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Jain S, Murphy TE, Falvey JR, Leo-Summers L, O’Leary JR, Zang E, Gill TM, Krumholz HM, Ferrante LE. Social Determinants of Health and Delivery of Rehabilitation to Older Adults During ICU Hospitalization. JAMA Netw Open 2024; 7:e2410713. [PMID: 38728030 PMCID: PMC11087837 DOI: 10.1001/jamanetworkopen.2024.10713] [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: 12/18/2023] [Accepted: 03/09/2024] [Indexed: 05/13/2024] Open
Abstract
Importance Older adults with socioeconomic disadvantage develop a greater burden of disability after critical illness than those without socioeconomic disadvantage. The delivery of in-hospital rehabilitation that can mitigate functional decline may be influenced by social determinants of health (SDOH). Whether rehabilitation delivery differs by SDOH during critical illness hospitalization is not known. Objective To evaluate whether SDOH are associated with the delivery of skilled rehabilitation during critical illness hospitalization among older adults. Design, Setting, and Participants This cohort study used data from the National Health and Aging Trends Study linked with Medicare claims (2011-2018). Participants included older adults hospitalized with a stay in the intensive care unit (ICU). Data were analyzed from August 2022 to September 2023. Exposures Dual eligibility for Medicare and Medicaid, education, income, limited English proficiency (LEP), and rural residence. Main Outcome and Measures The primary outcome was delivery of physical therapy (PT) and/or occupational therapy (OT) during ICU hospitalization, characterized as any in-hospital PT or OT and rate of in-hospital PT or OT, calculated as total number of units divided by length of stay. Results In the sample of 1618 ICU hospitalizations (median [IQR] patient age, 81.0 [75.0-86.0] years; 842 [52.0%] female), 371 hospitalizations (22.9%) were among patients with dual Medicare and Medicaid eligibility, 523 hospitalizations (32.6%) were among patients with less than high school education, 320 hospitalizations (19.8%) were for patients with rural residence, and 56 hospitalizations (3.5%) were among patients with LEP. A total of 1076 hospitalized patients (68.5%) received any PT or OT, with a mean rate of 0.94 (95% CI, 0.86-1.02) units/d. After adjustment for age, sex, prehospitalization disability, mechanical ventilation, and organ dysfunction, factors associated with lower odds of receipt of PT or OT included dual Medicare and Medicaid eligibility (adjusted odds ratio, 0.70 [95% CI, 0.50-0.97]) and rural residence (adjusted odds ratio, 0.65 [95% CI, 0.48-0.87]). LEP was associated with a lower rate of PT or OT (adjusted rate ratio, 0.55 [95% CI, 0.32-0.94]). Conclusions and Relevance These findings highlight the need to consider SDOH in efforts to promote rehabilitation delivery during ICU hospitalization and to investigate factors underlying inequities in this practice.
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Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terrence E. Murphy
- Department of Public Health Sciences, Pennsylvania State University, State College
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
| | | | - John R. O’Leary
- Program on Aging, Yale School of Medicine, New Haven, Connecticut
| | - Emma Zang
- Department of Sociology, Yale University, New Haven, Connecticut
| | - Thomas M. Gill
- Program on Aging, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Niedzwiecki MJ, Forrow LV, Gellar J, Pohl RV, Chen A, Miescier L, Kranker K. The Medicare Care Choices Model was associated with reductions in disparities in the use of hospice care for Medicare beneficiaries with terminal illness. Health Serv Res 2024. [PMID: 38419507 DOI: 10.1111/1475-6773.14289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE To assess the effects of the Medicare Care Choices Model (MCCM) on disparities in hospice use and quality of end-of-life care for Medicare beneficiaries from underserved groups-those from racial and ethnic minority groups, dually eligible for Medicare and Medicaid, or living in rural areas. DATA SOURCES AND STUDY SETTING Medicare enrollment and claims data from 2013 to 2021 for terminally ill Medicare fee-for-service beneficiaries nationwide. STUDY DESIGN Through MCCM, terminally ill enrolled Medicare beneficiaries received supportive and palliative care services from hospice providers concurrently with curative treatments. Using a matched comparison group, we estimated subgroup-specific effects on hospice use, days at home, and aggressive treatment and multiple emergency department visits in the last 30 days of life. DATA COLLECTION/EXTRACTION METHODS The sample included decedent Medicare beneficiaries enrolled in MCCM and a matched comparison group from the same geographic areas who met model eligibility criteria at time of enrollment: having a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or HIV/AIDS; living in the community; not enrolled in the Medicare hospice benefit in the previous 30 days; and having at least one hospital stay and three office visits in the previous 12 months. PRINCIPAL FINDINGS Eligible beneficiaries from underserved groups were underrepresented in MCCM. MCCM increased enrollees' hospice use and the number of days at home and reduced aggressive treatment among all subgroups analyzed. MCCM also reduced disparities in hospice use by race and ethnicity and dual eligibility by 4.1 (90% credible interval [CI]: 1.3-6.1) and 2.4 (90% CI: 0.6-4.4) percentage points, respectively. It also reduced disparities in having multiple emergency department visits for rural enrollees by 1.3 (90% CI: 0.1-2.7) percentage points. CONCLUSIONS MCCM increased hospice use and quality of end-of-life care for model enrollees from underserved groups and reduced disparities in hospice use and having multiple emergency department visits.
