of hospice referral or death rate was related to SES, which suggested that the outcomes were affected by SES and PAC types.
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Affiliation(s)
- Ye Zhu
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Aihie NS, Hougen HY, Kwon D, Punnen S, Nahar B, Parekh DJ, Gonzalgo ML, Ritch CR. Predictors of discharge to home following major surgery for urologic malignancies: Results from the national surgical quality improvement program. Urol Oncol 2023; 41:392.e19-392.e25. [PMID: 37495474 DOI: 10.1016/j.urolonc.2023.07.003] [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: 03/18/2023] [Revised: 06/16/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES To identify patient risk factors that predict nonhome discharge after surgery for urologic malignancies as well as determine whether discharge status had an impact on readmission rates in patients undergoing surgery for urologic malignancies. METHODS We identified patients who had undergone surgery for urologic malignancies including prostate, bladder, kidney, or upper tract urothelial cancer from 2011 to 2019 in the American College of Surgeon National Surgical Quality Improvement Program (ACS-NSQIP) database. Multivariable logistic regression analyses were performed to identify patient characteristics that were associated with nonhome discharges and 30-day postoperative readmission. RESULTS Nonhome discharge occurred in 2.8% of our study population. Women were less likely to be discharged to home (OR 0.60 p < 0.0001). Nonhome discharge was more common in patients who underwent cystectomy when compared to nephrectomy (OR 1.41 p < 0.0001) or prostatectomy (OR 4.16 p < 0.0001). Those with elevated BMI were less likely to experience non-home discharge (OR 0.86 p=0.0095) while patients who were identified as underweight and those with unexpected weight loss prior to surgery were more likely to have nonhome discharges (OR 1.76 p = 0.0002, OR 1.67, p < 0.0001). Comorbidities and presence of postoperative complications were also found to be significant independent predictors of nonhome discharges. Thirty-day postoperative readmission occurred in 6.9% of our study population. Of the patients who were readmitted 93.1% were initially discharged home, and 6.9% had nonhome discharges. Higher risk of readmission was seen in elderly patients and those with significant comorbidities. When controlling for predictors of readmission, on multivariate analysis, non-home discharge was associated with a decreased likelihood of readmission (OR 0.79, p = 0.0004). CONCLUSIONS Patient factors including age, gender, weight, comorbidities, postoperative complications, and site of procedure were found to be independent predictors of non-home discharge following surgery for urologic malignancies. Patients with these risk factors should be counseled preoperatively on the likelihood of requiring a non-home discharge to help manage expectations and create a standardized transition of care pathway following surgery.
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Affiliation(s)
- Nehizena S Aihie
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Helen Y Hougen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deukwoo Kwon
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sanoj Punnen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA
| | - Bruno Nahar
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA
| | - Dipen J Parekh
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA
| | - Mark L Gonzalgo
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA
| | - Chad R Ritch
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester ComprehensiveCancerCenter, Miami, FL, USA.
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Young DL, Johnson JK, Guo N, Tereshchenko LG, Martinez M, Rothberg MB. Association between physical therapy frequency and postacute care for a national cohort of patients hospitalized with pneumonia. J Hosp Med 2023; 18:803-811. [PMID: 37545436 DOI: 10.1002/jhm.13186] [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: 01/26/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Annually more than 300,000 patients hospitalized for pneumonia need postacute care. Patients and systems prefer home discharge, but physical limitations often necessitate postacute care. It is unknown whether frequency of physical therapy in the hospital affects postacute care discharges. OBJECTIVE Examine the relationship between physical therapy visit frequency and disposition among a national sample of patients hospitalized with pneumonia. DESIGNS Observational cohort study. SETTING Acute care hospital. PARTICIPANTS Adult patients with primary diagnosis of pneumonia in the Premier Data Set who received physical therapy in the hospital during a 5-day window, with therapy on at least days 1 and 5. INTERVENTION Physical therapy visit frequency. MAIN OUTCOME AND MEASURES Discharge disposition (home or postacute care). RESULTS We included 18,886 patients from 595 hospitals. Just over half were discharged home (n = 9638; 51.0%) and 558 (2.95%) died. Patients getting more frequent therapy were older, non-Hispanic white, treated in small non-teaching rural hospitals in the West, Midwest, or South, and had fewer severe illness indicators. In adjusted models, patients who received physical therapy on 100% of days were 7% [(95% confidence interval, 4.3-9.7), p < .0001] more likely to go home than patients who received physical therapy on 40% of days. As a falsification test, we found that there was no relationship between physical therapy frequency and all-cause mortality. Physical therapy visit frequency was positively associated with discharge to home. Increasing visit frequency of physical therapy in hospitals might reduce the need for postacute care, but randomized controlled trials are needed to confirm the effect.
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Affiliation(s)
- Daniel L Young
- Department of Physical Therapy, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Joshua K Johnson
- Department of Physical Medicine & Rehabilitation, Cleveland Clinic, Cleveland, Ohio, USA
- Rehabilitation and Sports Therapy, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ning Guo
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Maylyn Martinez
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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Hayes HA, Mor V, Wei G, Presson A, McDonough C. Medicare Advantage Patterns of Poststroke Discharge to an Inpatient Rehabilitation or Skilled Nursing Facility: A Consideration of Demographic, Functional, and Payer Factors. Phys Ther 2023; 103:pzad009. [PMID: 37014280 PMCID: PMC10655208 DOI: 10.1093/ptj/pzad009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/19/2022] [Accepted: 12/05/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the factors influencing the discharge to an inpatient rehabilitation facility (IRF) or a skilled nursing facility (SNF) of people poststroke with Medicare Advantage plans. METHODS A retrospective cohort study was conducted with data from naviHealth, a company that manages postacute care discharge placement on behalf of Medicare Advantage organizations. The dependent variable was discharge destination (IRF or SNF). Variables included age, sex, prior living setting, functional status (Activity Measure for Post-Acute Care [AM-PAC]), acute hospital length of stay, comorbidities, and payers (health plans). Analysis estimated relative risk (RR) of discharge to SNF, while controlling for regional variation. RESULTS Individuals discharged to an SNF were older (RR = 1.17), women (RR = 1.05), lived at home alone or in assisted living (RR = 1.13 and 1.39, respectively), had comorbidities impacting their function "some" or "severely" (RR = 1.43 and 1.81, respectively), and had a length of stay greater than 5 days (RR = 1.16). Individuals with better AM-PAC Basic Mobility (RR = 0.95) went to an IRF, and individuals with better Daily Activity (RR = 1.01) scores went to an SNF. There was a substantial, significant variation in discharge of individuals to SNF by payer group (RR range = 1.12-1.92). CONCLUSIONS The results of this study show that individuals poststroke are more likely to be discharged to an SNF than to an IRF. This study did not find a different discharge decision-making picture for those with Medicare Advantage plans than previously described for other insurance programs. IMPACT Medicare Advantage payers have varied patterns in discharge placement to an IRF or SNF for patients poststroke.
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Affiliation(s)
- Heather A Hayes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Providence Veteran’s Administration Medical Center, Providence, Rhode Island, USA
| | - Guo Wei
- Study Design and Biostatistics Center, University of Utah, Salt Lake City, Utah, USA
| | - Angela Presson
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Christine McDonough
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ren R, Dominy C, Bueno B, Pasik S, Markowitz J, Yeshoua B, Cho B, Arvind V, Valliani AA, Kim J, Cho S. Weekend Admission Increases Risk of Readmissions Following Elective Cervical Spinal Fusion. Neurospine 2023; 20:290-300. [PMID: 37016876 PMCID: PMC10080455 DOI: 10.14245/ns.2244816.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/10/2023] [Indexed: 04/03/2023] Open
Abstract
Objective: The “weekend effect” occurs when patients cared for during weekends versus weekdays experience worse outcomes. But reasons for this effect are unclear, especially amongst patients undergoing elective cervical spinal fusion (ECSF). Our aim was to analyze whether index weekend admission affects 30- and 90-day readmission rates post-ECSF.Methods: All ECSF patients > 18 years were retrospectively identified from the 2016–2018 Healthcare Cost and Utilization Project Nationwide Readmissions Database (NRD), using unique patient linkage codes and International Classification of Diseases, Tenth Revision codes. Patient demographics, comorbidities, and outcomes were analyzed. Univariate logistic regression analyzed primary outcomes of 30- and 90-day readmission rates in weekday or weekend groups. Multivariate regression determined the impact of complications on readmission rates.Results: Compared to the weekday group (n = 125,590), the weekend group (n = 1,026) held a higher percentage of Medicare/Medicaid insurance, incurred higher costs, had longer length of stay, and fewer routine home discharge (all p < 0.001). There was no difference in comorbidity burden between weekend versus weekday admissions, as measured by the Elixhauser Comorbidity Index (p = 0.527). Weekend admissions had higher 30-day (4.30% vs. 7.60%, p < 0.001) and 90-day (7.80% vs. 16.10%, p < 0.001) readmission rates, even after adjusting for sex, age, insurance status, and comorbidities. All-cause complication rates were higher for weekend admissions (8.62% vs. 12.7%, p < 0.001), specifically deep vein thrombosis, infection, neurological conditions, and pulmonary embolism.Conclusion: Index weekend admission increases 30- and 90-day readmission rates after ECSF. In patients undergoing ECSF on weekends, postoperative care for patients at risk for specific complications will allow for improved outcomes and health care utilization.
