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Lakra A, Tram MK, Bernasek TL, Lyons ST, O'Connor CM. Frailty is Associated With Increased Complication, Readmission, and Hospitalization Costs Following Primary Total Knee Arthroplasty. J Arthroplasty 2023; 38:S182-S186.e2. [PMID: 36858131 DOI: 10.1016/j.arth.2023.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/05/2023] [Accepted: 02/11/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Frailty has been associated with poor postoperative outcomes in various medical conditions and surgical procedures. However, the relationship between frailty and outcomes after primary total knee arthroplasty (TKA) has not been well-described. This study investigated the association of the Hospital Frailty Risk Score (HFRS) with postoperative events and hospitalization costs after primary TKA. METHODS Using a nationwide readmissions database, we identified 884,479 patients discharged after primary TKA for osteoarthritis between January 2017 and November 2019. HFRS was calculated for each patient to determine frailty status. We used multivariate logistic regressions to evaluate the association of frailty with 30-readmission rate and negative binomial regressions to evaluate lengths of hospital stay and hospitalization costs. The 30-day reoperation and complication rates were compared using chi-square tests. RESULTS Frailty was associated with increased odds of 30-day readmissions (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.82-1.96), longer lengths of stay (OR: 1.43, 95% CI: 1.43-1.44), and higher hospitalization costs (OR: 1.16, 95% CI: 1.16-1.17). Frail patients also had significantly higher rates of 30-day reoperations (0.6 versus 0.4%), surgical complications (0.6 versus 0.4%), medical complications (3.4 versus 1.3%), and other complications (0.9 versus 0.5%) (P < .01). CONCLUSIONS Frailty, as measured using HFRS, was associated with increased adverse events and health care burdens in patients undergoing TKA. The HFRS could be used to swiftly identify high-risk patients undergoing TKA and to potentially help optimize patients prior to elective TKA. TYPE OF STUDY Level III retrospective cohort study.
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Affiliation(s)
- Akshay Lakra
- Albany Medical Center, Department of Orthopedic Surgery, Albany, New York
| | - Michael K Tram
- Albany Medical Center, Department of Orthopedic Surgery, Albany, New York
| | - Thomas L Bernasek
- Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
| | - Steven T Lyons
- Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
| | - Casey M O'Connor
- Albany Medical Center, Department of Orthopedic Surgery, Albany, New York; Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
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Gupta A, David G, Kim L. The effect of performance pay incentives on market frictions: evidence from medicare. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2023; 23:27-57. [PMID: 36543962 DOI: 10.1007/s10754-022-09339-4] [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: 07/21/2020] [Accepted: 10/23/2022] [Indexed: 06/17/2023]
Abstract
Medicare has increased the use of performance pay incentives for hospitals, with the goal of increasing care coordination across providers, reducing market frictions, and ultimately to improve quality of care. This paper provides new empirical evidence by using novel operations and claims data from a large, independent home health care firm with the Hospital Readmissions Reduction Program (HRRP) penalty on hospitals providing identifying variation. We find that the penalty incentive to reduce re-hospitalizations passed through from hospitals to the firm for at least some types of patients, since it provided more care inputs for heart disease patients discharged from hospitals at greater penalty risk and that contributed more patients to the firm. This evidence suggests that HRRP helped increase coordination between hospitals and home health firms without formal integration. Greater home health effort does not appear to have led to lower patient readmissions.
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Affiliation(s)
- Atul Gupta
- The Wharton School, 3641 Locust Walk, 306 CPC, Philadelphia, PA, 19104, USA.
| | - Guy David
- The Wharton School and NBER, Philadelphia, USA
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Miranda SP, Blue R, Parasher AK, Lerner DK, Glicksman JT, Detchou D, Dimentberg R, Thurlow J, Lebold D, Hudgins J, Ebesutani D, Lee JYK, Storm PB, O'Malley BW, Palmer JN, Yoshor D, Adappa ND, Grady MS. Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery. World Neurosurg 2023; 172:e357-e363. [PMID: 36640831 DOI: 10.1016/j.wneu.2023.01.028] [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: 08/17/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications. METHODS We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions. RESULTS One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5 years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97 days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27 days (P = 0.008, 95% CI: 0.33-2.20). In-hospital costs were reduced across all domains, including $1964.87 in variable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P = 0.011), with fewer readmissions (0% vs. 6%, P = 0.021). CONCLUSIONS A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel Blue
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Arjun K Parasher
- Department of Otolaryngology: Head and Neck Surgery, University of South Florida, Tampa, Florida, USA; College of Public Health, University of South Florida, Tampa, Florida, USA
| | - David K Lerner
- Department of Otolaryngology: Head and Neck Surgery, Icahn School of Mount Sinai, New York, New York, USA
| | - Jordan T Glicksman
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA; New England Ear Nose and Throat, Newton, Massachusetts, USA
| | - Donald Detchou
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Dimentberg
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Thurlow
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lebold
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justine Hudgins
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Darren Ebesutani
- Office of Clinical Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Phillip B Storm
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bert W O'Malley
- Department of Otolaryngology - Head and Neck Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - James N Palmer
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Yoshor
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - M Sean Grady
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Azadeh-Fard N, Muchiri S, Pakdil F, Beazoglou H. Examining readmission rates of congestive heart failure patients in the United States between 2010 and 2017: Does length of stay matter? INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2022. [DOI: 10.1080/20479700.2022.2157074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Nasibeh Azadeh-Fard
- Rochester Institute of Technology, Department of Industrial and Systems Engineering, Rochester, NY, USA
| | - Steve Muchiri
- Eastern Connecticut State University, Department of Economics, Willimantic, CT, USA
| | - Fatma Pakdil
- Eastern Connecticut State University, Department of Business Administration, Willimantic, CT, USA
| | - Hannah Beazoglou
- Eastern Connecticut State University, Department of Business Administration, Willimantic, CT, USA
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Montgomery JR, Neiman PU, Brown CS, Cain-Nielsen AH, Scott JW, Sangji NF, Oliphant BW, Hemmila MR. Sources of Postacute Care Episode Payment Variation After Traumatic Hip Fracture Repair Among Medicare Beneficiaries: Cross-Sectional Retrospective Study. ANNALS OF SURGERY OPEN 2022; 3:e218. [PMID: 37600283 PMCID: PMC10406045 DOI: 10.1097/as9.0000000000000218] [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] [Received: 06/14/2022] [Accepted: 09/25/2022] [Indexed: 11/09/2022] Open
Abstract
The objective of this study was to evaluate how much variation in postacute care (PAC) spending after traumatic hip fracture exists between hospitals, and to what degree this variation is explained by patient factors, hospital factors, PAC setting, and PAC intensity. Background Traumatic hip fracture is a common and costly event. This is particularly relevant given our aging population and that a substantial proportion of these patients are discharged to PAC settings. Methods It is a cross-sectional retrospective study. In a retrospective review using Medicare claims data between 2014 and 2019, we identified PAC payments within 90 days of hospitalization discharges and grouped hospitals into quintiles of PAC spending. The degree of variation present in PAC spending across hospital quintiles was evaluated after accounting for patient case-mix factors and hospital characteristics using multivariable regression models, adjusting for PAC setting choice by fixing the proportion of PAC discharge disposition across hospital quintiles, and adjusting for PAC intensity by fixing the amount of PAC spending across hospital quintiles. The study pool included 125,745 Medicare beneficiaries who underwent operative management for traumatic hip fracture in 2078 hospitals. The primary outcome was PAC spending within 90 days of discharge following hospitalization for traumatic hip fracture. Results Mean PAC spending varied widely between top versus bottom spending hospital quintiles ($31,831 vs $17,681). After price standardization, the difference between top versus bottom spending hospital quintiles was $8,964. Variation between hospitals decreased substantially after adjustment for PAC setting ($25,392 vs $21,274) or for PAC intensity ($25,082 vs $21,292) with little variation explained by patient or hospital factors. Conclusions There was significant variation in PAC payments after a traumatic hip fracture between the highest- and lowest-spending hospital quintiles. Most of this variation was explained by choice of PAC discharge setting and intensity of PAC spending, not patient or hospital characteristics. These findings suggest potential systems-level inefficiencies that can be targeted for intervention to improve the appropriateness and value of healthcare spending.
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Affiliation(s)
- John R. Montgomery
- From the Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Pooja U. Neiman
- From the Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Craig S. Brown
- From the Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Anne H. Cain-Nielsen
- From the Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - John W. Scott
- From the Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Naveen F. Sangji
- From the Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Bryant W. Oliphant
- From the Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Mark R. Hemmila
- From the Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
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Shashikumar SA, Gulseren B, Berlin NL, Hollingsworth JM, Joynt Maddox KE, Ryan AM. Association of Hospital Participation in Bundled Payments for Care Improvement Advanced With Medicare Spending and Hospital Incentive Payments. JAMA 2022; 328:1616-1623. [PMID: 36282256 PMCID: PMC9597389 DOI: 10.1001/jama.2022.18529] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/20/2022] [Indexed: 11/14/2022]
Abstract
Importance Bundled Payments for Care Improvement Advanced (BPCI-A) is a Centers for Medicare & Medicaid Services (CMS) initiative that aims to produce financial savings by incentivizing decreases in clinical spending. Incentives consist of financial bonuses from CMS to hospitals or penalties paid by hospitals to CMS. Objective To investigate the association of hospital participation in BPCI-A with spending, and to characterize hospitals receiving financial bonuses vs penalties. Design, Setting, and Participants Difference-in-differences and cross-sectional analyses of 4 754 139 patient episodes using 2013-2019 US Medicare claims at 694 participating and 2852 nonparticipating hospitals merged with hospital and market characteristics. Exposures BPCI-A model years 1 and 2 (October 1, 2018, through December 31, 2019). Main Outcomes and Measures Hospitals' per-episode spending, CMS gross and net spending, and the incentive allocated to each hospital. Results The study identified 694 participating hospitals. The analysis observed a -$175 change in mean per-episode spending (95% CI, -$378 to $28) and an aggregate spending change of -$75.1 million (95% CI, -$162.1 million to $12.0 million) across the 428 670 episodes in BPCI-A model years 1 and 2. However, CMS disbursed $354.3 million (95% CI, $212.0 million to $496.0 million) more in bonuses than it received in penalties. Hospital participation in BPCI-A was associated with a net loss to CMS of $279.2 million (95% CI, $135.0 million to $423.0 million). Hospitals in the lowest quartile of Medicaid days received a mean penalty of $0.41 million; (95% CI, $0.09 million to $0.72 million), while those in the highest quartile received a mean bonus of $1.57 million; (95% CI, $1.09 million to $2.08 million). Similar patterns were observed for hospitals across increasing quartiles of Disproportionate Share Hospital percentage and of patients from racial and ethnic minority groups. Conclusions and Relevance Among US hospitals measured between 2013 and 2019, participation in BPCI-A was significantly associated with an increase in net CMS spending. Bonuses accrued disproportionately to hospitals providing care for marginalized communities.