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Affiliation(s)
| | | | | | | | | | - Lynn Miescier
- Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland, USA
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Lee-Foon NK, Haldane V, Brown A. Saying and doing are different things: a scoping review on how health equity is conceptualized when considering healthcare system performance. Int J Equity Health 2023; 22:133. [PMID: 37443086 DOI: 10.1186/s12939-023-01872-z] [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: 02/02/2022] [Accepted: 03/20/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Ensuring healthcare systems provide equitable, high quality care is critical to their users' overall health and wellbeing. Typically, systems use various performance frameworks and related indicators to monitor and improve healthcare. Although these frameworks usually include equity, the extent that equity is reflected in these measurements remains unclear. In order to create a system that meets patients' needs, addressing this uncertainty is important. This paper presents findings from a scoping review that sought to answer the question 'How is equity conceptualized in healthcare systems when assessing healthcare system performance?'. METHODS Levac's scoping review approach was used to locate relevant articles and create a protocol. Included, peer-reviewed articles were published between 2015 to 2020, written in English and did not discuss oral health and clinician training. These healthcare areas were excluded as they represent large, specialized bodies of literature beyond the scope of this review. Online databases (e.g., MEDLINE, CINAHL Plus) were used to locate articles. RESULTS Eight thousand six hundred fifty-five potentially relevant articles were identified. Fifty-four were selected for full review. The review yielded 16 relevant articles. Six articles emanated from North America, six from Europe and one each from Africa, Australia, China and India respectively. Most articles used quantitative methods and examined various aspects of healthcare. Studies centered on: indicators; equity policies; evaluating the equitability of healthcare systems; creating and/or testing equity tools; and using patients' sociodemographic characteristics to examine healthcare system performance. CONCLUSION Although equity is framed as an important component of most healthcare systems' performance frameworks, the scarcity of relevant articles indicate otherwise. This scarcity may point to challenges systems face when moving from conceptualizing to measuring equity. Additionally, it may indicate the limited attention systems place on effectively incorporating equity into performance frameworks. The disjointed and varied approaches to conceptualizing equity noted in relevant articles make it difficult to conduct comparative analyses of these frameworks. Further, these frameworks' strong focus on users' social determinants of health does not offer a robust view of performance. More work is needed to shift these narrow views of equity towards frameworks that analyze healthcare systems and not their users.
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Affiliation(s)
- Nakia K Lee-Foon
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.
| | - Victoria Haldane
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, ON, M5T 3M6, Canada
| | - Adalsteinn Brown
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, ON, M5T 3M6, Canada
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Rice K, Schuster A, Pack A, Dougherty GB. Development and Implementation of a Maryland State Program Providing Hospital Payment Incentives for Reduction in Readmission Disparities. Med Care 2023; 61:484-489. [PMID: 37289564 DOI: 10.1097/mlr.0000000000001863] [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: 06/10/2023]
Abstract
BACKGROUND Social factors are a key determinant of hospital readmission. We describe the development of the country's first statewide policy providing hospitals with financial incentives to reduce readmission disparities. OBJECTIVE To describe the development and evaluation of a novel program that measures hospital-level disparity in readmission and rewards hospitals for improvement. RESEARCH DESIGN Observational study using inpatient claims. PARTICIPANTS Baseline data included 454,372 all-cause inpatient discharges in 2018 and 2019. Of the included discharges, 34.01% involved Black patients, 40.44% involved female patients, 33.1% involved patients covered by Medicaid, and 11.76% involved patients who were readmitted. Mean age was 55.18. MEASURES The key measure was the percentage change over time within the hospital in readmission disparity. Readmission disparity was measured using a multilevel model that gauged the association between social factors and readmission risk at a given hospital. Three social factors (Race, Medicaid coverage, and Area Deprivation Index) were combined into an index reflecting exposure to social adversity. RESULTS Of the State's 45 acute-care hospitals, 26 exhibited improved disparity performance in 2019. LIMITATIONS The program is limited to inpatients within a single state; the analysis does not provide evidence on the causal relationship between the intervention and readmission disparities. CONCLUSION This represents the first large-scale effort in the US to link disparities to hospital payment. Because the methodology relies on claims data, it could easily be adopted elsewhere. The incentives are directed to within-hospital disparities, thus mitigating concerns about penalizing hospitals with patients with greater social exposure. This methodology could be used to measure disparity in other outcomes.