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Affiliation(s)
- Renee Ren
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Calista Dominy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian Bueno
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Pasik
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan Markowitz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brandon Yeshoua
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varun Arvind
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aly A. Valliani
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Corresponding Author Samuel Cho Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA
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15
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Torrini I, Lucifora C, Russo AG. The Long-Term Effects of Hospitalization on Health Care Expenditures: An Empirical Analysis for the Young-Old Population in Lombardy. Health Policy 2023; 132:104803. [PMID: 37030272 DOI: 10.1016/j.healthpol.2023.104803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023]
Abstract
As the burden of acute care on government budgets is mounting in many countries, documenting the evolution of health costs following patients' hospital admission is essential for assessing overall hospital-related costs. In this paper, we investigate the short- and long-term effects of hospitalization on different types of health care expenditures. We specify and estimate a dynamic DID model using register data of the entire population of individuals aged 50-70 residing in Milan, Italy, over the period 2008-2017. We find evidence of a large and persistent effect of hospitalization on total health care expenditures, with future medical expenses mostly accounted for by inpatient care. Considering all health treatments, the overall effect is sizable and is about twice the cost of a single hospital admission. We show that chronically ill and disabled individuals require greater post-discharge medical assistance, especially for inpatient care, and that cardiovascular and oncological diseases together account for more than half of expenditures on future hospitalizations. Alternative out-of-hospital management practices are discussed as a post-admission cost-containment measure.
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Affiliation(s)
- Irene Torrini
- Department of Economics, Quantitative Methods and Business Strategies, University of Milan - Bicocca, Piazza dell'Ateneo Nuovo 1, Milan 20126, Italy.
| | - Claudio Lucifora
- Department of Economics and Finance, Catholic University of Milan, Italy
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16
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Postacute Care Utilization and Episode of Care Payments Following Common Elective Operations. Ann Surg 2023; 277:e266-e272. [PMID: 33630438 DOI: 10.1097/sla.0000000000004814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe PAC utilization and associated payments for patients undergoing common elective procedures. SUMMARY OF BACKGROUND DATA Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures. METHODS Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012 to 2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization. RESULTS Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7830, P < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9439, P < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8062, P < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.29-2.02, P < 0.001]. Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, P < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, P = 0.039). CONCLUSIONS We found both modifiable (eg, obesity) and nonmodifiable (eg, female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors and systems and processes to address these factors.
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17
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Association of Skilled Nursing Facility Participation in Voluntary Bundled Payments With Postacute Care Outcomes for Joint Replacement. Med Care 2023; 61:109-116. [PMID: 36630561 DOI: 10.1097/mlr.0000000000001799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE The Medicare Bundled Payments for Care Improvement (BPCI) model 3 of 2013 holds participating skilled nursing facilities (SNFs) responsible for all episode costs. There is limited evidence regarding SNF-specific outcomes associated with BPCI. OBJECTIVE To examine the association between SNF BPCI participation and patient outcomes and across-facility differences in these outcomes among Medicare beneficiaries undergoing lower extremity joint replacement (LEJR). DESIGN, SETTING, AND PARTICIPANTS Observational difference-in-differences (DID) study of 2013-2017 for 330 unique persistent-participating SNFs, 146 unique dropout SNFs, and 14,028 unique eligible nonparticipating SNFs. MAIN OUTCOME MEASURES Rehospitalization within 30 and 90 days after SNF admission, and rate of successful discharge from the SNF to the community. RESULTS Total 636,355 SNF admissions after LEJR procedures were identified for 582,766 Medicare patients [mean (SD) age, 76.81 (9.26) y; 424,076 (72.77%) women]. The DID analysis showed that for persistent-enrollment SNFs, no BPCI-related changes were found in readmission and successful community discharge rates overall, but were found for their subgroups. Specifically, under BPCI, the 30-day readmission rate decreased by 2.19 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, and by 1.75 percentage-points for non-Medicaid-dependent SNFs in the persistent-participating group relative to those in the nonparticipating group; and the rate of successful community discharge increased by 4.44 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, whereas such relationship was not detected among non-White-serving SNFs, leading to increased between-facility differences (differential DID=-7.62). BPCI was not associated with readmission or successful community discharge rates for dropout SNFs, overall, or in subgroup analyses. CONCLUSIONS Among Medicare patients receiving LEJR, BPCI was associated with improved outcomes for White-serving/non-Medicaid-dependent SNFs but not for other SNFs, which did not help reduce or could even worsen the between-facility differences.
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18
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Hayes HA, Marcus R, Stoddard GJ, McFadden M, Magel J, Hess R. Is the Activity Measure for Postacute Care "6-Clicks" Tool Associated With Discharge Destination Postacute Stroke? Arch Rehabil Res Clin Transl 2022; 4:100228. [PMID: 36545521 PMCID: PMC9761263 DOI: 10.1016/j.arrct.2022.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective To investigate the association of poststroke physical function, measured within 24 hours prior to discharge from the acute care hospital using Activity Measure for Postacute Care (AM-PAC) Inpatient "6-Clicks" scores and discharge destination (home vs facility and inpatient rehabilitation facility [IRF] vs skilled nursing facility [SNF]). Design Retrospective cross-sectional cohort study. Setting Acute care, University Hospital. Participants Individuals post acute ischemic stroke, N=721, 51.3% male, mean age 63.6±16.4 years. Interventions Not applicable. Main Outcome Measures AM-PAC "6-Clicks" 3 domains: basic mobility, daily activity, and applied cognition. Results AM-PAC basic mobility and daily activity were significant predictors of discharge. Those in the home discharge group had AM-PAC basic mobility mean t scale score of 48.5 compared with a score of 34.8 for individuals sent to a facility and daily activity score of 47.2 compared with 32.7 for individuals sent to a facility. The AM-PAC variables accounted for an additional 24% of the variance in the discharge destination, with basic mobility and daily activity accounting for most of the variance.The AM-PAC scores were not statistically different and were not able to discriminate between placement in an IRF vs SNF. The mean basic mobility t scale score for individuals going to an IRF was 34.9 compared with 34.6 for those going to an SNF. The daily activity score for IRF was 32.8 compared with 32.6 for SNF. The AM-PAC accounted for no additional variance in discharge destination to an IRF or SNF. Conclusions The AM-PAC Inpatient "6-Clicks" 3 domains are able to distinguish individuals with stroke being discharged to home from postacute care (PAC) but not for differentiating between PAC facilities (IRF vs SNF) in this cohort of individuals post stroke.
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Affiliation(s)
- Heather Anne Hayes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | - Robin Marcus
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | | | - Molly McFadden
- Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Jake Magel
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | - Rachel Hess
- Division of Health System Innovation and Research, University of Utah, Salt Lake City, UT
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Zhu Y, Stearns SC, Holmes GM. The contributions of survey-based versus administrative measures of socioeconomic status in predicting type of post-acute care for hospitalized Medicare beneficiaries. J Eval Clin Pract 2022; 28:569-580. [PMID: 34940987 DOI: 10.1111/jep.13647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess and compare the associations between socioeconomic status (SES) measures from two sources (claims vs. survey data) and the type of post-acute care (PAC) locations following hospital discharge. METHODS This observational study included Medicare Fee-for-Service (FFS) beneficiaries age 65.5 years or older who participated in the Medicare Current Beneficiary Survey (MCBS) and were hospitalized in 2006-2011. Multiple data sets were used including: Area Deprivation Index; Medicare Cost Reports, Provider of Services files, and Area Health Resource File. Multinomial regression models estimated associations between beneficiary's SES and PAC type. SES measures came from surveys (income and education) and administrative records (dual enrollment and area deprivation). PAC types included home with self-care, home health agency, skilled nursing facility (SNF), or inpatient rehabilitation facility. RESULTS Low income and dual enrollment were associated with higher SNF use while living in a deprived area was associated with lower SNF use and higher use of home with self-care. Dual enrollment and area deprivation were associated with the largest differences. CONCLUSIONS If policies to modify payment based on SES are considered, administrative measures (dual enrollment and area deprivation) rather than survey measures (education and income) may be sufficient.
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Affiliation(s)
- Ye Zhu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Sally C Stearns
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - George M Holmes
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
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Levine DM, Cueva MA, Shi S, Limaj I, Wambolt B, Grabowski DC, Schnipper JL, Pu CT. Skilled Nursing Facility Care at Home for Adults Discharged From the Hospital: A Pilot Randomized Controlled Trial. J Appl Gerontol 2022; 41:1585-1594. [PMID: 35266835 DOI: 10.1177/07334648221077092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The ability to deliver SNF-level care at home is unclear. We sought to demonstrate the feasibility of rehabilitation at home (RAH) via a pilot randomized controlled trial. METHODS Daily care from a home health aide, certified nursing assistant, nurse, and physician. Core technologies included remote PT, automated medication dispensing, and continuous monitoring. Primary outcome: episode cost. RESULTS We randomized 10 patients. Home patients' episode cost a median $8404 (IQR, $2697) versus $9215 (IQR, $5702). LOS for both was 14 days. Home patients' ADLs improved between admission and 30-days post-discharge by median 4 (IQR, 5) versus 1 (IQR, 2). Home patients' median Picker patient experience score was 12/14 (IQR, 2) versus 7/14 (IQR, 3). DISCUSSION A RAH pilot compared favorably to traditional SNF, with trends toward lower cost, greater functional status improvement, and better patient experience. This delivery innovation could reimagine how we deliver post-acute care but requires replication. CLINICALTRIALS.GOV REGISTRATION NCT04048590.