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Affiliation(s)
- Sukruth A Shashikumar
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Baris Gulseren
- School of Public Health, University of Michigan, Ann Arbor
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor
| | - Nicholas L Berlin
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor
| | | | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Associate Editor, JAMA
| | - Andrew M Ryan
- School of Public Health, Brown University, Providence, Rhode Island
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Klemt C, Uzosike AC, Harvey MJ, Laurencin S, Habibi Y, Kwon YM. Neural network models accurately predict discharge disposition after revision total knee arthroplasty? Knee Surg Sports Traumatol Arthrosc 2022; 30:2591-2599. [PMID: 34716766 DOI: 10.1007/s00167-021-06778-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/15/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE Based on the rising incidence of revision total knee arthroplasty (TKA), bundled payment models may be applied to revision TKA in the near future. Facility discharge represents a significant cost factor for those bundled payment models; however, accurately predicting discharge disposition remains a clinical challenge. The purpose of this study was to develop and validate artificial intelligence algorithms to predict discharge disposition following revision total knee arthroplasty. METHODS A retrospective review of electronic patient records was conducted to identify patients who underwent revision total knee arthroplasty. Discharge disposition was defined as either home discharge or non-home discharge, which included rehabilitation and skilled nursing facilities. Four artificial intelligence algorithms were developed to predict this outcome and were assessed by discrimination, calibration and decision curve analysis. RESULTS A total of 2228 patients underwent revision TKA, of which 1405 patients (63.1%) were discharged home, whereas 823 patients (36.9%) were discharged to a non-home facility. The strongest predictors for non-home discharge following revision TKA were American Society of Anesthesiologist (ASA) score, Medicare insurance type and revision surgery for peri-prosthetic joint infection, non-white ethnicity and social status (living alone). The best performing artificial intelligence algorithm was the neural network model which achieved excellent performance across discrimination (AUC = 0.87), calibration and decision curve analysis. CONCLUSION This study developed four artificial intelligence algorithms for the prediction of non-home discharge disposition for patients following revision total knee arthroplasty. The study findings show excellent performance on discrimination, calibration and decision curve analysis for all four candidate algorithms. Therefore, these models have the potential to guide preoperative patient counselling and improve the value (clinical and functional outcomes divided by costs) of revision total knee arthroplasty patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Christian Klemt
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Akachimere Cosmas Uzosike
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Michael Joseph Harvey
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Samuel Laurencin
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Yasamin Habibi
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Young-Min Kwon
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Sedevich-Fons L. Quality and costs in health care: using target costing in support of bundled payment programs. TQM JOURNAL 2022. [DOI: 10.1108/tqm-03-2022-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe main purpose of this study is to provide healthcare institutions with a management accounting framework that helps them achieve their quality goals and cost targets when providing services under bundled payment schemes.Design/methodology/approachAfter providing a theoretical framework on both bundled payments and target costing, the success factors of the former are compared with the principles of the latter in order to analyze the compatibility and complementarity of these models. Afterwards, an example of their potential combination in practice is introduced and ideas for future research are suggested.FindingsIt is concluded that, apart from presenting similar underlying goals as regards quality and cost, bundled payments and target costing display elements in common that make them compatible from a theoretical standpoint.Originality/valueBecause bundled payments models are relatively new, studies on their compatibility with managerial techniques emerging from industries other than healthcare do not abound in the literature.
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Ricciardi R, Goldstone RN, Francone T, Wszolek M, Auchincloss H, de Groot A, Shih IF, Li Y. Healthcare Resource Utilization After Surgical Treatment of Cancer: Value of Minimally Invasive Surgery. Surg Endosc 2022; 36:7549-7560. [PMID: 35445834 PMCID: PMC9022614 DOI: 10.1007/s00464-022-09189-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/07/2022] [Indexed: 12/24/2022]
Abstract
Background As the US healthcare system moves towards value-based care, hospitals have increased efforts to improve quality and reduce unnecessary resource use. Surgery is one of the most resource-intensive areas of healthcare and we aim to compare health resource utilization between open and minimally invasive cancer procedures. Methods We retrospectively analyzed cancer patients who underwent colon resection, rectal resection, lobectomy, or radical nephrectomy within the Premier hospital database between 2014 and 2019. Study outcomes included length of stay (LOS), discharge status, reoperation, and 30-day readmission. The open surgical approach was compared to minimally invasive approach (MIS), with subgroup analysis of laparoscopic/video-assisted thoracoscopic surgery (LAP/VATS) and robotic (RS) approaches, using inverse probability of treatment weighting. Results MIS patients had shorter LOS compared to open approach: − 1.87 days for lobectomy, − 1.34 days for colon resection, − 0.47 days for rectal resection, and − 1.21 days for radical nephrectomy (all p < .001). All MIS procedures except for rectal resection are associated with higher discharge to home rates and lower reoperation and readmission rates. Within MIS, robotic approach was further associated with shorter LOS than LAP/VATS: − 0.13 days for lobectomy, − 0.28 days for colon resection, − 0.67 days for rectal resection, and − 0.33 days for radical nephrectomy (all p < .05) and with equivalent readmission rates. Conclusion Our data demonstrate a significant shorter LOS, higher discharge to home rate, and lower rates of reoperation and readmission for MIS as compared to open procedures in patients with lung, kidney, and colorectal cancer. Patients who underwent robotic procedures had further reductions in LOS compare to laparoscopic/video-assisted thoracoscopic approach, while the reductions in LOS did not lead to increased rates of readmission. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09189-8.
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Affiliation(s)
- Rocco Ricciardi
- Section of Colon & Rectal Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 460, Boston, MA, USA.
| | - Robert Neil Goldstone
- Section of Colon & Rectal Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 460, Boston, MA, USA
| | - Todd Francone
- Section of Colon & Rectal Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 460, Boston, MA, USA
| | - Matthew Wszolek
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hugh Auchincloss
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander de Groot
- Global Access, Value, & Economics, Intuitive Surgical, Sunnyvale, CA, USA
| | - I-Fan Shih
- Global Access, Value, & Economics, Intuitive Surgical, Sunnyvale, CA, USA
| | - Yanli Li
- Global Access, Value, & Economics, Intuitive Surgical, Sunnyvale, CA, USA
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Muchiri S, Azadeh-Fard N, Pakdil F. The Analysis of Hospital Readmission Rates After the Implementation of Hospital Readmissions Reduction Program. J Patient Saf 2022; 18:237-244. [PMID: 34292263 DOI: 10.1097/pts.0000000000000883] [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: 11/26/2022]
Abstract
OBJECTIVES This study aims to analyze the impact of Hospital Readmissions Reduction Program (HRRP) on the nationwide optimization efforts of length of stay (LOS) and readmissions in the United States. METHODS We use the Nationwide Readmission Database between 2010 and 2016 provided in the Healthcare Cost and Utilization Project by the Agency for Healthcare Research and Quality. The study focuses on acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure (CHF), pneumonia monitored by the HRRP and 2 conditions, septicemia, and mood disorders that were not monitored by the HRRP but had among the highest readmissions. Patient demographics and readmissions were analyzed based on insurance type, LOS, and Charlson Comorbidity Index. RESULTS The readmissions vary by conditions, LOS, and insurance types. Congestive heart failure has the highest readmissions among the 6 analyzed conditions at approximately 25%. The readmission rate of CHF rises to 30% for the Medicaid patients and varies between 30% and 35% by LOS. Patients with CHF with higher Charlson Comorbidity Index demonstrates the highest readmissions among 6 conditions. The patients with longer LOSs had higher readmissions, and Medicare patients have a higher reduction in readmissions in acute myocardial infarction and mood disorders compared with the other forms of payments. CONCLUSIONS Our figures show that targeted programs, such as HRRP, may have a positive impact on readmission rates. We, however, observe some graphical evidence that nontargeted conditions could exhibit similar trends. Because of heterogeneity in hospital and patient characteristics, it is pivotal for researcher to consider them in formal analyses.
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Affiliation(s)
- Steve Muchiri
- From the Eastern Connecticut State University, Willimantic, Connecticut
| | - Nasibeh Azadeh-Fard
- Department of Industrial and Systems Engineering, Rochester Institute of Technology, Rochester, New York
| | - Fatma Pakdil
- From the Eastern Connecticut State University, Willimantic, Connecticut
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Karlin J. Sam's Story: The Financial and Human Costs of Disjointed Logics of Care. Ann Fam Med 2022; 20:84-87. [PMID: 35074773 PMCID: PMC8786420 DOI: 10.1370/afm.2763] [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: 11/18/2020] [Revised: 05/16/2021] [Accepted: 06/10/2021] [Indexed: 11/09/2022] Open
Abstract
I am an anthropologist and family doctor who has the good fortune of working in northern California with colleagues who prioritize the social needs of our patients alongside medical ones. In the essay that follows, I share details from my patient Sam's (pseudonym) last 2 years of life to underscore how attending to social precarity cannot be fully achieved within our safety net institutions as they are currently structured. While we have strong evidence that addressing social needs as part of clinical care offers good return on investment, Sam's story makes visible the problems we face when attempting to address social determinants of health. After introducing a concept from the social sciences about rationales that underlie health care delivery, I call on primary care doctors to redefine the medical paradigm to remedy the disjointed logics of care that result in unnecessarily high financial and human costs.