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Affiliation(s)
- Kyle Rice
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health
| | - Alyson Schuster
- Maryland Health Services Cost Review Commission, Baltimore, MD
| | - Allan Pack
- Maryland Health Services Cost Review Commission, Baltimore, MD
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Breslau J, Haviland AM, Klein DJ, Martino S, Adams J, Dembosky JW, Tamayo L, Gaillot S, Overton Y, Elliott MN. Income-related disparities in Medicare advantage behavioral health care quality. Health Serv Res 2023; 58:579-588. [PMID: 36579742 PMCID: PMC10154171 DOI: 10.1111/1475-6773.14124] [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: 12/30/2022] Open
Abstract
OBJECTIVE To inform efforts to improve equity in the quality of behavioral health care by examining income-related differences in performance on HEDIS behavioral health measures in Medicare Advantage (MA) plans. DATA SOURCES AND STUDY SETTING Reporting Year 2019 MA HEDIS data were obtained and analyzed. STUDY DESIGN Logistic regression models were used to estimate differences in performance related to enrollee income, adjusting for sex, age, and race-and-ethnicity. Low-income enrollees were identified by Dual Eligibility for Medicare and Medicaid or receipt of the Low-Income Subsidy (DE/LIS). Models without and with random effects for plans were used to estimate overall and within-plan differences in measure performance. Heterogeneity by race-and-ethnicity in the associations of low-income with behavioral health quality were examined using models with interaction terms. DATA COLLECTION/EXTRACTION METHODS Data were included for all MA contracts in the 50 states and the District of Columbia that collect HEDIS data. PRINCIPAL FINDINGS For six of the eight measures, enrollees with DE/LIS coverage were more likely to have behavioral health conditions that qualify for HEDIS measures than higher income enrollees. In mixed-effects logistic regression models, DE/LIS coverage was associated with statistically significantly worse overall performance on five measures, with four large (>5 percentage point) differences (-7.5 to -11.1 percentage points) related to follow-up after hospitalization and avoidance of drug-disease interactions. Where the differences were large, they were primarily within-plan rather than between-plan. Interactions between DE/LIS and race-and-ethnicity were statistically significant (p < 0.05) for all measures; income-based quality gaps were larger for White enrollees than for Black or Hispanic enrollees. CONCLUSIONS Low income is associated with lower performance on behavioral health HEDIS measures in MA, but these associations differ across racial-and-ethnic groups. Improving care integration and addressing barriers to care for low-income enrollees may improve equity across income levels in behavioral health care.
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Affiliation(s)
| | - Amelia M. Haviland
- RAND CorporationPittsburghPennsylvaniaUSA
- Public Policy & ManagementCarnegie Mellon UniversityPittsburghPennsylvaniaUSA
| | | | | | - John Adams
- Kaiser Permanente Center for Effectiveness & Safety Research and Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCaliforniaUSA
| | | | - Loida Tamayo
- Centers for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Sarah Gaillot
- Centers for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Yvette Overton
- Centers for Medicare & Medicaid ServicesBaltimoreMarylandUSA
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Hausmann LR, Lamorte C, Estock JL. Understanding the Context for Incorporating Equity into Quality Improvement Throughout a National Health Care System. Health Equity 2023; 7:312-320. [PMID: 37284535 PMCID: PMC10240324 DOI: 10.1089/heq.2023.0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 06/08/2023] Open
Abstract
Purpose Although health care systems aspire to deliver equitable care, practical tools that empower the health care workforce to weave equity throughout quality improvement (QI) processes are lacking. In this article, we report findings from context of use interviews that informed the development of a user-centered tool to support equity-focused QI. Methods Semistructured interviews were conducted from February to April of 2019. Participants included 14 medical center administrators, departmental or service line leaders, and clinical staff involved in direct patient care from three Veterans Affairs (VA) Medical Centers within a single region. Interviews covered existing practices for monitoring health care quality (i.e., priorities, tasks, workflow, and resources) and explored how equity data might fit into current processes. Themes extracted through rapid qualitative analysis were used to draft initial functional requirements for a tool to support equity-focused QI. Results Although the potential value of examining disparities in health care quality was clearly recognized, the data necessary for examining disparities were lacking for most quality measures. Interviewees also desired guidance on how inequities could be addressed through QI. The ways in which QI initiatives were selected, carried out, and supported also had important design implications for tools to support equity-focused QI. Discussion The themes identified in this work guided the development of a national VA Primary Care Equity Dashboard to support equity-focused QI within VA. Understanding the ways in which QI was carried out across multiple levels of the organization provided a successful foundation upon which to build functional tools to support thoughtful engagement around equity in clinical settings.