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Affiliation(s)
- David M Levine
- Division of General Internal Medicine and Primary Care, 370908Brigham and Women's Hospital, Boston, MA, USA.,1811Harvard Medical School, Boston, MA, USA
| | - Mary A Cueva
- Division of General Internal Medicine and Primary Care, 370908Brigham and Women's Hospital, Boston, MA, USA
| | - Sandra Shi
- 1811Harvard Medical School, Boston, MA, USA
| | - Idriz Limaj
- Division of General Internal Medicine and Primary Care, 370908Brigham and Women's Hospital, Boston, MA, USA
| | | | - David C Grabowski
- 1811Harvard Medical School, Boston, MA, USA.,Department of Health Care Policy, 1811Harvard Medical School, Boston, MA, USA
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, 370908Brigham and Women's Hospital, Boston, MA, USA.,1811Harvard Medical School, Boston, MA, USA
| | - Charles T Pu
- 1811Harvard Medical School, Boston, MA, USA.,Division of Palliative Care & Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA.,Mass General Brigham Center for Population Health, Boston, MA, USA
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Chesley CF, Harhay MO, Small DS, Hanish A, Prescott HC, Mikkelsen ME. Hospital Readmission and Post-Acute Care Use After Intensive Care Unit Admissions: New ICU Quality Metrics? J Intensive Care Med 2022; 37:168-176. [PMID: 32912034 DOI: 10.1177/0885066620956633] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Care coordination is a national priority. Post-acute care use and hospital readmission appear to be common after critical illness. It is unknown whether specialty critical care units have different readmission rates and what these trends have been over time. METHODS In this retrospective cohort study, a cohort of 53,539 medical/surgical patients who were treated in a critical care unit during their index admission were compared with 209,686 patients who were not treated in a critical care unit. The primary outcome was 30-day all cause hospital readmission. Secondary outcomes included post-acute care resource use and immediate readmission, defined as within 7 days of discharge. RESULTS Compared to patients discharged after an index hospitalization without critical illness, surviving patients following ICU admission were not more likely to be rehospitalized within 30 days (15.8 vs. 16.1%, p = 0.08). However, they were more likely to receive post-acute care services (45.3% vs. 70.9%, p < 0.001) as well as be rehospitalized within 7 days (5.2 vs. 6.0%, p < 0.001). Post-acute care use and 30-day readmission rates varied by ICU type, the latter ranging from 11.7% after admission in a cardiothoracic critical care unit to 23.1% after admission in a medical critical care unit. 30-day readmission after ICU admission did not decline between 2010 and 2015 (p = 0.38). Readmission rates declined over time for 2 of 4 targeted conditions (heart failure and chronic obstructive pulmonary disease), but only when the hospitalization did not include ICU admission. CONCLUSIONS Rehospitalization for survivors following ICU admission is common across all specialty critical care units. Post-acute care use is also common for this population of patients. Overall trends for readmission rates after critical illness did not change over time, and readmission reductions for targeted conditions were limited to hospitalizations that did not include an ICU admission.
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Affiliation(s)
- Christopher F Chesley
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael O Harhay
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Dylan S Small
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Statistics, The Wharton School The Wharton School at the University of Pennsylvania, Philadelphia, PA, USA
| | - Asaf Hanish
- Penn Medicine, Center for Predictive, Healthcare, Philadelphia, PA, USA
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Ying M, Temkin-Greener H, Thirukumaran CP, Maddox KEJ, Holloway RG, Li Y. Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance. Med Care 2022; 60:83-92. [PMID: 34812788 PMCID: PMC8665005 DOI: 10.1097/mlr.0000000000001659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents. OBJECTIVE The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance. DESIGN, SETTING, AND PARTICIPANTS A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs. MAIN OUTCOME MEASURES Inflation-adjusted operating expenses, revenues, profit, and profit margin. RESULTS BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures. CONCLUSIONS BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.
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Affiliation(s)
- Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Helena Temkin-Greener
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Caroline Pinto Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY
| | - Karen E. Joynt Maddox
- Cardiovascular Division, School of Medicine, Washington University in St. Louis, St. Louis, MO
- Center for Health Economics and Policy, Washington University Institute for Public Health, St. Louis, MO
| | - Robert G. Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
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23
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Gazendam A, Zhu M, Chang Y, Phillips S, Bhandari M. Virtual reality rehabilitation following total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc 2022; 30:2548-2555. [PMID: 35182172 PMCID: PMC8857886 DOI: 10.1007/s00167-022-06910-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/27/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE The use of virtual reality (VR) based rehabilitation has increased substantially within orthopedic surgery, particularly in the field of total knee arthroplasty (TKA). The objective of this systematic review and meta-analysis was to compare patient-reported outcomes and cost analyses from randomized controlled trials (RCT) utilizing VR-based rehabilitation in patients following TKA. METHODS MEDLINE, EMBASE, and Cochrane databases were searched for RCTs involving VR-based rehabilitation following TKA. Quantitative synthesis was conducted for pain scores and functional outcomes. Narrative outcomes were reported for results not amenable to quantitative synthesis. RESULTS A total of 9 RCTs with 835 patients were included with follow-up ranging from 10 days to 6 months postoperatively. No differences in pain scores were demonstrated between VR-based and traditional rehabilitation at 2 weeks and 3 months postoperatively. VR-based rehabilitation demonstrated improved functional outcomes at 12 weeks (n = 353) postoperatively [mean difference (MD) - 3.32, 95% confidence interval (CI) - 5.20 to - 1.45, moderate certainty evidence] and 6 months (n = 66) postoperatively [MD - 4.75, 95% CI - 6.69 to - 2.81, low certainty evidence], compared to traditional rehabilitation. One trial demonstrated significant cost savings with the use of VR-based rehabilitation. CONCLUSIONS VR-based rehabilitation for patients undergoing TKA represents an evolving field that may have advantages over traditional therapy for some patients. The current review is limited by the low quality of evidence in the literature. This is a rapidly evolving field with more trials needed to determine the impact of VR-based rehabilitation on patients undergoing TKA. LEVEL OF EVIDENCE Level I; meta-analysis of randomized controlled trials.
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Affiliation(s)
- Aaron Gazendam
- OrthoEvidence, Burlington, ON, Canada. .,Division of Orthopaedics, Department of Surgery, McMaster University, St. Joseph's Hospital, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
| | - Meng Zhu
- OrthoEvidence, Burlington, ON Canada
| | | | | | - Mohit Bhandari
- OrthoEvidence, Burlington, ON Canada ,Division of Orthopaedics, Department of Surgery, McMaster University, St. Joseph’s Hospital, Room G522, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
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24
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Boehmer KR, Pine KH, Whitman S, Organick P, Thota A, Espinoza Suarez NR, LaVecchia CM, Lee A, Behnken E, Thorsteinsdottir B, Pawar AS, Beck A, Lorenz EC, Albright RC. Do patients with high versus low treatment and illness burden have different needs? A mixed-methods study of patients living on dialysis. PLoS One 2021; 16:e0260914. [PMID: 34962932 PMCID: PMC8714126 DOI: 10.1371/journal.pone.0260914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/21/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Approximately 750,000 people in the U.S. live with end-stage kidney disease (ESKD); the majority receive dialysis. Despite the importance of adherence to dialysis, it remains suboptimal, and one contributor may be patients' insufficient capacity to cope with their treatment and illness burden. However, it is unclear what, if any, differences exist between patients reporting high versus low treatment and illness burden. METHODS We sought to understand these differences using a mixed methods, explanatory sequential design. We enrolled adult patients receiving dialysis, including in-center hemodialysis, home hemodialysis, and peritoneal dialysis. Descriptive patient characteristics were collected. Participants' treatment and illness burden was measured using the Illness Intrusiveness Scale (IIS). Participants scoring in the highest quartile were defined as having high burden, and participants scoring in the lowest quartile as having low burden. Participants in both quartiles were invited to participate in interviews and observations. RESULTS Quantitatively, participants in the high burden group were significantly younger (mean = 48.4 years vs. 68.6 years respectively, p = <0.001). No other quantitative differences were observed. Qualitatively, we found differences in patient self-management practices, such as the high burden group having difficulty establishing a new rhythm of life to cope with dialysis, greater disruption in social roles and self-perception, fewer appraisal focused coping strategies, more difficulty maintaining social networks, and more negatively portrayed experiences early in their dialysis journey. CONCLUSIONS AND RELEVANCE Patients on dialysis reporting the greatest illness and treatment burden have difficulties that their low-burden counterparts do not report, which may be amenable to intervention.