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12
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Effects of Skilled Nursing Facility Partnerships on Outcomes Following Total Joint Arthroplasty. J Am Acad Orthop Surg 2021; 29:e1313-e1320. [PMID: 33999879 DOI: 10.5435/jaaos-d-20-01378] [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: 12/15/2020] [Accepted: 03/26/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Post-total joint arthroplasty (TJA) discharge to a skilled nursing facility (SNF) is associated with higher costs and more complications than home discharge; however, some patients still require postoperative SNF care. To improve outcomes for patients requiring postoperative SNF care, this article analyzed the effect of SNF-surgeon partnerships on TJA postoperative costs and patient outcomes. METHODS This was a retrospective study of primary TJA patients who were part of Medicare's Comprehensive Care for Joint Replacement (CJR) pilot program at our urban, academic medical center. We identified all patients discharged to SNF and designated SNFs as "preferred" if they maintained a partnership with our surgical team. SNF costs, total 90-day postoperative costs, average length of stay in SNF, 90-day readmission rates, and readmission diagnoses were recorded. Data were compared using Student t-tests. Readmission rates and the presence of a readmission diagnosis were analyzed using z-scores. RESULTS Our search identified 189 patients (22.9%) discharged to SNFs, with 128 (67.8%) discharged to preferred and 61 (32.2%) discharged to nonpreferred facilities. Over the 4-year CJR pilot program, SNF costs ($10,981.23 versus $7,343.34; P < 0.005) and overall postdischarge costs ($23,952.52 versus $18,339.26; P = 0.07) were higher for patients discharged to nonpreferred SNFs versus preferred SNFs. Patients discharged to nonpreferred SNFs also had increased length of stay (14.8 versus 10.1 days; P < 0.005) and increased readmission rates (19.7% versus 3.9%; P < 0.005). These differences became more pronounced across the study period. CONCLUSION For patients undergoing primary TJA, hospital partnership with SNFs can improve CJR performance by cost reduction and overall outcomes for TJA patients.
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Duque M, Schnetz MP, Yates AJ, Monahan A, Whitehurst S, Mahajan A, Kaynar AM. Impact of Neuraxial Versus General Anesthesia on Discharge Destination in Patients Undergoing Primary Total Hip and Total Knee Replacement. Anesth Analg 2021; 133:1379-1386. [PMID: 34784324 DOI: 10.1213/ane.0000000000005156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Total knee replacement (TKR) and total hip replacement (THR) are 2 of the most common orthopedic surgical procedures in the United States. These procedures, with fairly low mortality rates, incur significant health care costs, with almost 40% of the costs associated with post acute care. We assessed the impact of general versus neuraxial anesthesia on discharge destination and 30-day readmissions in patients who underwent total knee and hip replacement in our health system. METHODS This was a retrospective cohort study of 24,684 patients undergoing total knee or hip replacement in 13 hospitals of a large health care network. Following propensity score matching, we studied the impact of type of anesthetic technique on discharge destination (primary outcome) and postoperative complications including readmissions in 8613 patients who underwent THR and 13,004 patients for TKR. RESULTS Our results showed that in patients undergoing THR and TKR, neuraxial anesthesia is associated with higher odds of being discharged from hospital to home versus other facilities compared to general anesthesia (odds ratio [OR] = 1.63, 95% confidence interval [CI], 1.52-1.76; P < .01) and (OR = 1.58, 95% CI, 1.49-1.67; P < .01), respectively. CONCLUSIONS Our results suggest an association between use of neuraxial anesthesia for total joint arthroplasty and a higher probability of discharge to home and a reduction in readmissions.
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Affiliation(s)
- Melissa Duque
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | | | - Amanda Monahan
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | - Aman Mahajan
- From the Departments of Anesthesiology and Perioperative Medicine
| | - A Murat Kaynar
- From the Departments of Anesthesiology and Perioperative Medicine.,Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Salvatore FP, Fanelli S, Donelli CC, Milone M. Value-based health-care principles in health-care organizations. INTERNATIONAL JOURNAL OF ORGANIZATIONAL ANALYSIS 2021. [DOI: 10.1108/ijoa-07-2020-2322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This study aims to analyze the value-based health-care model in defining a strategy to guide the evolution of health-care organizations toward a value-oriented model. To improve the quality of care by ensuring economic sustainability, it is necessary to redefine the concept of competition in healthcare and align it with the concept of maximizing value for patients.
Design/methodology/approach
Performance measurement is a crucial aspect of the analysis of health-care organizations. Porter developed an effective analytical technique and presented the measurement of health-care outcomes based on health conditions, the efficiency of health-care organizations and the type of service provided.
Findings
Clinical outcomes and data on the costs of care of each patient are essential to evaluate improvement in treatment value over time. Engaging in the evaluation of what happens to patients in their course of care enables the expansion of the measurement of outcomes because it measures all the health services related to it.
Originality/value
Building a health-care system based on the value and continuous improvement of care and services provided is a goal shared by many countries and international organizations. Today, the analysis of outcomes is important for making informed decisions, directing and planning clinical and organizational changes by improving the quality of care and services.
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McClellan SR, Trombley MJ, Maughan BC, Kahvecioglu DC, Marshall J, Marrufo GM, Kummet C, Hassol A. Patient-reported Outcomes Among Vulnerable Populations in the Medicare Bundled Payments for Care Improvement Initiative. Med Care 2021; 59:980-988. [PMID: 34644284 DOI: 10.1097/mlr.0000000000001644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative tested whether episode-based payment models could reduce Medicare payments without harming quality. Among patients with vulnerabilities, BPCI appeared to effectively reduce payments while maintaining the quality of care. However, these findings could overlook potential adverse patient-reported outcomes in this population. RESEARCH DESIGN We surveyed beneficiaries with 4 characteristics (Medicare-Medicaid dual eligibility; dementia; recent institutional care; or racial/ethnic minority) treated at BPCI-participating or comparison hospitals for congestive heart failure, sepsis, pneumonia, or major joint replacement of the lower extremity. We estimated risk-adjusted differences in patient-reported outcomes between BPCI and comparison respondents, stratified by clinical episode and vulnerable characteristic. MEASURES Patient care experiences during episodes of care and patient-reported functional outcomes assessed roughly 90 days after hospitalization. RESULTS We observed no differences in self-reported functional improvement between BPCI and comparison respondents with vulnerable characteristics. Patient-reported care experience was similar between BPCI and comparison respondents in 11 of 15 subgroups of clinical episode and vulnerability. BPCI respondents with congestive heart failure, sepsis, and pneumonia were less likely to indicate positive care experiences than comparison respondents for at least 1 subgroup with vulnerabilities. CONCLUSIONS As implemented by hospitals, BPCI Model 2 was not associated with adverse effects on patient-reported functional status among beneficiaries who may be vulnerable to reductions in care. Hospitals participating in heart failure, sepsis or pneumonia bundled payment episodes should focus on patient care experience while implementing changes in care delivery.
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Affiliation(s)
| | | | - Brandon C Maughan
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | | | | | | | - Colleen Kummet
- General Dynamics Information Technology, West Des Moines, IA
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Sood N, Shier V, Huckfeldt PJ, Weissblum L, Escarce JJ. The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities. Health Serv Res 2021; 56:828-838. [PMID: 33969480 PMCID: PMC8522568 DOI: 10.1111/1475-6773.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes. DATA SOURCES Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014. STUDY DESIGN We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions. DATA EXTRACTION METHODS We identified Medicare beneficiaries discharged from a hospital to IRF. PRINCIPAL FINDINGS In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals. CONCLUSIONS Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.
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Affiliation(s)
- Neeraj Sood
- Leonard D. Schaeffer Center for Health Policy and Economics, Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Victoria Shier
- Leonard D. Schaeffer Center for Health Policy and Economics, Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Peter J. Huckfeldt
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | | | - José J. Escarce
- David Geffen School of Medicine at UCLACaliforniaLos AngelesUSA
- UCLA Fielding School of Public Health, Los AngelesCaliforniaUSA
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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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Variability in skilled nursing facility screening and admission processes: Implications for value-based purchasing. Health Care Manage Rev 2021; 45:353-363. [PMID: 30418292 DOI: 10.1097/hmr.0000000000000225] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospitalized older adults are increasingly admitted to skilled nursing facilities (SNFs) for posthospital care. However, little is known about how SNFs screen and evaluate potential new admissions. In an era of increasing emphasis on postacute care outcomes, these processes may represent an important target for interventions to improve the value of SNF care. PURPOSE The aim of this study was to understand (a) how SNF clinicians evaluate hospitalized older adults and make decisions to admit patients to an SNF and (b) the limitations and benefits of current practices in the context of value-based payment reforms. METHODS We used semistructured interviews to understand the perspective of 18 clinicians at three unique SNFs-including physicians, nurses, therapists, and liaisons. All transcripts were analyzed using a general inductive theme-based approach. RESULTS We found that the screening and admission processes varied by SNF and that variability was influenced by three key external pressures: (a) inconsistent and inadequate transfer of medical documentation, (b) lack of understanding among hospital staff of SNF processes and capabilities, and (c) hospital payment models that encouraged hospitals to discharge patients rapidly. Responses to these pressures varied across SNFs. For example, screening and evaluation processes to respond to these pressures included gaining access to electronic medical records, providing inpatient physician consultations prior to SNF acceptance, and turning away more complex patients for those perceived to be more straightforward rehabilitation patients. CONCLUSIONS We found facility behavior was driven by internal and external factors with implications for equitable access to care in the era of value-based purchasing. PRACTICE IMPLICATIONS SNFs can most effectively respond to these pressures by increasing their agency within hospital-SNF relationships and prioritizing more careful patient screening to match patient needs and facility capabilities.
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Thirukumaran CP. Lessons from Medicare's Bundled Payments for Care Improvement initiative for postacute care. J Am Geriatr Soc 2021; 69:3410-3412. [PMID: 34510413 DOI: 10.1111/jgs.17439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/15/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Caroline P Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York, USA.,Department of Public Health Sciences, University of Rochester, Rochester, New York, USA.,Center for Musculoskeletal Research, University of Rochester, Rochester, New York, USA
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20
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Zhao H, Liu Z, Li M, Liang L. Healthcare Warranty Policies Optimization for Chronic Diseases Based on Delay Time Concept. Healthcare (Basel) 2021; 9:healthcare9081088. [PMID: 34442225 PMCID: PMC8392548 DOI: 10.3390/healthcare9081088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 11/16/2022] Open
Abstract
Warranties for healthcare can be greatly beneficial for cost reductions and improvements in patient satisfaction. Under healthcare warranties, healthcare providers receive a lump sum payment for the entire care episode, which covers a bundle of healthcare services, including treatment decisions during initial hospitalization and subsequent readmissions, as well as disease-monitoring plans composed of periodic follow-ups. Higher treatment intensities and more radical monitoring strategies result in higher medical costs, but high treatment intensities reduce the baseline readmission rates. This study intends to provide a systematic optimization framework for healthcare warranty policies. In this paper, the proposed model allows healthcare providers to determine the optimal combination of treatment decisions and disease-monitoring policies to minimize the total expected healthcare warranty cost over the prespecified period. Given the nature of the disease progression, we introduced a delay time model to simulate the progression of chronic diseases. Based on this, we formulated an accumulated age model to measure the effect of follow-up on the patient's readmission risk. By means of the proposed model, the optimal treatment intensity and the monitoring policy can be derived. A case study of pediatric type 1 diabetes mellitus is presented to illustrate the applicability of the proposed model. The findings could form the basis of developing effective healthcare warranty policies for patients with chronic diseases.