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Affiliation(s)
- Leslie R.M. Hausmann
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Jamie L. Estock
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Naylor MD, Hirschman KB, Morgan B, McHugh M, Hanlon AL, Ahrens M, McCauley K, Shaid EC, Pauly MV. The study protocol to evaluate implementation of the transitional care model in four U.S. healthcare systems during the Covid-19 pandemic. Arch Gerontol Geriatr 2023; 108:104944. [PMID: 36709563 PMCID: PMC9873366 DOI: 10.1016/j.archger.2023.104944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/10/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
This study protocol describes the conceptual framework, design, and methods being employed to evaluate the implementation of the Transitional Care Model (TCM) as part of a randomized controlled trial. The trial, designed to examine the health and cost outcomes of at-risk hospitalized older adults, is being conducted in the context of the COVID-19 pandemic. This parallel study is guided by the Practical, Robust, Implementation and Sustainability Model (PRISM) and uses a fixed, mixed methods convergent parallel design to identify challenges encountered by participating hospitals and post-acute and community-based providers that impact the implementation of the TCM with fidelity, strategies implemented to address those challenges and the relationships between challenges, strategies, and rates of fidelity to TCM's core components over time. Prior to the study's launch and throughout its implementation, qualitative and quantitative data related to COVID and non-COVID challenges are being collected via surveys and meetings with healthcare system staff. Strategies implemented to address challenges and fidelity to TCM's core components are also being assessed. Analyses of quantitative (established metrics to evaluate TCM's core components) and qualitative data (barriers and facilitators to implementation) are being conducted independently. These datasets are then merged and interpreted together. General linear and mixed effects modeling using all merged data and patients' socio-demographic and social determinants of health characteristics, will be used to examine relationships between key variables and fidelity rates. Implications of study findings in the context of COVID-19 and future research opportunities are suggested. Trial registration: ClinicalTrials.gov Identifier: NCT04212962.
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Affiliation(s)
- Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104.
| | - Karen B Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Brianna Morgan
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Molly McHugh
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Alexandra L Hanlon
- Center for Biostatistics and Health Data Science, College of Science, Department of Statistics, Virginia Tech, Four Riverside Circle, Roanoke, VA 24016
| | - Monica Ahrens
- Center for Biostatistics and Health Data Science, College of Science, Department of Statistics, Virginia Tech, Four Riverside Circle, Roanoke, VA 24016
| | - Kathleen McCauley
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Elizabeth C Shaid
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Mark V Pauly
- Wharton School, University of Pennsylvania, Philadelphia, PA 19104
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A Targeted Discharge Planning for High-Risk Readmissions: Focus on Patients and Caregivers. Prof Case Manag 2023; 28:60-73. [PMID: 36662660 DOI: 10.1097/ncm.0000000000000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF STUDY Racial and ethnic minorities with socioeconomic disadvantages are vulnerable to 30-day hospital readmissions. A 16-week quality improvement (QI) project aimed to decrease readmissions of the vulnerable patient populations through tailored discharge planning. The project evaluated the effectiveness of using a 25-item checklist to increase patients' and caregivers' health knowledge, skills, and willingness for self-care and decrease readmissions. PRIMARY PRACTICE SETTING The project took place in an inner-city teaching hospital in the Mid-Atlantic region. METHODOLOGY AND PARTICIPANTS A casual comparative design compared readmissions of the before-intervention group (May 1-July 31, 2021) and the after-intervention group (August 1-October 31, 2021). A pre- and postintervention design evaluated the effectiveness of a 25-item checklist by analyzing the differences of Patient Activation Measure (PAM) pre- and postintervention survey scores and levels in the after-intervention group. Participants were General Medicine Unit patients 18 years or older who had Medicare Fee-for-Service, resided in 10 zip codes near the hospital, and were discharged home. RESULTS Of 30 patients who received the intervention, one patient was readmitted compared with 11 readmissions from 58 patients who did not receive the intervention. The readmission rate was decreased from 19% to 4% during the 16-week project: 11 (19%) versus 1 (4%), p = .038. After receiving the intervention, patients' PAM scores were increased by 8.55, t(22) = 2.67, p < .014. Three patients had a lower postintervention survey level, whereas 12 patients obtained a higher postintervention survey level (p = .01). The increase in scores and levels supported that the intervention effectively improved patients' self-management knowledge, skill, and willingness for self-care. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE The QI project showed that the hospital could partner with patients at high risk for readmission and their caregivers. Accurate evaluation of patients' health knowledge, skills, and willingness for self-care was essential for sufficient discharge planning. Tailored use of the checklist improved patients' self-activation and functionally facilitated patients' and caregivers' care needs and capabilities. The checklist was statistically and clinically effective in decreasing 30-day hospital readmissions of vulnerable patient populations.