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Affiliation(s)
- Kasey R. Boehmer
- Knoweldge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
| | - Kathleen H. Pine
- College of Health Solutions, Arizona State University, Phoenix, Arizona, United States of America
| | - Samantha Whitman
- Human & Social Dimensions of Science & Technology, Arizona State University, Phoenix, Arizona, United States of America
| | - Paige Organick
- Knoweldge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Anjali Thota
- Knoweldge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Nataly R. Espinoza Suarez
- Knoweldge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Christina M. LaVecchia
- Knoweldge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, United States of America
- Neumann University, Aston, Pennsylvania, United States of America
| | - Alexander Lee
- Health Services Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Emma Behnken
- Knoweldge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Bjorg Thorsteinsdottir
- Knoweldge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota, United States of America
- Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Aditya S. Pawar
- Neprhology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Annika Beck
- Bioethics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Elizabeth C. Lorenz
- Neprhology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Robert C. Albright
- Neprhology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America
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25
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Serper M, Tao SY, Kent DS, Garren P, Burdzy AE, Lai JC, Gougol A, Bloomer PM, Reddy KR, Dunn MA, Duarte-Rojo A. Inpatient Frailty Assessment Is Feasible and Predicts Nonhome Discharge and Mortality in Decompensated Cirrhosis. Liver Transpl 2021; 27:1711-1722. [PMID: 34018303 PMCID: PMC8809112 DOI: 10.1002/lt.26100] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/13/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
Objective inpatient frailty assessments in decompensated cirrhosis are understudied. We examined the feasibility of inpatient frailty measurements and associations with nonhome discharge, readmission, and all-cause mortality among patients admitted for cirrhosis complications. We conducted a prospective study at 3 liver transplantation (LT) centers. Frailty was assessed using the liver frailty index (LFI). Multivariable logistic and competing risk models evaluated associations between frailty and clinical outcomes. We included 211 patients with median MELD-Na score 21 (interquartile range [IQR],15-27); 96 (45%) were women, and 102 (48%) were on the LT waiting list. At a median follow-up of 8.3 months, 29 patients (14%) were nonhome discharged, 144 (68%) were readmitted, 70 (33%) underwent LT, and 44 (21%) died. A total of 124 patients (59%) were frail, with a median LFI of 4.71 (IQR, 4.07-5.54). Frail patients were older (mean, 59 versus 54 years) and more likely to have chronic kidney disease (40% versus 20%; P = 0.002) and coronary artery disease (17% versus 7%; P = 0.03). Frailty was associated with hospital-acquired infections (8% versus 1%; P = 0.02). In multivariable models, LFI was associated with nonhome discharge (odds ratio, 1.81 per 1-point increase; 95% confidence interval [CI], 1.14-2.86). Frailty (LFI≥4.5) was associated with all-cause mortality in models accounting for LT as competing risk (subhazard ratio [sHR], 2.4; 95% CI, 1.13-5.11); results were similar with LFI as a continuous variable (sHR, 1.62 per 1-point increase; 95% CI, 1.15-2.28). A brief, objective inpatient frailty assessment was feasible and predicted nonhome discharge and mortality in decompensated cirrhosis. Inpatient point-of-care frailty assessment prior to hospital discharge can be useful for risk stratification and targeted interventions to improve physical fitness and reduce adverse outcomes.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Sunny Y. Tao
- University of Pittsburgh Medical Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA
| | - Dorothea S. Kent
- University of Pittsburgh Medical Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA
| | - Patrik Garren
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Alexander E. Burdzy
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jennifer C. Lai
- Division of Gastroenterology/Hepatology, University of California San Francisco, San Francisco, CA
| | - Amir Gougol
- University of Pittsburgh Medical Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA
| | - Pamela M. Bloomer
- Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael A. Dunn
- University of Pittsburgh Medical Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA,Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Andres Duarte-Rojo
- University of Pittsburgh Medical Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA,Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
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Burke RE, Xu Y, Ritter AZ. Use of Post-Acute Care by Medicare Beneficiaries With a Diagnosis of Dementia. J Am Med Dir Assoc 2021; 23:877-879.e3. [PMID: 34644532 DOI: 10.1016/j.jamda.2021.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Hospitalized patients with dementia transitioning to post-acute care may be particularly vulnerable to changes in post-acute care utilization driven by payment reforms; however, use of post-acute care in this population is incompletely understood. We sought to describe post-acute care utilization in skilled nursing facilities (SNFs) and from home health (HH) agencies among Medicare beneficiaries with a diagnosis of dementia. DESIGN Retrospective, observational study using 100% sample of Medicare beneficiaries from 2013 to 2016. SETTING AND PARTICIPANTS We identified hospitalizations and diagnoses using Medicare Provider Analysis and Review (MedPAR), SNF stays using the Minimum Data Set, HH episodes using the Outcome and Assessment Information Set, and dementia diagnoses using the Medicare Beneficiary Summary File Chronic Conditions segment. METHODS We calculated overall utilization and trends in post-acute care use over time, stratified by dementia diagnosis, type of post-acute care (SNF vs HH), and payer (fee-for-service vs Medicare Advantage). RESULTS Of the 9,762,208 Medicare fee-for-service beneficiaries who received post-acute care from 2013 to 2016, 3,155,560 (32.3%) carried a diagnosis of dementia. Rates of post-acute care use were similar over time. More beneficiaries with a diagnosis of dementia received post-acute care (44.2% vs 27.7%) and proportionally more SNF care (71.7% vs 49.6%). Overall use and trends were similar in the Medicare Advantage population. CONCLUSIONS AND IMPLICATIONS One-third of all fee-for-service Medicare beneficiaries receiving post-acute care have a diagnosis of dementia, and more than 7 in 10 receive this care in an SNF. These findings serve as a foundation for needed evaluations of how best to meet the post-hospital needs of older adults with dementia.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA; Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Yao Xu
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Z Ritter
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
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Pierce J, Needham K, Adams C, Coppolecchia A, Lavernia C. Robotic-assisted total hip arthroplasty: an economic analysis. J Comp Eff Res 2021; 10:1225-1234. [PMID: 34581189 DOI: 10.2217/cer-2020-0255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Aim: To evaluate 90-day episode-of-care (EOC) resource consumption in robotic-assisted total hip arthroplasty (RATHA) versus manual total hip arthroplasty (mTHA). Methods: THA procedures were identified in Medicare 100% data. After propensity score matching 1:5, 938 RATHA and 4,670 mTHA cases were included. 90-day EOC cost, index costs, length of stay and post-index rehabilitation utilization were assessed. Results: RATHA patients were significantly less likely to have post-index inpatient rehabilitation or skilled nursing facility admissions and used fewer home health agency visits, compared with mTHA patients. Total 90-day EOC costs for RATHA patients were found to be US$785 less than those of mTHA patients (p = 0.0095). Conclusion: RATHA was associated with an overall lower 90-day EOC cost when compared with mTHA. The savings associated with RATHA were driven by reduced utilization and cost of post-index rehabilitation services.
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Affiliation(s)
| | | | | | | | - Carlos Lavernia
- Department of Biomedical Engineering, University of Miami, Miami, FL, USA
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28
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Abstract
BACKGROUND Hospitals are facing incentives to manage the total cost of care for episodes of illness, including the costs of inpatient care as well as the cost of care provided by physicians and postacute care (PAC) providers. PAC is an especially important component of the overall cost of care. One strategy hospitals employ in managing this cost is to own PAC providers. Prior work on the relationship between PAC ownership and cost has reached mixed conclusions. PURPOSE The aim of this study was to examine the associations between the episodic costs of care and hospital ownership of PAC providers, including skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRF). METHODOLOGY We examine panel data on hospital ownership of PAC providers from the American Hospital Association for 2013-2015 and cost of care data from Centers for Medicare & Medicaid Services' Value-Based Purchasing Program. Using ordinary least squares, we quantify the association between a hospital's PAC ownership choice (both ownership of any PAC provider and ownership of particular types of providers) and the episodic cost of care. RESULTS In 2015, 80% of hospitals owned some type of PAC provider. We find that ownership of SNFs and HHAs is associated with a lower episodic cost of care, whereas ownership of inpatient rehabilitation facilities is associated with higher episodic costs of care. The effects of ownership do not differ for hospitals that participate in a voluntary shared saving program (Bundled Payment for Care Improvement). CONCLUSION The effects of PAC ownership vary by the type of PAC provider owned. Our results suggest that ownership of SNFs and HHAs may be a viable strategy for success in reimbursement programs that reward hospitals for managing the total costs for episodes of care.
