Association between physician-hospital integration and inpatient care delivery in accountable care organizations: An instrumental variable analysis

OBJECTIVE

To investigate the relationship between physician-hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure.

DATA SOURCES

The primary data were Massachusetts All-Payer Claims Database (2009-2013).

STUDY SETTING

Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013.

STUDY DESIGN

Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician-hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital. The study sample comprised non-elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30-day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician-hospital integration was associated with a 10.6% reduction in 30-day expenditure (95% CI, -15.1% to -5.9%). Corresponding estimates for 45 and 60 days were - 9.7% (95%CI, -14.2% to -4.9%) and - 9.6% (95%CI, -14.3% to -4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, -22.6% to -8.2%) but unrelated to 30-day readmission rate.

CONCLUSIONS

Our instrumental variable analysis shows physician-hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates.

Mental health care provision in community health centers and hospital emergency department utilization

OBJECTIVES

To examine whether community health centers (CHCs) are effective in offsetting mental health emergency department (ED) visits.

DATA SOURCES AND STUDY SETTING

The HRSA Uniform Data System and the HCUP State ED Databases for Florida patients during 2012-2019.

STUDY DESIGN

We identified CHC-year-specific service areas using patient origin zip codes. We then estimated panel data models for number of ED mental health visits per capita in a CHC's service area. Models measured CHC mental health utilization as number of visits, unique patients, and intensity (visits per patient).

PRINCIPAL FINDINGS

CHC mental health utilization increased approximately 100% during 2012-2019. Increased CHC mental health provision was associated with small reductions in ED mental health utilization. An annual increase of 1000 CHC mental health care visits (5%) was associated with 0.44% fewer ED mental health care visits (p = 0.153), and an increase of 1000 CHC mental health care patients (15%) with 1.9% fewer ED mental health care visits (p = 0.123). An increase of 1 annual mental health visit per patient was associated with 16% fewer ED mental health care visits (p = 0.011).

CONCLUSIONS

Results suggest that mental health provision in CHCs may reduce reliance on hospital EDs, albeit minimally. Policies that promote alignment of services between CHCs and local hospitals may accelerate this effect.

A Comparison of Telemedicine and Office Visit Payments in a Commercially Insured Population

In recent years, commercial insurers have been slowly advancing coverage for telemedicine, raising questions regarding payment. Many states now have laws that address telemedicine reimbursement and as of 2019, 10 required full payment parity. Using a large commercial insurance claims database, this study conducted two natural experiments to better understand whether payment parity is effective in driving more telemedicine provision. Payments for common outpatient procedures provided by telemedicine and in offices during 2018-2019 were examined according to whether the service was subject to payment parity. For medical visits, evidence of payment incentives in promoting telemedicine was limited, and for psychotherapy telemedicine payments were comparable or greater than office visit payments. As telemedicine escalated during the COVID-19 peak and continues to grow beyond the pandemic, a valuable message is that payment parity laws may be a less effective strategy for encouraging telemedicine use than presumed by many state policymakers.

Safety-net hospital performance under Comprehensive Care for Joint Replacement

OBJECTIVE

To investigate the relative progress of safety-net hospitals (SNHs) under Medicare's Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment model over 2016-2020 and to identify the contributors to SNHs' realization of success under the program.

DATA SOURCES/STUDY SETTING

Secondary data on all CJR hospitals were collected from the Centers for Medicare and Medicaid Services (CMS) public use files and from the American Hospital Association.

STUDY DESIGN

We addressed whether SNHs can achieve progress in financial performance under CJR by focusing on the relative change in reconciliation payments or the difference between episode spending and target prices. We applied the method of dominance analysis to ordinary least squares regression to determine the relative importance of predictors of change in reconciliation payments over time.

PRINCIPAL FINDINGS

Compared to CJR hospitals overall, SNHs were less successful in meeting episode spending targets. Hospital factors dominated socioeconomic factors in explaining progress among SNHs, but not among non-SNHs. The contribution of nurse staffing was negligible across all CJR hospitals.