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Herrin J, Barthel A, Goutos D, Du C, Zhou S, Peltz A, Poyer J, Lin Z, Bernheim S. Measuring health disparities using a continuous social risk factor. Health Serv Res 2023; 58:30-39. [PMID: 36146904 PMCID: PMC9836958 DOI: 10.1111/1475-6773.14048] [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: 01/19/2023] Open
Abstract
OBJECTIVE To propose and evaluate a novel approach for measuring hospital-level disparities according to the effect of a continuous, polysocial risk factor on those outcomes. STUDY SETTING Our cohort consisted of Medicare Fee-for-Service (FFS) patients 65 years and older admitted to acute care hospitals for one of six common conditions or procedures. Medicare administrative claims data for six hospital readmission measures including hospitalizations from July 2015 to June 2018 were used. STUDY DESIGN We adapted existing methodologies that were developed to report hospital-level disparities using dichotomous social risk factors (SRFs). The existing methods report disparities within and across hospitals; we developed and tested modified approaches for both methods using the Agency for Healthcare Research and Quality Socioeconomic Status Index. We applied the adapted methodologies to six 30-day hospital readmission measures included in the Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program measures. We compared the within- and across-hospital results for each to those obtained from using the original methods and dichotomizing the AHRQ SES Index into "low" and "high" scores. DATA COLLECTION We used Medicare FFS administrative claims data linked to U.S. Census data. PRINCIPAL FINDINGS For all six readmission measures we find that, when compared with the existing methods, the methods for continuous SRFs provide disparity results for more facilities though across a narrower range of values. Measures of disparity based on this approach are moderately to highly correlated with those based on a dichotomous version of the same risk factor, while reflecting a fuller spectrum of risk. This approach represents an opportunity for detection of provider-level results that more closely align with underlying social risk. CONCLUSION We have demonstrated the feasibility and utility of estimating hospital disparities of care using a continuous, polysocial risk factor. This approach expands the potential for reporting hospital-level disparities while better accounting for the multifactorial nature of social risk on hospital outcomes.
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Affiliation(s)
- Jeph Herrin
- The Yale Center for Outcomes Research and EvaluationYale New Haven Health Systems CorporationNew HavenConnecticutUSA
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
- Flying Buttress AssociatesCharlottesvilleVirginiaUSA
| | - Andrea Barthel
- The Yale Center for Outcomes Research and EvaluationYale New Haven Health Systems CorporationNew HavenConnecticutUSA
| | - Demetri Goutos
- The Yale Center for Outcomes Research and EvaluationYale New Haven Health Systems CorporationNew HavenConnecticutUSA
- Department of Health Law, Policy, and ManagementBoston University School of Public HealthBostonMassachusettsUSA
| | - Chengan Du
- The Yale Center for Outcomes Research and EvaluationYale New Haven Health Systems CorporationNew HavenConnecticutUSA
- Section of Cardiovascular MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Sheng Zhou
- The Yale Center for Outcomes Research and EvaluationYale New Haven Health Systems CorporationNew HavenConnecticutUSA
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Alon Peltz
- The Yale Center for Outcomes Research and EvaluationYale New Haven Health Systems CorporationNew HavenConnecticutUSA
- Department of Population MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - James Poyer
- The Center for Clinical Standards and QualityThe Centers for Medicare and Medicaid ServicesBaltimoreMarylandUSA
| | - Zhenqiu Lin
- The Yale Center for Outcomes Research and EvaluationYale New Haven Health Systems CorporationNew HavenConnecticutUSA
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Susannah Bernheim
- The Yale Center for Outcomes Research and EvaluationYale New Haven Health Systems CorporationNew HavenConnecticutUSA
- Section of General Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
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Effect Modification by Social Determinants of Pharmacogenetic Medication Interactions on 90-Day Hospital Readmissions within an Integrated U.S. Healthcare System. J Pers Med 2022; 12:jpm12071145. [PMID: 35887642 PMCID: PMC9319564 DOI: 10.3390/jpm12071145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/09/2022] [Accepted: 07/12/2022] [Indexed: 11/30/2022] Open
Abstract
The present study builds on our prior work that demonstrated an association between pharmacogenetic interactions and 90-day readmission. In a substantially larger, more diverse study population of 19,999 adults tracked from 2010 through 2020 who underwent testing with a 13-gene pharmacogenetic panel, we included additional covariates to evaluate aggregate contribution of social determinants and medical comorbidity with the presence of identified gene-x-drug interactions to moderate 90-day hospital readmission (primary outcome). Univariate logistic regression analyses demonstrated that strongest associations with 90 day hospital readmissions were the number of medications prescribed within 30 days of a first hospital admission that had Clinical Pharmacogenomics Implementation Consortium (CPIC) guidance (CPIC medications) (5+ CPIC medications, odds ratio (OR) = 7.66, 95% confidence interval 5.45−10.77) (p < 0.0001), major comorbidities (5+ comorbidities, OR 3.36, 2.61−4.32) (p < 0.0001), age (65 + years, OR = 2.35, 1.77−3.12) (p < 0.0001), unemployment (OR = 2.19, 1.88−2.64) (p < 0.0001), Black/African-American race (OR 2.12, 1.47−3.07) (p < 0.0001), median household income (OR = 1.63, 1.03−2.58) (p = 0.035), male gender (OR = 1.47, 1.21−1.80) (p = 0.0001), and one or more gene-x-drug interaction (defined as a prescribed CPIC medication for a patient with a corresponding actionable pharmacogenetic variant) (OR = 1.41, 1.18−1.70). Health insurance was not associated with risk of 90-day readmission. Race, income, employment status, and gene-x-drug interactions were robust in a multivariable logistic regression model. The odds of 90-day readmission for patients with one or more identified gene-x-drug interactions after adjustment for these covariates was attenuated by 10% (OR = 1.31, 1.08−1.59) (p = 0.006). Although the interaction between race and gene-x-drug interactions was not statistically significant, White patients were more likely to have a gene-x-drug interaction (35.2%) than Black/African-American patients (25.9%) who were not readmitted (p < 0.0001). These results highlight the major contribution of social determinants and medical complexity to risk for hospital readmission, and that these determinants may modify the effect of gene-x-drug interactions on rehospitalization risk.