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29
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Jordan N, Deutsch A. Why and How to Demonstrate the Value of Rehabilitation Services. Arch Phys Med Rehabil 2021; 103:S172-S177. [PMID: 34407445 DOI: 10.1016/j.apmr.2021.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/29/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022]
Abstract
The health care delivery landscape in the United States is changing as payment models consider both costs and health outcomes, which are key components of value in health care. Without evidence about the effectiveness and costs of rehabilitation interventions, it is difficult to judge the value of rehabilitation interventions. Understanding the short- and long-term costs associated with implementing a rehabilitation intervention and the intervention's cost-effectiveness compared with other alternatives is critical to supporting decision-making by policymakers, health care administrators, and other decision makers. This article describes the policy context for considering the costs and outcomes of postacute care and rehabilitation interventions, introduces methods for assessing the value of rehabilitation interventions, and summarizes the challenges and opportunities associated with applying value measurement to rehabilitation services. Assessing the value of rehabilitation interventions is critical as we continue to identify, implement, and sustain evidence-based interventions that promote the health and function of people with disabilities.
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Affiliation(s)
- Neil Jordan
- Northwestern University Feinberg School of Medicine, Chicago, IL; Edward J Hines Jr Hospital VA, Hines, IL.
| | - Anne Deutsch
- Northwestern University Feinberg School of Medicine, Chicago, IL; Shirley Ryan AbilityLab, Chicago, IL; RTI International, Chicago, IL
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30
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Burke RE, Xu Y, Ritter AZ, Werner RM. Postacute care outcomes in home health or skilled nursing facilities in patients with a diagnosis of dementia. Health Serv Res 2021; 57:497-504. [PMID: 34389982 DOI: 10.1111/1475-6773.13855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To compare the outcomes of postacute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with a diagnosis of dementia. DATA SOURCES 100% MedPAR data, Minimum Data Set, and Outcome and Assessment Information Set assessment data from January 1, 2015 to December 31, 2016. STUDY DESIGN Retrospective cohort analysis using an instrumental variable design to compare outcomes (30-day readmission and mortality, 100-day mortality) of HH versus SNF following acute hospitalization. We used the differential distance between patients' home and the closest HH agency and SNF to instrument for nonrandom allocation of patients. DATA COLLECTION/EXTRACTION METHODS We identified hospital discharges followed by SNF and HH stays for Medicare fee-for-service beneficiaries with dementia. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or enrolled in hospice. We identified dementia using validated diagnostic codes with a 3-year look-back. PRINCIPAL FINDINGS Our sample included 977,946 beneficiaries with a diagnosis of dementia; 297,732 (30.4%) received HH, while 680,214 (69.6%) went to SNF. Overall, 16.8% were readmitted to the hospital and 6.1% died within 30 days, while 15.4% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two postacute care settings. CONCLUSIONS Medicare beneficiaries with a diagnosis of dementia receiving postacute care in HH or SNF experienced similar rates of readmission and mortality across settings. This finding raises important questions about current postacute care referral patterns, given 7 in 10 patients with a diagnosis of dementia in our sample were discharged to SNF.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Yao Xu
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Z Ritter
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel M Werner
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Satheeshkumar PS, Mohan MP. Association and risk factors of healthcare-associated infection and burden of illness among chemotherapy-induced ulcerative mucositis patients. Clin Oral Investig 2021; 26:1323-1332. [PMID: 34355291 PMCID: PMC8342036 DOI: 10.1007/s00784-021-04106-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/24/2021] [Indexed: 12/18/2022]
Abstract
Objectives To evaluate the association and risk factors of healthcare-associated infection (HAI) and burden of illness among chemotherapy-induced ulcerative mucositis (UM) patients. Methods For this research, US National Inpatient Sample database 2017 was utilized to study UM patients. The association of healthcare-associated infection-related burden of illness among UM patients was assessed on the outcome––length of hospital stays (LOS), total charges, in-hospital mortality, and discharge disposition. Result In 2017, there were 11,350 adult (> 18 years of age) UM patients, among them there were 415 (3.5%) HAI. After adjusting for patient and clinical characteristics, UM patients with HAI were most likely to have higher total charges and longer LOS (1.91; 95% CIs: 1.51–2.41; P < 0.001; 1.84; 95% CIs: 1.53–2.21; P < 0.001) than those without HAI. Further, mortality was not significantly different. UM patients with HAI were less likely to have higher burden of illness who were younger, females, those living in non-metropolitan or micropolitan counties, and those with lower co-morbidity score. Additionally, UM patients with HAI were more likely to discharge to skilled nursing facility (SNF), intermediate care facility (ICF), and another type of facility (ATF), (aOR = 2.58 (1.16–5.76), P = 0.02), than they were to discharge to self-care or home care. Conclusion UM patients with HAI were more likely to have higher burden of illness and more likely to discharged to the SNF, ICF, and ATF rather than to home or self-care. Clinical relevance UM patients when associated with HAI have higher burden of illness; a tailored approach to oral care might prevent HAIs and burden of illness among UM. Supplementary Information The online version contains supplementary material available at 10.1007/s00784-021-04106-0.
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Affiliation(s)
- P. S. Satheeshkumar
- Harvard Medical School, Boston, MA 02115 USA
- Department of Oral Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263 USA
| | - M. P. Mohan
- Zuckerberg College of Health Sciences, University of Massachusetts, Lowell, MA 01854 USA
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32
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Sheets K, Kats AM, Langsetmo L, Mackey D, Fink HA, Diem SJ, Duan-Porter W, Cawthon PM, Schousboe JT, Ensrud KE. Life-space mobility and healthcare costs and utilization in older men. J Am Geriatr Soc 2021; 69:2262-2272. [PMID: 33961699 PMCID: PMC8542432 DOI: 10.1111/jgs.17187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To determine the association of life-space score with subsequent healthcare costs and utilization. DESIGN Prospective cohort study (Osteoporotic Fracture in Men [MrOS]). SETTING Six U.S. sites. PARTICIPANTS A total of 1555 community-dwelling men (mean age 79.3 years; 91.5% white, non-Hispanic) participating in the MrOS Year 7 (Y7) examination linked with their Medicare claims data. MEASUREMENTS Life-space during the past month was assessed as 0 (daily restriction to one's bedroom) to 120 (daily trips outside one's town without assistance) and categorized (0-40, 41-60, 61-80, 81-100, 101-120). Total annualized direct healthcare costs and utilization were ascertained during 36 months after the Y7 examination. RESULTS Mean total annualized costs (2020 U.S. dollars) steadily increased across category of life-space score, from $7954 (standard deviation [SD] 16,576) among men with life-space scores of 101-120 to $26,430 (SD 28,433) among men with life-space scores of 0-40 (p < 0.001). After adjustment for demographics, men with a life-space score of 0-40 versus men with a life-space score of 101-120 had greater mean total costs (cost ratio [CR] = 2.52; 95% confidence interval [CI] = 1.84-3.45) and greater risk of subsequent hospitalization (odds ratio [OR] 4.72, 95% CI 2.61-8.53) and skilled nursing facility (SNF) stay (OR 7.32, 95% CI 3.65-14.66). Life-space score was no longer significantly associated with total healthcare costs (CR for 0-40 vs 101-120 1.29; 95% CI 0.91-1.84) and hospitalization (OR 1.76, 95% CI 0.89-3.51) after simultaneous consideration of demographics, medical factors, self-reported health and function, and the frailty phenotype; the association of life-space with SNF stay remained significant (OR 2.86, 95% CI 1.26-6.49). CONCLUSION Our results highlight the importance of function and mobility in predicting future healthcare costs and suggest the simple and convenient life-space score may in part capture risks from major geriatric domains and improve identification of older, community-dwelling men likely to require costly care.
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Affiliation(s)
- Kerry Sheets
- Hennepin Healthcare, Minneapolis, Minnesota
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Allyson M. Kats
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Lisa Langsetmo
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Dawn Mackey
- Aging and Population Health Laboratory, Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Howard A. Fink
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, MN
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, MN
| | - Susan J. Diem
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, MN
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Wei Duan-Porter
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Peggy M. Cawthon
- Research Institute, California Pacific Medical Center, San Francisco, California
| | - John T. Schousboe
- HealthPartners Institute, Bloomington, MN
- Division of Health Policy & Management, University of Minnesota, Minneapolis, Minnesota
| | - Kristine E. Ensrud
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, MN
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
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Lussiez A, Montgomery JR, Sangji NF, Fan Z, Oliphant BW, Hemmila MR, Dimick JB, Scott JW. Hospital effects drive variation in access to inpatient rehabilitation after trauma. J Trauma Acute Care Surg 2021; 91:413-421. [PMID: 34108424 PMCID: PMC8375412 DOI: 10.1097/ta.0000000000003215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postacute care rehabilitation is critically important to recover after trauma, but many patients do not have access. A better understanding of the drivers behind inpatient rehabilitation facility (IRF) use has the potential for major cost-savings as well as higher-quality and more equitable patient care. We sought to quantify the variation in hospital rates of trauma patient discharge to inpatient rehabilitation and understand which factors (patient vs. injury vs. hospital level) contribute the most. METHODS We performed a retrospective cohort study of 668,305 adult trauma patients admitted to 900 levels I to IV trauma centers between 2011 and 2015 using the National Trauma Data Bank. Participants were included if they met the following criteria: age >18 years, Injury Severity Score of ≥9, identifiable injury type, and who had one of the Centers for Medicare & Medicaid Services preferred diagnoses for inpatient rehabilitation under the "60% rule." RESULTS The overall risk- and reliability-adjusted hospital rates of discharge to IRF averaged 18.8% in the nonelderly adult cohort (18-64 years old) and 23.4% in the older adult cohort (65 years or older). Despite controlling for all patient-, injury-, and hospital-level factors, hospital discharge of patients to IRF varied substantially between hospital quintiles and ranged from 9% to 30% in the nonelderly adult cohort and from 7% to 46% in the older adult cohort. Proportions of total variance ranged from 2.4% (patient insurance) to 12.1% (injury-level factors) in the nonelderly adult cohort and from 0.3% (patient-level factors) to 26.0% (unmeasured hospital-level factors) in the older adult cohort. CONCLUSION Among a cohort of injured patients with diagnoses that are associated with significant rehabilitation needs, the hospital at which a patient receives their care may drive a patient's likelihood of recovering at an IRF just as much, if not more, than their clinical attributes. LEVEL OF EVIDENCE Care management, level IV.