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Affiliation(s)
- Heng Zhao
- College of Management and Economics, Tianjin University, Tianjin 300072, China; (H.Z.); (Z.L.); (M.L.)
| | - Zixian Liu
- College of Management and Economics, Tianjin University, Tianjin 300072, China; (H.Z.); (Z.L.); (M.L.)
| | - Mei Li
- College of Management and Economics, Tianjin University, Tianjin 300072, China; (H.Z.); (Z.L.); (M.L.)
| | - Lijun Liang
- School of Management, Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
- Correspondence:
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21
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Burnett RA, Serino J, Yang J, Della Valle CJ, Courtney PM. National Trends in Post-Acute Care Costs Following Total Knee Arthroplasty From 2007 to 2016. J Arthroplasty 2021; 36:2268-2275. [PMID: 33549419 DOI: 10.1016/j.arth.2021.01.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/28/2020] [Accepted: 01/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Post-acute care continues to represent a target for cost savings with increasing popularity of value-based payment models in total knee arthroplasty (TKA). Rapid recovery and accelerated rehabilitation protocols have been successful in reducing costs at the institutional level, but national trends are less clear. This study aimed to determine if advancements in perioperative care led to a reduction in post-acute care costs and resource utilization following TKA. METHODS We reviewed a consecutive series of 79,843 primary TKA patients from the Humana claims dataset from 2007 to 2016. Post-acute care costs included any claims within 90 days of surgery for subacute or inpatient rehabilitation, home health, outpatient or emergency visits, prescription medications, physical therapy, and readmissions. Demographics, episode-of-care and post-acute care costs, readmissions, and discharge disposition were compared. Controlling for demographics and comorbidities, multivariate regression analyses were performed to compare trends in discharge disposition and post-acute care costs. RESULTS From 2007 to 2016, the average episode-of-care costs ($46,754 vs $31,856) and post-acute care costs per patient decreased ($20,224 vs $13,498). Rates of discharge to skilled nursing facilities (25.0% vs 22.5%) and inpatient rehabilitation also declined (12.4% vs 2.1%). Readmissions also decreased (8.1% vs 7.1%) saving an average of $324 per patient. When compared to 2007-2012, total costs declined most rapidly after 2013 primarily due to a $3516 (21%) decrease in post-acute spending. CONCLUSION There has been a substantial decline in post-acute care costs and resource utilization following TKA, with the largest decrease occurring following the introduction of Medicare bundled payment models in 2013.
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Affiliation(s)
| | - Joseph Serino
- Department of Orthopaedic Surgery, Rush University, Chicago, IL
| | - JaeWon Yang
- Department of Orthopaedic Surgery, Rush University, Chicago, IL
| | | | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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22
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Basu R, Steiner AC, Stevens AB. Long-Term Care Market Trend and Patterns of Caregiving in the U.S. J Aging Soc Policy 2021; 34:20-37. [PMID: 34016034 DOI: 10.1080/08959420.2021.1926209] [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: 10/21/2022]
Abstract
Informal care is a major source of long-term services and supports (LTSS) for older adults in the U.S. However, the increasing gap between available family caregivers and those needing LTSS in coming years warrants better understanding of the balance between informal and formal home or community-based LTSS to meet the growing demand. The current study aimed to 1) identify patterns of informal and formal LTSS use among community-dwelling individuals, and 2) examine if the supply of formal LTSS predicts the use of informal care. These aims were investigated by linking the market supply of formal LTSS at the state-level to the Health and Retirement Survey data (N = 7,781). Results provide important empirical evidence that patterns of informal and formal LTSS use among older adults are heterogeneous and market supply of formal home and community-based services (HCBS) significantly predicts the use of informal care. Most older adults rely on informal care in combination with some formal supports, suggesting that the two systems work in tandem to meet the growing needs of LTSS. This offers important implications for states allocating resources to meet the LTSS needs of older adults and individuals with disabilities since states play key roles in U.S. long-term care policies.
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Affiliation(s)
- Rashmita Basu
- Assistant Professor, Department of Public Health, East Carolina University, Greenville, North Carolina, USA
| | - Adrienne C Steiner
- Assistant Professor, Department of Music Education/Therapy, East Carolina University, Greenville, North Carolina, USA
| | - Alan B Stevens
- Professor and Director, Center for Applied Health Research, Baylor Scott & White Healthm, Temple, Texas, USA
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Karimi M, Tsiachristas A, Looman W, Stokes J, Galen MV, Rutten-van Mölken M. Bundled payments for chronic diseases increased health care expenditure in the Netherlands, especially for multimorbid patients. Health Policy 2021; 125:751-759. [PMID: 33947604 DOI: 10.1016/j.healthpol.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/09/2021] [Accepted: 04/11/2021] [Indexed: 11/29/2022]
Abstract
Bundled payments aim to stimulate the integration of healthcare services and ultimately reduce healthcare expenditure growth through improved quality of care. The Netherlands introduced bundled payments for chronic diseases in 2010 by reimbursing providers annually for a bundle of primary care services related to COPD, Diabetes, or Vascular Risk Management. We aimed to assess the long-term effects of these bundled payments on healthcare expenditure. We used health insurance claims data from 2008 to 2015 to compare the healthcare expenditure between everyone who was included in bundled payments and a control group. We performed a difference-in-difference analysis in combination with propensity score matching and found that bundled payments consistently increased health care expenditure over seven years. The average half-year increase was €233 (95%CI: 204-262) for DM2, €609 (95%CI: 533-686) for COPD, and €231 (95%CI: 208-254) for VRM, representing 13%, 52%, and 20% of 2008 half-year cost. The increase was higher for those with multimorbidity compared to those without multimorbidity. This suggests that the expectations of the bundled payments are yet to be fulfilled.
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Affiliation(s)
- Milad Karimi
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, the Netherlands
| | - Apostolos Tsiachristas
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, the Netherlands; Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Willemijn Looman
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, the Netherlands
| | - Jonathan Stokes
- Health Organisation, Policy and Economics, Primary Care and Health Services Research Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Mirte van Galen
- Vektis C.V., Sparrenheuvel 18, Building B, 3708 JE Zeist, the Netherlands
| | - Maureen Rutten-van Mölken
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, the Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands, PO Box 1738, 3000 DR Rotterdam.
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Hou Y, Bushnell CD, Duncan PW, Kucharska-Newton AM, Halladay JR, Freburger JK, Trogdon JG. Hospital to Home Transition for Patients With Stroke Under Bundled Payments. Arch Phys Med Rehabil 2021; 102:1658-1664. [PMID: 33811853 PMCID: PMC10152978 DOI: 10.1016/j.apmr.2021.03.010] [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] [Received: 07/29/2020] [Revised: 02/19/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022]
Abstract
Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.
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Affiliation(s)
- Yucheng Hou
- Department of Health Policy and Management, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
| | - Jacqueline R Halladay
- Department of Family Medicine, UNC School of Medicine, the University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC
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Current Procedural Terminology-based Procedure Categorization Enhances Cost Prediction of Medicare Severity Diagnosis Related Group in Spine Surgery. Spine (Phila Pa 1976) 2021; 46:391-400. [PMID: 33620184 DOI: 10.1097/brs.0000000000003801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to analyze how a Current Procedural Terminology (CPT)-based categorization method can predict cost variation in surgical spine procedures. SUMMARY OF BACKGROUND DATA Neck and back disorders affect a majority of the adult population and account for tens of billions of dollars in health care spending each year. In the era of bundled payments and value-based reimbursement, it is imperative for surgeons to identify sources of cost variability across surgical spine procedures. Historically, this has been accomplished using Medicare Severity Diagnosis Related Group (MS-DRG) codes, but they utilize an overly simplistic categorization of surgical procedures. The specificity and familiarity of the CPT coding structure makes it a better option for categorizing differences in surgical decision making and technique. METHODS Hospital billing data for patients undergoing a surgical spine procedure requiring an overnight, in-patient stay was retrospectively collected over 4 fiscal years (2012-2016) from a single health care system. Linear regression analysis was performed to assess the correlation between cost variation and: spine-specific MS-DRG codes; a novel CPT-based categorization method; and the combination of MS-DRG codes and CPT-based categorization. RESULTS There were 5020 surgical procedures were analyzed with respect to 16 different MS-DRG codes and 30 distinct CPT-based surgical categories (CSCs). Linear regression results were: MS-DRG R2 = 0.6545 (P < 0.001); CSC R2 = 0.5709 (P < 0.001); and R2 = 0.744 for the combined MS-DRG and CSC methods (P < 0.05). Median difference between the actual and predicted cost for the combined model was -$261.00, compared with -$727.50 for the CSC model and -$478.70 for the MS-DRG model. CONCLUSION Addition of the CPT-based categorization method to MS-DRG coding provides an enhanced method to evaluate the association between predicted and actual cost when using linear regression analysis to assess cost variation in spine surgery.Level of Evidence: 3.
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Albertz M, Whitlock P, Yang F, Ding L, Uchtman M, Mecoli M, Olbrecht V, Moore D, McCarthy J, Chidambaran V. Pragmatic comparative effectiveness study of multimodal fascia iliaca nerve block and continuous lumbar epidural-based protocols for periacetabular osteotomy. J Hip Preserv Surg 2021; 7:728-739. [PMID: 34377516 PMCID: PMC8349585 DOI: 10.1093/jhps/hnab010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/25/2022] Open
Abstract
Perioperative pain management protocols have a significant impact on early surgical outcomes and recovery. We hypothesized that multimodal protocol including fascia iliaca compartment nerve block (MM-FICNB) would decrease the length of hospital stay (LOS) by facilitating earlier mobilization, without compromising analgesia, compared to a traditional lumbar epidural-based protocol (EP). Demographics/comorbidities, surgical/block characteristics and perioperative pain/mobilization data were collected from a prospectively recruited MM-FICNB group (N = 16) and a retrospective EP cohort (N = 16) who underwent PAO using similar surgical techniques, physical therapy/discharge criteria. Association of MM-FICNB group with LOS (primary outcome), postoperative pain, postoperative opioid requirements in morphine equivalent rates (MER) (mcg/kg/h) and time to complete physical therapy were tested using multivariable and survival regression. Patient and surgical characteristics were similar between groups. Median time for FICNB performance was significantly less than epidural (6 versus 15 min; P < 0.001). LOS was significantly decreased in the MM-FICNB group (2.88 ± 0.72 days) compared to the EP group (4.38 ± 1.02 days); P < 0.001. MM-FICNB group had significantly lower MER on POD1 (P = 0.006) and POD2 (P < 0.001), with similar pain scores on all POD. MM-FICNB group was associated with decreased LOS and earlier mobilization (P < 0.001) by covariate-adjusted multivariate regression. Cox proportional hazard regression model showed MM-FICNB subjects had 63 (95% CI 7–571, P < 0.001) times the chance of completing physical therapy goals, compared to EP. Compared to EP, MM-FICNB protocol allowed earlier mobilization and decreased post-surgical hospitalization by 1.5 days, without compromising analgesia, with important implications for value-based healthcare and cost-effectiveness.