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Jain S, Murphy TE, O’Leary JR, Leo-Summers L, Ferrante LE. Association Between Socioeconomic Disadvantage and Decline in Function, Cognition, and Mental Health After Critical Illness Among Older Adults : A Cohort Study. Ann Intern Med 2022; 175:644-655. [PMID: 35254879 PMCID: PMC9316386 DOI: 10.7326/m21-3086] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Older adults admitted to an intensive care unit (ICU) are at risk for developing impairments in function, cognition, and mental health. It is not known whether socioeconomically disadvantaged older persons are at greater risk for these impairments than their less vulnerable counterparts. OBJECTIVE To evaluate the association between socioeconomic disadvantage and decline in function, cognition, and mental health among older survivors of an ICU hospitalization. DESIGN Retrospective analysis of a longitudinal cohort study. SETTING Community-dwelling older adults in the National Health and Aging Trends Study (NHATS). PARTICIPANTS Participants with ICU hospitalizations between 2011 and 2017. MEASUREMENTS Socioeconomic disadvantage was assessed as dual-eligible Medicare-Medicaid status. The outcome of function was defined as the count of disabilities in 7 activities of daily living and mobility tasks, the cognitive outcome as the transition from no or possible to probable dementia, and the mental health outcome as the Patient Health Questionnaire-4 score in the NHATS interview after ICU hospitalization. The analytic sample included 641 ICU hospitalizations for function, 458 for cognition, and 519 for mental health. RESULTS After accounting for sociodemographic and clinical characteristics, dual eligibility was associated with a 28% increase in disability after ICU hospitalization (incidence rate ratio, 1.28; 95% CI, 1.00 to 1.64); and nearly 10-fold greater odds of transitioning to probable dementia (odds ratio, 9.79; 95% CI, 3.46 to 27.65). Dual eligibility was not associated with symptoms of depression and anxiety after ICU hospitalization (incidence rate ratio, 1.33; 95% CI, 0.99 to 1.79). LIMITATION Administrative data, variability in timing of baseline and outcome assessments, proxy selection. CONCLUSION Dual-eligible older persons are at greater risk for decline in function and cognition after an ICU hospitalization than their more advantaged counterparts. This finding highlights the need to prioritize low-income seniors in rehabilitation and recovery efforts after critical illness and warrants investigation into factors leading to this disparity. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Terrence E. Murphy
- Program on Aging, Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - John R. O’Leary
- Program on Aging, Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Linda Leo-Summers
- Program on Aging, Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
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12
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Silvestri D, Goutos D, Lloren A, Zhou S, Zhou G, Farietta T, Charania S, Herrin J, Peltz A, Lin Z, Bernheim S. Factors Associated With Disparities in Hospital Readmission Rates Among US Adults Dually Eligible for Medicare and Medicaid. JAMA HEALTH FORUM 2022; 3:e214611. [PMID: 35977231 PMCID: PMC8903116 DOI: 10.1001/jamahealthforum.2021.4611] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/02/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Low-income older adults who are dually eligible (DE) for Medicare and Medicaid often experience worse outcomes following hospitalization. Among other federal policies aimed at improving health for DE patients, Medicare has recently begun reporting disparities in within-hospital readmissions. The degree to which disparities for DE patients are owing to differences in community-level factors or, conversely, are amenable to hospital quality improvement, remains heavily debated. Objective To examine the extent to which within-hospital disparities in 30-day readmission rates for DE patients are ameliorated by state- and community-level factors. Design Setting and Participants In this retrospective cohort study, Centers for Medicare & Medicaid Services (CMS) Disparity Methods were used to calculate within-hospital disparities in 30-day risk-adjusted readmission rates for DE vs non-DE patients in US hospitals participating in Medicare. All analyses were performed in February and March 2019. The study included Medicare patients (aged ≥65 years) hospitalized for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2014 to 2017. Main Outcomes and Measures Within-hospital disparities, as measured by the rate difference (RD) in 30-day readmission between DE vs non-DE patients following admission for AMI, HF, or pneumonia; variance across hospitals; and correlation of hospital RDs with and without adjustment for state Medicaid eligibility policies and community-level factors. Results The final sample included 475 444 patients admitted for AMI, 898 395 for HF, and 1 214 282 for pneumonia, of whom 13.2%, 17.4%, and 23.0% were DE patients, respectively. Dually eligible patients had higher 30-day readmission rates relative to non-DE patients (RD >0) in 99.0% (AMI), 99.4% (HF), and 97.5% (pneumonia) of US hospitals. Across hospitals, the mean (IQR) RD between DE vs non-DE was 1.00% (0.87%-1.10%) for AMI, 0.82% (0.73%-0.96%) for HF, and 0.53% (0.37%-0.71%) for pneumonia. The mean (IQR) RD after adjustment for community-level factors was 0.87% (0.73%-0.97%) for AMI, 0.67% (0.57%-0.80%) for HF, and 0.42% (0.29%-0.57%) for pneumonia. Relative hospital rankings of corresponding within-hospital disparities before and after community-level adjustment were highly correlated (Pearson coefficient, 0.98). Conclusions and Relevance In this cohort study, within-hospital disparities in 30-day readmission for DE patients were modestly associated with differences in state Medicaid policies and community-level factors. This suggests that remaining variation in these disparities should be the focus of hospital efforts to improve the quality of care transitions at discharge for DE patients in efforts to advance equity.