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Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - John R Montgomery
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - Naveen F Sangji
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Bryant W Oliphant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Mark R Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
| | - John W Scott
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Health Outcomes and Policy
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Gruss J, Smith CH. Demonstrating the vital role of physiatry throughout the health care continuum: Lessons learned from the impacts of the COVID-19 pandemic on skilled nursing facilities. PM R 2021; 13:563-571. [PMID: 34097366 PMCID: PMC8206924 DOI: 10.1002/pmrj.12609] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Jason Gruss
- Advanced Rehabilitation Care, Elk Grove Village, Illinois, USA
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Chiu CC, Lin HF, Lin CH, Chang HT, Hsien HH, Hung KW, Tung SL, Shi HY. Multidisciplinary Care after Acute Care for Stroke: A Prospective Comparison between a Multidisciplinary Post-Acute Care Group and a Standard Group Matched by Propensity Score. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147696. [PMID: 34300144 PMCID: PMC8303420 DOI: 10.3390/ijerph18147696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/15/2021] [Accepted: 07/18/2021] [Indexed: 02/07/2023]
Abstract
In this large-scale prospective cohort study, a propensity score matching method was applied in a natural experimental design to investigate how post-acute care (PAC) after stroke affects functional status and to identify predictors of functional status. The main objective of this study was to examine longitudinal changes in various measures of functional status in stroke patients and predictors of scores for these measures before and after PAC. A group of patients who had received PAC for stroke at one of two medical centers (PAC group, n = 273) was compared with a group who had received standard care for stroke at one of four hospitals (three regional hospital and one district hospital; non-PAC group, n = 273) in Taiwan from March, 2014, to October, 2018. The patients completed the functional status measures before rehabilitation, the 12th week and the 1st year after rehabilitation. Generalized estimating equations were used to estimate differences-in-differences models for examining the effects of PAC. The average age was 68.0 (SD = 8.1) years, and males accounted for 57.9%. During the follow-up period, significant risk factors for poor functional outcomes were advanced age, hemorrhagic stroke, and poor function scores before rehabilitation (p < 0.05). Between-group comparisons at subsequent time points revealed significantly higher functional status scores in the PAC group versus the non-PAC group (p < 0.001). Notably, for all functional status measures, between-group differences in total scores significantly increased over time from baseline to 1 year post-rehabilitation (p < 0.001). The contribution of this study is its further elucidation of the clinical implications and health policy implications of rehabilitative care after stroke. Specifically, it improves understanding of the effects of PAC in stroke patients at different follow-up times. Therefore, a policy implication of this study is that standard care for stroke should include intensive rehabilitative PAC to maximize recovery of overall function.
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Affiliation(s)
- Chong-Chi Chiu
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung 82445, Taiwan;
- Department of General Surgery, E-Da Cancer Hospital, Kaohsiung 82445, Taiwan
| | - Hsiu-Fen Lin
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung 80708, Taiwan;
- Department of Neurology, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Ching-Huang Lin
- Division of Neurology, Kaohsiung Veterans General Hospital, Kaohsiung 81341, Taiwan;
| | - Hong-Tai Chang
- Department of Surgery, Kaohsiung Municipal United Hospital, Kaohsiung 80457, Taiwan;
- Department of Business Management, National Sun Yat-sen University, Kaohsiung 80424, Taiwan
| | - Hong-Hsi Hsien
- Department of Internal Medicine, St. Joseph Hospital, Kaohsiung 80288, Taiwan;
| | - Kuo-Wei Hung
- Division of Neurology, Department of Internal Medicine, Yuan’s General Hospital, Kaohsiung 80249, Taiwan;
| | - Sheng-Li Tung
- Department of Medical Research, Chiayi Chang Gung Hospital, Chiayi 61301, Taiwan;
| | - Hon-Yi Shi
- Department of Business Management, National Sun Yat-sen University, Kaohsiung 80424, Taiwan
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung 08708, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402, Taiwan
- Correspondence: ; Tel.: +886-7-3211101 (ext. 2648); Fax: +886-7-3137487
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Satheeshkumar PS, El-Dallal M, Raita Y, Mohan MP, Boakye EA. Association between palliative care referral and burden of illness among cancers of the lip, oral cavity and pharynx. Support Care Cancer 2021; 29:7737-7745. [PMID: 34159429 DOI: 10.1007/s00520-021-06370-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the burden of illness--length of stay (LOS), total charges, and discharge disposition--among cancers of the lip, oral cavity and pharynx (CLOP) patients with and without palliative care (PC) referral. METHODS This cross-sectional study utilized the 2017 National inpatient sample database to identify hospitalizations with a primary diagnosis of CLOP. Generalized linear models were used to assess the association between PC referral status and the outcomes-LOS, total charges, and discharge disposition while controlling for patients' characteristics. RESULTS There were 4165 PC referral among 52, 524 CLOP patients. The geometric mean of LOS for non-PC referral patients was 3.7 days, and for PC referral was 5.02 days, P < 0.001. In the adjusted analysis, CLOP patients with PC referral were more likely to have a higher LOS (Coefficient: 1.16; 95% CI, 1.01-1.25) compared to those without PC referral. The geometric mean of total charge among non-PC referral group was 48,308 USD, and CLOP-PC referral was 48,983 USD, P = 0.72. After adjusting for covariates, there was still no significant difference between the PC and non-PC referral groups. Discharge disposition were considerably different across the non-PC vs. PC referral groups. Compared to non-PC referral patients, PC referral patients were more likely to be discharge to skilled nursing facility, intermediate care, and another type of facility (aOR = 7.10; CIs, 5.51-9.12), or home health care (aOR = 4.13; CIs, 3.31-5.15). CONCLUSION During primary hospitalization, total charges was not different between patient non-PC and PC referral groups; however, the LOS and discharge dispositions were significantly different.
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Affiliation(s)
- Poolakkad S Satheeshkumar
- Harvard Medical School, Boston, MA, USA. .,Now with the Department of Oral Oncology, Roswell Park Comprehensive Cancer Center, Elm & Carlton Streets, Buffalo, NY, USA.
| | - Mohammed El-Dallal
- Division of Hospital Medicine, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA.,Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Y Raita
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Minu P Mohan
- Zuckerberg College of Health Sciences, University of Massachusetts, Lowell, MA, USA
| | - E Adjei Boakye
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
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Patient Engagement Technologies in Orthopaedics: What They Are, What They Offer, and Impact. J Am Acad Orthop Surg 2021; 29:e584-e592. [PMID: 33826580 DOI: 10.5435/jaaos-d-20-00585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 12/06/2020] [Indexed: 02/01/2023] Open
Abstract
The modern era is an increasingly digital and connected world. Most of the Americans now use a smartphone irrespective of age or income level. As smartphone technologies become ubiquitous, there is tremendous interest and growth in mobile health applications. One segment of these new technologies are the so-called patient engagement platforms. These technologies present a host of features that may improve care. This article provides an introduction to this growing technology sector, offers insight into what they may offer patients and surgeons, and discusses how to evaluate various platforms.
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Abstract
ISSUE/TREND Postacute care has been identified as a primary area for cost containment. The continued shift of payment structures from volume to value has often put hospitals at the forefront of addressing postacute care cost containment. However, hospitals continue to struggle with models to manage patients in postacute care institutions, such as skilled nursing facilities or in home health agencies. Recent research has identified postacute care network development as one mechanism to improve outcomes for patients sent to postacute care providers. Many hospitals, though, have not utilized this strategy for fear of not adhering to Centers for Medicare & Medicaid Services requirements that patients are given choice when discharged to postacute care. MANAGERIAL APPROACH A hospital's approach to postacute care integration will be dictated by environmental uncertainty and the level of embeddedness hospitals have with potential postacute care partners. Hospitals, though, must also consider how and when to extend shared savings to postacute care partners, which will be based on the complexity of the risk-sharing calculation, the ability to maintain network flexibility, and the potential benefits of preserving competition and innovation among the network members. For hospital leaders, postacute care network development should include a robust and transparent data management process, start with an embedded network that maintains network design flexibility, and include a care management approach that includes patient-level coordination. CONCLUSION The design of care management models could benefit from elevating the role of postacute care providers in the current array of risk-based payment models, and these providers should consider developing deeper relationships with select postacute care providers to achieve cost containment.