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Affiliation(s)
- Megan Albertz
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Patrick Whitlock
- Department of Orthopedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Fang Yang
- Division of Biostatistics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Lili Ding
- Division of Biostatistics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Molly Uchtman
- Department of Orthopedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Marc Mecoli
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Vanessa Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - David Moore
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - James McCarthy
- Department of Orthopedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Plummer E, Wempe WF. Home Health Agencies: Empirical Evidence on the Patient-Driven Groupings Model’s Expected Effects on Agency Reimbursements. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2021. [DOI: 10.1177/1084822321990382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Beginning January 1, 2020, Medicare’s Patient-Driven Groupings Model (PDGM) eliminated therapy as a direct determinant of Home Health Agencies’ (HHAs’) reimbursements. Instead, PDGM advances Medicare’s shift toward value-based payment models by directly linking HHAs’ reimbursements to patients’ medical conditions. We use 3 publicly-available datasets and ordered logistic regression to examine the associations between HHAs’ pre-PDGM provision of therapy and their other agency, patient, and quality characteristics. Our study therefore provides evidence on PDGM’s likely effects on HHA reimbursements assuming current patient populations and service levels do not change. We find that PDGM will likely increase payments to rural and facility-based HHAs, as well as HHAs serving greater proportions of non-white, dual-eligible, and seriously ill patients. Payments will also increase for HHAs scoring higher on quality surveys, but decrease for HHAs with higher outcome and process quality scores. We also use ordinary least squares regression to examine residual variation in HHAs’ expected reimbursement changes under PDGM, after accounting for any expected changes related to their pre-PDGM levels of therapy provision. We find that larger and rural HHAs will likely experience residual payment increases under PDGM, as will HHAs with greater numbers of seriously ill, younger, and non-white patients. HHAs with higher process quality, but lower outcome quality, will similarly benefit from PDGM. Understanding how PDGM affects HHAs is crucial as policymakers seek ways to increase equitable access to safe and affordable non-facility-provided healthcare that provides appropriate levels of therapy, nursing, and other care.
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Affiliation(s)
- Elizabeth Plummer
- Texas Christian University, Fort Worth, TX, USA
- Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, TX, USA
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Shafrin J, Aliyev ER, Brauer M, Park S, Shen X. Alternative payment models and innovation: a case study of US health system adoption of a sacubitril/valsartan to treat acute decompensated heart failure. J Med Econ 2020; 23:1450-1460. [PMID: 32945737 DOI: 10.1080/13696998.2020.1825454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM To understand the financial impact of health system adoption of novel heart failure medications under US alternative payment models (APMs). MATERIALS AND METHODS This study used a decision tree model to assess the financial impact of health system adoption of sacubitril/valsartan to treat acute decompensated heart failure (ADHF). A comparator scenario modeled current health care utilization and cost for treating hospitalized ADHF patients with angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB). The study then measured the impact of adopting sacubitril/valsartan to treat ADHF on health system economic outcomes. Differences in treatment efficacy were based on the PIONEER-HF clinical trial. The financial impact of changes in patient outcomes under the sacubitril/valsartan and ACEi/ARB arms was assessed across three APMs: the Medicare Shared Savings Program, Bundled Payments for Care Improvement, and fee-for-service payments adjusted according to the Hospital Readmission Reduction Program. RESULTS Sacubitril/valsartan reduced re-hospitalizations after an initial ADHF admission by 46.3% for individuals aged 18-64 years and 23.4% for individuals aged ≥65 years. Health systems' financial benefit of adopting sacubitril/valsartan was $740 per ADHF case per year (PCPY). Savings were larger for patients aged ≥65 years ($803 PCPY) compared to those <65 years ($653 PCPY). The majority of the health system financial benefit came from changes in APM bonus and penalty reimbursements. Value-based payments from the Hospital Readmission Reduction Program ($1,190 financial gain PCPY) and the Bundled Care Payment Improvement Initiative ($645 financial gain PCPY) produced larger financial benefits than participation in the Medicare Shared Savings Program ($253 financial gain PCPY). LIMITATIONS The model uses clinical trial data, which may not reflect real-world outcomes. Further, the financial implications were modeled based only on three widely used APMs. CONCLUSION Sacubitril/valsartan adoption decreased hospitalizations and led to a positive net financial impact on health systems after accounting for APM bonus payments.
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Affiliation(s)
| | | | | | - Siyeon Park
- University of Maryland, Baltimore, Baltimore, MD, USA
| | - Xian Shen
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
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29
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Postoperative Pain Management in Pediatric Spinal Fusion Surgery for Idiopathic Scoliosis. Paediatr Drugs 2020; 22:575-601. [PMID: 33094437 DOI: 10.1007/s40272-020-00423-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
This article reviews and summarizes current evidence and knowledge gaps regarding postoperative analgesia after pediatric posterior spine fusion for adolescent idiopathic scoliosis, a common procedure that results in severe acute postoperative pain. Inadequate analgesia may delay recovery, cause patient dissatisfaction, and increase chronic pain risk. Despite significant adverse effects, opioids are the analgesic mainstay after scoliosis surgery. However, growing emphasis on opioid minimization and enhanced recovery has increased adoption of multimodal analgesia (MMA) regimens. While opioid adverse effects remain a concern, MMA protocols must also consider risks and benefits of adjunct medications. We discuss use of opioids via different administration routes and elaborate on the effect of MMA components on opioid/pain and recovery outcomes including upcoming regional analgesia. We also discuss risk for prolonged opioid use after surgery and chronic post-surgical pain risk in this population. Evidence supports use of neuraxial opioids at safe doses, low-dose ketorolac, and methadone for postoperative analgesia. There may be a role for low-dose ketamine in those who are opioid-tolerant or have chronic pain, but the evidence for preoperative gabapentinoids and intravenous lidocaine is currently insufficient. There is a need for further studies to evaluate pediatric-specific optimal MMA dosing regimens after scoliosis surgery. Questions remain regarding how best to prevent acute opioid tolerance, opioid-induced hyperalgesia, and chronic postsurgical pain. We anticipate that this timely update will enable clinicians to develop efficient pain regimens and provide impetus for future research to optimize recovery outcomes after spine fusion.
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Hakim S, Aneese AM, Edhi A, Shams C, Purohit T, Cannon ME, Cappell MS. A Statistically Significant Reduction in Length of Stay and Hospital Costs with Equivalent Quality of Care Metrics for ERCPs Performed During the Weekend Versus Postponed to Weekdays: A 6-Year Study of 533 ERCPs at Four Teaching Hospitals. Dig Dis Sci 2020; 65:3132-3142. [PMID: 31974912 DOI: 10.1007/s10620-020-06066-z] [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: 06/16/2019] [Accepted: 01/09/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic/therapeutic endoscopic procedure for numerous pancreaticobiliary diseases. Data regarding performing ERCP on weekend (WE; Saturday/Sunday) versus postponing ERCP to first two available weekdays (WD; Monday/Tuesday) are scarce. ERCP requires costly resources including specialized nurses, endoscopy room equipped with fluoroscopy, anesthesia services, and highly trained therapeutic endoscopists. Hospitals frequently do not have these resources readily available during WE, leading to postponing ERCPs to WD. AIMS This study analyzes the effect of performing ERCP on WE versus postponement to WD on hospital efficiency, and on patient safety/outcomes. METHODS A computerized search of electronic medical records, January 2011-December 2016, at four Beaumont Hospitals retrospectively identified all gastroenterology consults performed on Friday or Saturday before 12:00 noon, which resulted in ERCP performed for any indication on WE versus postponing ERCP to WD. Length of stay (LOS), hospital costs, hospital charges, and hospital reimbursements were compared between both groups, as were quality of care measures. RESULTS Among 5196 patients undergoing ERCPs, 533 patients were identified, including 315 patients in the WE group and 218 patients in the WD group. Comparing WE versus WD groups, median LOS was shorter (4.5 days vs. 6.9 days, p < 0.0001); median hospital costs were less ($9208 vs. $11,657, p < 0.0001); and median hospital charges were less ($28,026 vs. $37,899, p < 0.0001). Median hospital reimbursements were not significantly different in WE versus WD groups ($10,277 vs. $10,362, p = 0.65). Median hospital charges were lower than median hospital reimbursements (net profit) in WE but not in WD. WE versus WD had no significant differences in morbidity, mortality, ≤ 30-day readmission rates, need for repeat ERCP ≤ 30 days, or post-ERCP complications. LIMITATIONS This is a retrospective study. CONCLUSIONS Performing ERCPs during weekends significantly reduced LOS, hospital costs, and hospital charges compared to postponing ERCP to WD and resulted in net hospital profits, without impairing quality of medical care.
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Affiliation(s)
- Seifeldin Hakim
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA
| | - Andrew M Aneese
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA
| | - Ahmed Edhi
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA
| | - Christienne Shams
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA
| | - Treta Purohit
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA.,San Jose Gastroenterology, 231 O'Connor Dr., San Jose, CA, 95128, USA
| | - Michael E Cannon
- Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA.,Oakland University William Beaumont School of Medicine, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA
| | - Mitchell S Cappell
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA. .,Oakland University William Beaumont School of Medicine, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA.