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Affiliation(s)
- David Silvestri
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Demetri Goutos
- The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut
| | - Anouk Lloren
- Mathematica Policy Research, Cambridge, Massachusetts
| | - Sheng Zhou
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut,The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut
| | - Guohai Zhou
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Sana Charania
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut,Flying Buttress Associates, Charlottesville, Virginia
| | - Alon Peltz
- The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut,Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Zhenqiu Lin
- The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Susannah Bernheim
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut,The Yale Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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13
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MIRROR-TCM: Multisite Replication of a Randomized Controlled Trial - Transitional Care Model. Contemp Clin Trials 2021; 112:106620. [PMID: 34785306 DOI: 10.1016/j.cct.2021.106620] [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] [Received: 07/10/2021] [Revised: 09/22/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022]
Abstract
In the U.S., older adults hospitalized with acute episodes of chronic conditions often are rehospitalized within 30 days of discharge. Numerous studies reveal that poor management of the complex needs of this population remains the norm. METHODS: This prospective, intent-to-treat, randomized controlled trial (RCT) will assess the effects of replicating the rigorously studied Transitional Care Model (TCM) in four U.S. healthcare systems. The TCM is an advanced practice registered nurse led, team-based, care management intervention that supports older adults throughout vulnerable care episodes that span hospital to home. This RCT will compare health and economic outcomes demonstrated by at-risk older adults hospitalized with heart failure, chronic obstructive pulmonary disease or pneumonia randomized to receive usual discharge planning (control group, N = 800) to those observed by a similar group of older adults randomized to receive the TCM protocol (N = 800). The primary outcome is number of rehospitalizations at 12 months post-discharge, with secondary resource use outcomes measured at multiple intervals. Patient experience with care, health and quality of life outcomes will be assessed at 90 days post-discharge. DISCUSSION: Based on health and economic benefits demonstrated in multiple NIH funded RCTs, the study team hypothesizes that the intervention group, both within and across participating health systems, will have decreased acute care resource use and costs at 12 months and better ratings of the care experience and health and quality of life through 90 days post-discharge compared to the control group. The impact of COVID-19 on implementation of this study also is discussed.
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The impact of nurse practitioner and physician assistant workforce supply on Medicaid-related emergency department visits and hospitalizations. J Am Assoc Nurse Pract 2021; 33:1190-1197. [PMID: 33534285 DOI: 10.1097/jxx.0000000000000542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND New York State (NYS) has approximately 4.7 million Medicaid beneficiaries with 75% having at least one or more chronic conditions. An estimated 10% of Medicaid beneficiaries seek emergency department (ED) services for nonurgent matters. It is unclear if an increased supply of nurse practitioners (NPs) and physician assistants (PAs) impact utilization of ED and subsequent hospitalizations for chronic conditions. PURPOSE To investigate the relationship between NYS workforce supply (physicians, NPs, and PAs) and 1) ED use and 2) in-patient hospitalizations for chronically ill Medicaid beneficiaries. METHODS A cross-sectional study design was employed by calculating total workforce supply per NYS county and the proportion of physicians, NPs, and PAs per total number of Medicaid beneficiaries. We extracted the frequencies of all NYS Medicaid beneficiary chronic condition-related ED visits and in-patient admissions. Medicaid beneficiaries were considered to have a chronic condition if there was a claim indicating that the beneficiary received a service or treatment for this specific condition. We calculated the proportion of ED visits/beneficiary for each chronic disease category and the proportion of category-specific in-patient hospitalizations per the number of beneficiaries with that diagnosis. RESULTS As the NP/beneficiary proportion increased, ED visits for dual and nondual eligible beneficiaries decreased (p = .007; β = -2.218; 95% confidence interval [CI]: -3.79 to -0.644 and p = .04; β = -2.698; 95% CI: -5.268 to -0.127, respectively). IMPLICATIONS FOR PRACTICE Counties with a higher proportion of NPs and PAs had significantly lower numbers of ED visits and hospitalizations for Medicaid beneficiaries.