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Abstract
OBJECTIVE Spinal decompression with or without fusion is one of the most commonly performed procedures in spine surgery. However, there is limited evidence on the effect of discharge environment on outcomes after surgery. The purpose of this study is to identify the effects of discharge disposition setting on clinical outcomes after spine surgery. METHODS Patients who underwent lumbar decompression, lumbar decompression and fusion, or posterior cervical decompression and fusion surgery were retrospectively identified. All clinical and demographic data were obtained from electronic health records. Surgical outcomes included wound complications, revision surgery, "30-day" readmission (0-30 d), and "90-day" readmission (31-90 d). Discharge disposition was stratified into home/self-care, acute inpatient rehabilitation, and subacute rehabilitation. Patient-reported outcome measures including VAS Back, VAS Leg, VAS Neck, VAS Arm, PCS-12 and MCS-12, ODI, and NDI were compared between patient discharge disposition settings using the Mann-Whitney U test. Pearson's chi-square analysis was used to assess for differences in wound complications, revision surgery, 30-day readmission, or 90-day readmission rates. Multivariate logistic regression incorporating age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), and discharge disposition was used to determine independent predictors of wound complications. RESULTS A total of 637 patients were included in the study. A significant difference (P = 0.03) was found in wound complication based on discharge disposition, with subacute disposition having the highest proportion of wound complications (6.1%) and home disposition having the lowest (1.5%). There were no significant differences in the rates of revision surgery, 30-day readmission, or 90-day readmission between groups. Subacute rehabilitation (odds ratio: 3.67, P = 0.047) and CCI (odds ratio 1.49, P = 0.01) were independent predictors of wound complications. Significant improvement in PROMs was seen across all postacute discharge dispositions. Baseline (P = 0.02) and postoperative (P = 0.02) ODI were significantly higher among patients discharged to an acute facility (49.4 and 32.0, respectively) compared to home (42.2 and 20.0) or subacute (47.4 and 28.4) environments. CONCLUSION Subacute rehabilitation disposition and CCI are independent predictors of wound complications after spinal decompression surgery. Patients undergoing spine surgery have similar readmission and revision rates and experience similar clinical improvement across all postacute discharge dispositions.
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Abrams LR, Hoffman GJ. Skilled Nursing Facilities Modify the Relationship Between Depressive Symptoms and Hospital Readmissions but Not Health Outcomes Among Older Adults. J Aging Health 2021; 33:817-827. [PMID: 33929271 DOI: 10.1177/08982643211013127] [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: 11/17/2022]
Abstract
Objectives: Despite detrimental effects of depressive symptoms on self-care and health, hospital discharge practices and the benefits of different discharge settings are poorly understood in the context of depression. Methods: This retrospective cohort study comprised 23,485 hospitalizations from Medicare claims linked to the Health and Retirement Study (2000-2014). Results: Respondents with depressive symptoms were no more likely to be referred to home health, whereas the probability of discharge to skilled nursing facilities (SNFs) went up a half percentage point with each increasing symptom, even after adjusting for family support and health. Rehabilitation in SNFs, compared to routine discharges home, reduced the positive association between depressive symptoms and 30-day hospital readmissions (OR = 0.95, p = 0.029) but did not prevent 30-day falls, 1-year falls, or 1-year mortality associated with depressive symptoms. Discussion: Depressive symptoms were associated with discharges to SNFs, but SNFs do not appear to address depressive symptoms to enhance functioning and survival.
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Affiliation(s)
- Leah R Abrams
- Harvard Center for Population and Development Studies, 1857Harvard T.H. Chan School of Public Health, Cambridge, MA, USA
| | - Geoffrey J Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA
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McHugh JP, Rapp T, Mor V, Rahman M. Higher hospital referral concentration associated with lower-risk patients in skilled nursing facilities. Health Serv Res 2021; 56:839-846. [PMID: 33779987 DOI: 10.1111/1475-6773.13654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine whether stronger referral relationships between hospitals and skilled nursing facilities (SNF) are associated with lower-risk patients being admitted to SNF. DATA SOURCES/COLLECTION We used MedPAR data to estimate referral relationship strength and nursing home survey data (OSCAR and CASPER) to determine the risk of patient admissions at nearly 14 000 SNFs from 2008 to 2014. STUDY DESIGN We examined the association of hospital referral concentration with the percentage of higher-risk patients admitted to non-hospital-based (freestanding) SNFs using an instrumental variables approach. We used the distance between patients and SNFs and hospitals and SNFs as the instrument. DATA COLLECTION/EXTRACTION METHODS We used previously collected MedPAR and OSCAR/CASPER survey data. PRINCIPAL FINDINGS We find greater observed referral concentration among freestanding SNFs is associated with lower percentages of patients with pressure sores (coefficient, -2.64; 95% CI, [-2.82 to -2.46]), catheters (-0.55; [-0.74 to -0.36]), and physical restraints (-0.16; [-0.29 to -0.03]) at admission to a skilled nursing facility. CONCLUSIONS We find evidence that freestanding SNFs with stronger hospital referral relationships may be admitting less risky patients, possibly contributing to disparities across SNFs.
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Affiliation(s)
- John P McHugh
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York, USA
| | | | - Vincent Mor
- Department of Health Services Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Momotazur Rahman
- Department of Health Services Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
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Pandey A, Keshvani N, Vaughan-Sarrazin MS, Gao Y, Fonarow GC, Yancy C, Girotra S. Evaluation of Risk-Adjusted Home Time After Hospitalization for Heart Failure as a Potential Hospital Performance Metric. JAMA Cardiol 2021; 6:169-176. [PMID: 33112393 DOI: 10.1001/jamacardio.2020.4928] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Thirty-day home time, defined as time spent alive and out of a hospital or facility, is a novel, patient-centered performance metric that incorporates readmission and mortality. Objectives To characterize risk-adjusted 30-day home time in patients discharged with heart failure (HF) as a hospital-level quality metric and evaluate its association with the 30-day risk-standardized readmission rate (RSRR), 30-day risk-standardized mortality rate (RSMR), and 1-year RSMR. Design, Setting, and Participants This hospital-level cohort study retrospectively analyzed 100% of Medicare claims data from 2 968 341 patients from 3134 facilities from January 1, 2012, to November 30, 2017. Exposures Home time, defined as time spent alive and out of a short-term hospital, skilled nursing facility, or intermediate/long-term facility 30 days after discharge. Main Outcomes and Measures For each hospital, a risk-adjusted 30-day home time for HF was calculated similar to the Centers for Medicare & Medicaid Services risk-adjustment models for 30-day RSRR and RSMR. Hospitals were categorized into quartiles (lowest to highest risk-adjusted home time). The correlations between hospital rates of risk-adjusted 30-day home time and 30-day RSRR, 30-day RSMR, and 1-year RSMR were estimated using the Pearson correlation coefficient. Distribution of days lost from a perfect 30-day home time were calculated. Reclassification of hospital performance using 30-day home time vs 30-day RSRR was also evaluated. Results Overall, 2 968 341 patients (mean [SD] age, 81.0 [8.3] years; 53.6% female) from 3134 hospitals were included in this study. The median hospital risk-adjusted 30-day home time for patients with HF was 21.77 days (range, 8.22-28.41 days). Hospitals in the highest quartile of risk-adjusted 30-day home time (best-performing hospitals) were larger (mean [SD] number of beds, 285 [275]), with a higher volume of patients with HF (median, 797 patients; interquartile range, 395-1484) and were more likely academic hospitals (59.9%) with availability of cardiac surgery (51.1%) and cardiac rehabilitation (68.8%). A total of 72% of home time lost was attributable to stays in an intermediate- or long-term care facility (mean [SD], 2.65 [6.44] days) or skilled nursing facility (mean [SD], 3.96 [9.04] days), 13% was attributable to short-term readmissions (mean [SD], 1.25 [3.25] days), and 15% was attributable to death (mean [SD], 1.37 [6.04] days). Among 30-day outcomes, the 30-day RSRR and 30-day RSMR decreased in a graded fashion across increasing 30-day home time categories (correlation coefficients: 30-day RSRR and 30-day home time, -0.23, P < .001; 30-day RSMR and 30-day home time, -0.31, P < .001). Similar patterns of association were also noted for 1-year RSMR and 30-day home time (correlation coefficient, -0.35, P < .001). Thirty-day home time meaningfully reclassified hospital performance in 30% of the hospitals compared with 30-day RSRR and in 25% of hospitals compared with 30-day RSMR. Conclusions and Relevance In this study, 30-day home time among patients discharged after a hospitalization for HF was objectively assessed as a hospital-level quality metric using Medicare claims data and was associated with readmission and mortality outcomes and with reclassification of hospital performance compared with 30-day RSRR and 30-day RSMR.