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Paredes-Fernández D, Lenz-Alcayaga R, Hernández-Sánchez K, Quiroz-Carreño J. Characterization and analysis of the basic elements of health payment mechanisms and their most frequent types. Medwave 2020; 20:e8041. [DOI: 10.5867/medwave.2020.09.8041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/07/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction Healthcare systems are developed in imperfect scenarios, in which there are constant failures (uncertainty, information asymmetry, agency relationship problem, and supply-induced demand). These failures, based on the imperfection of the sector, determine the relationships and incentives between the actors. It is within this context that payment mechanisms regulate aspects of the system behavior and incentives, acting as instruments for the purchasing of health care from providers, mediated by health insurance on behalf of users. Objective To characterize the basic elements of most frequent payment mechanisms to help providers in their relationship with payers. Methods A review of the evidence was conducted in PubMed, Google, Google Scholar, and strategic snowball selection. Payment mechanisms consist of three classical microeconomics variables, fixed or variable: price, quantity, and expense. Time dimensions are used to analyze their attributes and effects. Different mechanisms emerge from the combination of these variables. Results Among the most used are: Fee-For-Service, Global Budget, Bundled Payments, Diagnosis-Related Groups, Per-capita, Performance Pay, and Risk-Sharing Agreements. A fourth has also gained importance: Financial Risk. Conclusions Payment mechanisms are essential to link health efforts with clinical practice. They make it possible to regulate relationships between insurers, providers, and users, which, depending on the architecture of the mechanism, can become beneficial or hinder the fulfillment of the objectives of the health system.
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Sivaganesan A, Chotai S, Parker SL, McGirt MJ, Devin CJ. Drivers of Variability in 90-Day Cost for Elective Laminectomy and Fusion for Lumbar Degenerative Disease. Neurosurgery 2020; 84:1043-1049. [PMID: 30053215 DOI: 10.1093/neuros/nyy264] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/09/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Considerable variability exists in the cost of surgery following spine surgery for common degenerative spine diseases. This variation in the cost of surgery can affect the payment bundling during the postoperative 90 d. OBJECTIVE To determine the drivers of variability in total 90-d cost for laminectomy and fusion surgery. METHODS A total of 752 patients who underwent elective laminectomy and fusion for degenerative lumbar conditions and were enrolled into a prospective longitudinal registry were included in the study. Total cost during the 90-d global period was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multivariable regression models were built for total 90-d cost. RESULTS The mean 90-d direct cost was $29 295 (range, $28 612-$29 973). Based on our regression tree analysis, the following variables were found to drive the 90-d cost: age, BMI, gender, diagnosis, postop imaging, number of operated levels, ASA grade, hypertension, arthritis, preop and postop opioid use, length of hospital stay, duration of surgery, 90-d readmission, outpatient physical/occupational therapy, inpatient rehab, postop healthcare visits, postop nonopioid pain medication use nonsteroidal antiinflammatory drug (NSAIDs), and muscle relaxant use. The R2 for tree model was 0.64. CONCLUSION Utilizing prospectively collected data, we demonstrate that considerable variation exists in total 90-d cost, nearly 70% of which can be explained by those factors included in our modeling. Risk-adjusted payment schemes can be crafted utilizing the significant drivers presented here. Focused interventions to target some of the modifiable factors have potential to reduce cost and increase the value of care.
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Affiliation(s)
- Ahilan Sivaganesan
- Departments of Orthopedic and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Silky Chotai
- Departments of Orthopedic and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott L Parker
- Departments of Orthopedic and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Clinton J Devin
- Departments of Orthopedic and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
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Changes in Use of Postacute Care Associated With Accountable Care Organizations in Hip Fracture, Stroke, and Pneumonia Hospitalized Cohorts. Med Care 2019; 57:444-452. [PMID: 31008898 DOI: 10.1097/mlr.0000000000001121] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine changes in more and less discretionary condition-specific postacute care use (skilled nursing, inpatient rehabilitation, home health) associated with Medicare accountable care organization (ACO) implementation. DATA SOURCES 2009-2014 Medicare fee-for-service claims. STUDY DESIGN Difference-in-difference methodology comparing postacute outcomes after hospitalization for hip fracture and stroke (where rehabilitation is fundamental to the episode of care) to pneumonia, (where it is more discretionary) for beneficiaries attributed to ACO and non-ACO providers. PRINCIPAL FINDINGS Across all 3 cohorts, in the baseline period ACO patients were more likely to receive Medicare-paid postacute care and had higher episode spending. In hip fracture patients where rehabilitation is standard of care, ACO implementation was associated with 6%-8% increases in probability of admission to a skilled nursing facility or inpatient rehabilitation (compared with home without care), and a slight reduction in readmissions. In a clinical condition where rehabilitation is more discretionary, pneumonia, ACO implementation was not associated with changes in postacute location, but episodic spending decreased 2%-3%. Spending decreases were concentrated in the least complex patients. Across all cohorts, the length of stay in skilled nursing facilities decreased with ACO implementation. CONCLUSIONS ACOs decreased spending on postacute care by decreasing use of discretionary services. ACO implementation was associated with reduced length of stay in skilled nursing facilities, while hip fracture patients used institutional postacute settings at higher rates. Among pneumonia patients, we observed decreases in spending, readmission days, and mortality associated with ACO implementation.
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Intravenous Acetaminophen Reduces Length of Stay Via Mediation of Postoperative Opioid Consumption After Posterior Spinal Fusion in a Pediatric Cohort. Clin J Pain 2019; 34:593-599. [PMID: 29200016 DOI: 10.1097/ajp.0000000000000576] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Since approval of intravenous acetaminophen (IV APAP), its use has become quite common without strong positive evidence. Our goal was to determine the effect of IV APAP on length of hospital stay (LOS) via mediation of opioid-related side effects in pediatric patients. MATERIALS AND METHODS After Institutional Review Board approval, 114 adolescents undergoing posterior spinal fusion were prospectively recruited and managed postoperatively with patient-controlled analgesia and adjuvant therapy. Patients were divided into 2 groups based on the use of IV APAP: control (n=70) and treatment (n=44). Association of IV APAP use with opioid outcomes was analyzed using inverse probability of treatment weighting (IPTW)-adjusted propensity scores to balance the 2 groups for all significant covariates except postoperative opioid consumption. Mediation analysis was carried out for LOS with IV APAP as the independent variable and morphine consumption as the mediator. RESULTS Oral intake was delayed by ∼1 day (P<0.001) and LOS was 0.6 days longer in the control group (P=0.044). After IPTW, time to oral intake remained significantly longer in the control group (P=0.014). The mediation model with IPTW revealed a significant negative association between IV APAP and morphine consumption (P<0.001), which significantly increased LOS (P<0.003). IV APAP had a significant opioid-sparing effect associated with shorter LOS. DISCUSSION IV APAP hastens oral intake and is associated with decreased LOS in an adolescent surgery population likely through decreased opioid consumption. Through addition of IV APAP in this population, LOS may be decreased, an important implication in the setting of escalating health care costs.
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Delanois RE, Etcheson JI, Dávila Castrodad IM, Mohamed NS, Pollak AN, Mont MA. Influence of the Maryland All-Payer Model on Primary Total Knee Arthroplasties. JB JS Open Access 2019; 4:e0041. [PMID: 32043062 PMCID: PMC6959916 DOI: 10.2106/jbjs.oa.19.00041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In 2014, Maryland received a waiver for the Global Budget Revenue (GBR) program. We evaluated GBR's impact on patient and hospital trends for total knee arthroplasty (TKA) in Maryland compared with the U.S. Specifically, we examined (1) patient characteristics, (2) inpatient course, and (3) costs and charges associated with TKAs from 2014 through 2016. METHODS A comparative analysis of TKA-treated patients in the Maryland State Inpatient Database (n = 36,985) versus those in the National Inpatient Sample (n = 2,117,191) was performed. Patient characteristics included race, Charlson Comorbidity Index (CCI), morbid obesity, patient income status, and primary payer. Inpatient course included length of hospital stay (LOS), discharge disposition, and complications. RESULTS In the Maryland TKA cohort, the proportion of minorities increased from 2014 to 2016 while the proportion of whites decreased (p = 0.001). The proportion of patients with a CCI of ≥3 decreased (p = 0.014), that of low-income patients increased (p < 0.001), and that of patients covered by Medicare or Medicaid increased (p < 0.001). In the U.S. TKA cohort, the proportion of blacks increased (p < 0.001), that of patients with a CCI score of ≥3 decreased (p < 0.001), and the proportions of low-income patients (p < 0.001) and those covered by Medicare or Medicaid increased (p < 0.001). In both Maryland and the U.S., the LOS (p < 0.001) and complication rate (p < 0.001) decreased while home-routine discharges increased (p < 0.001). Costs and charges decreased in Maryland (p < 0.001 for both) whereas charges in the U.S. increased (p < 0.001) and costs decreased (p < 0.001). CONCLUSIONS While the U.S. health reform and GBR achieved similar patient and hospital-specific outcomes and broader inclusion of minority patients, Maryland experienced decreased hospital charges while hospital charges increased in the U.S. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I Etcheson
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Iciar M Dávila Castrodad
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha S Mohamed
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Andrew N Pollak
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
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Chotai S, Sivaganesan A, Parker SL, Sielatycki JA, McGirt MJ, Devin CJ. Drivers of Variability in 90-Day Cost for Elective Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disease. Neurosurgery 2019; 83:898-904. [PMID: 29718416 DOI: 10.1093/neuros/nyy140] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 03/25/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period. OBJECTIVE To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease. METHODS Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost. RESULTS The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616. CONCLUSION There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons' and institution-specific differences.
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Affiliation(s)
- Silky Chotai
- Department of Orthopedics Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ahilan Sivaganesan
- Department of Orthopedics Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott L Parker
- Department of Orthopedics Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John A Sielatycki
- Department of Orthopedics Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Clinton J Devin
- Department of Orthopedics Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
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Delisle DR. Big Things Come in Bundled Packages: Implications of Bundled Payment Systems in Health Care Reimbursement Reform .. Am J Med Qual 2019; 34:482-487. [PMID: 31479298 DOI: 10.1177/1062860619873220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
With passage of the Affordable Care Act, the ever-evolving landscape of health care braces for another shift in the reimbursement paradigm. As health care costs continue to rise, providers are pressed to deliver efficient, high-quality care at flat to minimally increasing rates. Inherent systemwide inefficiencies between payers and providers at various clinical settings pose a daunting task for enhancing collaboration and care coordination. A change from Medicare's fee-for-service reimbursement model to bundled payments offers one avenue for resolution. Pilots using such payment models have realized varying degrees of success, leading to the development and upcoming implementation of a bundled payment initiative led by the Center for Medicare and Medicaid Innovation. Delivery integration is critical to ensure high-quality care at affordable costs across the system. Providers and payers able to adapt to the newly proposed models of payment will benefit from achieving cost reductions and improved patient outcomes and realize a competitive advantage.