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Are Improvements Still Needed to the Modified Hospital Readmissions Reduction Program: a Health and Retirement Study (2000-2014)? J Gen Intern Med 2020; 35:3564-3571. [PMID: 33051840 PMCID: PMC7728935 DOI: 10.1007/s11606-020-06222-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/07/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND To address concerns that the Hospital Readmissions Reduction Program (HRRP) unfairly penalized safety net hospitals treating patients with high social and functional risks, Medicare recently modified HRRP to compare hospitals with similar proportions of high-risk, dual-eligible patients ("peer group hospitals"). Whether the change fully accounts for patients' social and functional risks is unknown. OBJECTIVE Examine risk-standardized readmission rates (RSRRs) and hospital penalties after adding patient-level social and functional and community-level risk factors. DESIGN Using 2000-2014 Medicare hospital discharge, Health and Retirement Study, and community-level data, latent factors for patient social and functional factors and community factors were identified. We estimated RSRRs for peer groups and by safety net status using four hierarchical logistic regression models: "base" (HRRP model); "patient" (base plus patient factors); "community" (base plus community factors); and "full" (all factors). The proportion of hospitals penalized was calculated by safety net status. PATIENTS 20,255 fee-for-service Medicare beneficiaries (65+) with eligible index hospitalizations MAIN MEASURES: RSRRs KEY RESULTS: Half of safety net hospitals are in peer group 5. Compared with other hospitals, peer group 5 hospitals (most dual-eligibles) treated sicker, more functionally limited patients from socially disadvantaged groups. RSRRs decreased by 0.7% for peer groups 2 and 4 and 1.3% for peer group 5 under the patient and full (versus base) models. Measured performance improved after adjusting for patient risk factors for hospitals in peer group 4 and 5 hospitals, but worsened for those in peer groups 1, 2, and 3. Under the patient (versus base) model, fewer safety net hospitals (48.7% versus 51.3%) but more non-safety net hospitals (50.0% versus 49.1%) were penalized. CONCLUSIONS Patient-level risk adjustment decreased RSRRs for hospitals serving more at-risk patients and proportion of safety net hospitals penalized, while modestly increasing RSRRs and proportion of non-safety net hospitals penalized. Results suggest HRRP modifications may not fully account for hospital variation in patient-level risk.
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16
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Perpetuation of Inequity: Disproportionate Penalties to Minority-serving and Safety-net Hospitals Under Another Medicare Value-based Payment Model. Ann Surg 2020; 271:994-995. [DOI: 10.1097/sla.0000000000003911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Lloren A, Liu S, Herrin J, Lin Z, Zhou G, Wang Y, Kuang M, Zhou S, Farietta T, McCole K, Charania S, Dorsey Sheares K, Bernheim S. Measuring hospital-specific disparities by dual eligibility and race to reduce health inequities. Health Serv Res 2020; 54 Suppl 1:243-254. [PMID: 30666634 PMCID: PMC6341208 DOI: 10.1111/1475-6773.13108] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To propose and evaluate a metric for quantifying hospital‐specific disparities in health outcomes that can be used by patients and hospitals. Data Sources/Study Setting Inpatient admissions for Medicare patients with acute myocardial infarction, heart failure, or pneumonia to all non‐federal, short‐term, acute care hospitals during 2012‐2015. Study Design Building on the current Centers for Medicare and Medicaid Services methodology for calculating risk‐standardized readmission rates, we developed models that include a hospital‐specific random coefficient for either patient dual eligibility status or African American race. These coefficients quantify the difference in risk‐standardized outcomes by dual eligibility and race at a given hospital after accounting for the hospital's patient case mix and proportion of dual eligible or African American patients. We demonstrate this approach and report variation and performance in hospital‐specific disparities. Principal Findings Dual eligibility and African American race were associated with higher readmission rates within hospitals for all three conditions. However, this disparity effect varied substantially across hospitals. Conclusion Our models isolate a hospital‐specific disparity effect and demonstrate variation in quality of care for different groups of patients across conditions and hospitals. Illuminating within‐hospital disparities can incentivize hospitals to reduce inequities in health care quality.
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Affiliation(s)
- Anouk Lloren
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut
| | - Shuling Liu
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut
| | - Jeph Herrin
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut
| | - Guohai Zhou
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Medicine, Center for Outcomes Research and Evaluation (CORE), Yale Univerity, New Haven, Connecticut
| | - Meng Kuang
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Sheng Zhou
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Thalia Farietta
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Kerry McCole
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Sana Charania
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Karen Dorsey Sheares
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Section of Pediatrics, Department of Pediatrics, Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Susannah Bernheim
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, Connecticut.,Section of General Internal Medicine, Department of Internal Medicine, Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
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