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Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Mary S Vaughan-Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
| | - Yubo Gao
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
| | - Gregg C Fonarow
- Division of Cardiology, Northwestern University, Chicago, Illinois.,Associate Editor, JAMA Cardiology
| | - Clyde Yancy
- Division of Cardiology, Ronald Reagan-UCLA (University of California, Los Angeles) Medical Center, Los Angeles.,Deputy Editor, JAMA Cardiology
| | - Saket Girotra
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City.,Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
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Machine-Learning Modeling to Predict Hospital Readmission Following Discharge to Post-Acute Care. J Am Med Dir Assoc 2021; 22:1067-1072.e29. [PMID: 33454309 DOI: 10.1016/j.jamda.2020.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Primary purpose was to generate a model to identify key factors relevant to acute care hospital readmission within 90 days from 3 types of post-acute care (PAC) sites: home with home care services (HC), skilled nursing facility (SNF), and inpatient rehabilitation facility (IRF). Specific aims were to (1) examine demographic characteristics of adults discharged to 3 types of PAC sites and (2) compare 90-day acute hospital readmission rate across PAC sites and risk levels. DESIGN Retrospective, secondary analysis design was used to examine hospital readmissions within 90 days for persons discharged from hospital to SNF, IRF, or HC. SETTINGS AND PARTICIPANTS Cohort sample was composed of 2015 assessment data from 3,592,995 Medicare beneficiaries, including 1,536,908 from SNFs, 306,878 from IRFs, and 1,749,209 patients receiving HC services. MEASURES Initial level of analysis created multiple patient profiles based on predictive patient characteristics. Second level of analysis consisted of multiple logistic regressions within each profile to create predictive algorithms for likelihood of readmission within 90 days, based on risk profile and PAC site. RESULTS Total sample 90-day hospital readmission rate was 27.48%. Patients discharged to IRF had the lowest readmission rate (23.34%); those receiving HC services had the highest rate (31.33%). Creation of model risk subgroups, however, revealed alternative outcomes. Patients seem to do best (i.e., lowest readmission rates) when discharged to SNF with one exception, those in the very high risk group. Among all patients in the low-, intermediate-, and high-risk groups, the lowest readmission rates occurred among SNF patients. CONCLUSIONS AND IMPLICATIONS The proposed model has potential use to stratify patients' potential risk for readmission as well as optimal PAC destination. Machine-learning modeling with large data sets is a useful strategy to increase the precision accuracy in predicting outcomes among patients who have nonhome discharges from the hospital.
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McHugh JP, Shield RR, Gadbois EA, Winblad U, Mor V, Tyler DA. Readmission Reduction Strategies for Patients Discharged to Skilled Nursing Facilities: A Case Study From 2 Hospital Systems in 1 City. J Nurs Care Qual 2021; 36:91-98. [PMID: 31834200 PMCID: PMC7266704 DOI: 10.1097/ncq.0000000000000459] [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: 11/26/2022]
Abstract
BACKGROUND Some hospitals seek integration with skilled nursing facilities (SNFs) to reduce readmissions while others focus more on patients discharged home. PURPOSE Our objective was to understand different approaches for readmission reduction for patients discharged to SNFs based on contrasting strategies from 2 competing hospital systems. METHODS Employing a case study methodology, we compared 1 hospital system that integrated with SNFs to a competing system that did not. We compared interview data from clinical and administrative staff and publicly reported rehospitalization rate changes from the 2 systems. RESULTS Analysis of integrating hospital system interviews noted providing patients detailed discharge information and educating SNF staff regarding care protocols. Integrated hospital system all-cause readmission rates declined by nearly 1 percentage point more than the nonintegrated hospital system (coefficient, -0.008; 95% confidence interval, -0.003 to -0.012) between 2014 and 2017. CONCLUSION As hospitals explore care transition improvements to SNFs, developing more embedded relationships highlights one approach to improve value.
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Affiliation(s)
- John P McHugh
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York (Dr McHugh); Department of Health Services Policy and Practice (Drs Shield and Mor) and Center for Gerontology and Healthcare Research (Dr Gadbois), School of Public Health, Brown University, Providence, Rhode Island; Department of Public Health and Caring Sciences, Uppsala University, Sweden (Dr Winblad); and Aging, Disability and Long Term Care Program, RTI International, Raleigh, North Carolina (Dr Tyler)
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An Explanatory Model for the Relationship Between Physical Therapists' Self-perceptions of Value and Care Prioritization Decisions in the Acute Hospital. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2020. [DOI: 10.1097/jat.0000000000000157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Jones AJ, Campiti VJ, Alwani M, Novinger LJ, Bonetto A, Sim MW, Yesensky JA, Moore MG, Mantravadi AV. Skeletal Muscle Index's Impact on Discharge Disposition After Head and Neck Cancer Free Flap Reconstruction. Otolaryngol Head Neck Surg 2020; 165:59-68. [PMID: 33290190 DOI: 10.1177/0194599820973232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the role of skeletal muscle index (SMI) in the assessment of frailty and determination of discharge to post-acute care facilities (PACF) after head and neck cancer free flap reconstruction (HNCFFR). STUDY DESIGN Retrospective cohort. SETTING Single-institution, academic tertiary referral center. METHODS Adult patients undergoing HNCFFR from 2014 to 2019 with preoperative abdominal computed tomography imaging were retrospectively analyzed. Patient demographics, 5-factor modified frailty index (5-mFI), body mass index (BMI), SMI at the third lumbar vertebra, oncologic history, perioperative data, and Clavien-Dindo (CD) complications were collected. Binary logistic regression was used to identify independent predictors of discharge disposition. RESULTS The cohort consisted of 206 patients, 62 (30.1%) of whom were discharged to PACF. Patients discharged to PACF were of older age (65.4 vs 57.1 years, P < .0001) and had a lower SMI (38.8 vs 46.8 cm2/m2, P < .0001), higher 5-mFI (≥3; 25.8% vs 4.2%, P < .0001), and greater incidence of stage IV (80.6% vs 64.1%, P = .0211) aerodigestive cancer (80.6% vs 66.7%, P = .0462). Patients discharged to PACF experienced more blood transfusions (74.2% vs 35.4%, P < .0001), major postoperative complications (CD ≥3, 40.3% vs 12.9%, P < .0001), and delirium (33.9% vs 4.2%, P < .0001). After adjusting for pre- and postoperative factors, multivariate binary logistic regression identified age (P = .0255), 5-mFI (P < .0042), SMI (P = .0199), stage IV cancer (P = .0250), aerodigestive tumor (P = .0366), delirium (P < .0001), and perioperative blood transfusion (P = .0144) as independent predictors of discharge to PACF. CONCLUSIONS SMI and 5-mFI are independently associated with discharge to PACF after HNCFFR and should be considered in preoperative planning and assessment of frailty.
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Affiliation(s)
- Alexander Joseph Jones
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Mohamedkazim Alwani
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Leah J Novinger
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrea Bonetto
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael W Sim
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jessica A Yesensky
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael G Moore
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Avinash V Mantravadi
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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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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Commentary on the Challenges and Benefits of Implementing Standardized Outcome Measures. Arch Phys Med Rehabil 2020; 103:S246-S251. [PMID: 33248124 DOI: 10.1016/j.apmr.2020.10.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/09/2020] [Accepted: 10/01/2020] [Indexed: 11/23/2022]
Abstract
The Institute of Medicine (now the National Academy of Medicine) has proposed a Learning Heath system (LHS) as a model to improve health care. A LHS focuses on capturing data from the clinical encounter and applying those data to improve practice. The process can be described as an iterative learning cycle composed of 3 areas: performance to data, data to knowledge, and knowledge to performance or often knowledge translation. Adoption of new knowledge in medicine is notoriously slow, and the relatively new field of knowledge translation is systematically examining the critical success factors. In this issue of the Archives, Moore reports a knowledge translation project in a key aspect of rehabilitation: implementing standardized outcome measures. We report on the challenges and benefits of that project from a practical perspective and identify the critical success ingredient, leadership for implementation, which was composed of 3 key behaviors: setting clear expectations, engaging stakeholders, and providing support. Furthermore, the additional benefits, challenges, and costs are addressed.
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Munnich EL, Richards MR. Treatment flows after outsourcing public insurance provision: Evidence from Florida Medicaid. HEALTH ECONOMICS 2020; 29:1343-1363. [PMID: 32757320 DOI: 10.1002/hec.4135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/15/2020] [Accepted: 06/19/2020] [Indexed: 06/11/2023]
Abstract
While politics can determine what public goods are available, elected officials must decide on the method of allocation. Commonly, governments provide public health insurance directly or pay private parties to administer it on their behalf. Such contracting can leverage private sector expertise but also raises agency concerns. In particular, little is known about how private provision of public health insurance impacts medical decision-making and treatment flows for low-income populations. An example comes from the Medicaid program, which has increasingly relied on outside insurers to deliver health services to enrollees. We exploit a large legislative intervention in Florida to show that Medicaid managed care (MMC) organizations generally do not skimp on short-run treatment delivery in the inpatient setting. In fact, patients with severe and chronic illnesses receive more inpatient services under these contracts, especially in relation to managing care transitions. We also document increased competition in the MMC market following the state's policy intervention.
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Affiliation(s)
- Elizabeth L Munnich
- Department of Economics, University of Louisville, Louisville, Kentucky, USA
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