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Chitnis AS, Vanderkarr M, Ruppenkamp J, Lerner J, Holy CE, Sparks C. Reoperations in intramedullary fixation of pertrochanteric hip fractures. J Med Econ 2019; 22:706-712. [PMID: 30912723 DOI: 10.1080/13696998.2019.1600526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: This study evaluated the frequency of reoperation within 1 year of initial intramedullary fixation for patients with pertrochanteric hip fracture and compared 1-year healthcare resource utilization and cost burden for patients with and without reoperation. Methods: This is a retrospective evaluation of medical claims from the US Centers for Medicare and Medicaid Standard Analytic File. Patients aged ≥65 years who underwent fixation with an intramedullary implant for a pertrochanteric fracture between 2013 and 2015 were included. Healthcare resources that were evaluated included skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), readmissions, and outpatient hospital visits. All-cause payments for these services comprised overall cost burden. Generalized Linear Models were used to evaluate healthcare resources and cost burden over 1-year post-surgery and to adjust for confounding between patients with and without a reoperation. Results: A total of 6,423 Medicare patients were included in the analysis. Mean (SD) age was 82.4 (7.8) years, 76.0% were female, and 93.3% were white. A second hip surgery within 1 year after the index fixation procedure was performed in 414 patients (6.4%): 121 (29.2%) contralateral, 115 (27.8%) ipsilateral, and 178 (43.0%) without specified laterality. After adjusting for confounding factors, Medicare patients with ipsilateral reoperations had statistically significantly higher readmissions (100% vs 32.5%, p < 0.0001), outpatient hospital visits (96.4% vs 88.8%, p = 0.018), admissions to a SNF (88.5% vs 80.4%, p = 0.024), and admissions to an IRF (38.8% vs 22.0%, p < 0.0001) compared to patients without reoperations. The adjusted mean total all-cause payments ($90,162 vs $55,131, p < 0.0001) during the 1-year follow-up were statistically significantly higher among patients with reoperations as compared to patients without reoperations. Conclusions: Patients who require a second hip surgery after initial fixation with an intramedullary implant for pertrochanteric hip fractures have significantly higher 1-year healthcare resource utilization and 63.5% higher costs than patients without reoperation.
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Affiliation(s)
- Abhishek S Chitnis
- a Medical Devices Epidemiology, Real World Data Sciences , Johnson & Johnson , New Brunswick , NJ , USA
| | - Mollie Vanderkarr
- b Health Economics and Market Access , DePuy Synthes Orthopaedics , West Chester , PA , USA
| | - Jill Ruppenkamp
- a Medical Devices Epidemiology, Real World Data Sciences , Johnson & Johnson , New Brunswick , NJ , USA
| | - Jason Lerner
- c Health Economics and Market Access Analytics , Johnson & Johnson , Raynham , MA , USA
| | - Chantal E Holy
- a Medical Devices Epidemiology, Real World Data Sciences , Johnson & Johnson , New Brunswick , NJ , USA
| | - Charisse Sparks
- d Medical Affairs, DePuy Synthes Orthopaedics , West Chester , PA , USA
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Cornell PY, Grabowski DC, Norton EC, Rahman M. Do report cards predict future quality? The case of skilled nursing facilities. JOURNAL OF HEALTH ECONOMICS 2019; 66:208-221. [PMID: 31280055 PMCID: PMC7248645 DOI: 10.1016/j.jhealeco.2019.05.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 04/23/2019] [Accepted: 05/20/2019] [Indexed: 05/20/2023]
Abstract
Report cards on provider performance are intended to improve consumer decision-making and address information gaps in the market for quality. However, inadequate risk adjustment of report-card measures often biases comparisons across providers. We test whether going to a skilled nursing facility (SNF) with a higher star rating leads to better quality outcomes for a patient. We exploit variation over time in the distance from a patient's residential ZIP code to SNFs with different ratings to estimate the causal effect of admission to a higher-rated SNF on health care outcomes, including mortality. We found that patients who go to higher-rated SNFs achieved better outcomes, supporting the validity of the SNF report card ratings.
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Affiliation(s)
- Portia Y Cornell
- Department of Health Services Policy and Practice, Brown University, Box G-S121(6), Providence, RI, 02912, United States; Providence Veterans Administration Medical Center, United States.
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA, 02115, United States.
| | - Edward C Norton
- Department of Health Management and Policy and Department of Economics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, United States; National Bureau of Economic Research, United States.
| | - Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Box G-S121(6), Providence, RI, 02912, United States.
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Sood N, Shier V, Nakata H, Iorio R, Lieberman JR. The Impact of Comprehensive Care for Joint Replacement Bundled Payment Program on Care Delivery. J Arthroplasty 2019; 34:609-612.e1. [PMID: 30612831 PMCID: PMC6430686 DOI: 10.1016/j.arth.2018.11.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/26/2018] [Accepted: 11/20/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Comprehensive Care for Joint Replacement (CJR) is a Medicare initiative to test the impact of holding a hospital accountable for services provided during an episode of care for a lower extremity joint arthroplasty on costs and quality. This study examines whether hospital participation in CJR is associated with having programs focused on improving posthospitalization care or reducing costs using a survey of orthopedic surgeons. METHODS Seventy-three (of 104) orthopedic surgeon members of the Hip Society, a national professional organization of hip surgeons, completed the survey. RESULTS Surgeons practicing in CJR hospitals were more likely to report that their hospital had implemented programs focused on improving posthospitalization care or reducing costs. Surgeons in CJR hospitals were significantly more likely to report that the hospital had a narrow network of skilled nursing facilities to enhance care and limit length of stay in skilled nursing facilities (83% vs 47%, P < .01). Surgeons in CJR hospitals were also more likely to report the hospital provides incentives or some type of gainsharing. There were no statistically significant differences in implementation of having programs to reduce costs or improve care during hospitalization. CONCLUSION Participation in CJR is associated with higher utilization of hospital practices aimed at improving postdischarge care and higher utilization of linking surgeon compensation to cost and quality.
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Affiliation(s)
- Neeraj Sood
- Corresponding author, Neeraj Sood, PhD, Sol Price School of Public Policy and Schaeffer Center for Health Policy and Economics, University of Southern California, Verna & Peter Dauterive Hall Suite 512, 635 Downey Way, Los Angeles, California, 90089; 213-821-7949;
| | - Victoria Shier
- Schaeffer Center for Health Policy, University of Southern California; Verna & Peter Dauterive Hall Suite 512, 635 Downey Way, Los Angeles, California, 90089;
| | - Haley Nakata
- Keck School of Medicine of University of Southern California; 1975 Zonal Ave, Los Angeles, CA 90033;
| | - Richard Iorio
- Brigham and Women’s Hospital, Department of Orthopaedic Surgery; 75 Francis Street Boston, MA 02115;
| | - Jay R. Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California; 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033;
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Gupta S, Zengul FD, Davlyatov GK, Weech-Maldonado R. Reduction in Hospitals' Readmission Rates: Role of Hospital-Based Skilled Nursing Facilities. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 56:46958018817994. [PMID: 30894035 PMCID: PMC6429649 DOI: 10.1177/0046958018817994] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hospital readmission within 30 days of discharge is an important quality measure given that it represents a potentially preventable adverse outcome. Approximately, 20% of Medicare beneficiaries are readmitted within 30 days of discharge. Many strategies such as the hospital readmission reduction program have been proposed and implemented to reduce readmission rates. Prior research has shown that coordination of care could play a significant role in lowering readmissions. Although having a hospital-based skilled nursing facility (HBSNF) in a hospital could help in improving care for patients needing short-term skilled nursing or rehabilitation services, little is known about HBSNFs' association with hospitals' readmission rates. This study seeks to examine the association between HBSNFs and hospitals' readmission rates. Data sources included 2007-2012 American Hospital Association Annual Survey, Area Health Resources Files, the Centers for Medicare and Medicaid Services (CMS) Medicare cost reports, and CMS Hospital Compare. The dependent variables were 30-day risk-adjusted readmission rates for acute myocardial infarction (AMI), congestive heart failure, and pneumonia. The independent variable was the presence of HBSNF in a hospital (1 = yes, 0 = no). Control variables included organizational and market factors that could affect hospitals' readmission rates. Data were analyzed using generalized estimating equation (GEE) models with state and year fixed effects and standard errors corrected for clustering of hospitals over time. Propensity score weights were used to control for potential selection bias of hospitals having a skilled nursing facility (SNF). GEE models showed that the presence of HBSNFs was associated with lower readmission rates for AMI and pneumonia. Moreover, higher SNFs to hospitals ratio in the county were associated with lower readmission rates. These findings can inform policy makers and hospital administrators in evaluating HBSNFs as a potential strategy to lower hospitals' readmission rates.
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Affiliation(s)
- Shivani Gupta
- 1 The University of Southern Mississippi, Hattiesburg, USA
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Abstract
INTRODUCTION Total joint arthroplasty represents the largest expense for a single condition among Medicare beneficiaries. Payment models exist, such as bundled payments, where physicians and hospitals are reimbursed based on providing cost-efficient, high-quality care. There is a need to explicitly define "quality" relevant to hip and knee arthroplasty. Based on prior quality measure research, we hypothesized that less than 20% of developed quality measures are outcome measures. METHODS This study systematically reviewed current and candidate quality measures relevant to total hip and knee arthroplasty using several quality measure databases and an Internet library search. RESULTS We found a total of 35 quality measures and 81 candidate measures, most of which were process measures (N = 21, 60%), and represented the National Quality Strategy priorities of patient- and caregiver-centered experience and outcomes (31%), effective clinical care (28%), or patient safety (19%). CONCLUSION Various stakeholders have developed quality measures in total joint arthroplasty, with increasing focus on developing outcome measures. The results of this review inform orthopaedic surgeons on quality measures that payers could use value-based payment models like the Merit-based Incentive Payment System and Comprehensive Care for Joint Replacement. LEVEL OF EVIDENCE Level I, systematic review of level I evidence.
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Huckfeldt PJ, Weissblum L. Preferred Post-Acute Care Providers in Bundled Payment: Implications for Patient Choice. J Am Geriatr Soc 2019; 67:1020-1022. [PMID: 30801658 DOI: 10.1111/jgs.15806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Peter J Huckfeldt
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Lianna Weissblum
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
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EMBULDENIYA GAYATHRI, KIRST MARITT, WALKER KEVIN, WODCHIS WALTERP. The Generation of Integration: The Early Experience of Implementing Bundled Care in Ontario, Canada. Milbank Q 2018; 96:782-813. [PMID: 30417941 PMCID: PMC6287073 DOI: 10.1111/1468-0009.12357] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Policy Points Policymakers interested in advancing integrated models of care may benefit from understanding how integration itself is generated. Integration is analyzed as the generation of connectivity and consensus-the coming together of people, practices, and things. Integration was mediated by chosen program structures and generated by establishing partnerships, building trust, developing thoughtful models, engaging clinicians in strategies, and sharing data across systems. This study provides examples of on-the-ground integration strategies in 6 programs, suggests contexts that better lend themselves to integration initiatives, and demonstrates how programs may be examined for the very thing they seek to implement-integration itself. CONTEXT By bundling services and encouraging interprofessional and interorganizational collaboration, integrated health care models counter fragmented health care delivery and rising system costs. Building on a policy impetus toward integration, the Ministry of Health and Long-Term Care in the Canadian province of Ontario chose 6 programs, each comprising multiple hospital and community partners, to implement bundled care, also referred to as integrated-funding models. While research has been conducted on the facilitators and challenges of integration, there is less known about how integration is generated. This article explores the generation of integration through the dynamic interplay of contexts and mechanisms and of structures and subjects. METHODS For this qualitative study, we conducted 48 interviews with program stakeholders, from organization leaders and managers to physicians and integrated care coordinators, across the hospital-community spectrum. We then used content analysis to explore the extent to which themes were shared across programs and to identify idiosyncrasies, followed by a realist evaluation approach to understand how integration was produced in structural and everyday ways in local program contexts. FINDINGS Integration was generated through the successful production of connectivity and consensus-the coming together of people, practice, and things, as perceived and experienced by stakeholders. When able, the programs harnessed existing cultures of clinician engagement, and leveraged established partnerships. However, integration could be achieved even without these histories, by building trust, developing thoughtful models, using clinicians' existing engagement strategies, and implementing shared systems and technologies. The programs' structures (from their scale to their chosen patient population) also contextualized and mediated integration. CONCLUSIONS This article has both practical and theoretical implications. It provides transferable insights into the strategies by which integration is generated. It also contributes conceptually to realist approaches to evaluation by advancing an understanding of mechanisms as contextually and temporally contingent, with the capacity to produce new contexts, which in turn generate new sets of mechanisms.
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Affiliation(s)
| | - MARITT KIRST
- Institute of Health PolicyManagement and Evaluation, University of Toronto
- Wilfrid Laurier University
| | - KEVIN WALKER
- Institute of Health PolicyManagement and Evaluation, University of Toronto
| | - WALTER P. WODCHIS
- Institute of Health PolicyManagement and Evaluation, University of Toronto
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Value-based provider payment: towards a theoretically preferred design. HEALTH ECONOMICS POLICY AND LAW 2018; 15:94-112. [PMID: 30259825 DOI: 10.1017/s1744133118000397] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Worldwide, policymakers and purchasers are exploring innovative provider payment strategies promoting value in health care, known as value-based payments (VBP). What is meant by 'value', however, is often unclear and the relationship between value and the payment design is not explicated. This paper aims at: (1) identifying value dimensions that are ideally stimulated by VBP and (2) constructing a framework of a theoretically preferred VBP design. Based on a synthesis of both theoretical and empirical studies on payment incentives, we conclude that VBP should consist of two components: a relatively large base payment that implicitly stimulates value and a relatively small payment that explicitly rewards measurable aspects of value (pay-for-performance). Being the largest component, the base payment design is essential, but often neglected when it comes to VBP reform. We explain that this base payment ideally (1) is paid to a multidisciplinary provider group (2) for a cohesive set of care activities for a predefined population, (3) is fixed, (4) is adjusted for the population's risk profile and (5) includes risk-mitigating measures. Finally, some important trade-offs in the practical operationalisation of VBP are discussed.
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Kahn EN, Ellimoottil C, Dupree JM, Park P, Ryan AM. Variation in payments for spine surgery episodes of care: implications for episode-based bundled payment. J Neurosurg Spine 2018; 29:214-219. [DOI: 10.3171/2017.12.spine17674] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVESpine surgery is expensive and marked by high variation across regions and providers. Bundled payments have potential to reduce unwarranted spending associated with spine surgery. This study is a cross-sectional analysis of commercial and Medicare claims data from January 2012 through March 2015 in the state of Michigan. The objective was to quantify variation in payments for spine surgery in adult patients, document sources of variation, and determine influence of patient-level, surgeon-level, and hospital-level factors.METHODSHierarchical regression models were used to analyze contributions of patient-level covariates and influence of individual surgeons and hospitals. The primary outcome was price-standardized 90-day episode payments. Intraclass correlation coefficients—measures of variability accounted for by each level of a hierarchical model—were used to quantify sources of spending variation.RESULTSThe authors analyzed 17,436 spine surgery episodes performed by 195 surgeons at 50 hospitals. Mean price-standardized 90-day episode payments in the highest spending quintile exceeded mean payments for episodes in the lowest cost quintile by $42,953 (p < 0.001). Facility payments for index admission and post-discharge payments were the greatest contributors to overall variation: 39.4% and 32.5%, respectively. After accounting for patient-level covariates, the remaining hospital-level and surgeon-level effects accounted for 2.0% (95% CI 1.1%–3.8%) and 4.0% (95% CI 2.9%–5.6%) of total variation, respectively.CONCLUSIONSSignificant variation exists in total episode payments for spine surgery, driven mostly by variation in post-discharge and facility payments. Hospital and surgeon effects account for relatively little of the observed variation.
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Affiliation(s)
- Elyne N. Kahn
- 1Institute for Healthcare Policy and Innovation,
- 2Department of Neurosurgery,
| | - Chandy Ellimoottil
- 1Institute for Healthcare Policy and Innovation,
- 3Department of Urology, and
| | - James M. Dupree
- 1Institute for Healthcare Policy and Innovation,
- 3Department of Urology, and
| | - Paul Park
- 1Institute for Healthcare Policy and Innovation,
- 2Department of Neurosurgery,
| | - Andrew M. Ryan
- 1Institute for Healthcare Policy and Innovation,
- 4Department of Health Management and Policy/School of Public Health, University of Michigan, Ann Arbor, Michigan
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Adogwa O, Lilly DT, Vuong VD, Desai SA, Ouyang B, Khalid S, Khanna R, Bagley CA, Cheng J. Extended Length of Stay in Elderly Patients after Anterior Cervical Discectomy and Fusion Is Not Attributable to Baseline Illness Severity or Postoperative Complications. World Neurosurg 2018; 115:e552-e557. [DOI: 10.1016/j.wneu.2018.04.094] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 11/30/2022]
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Chotai S, Sivaganesan A, Parker SL, Sielatycki JA, Archer KR, Nian H, Stephens E, Aaronson OS, McGirt MJ, Devin CJ. Drivers of Variability in 90-day Cost for Primary Single-level Microdiscectomy. Neurosurgery 2018; 83:1153-1160. [DOI: 10.1093/neuros/nyy209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 04/24/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Silky Chotai
- Department of Orthopedics Surgery, Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ahilan Sivaganesan
- Department of Orthopedics Surgery, Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott L Parker
- Department of Orthopedics Surgery, Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John A Sielatycki
- Department of Orthopedics Surgery, Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kristin R Archer
- Department of Orthopedic Surgery, Vanderbilt Spine Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eric Stephens
- Strategic and Operations Analytics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oran S Aaronson
- Department of Orthopedics Surgery, Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Clinton J Devin
- Department of Orthopedics Surgery, Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee
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Qin CD, Helfrich MM, Fitz DW, Oyer MA, Hardt KD, Manning DW. Differences in Post-Operative Outcome Between Conversion and Primary Total Hip Arthroplasty. J Arthroplasty 2018; 33:1477-1480. [PMID: 29295772 DOI: 10.1016/j.arth.2017.11.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 10/31/2017] [Accepted: 11/22/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The demand for conversion of prior hip surgery to total hip arthroplasty (conversion THA) is likely to increase as a function of increasing US hip fracture burden in addition to its application in managing other conditions. Thus, outcome analysis is warranted to better inform value-based reimbursement schemes in the era of bundled payments. METHODS Via Current Procedural Terminology codes, the National Surgical Quality Improvement Project data files were queried for all patients who underwent primary THA and conversion of previous hip surgery to THA from 2005 to 2014. To better understand the isolated effect of procedure type on adverse outcomes, primary and conversion cohorts were then propensity-score matched via logistic regression modeling. Comparisons of the study's primary outcomes were drawn between matched cohorts. Statistical significance was defined by a P-value less than or equal to .05. RESULTS Relative to the primary THA group, the conversion THA group had statistically greater rates of Center Medicare and Medicaid Services (CMS) complications (7.5% vs 4.5%), non-home bound discharge (19.6% vs 14.7%), and longer length of hospital stay. Conversion THA was associated with increased likelihood of CMS complications (odds ratio 1.68, confidence interval 1.39-2.02) and non-home bound discharge (odds ratio 1.41, confidence interval 1.25-1.58). No statistically significant differences in mortality and readmission were detected. CONCLUSION The elevated risk for CMS-reported complications, increased length of hospital stay, and non-home bound discharge seen in our study of conversion THA indicates that it is dissimilar to elective primary THA and likely warrants consideration for modified treatment within the Comprehensive Care for Joint Replacement structure in a manner similar to THA for fracture.
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Affiliation(s)
- Charles D Qin
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago Medicine, Chicago, Illinois
| | - Mia M Helfrich
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David W Fitz
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mark A Oyer
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kevin D Hardt
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David W Manning
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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David G, Kim KL. The effect of workforce assignment on performance: Evidence from home health care. JOURNAL OF HEALTH ECONOMICS 2018; 59:26-45. [PMID: 29627675 DOI: 10.1016/j.jhealeco.2018.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 02/24/2018] [Accepted: 03/20/2018] [Indexed: 06/08/2023]
Abstract
Effective workforce assignment has the potential for improving performance. Using novel home health data combining provider work logs, personnel data, and detailed patient records, we estimate the effect of provider handoffs-a marker of care discontinuity-on hospital readmissions, an important performance measure for healthcare systems. We use workflow interruption caused by attrition and providers' work inactivity as an instrument for nurse handoffs. We find handoffs to substantially increase hospital readmissions. Our estimates imply that a single handoff increases the likelihood of 30-day hospital readmission by 16 percent and one in four hospitalizations during home health care would be avoided if handoffs were eliminated. Moreover, handoffs are more detrimental for high-severity patients and expedite hospital readmission. The frequency and sequencing of handoffs also affect the likelihood of rehospitalization.
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Affiliation(s)
- Guy David
- The Wharton School, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kunhee Lucy Kim
- New York University School of Medicine, New York, NY 10016, USA
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