CONCLUSIONS

The formula used by CMS to determine spending targets may not be sufficient to address disparities in SNH financial performance under mandatory bundled payment.

Comparison of Visit Rates Before vs After Telehealth Expansion Among Patients With Mental Health Diagnoses Treated at Federally Qualified Health Centers

This cohort study assesses visit rates before and after telehealth expansion to assess whether telehealth availability at federally qualified health centers is associated with visit rates for patients with mental health diagnoses.

P06 The use of procalcitonin testing to improve antibiotic stewardship in all cause respiratory admissions: a retrospective analysis

Background

Improving antibiotic stewardship whilst simultaneously optimizing patient safety is a perpetually vexing clinical conundrum, which has been compounded by the current COVID-19 pandemic. Procalcitonin (PCT) measurement has previously demonstrated utility in this regard, when combined with routine clinical investigation, in certain patient populations.

Objectives

To assess whether the inclusion of PCT measurement as part of routine clinical care, instituted during a quality improvement project (QIP), increases the appropriateness of antibiotic administration.

Methods

A retrospective analysis was performed on 6 month interim data obtained from May to October 2021 during a QIP, which assessed the effect of PCT measurement on antimicrobial stewardship. All patients included had a primary diagnosis of respiratory illness and were analysed both together and as COVID-19 and non-COVID-19 subgroups to assess how often antibiotics were commenced on admission, duration of treatment and appropriateness of use. Finally, as sending microbiological samples made up part of the protocol, sample sending frequency was also studied.

Results

Thirty patients were included in both the COVID-19 and non-COVID-19 baseline subgroups who did not have PCT testing performed. Fifty-two patients were included in the PCT subgroup (27 COVID-19 positive and 25 COVID-19 negative). Following introduction of PCT testing, commencement of antibiotics on admission was reduced overall and in the COVID-19 positive subgroup (P = 0.0426 and P = 0.0446, respectively) with a significant decrease in inappropriate antibiotic prescribing in these two groups (P = 0.011 and P = 0.0157, respectively) and a trend towards reduced prescribing of AWaRe watch group antibiotics such as ceftriaxone. However, once prescribed, there was no difference in duration of antibiotic treatment or the frequency of microbiological sampling.

Conclusions

The data from this interim data analysis demonstrate that PCT measurement, when combined with routine clinical investigations in the acute respiratory setting, can be used to reduce inappropriate antibiotic prescribing. This was significantly reduced overall and in the COVID-19 positive subgroup but lost statistical significance in the COVID-19 negative subgroup, where it could be hypothesized that heterogeneity and inclusion of respiratory diseases where PCT has previously encountered difficulty in determining the presence of acute bacterial infection may be the cause. The significant effect demonstrated in the COVID-19 positive subgroup suggests particular utility in this patient population.

Influence of fibroids on cell-free DNA screening accuracy

OBJECTIVE

Cell-free DNA (cfDNA) screening assesses both maternal and placental cfDNA. Fibroids are common and release cfDNA into maternal serum. Genetic abnormality is seen in 50% of fibroids. We aimed to assess the impact of fibroids on the accuracy of genome-wide cfDNA screening.

METHODS

This was a prospective cohort study of singleton pregnancies examined at one of two centers in Melbourne and Sydney, Australia, between 1 November 2019 and 31 December 2020. All cases underwent pretest ultrasound examination to confirm an ongoing pregnancy of at least 10 weeks' gestation, and, at this stage, the number and volume of any uterine fibroid were documented. Genome-wide cfDNA screening was performed to detect all copy-number variants (CNV) > 7 megabases. The incidence of a false-positive result was compared between cases with and those without fibroids.

RESULTS

Over the 14-month study period, 13 184 patients underwent cfDNA screening, of whom 1017 (7.7%) had fibroids. Fibroids were not identified in any of the 17 participants who had a false-positive result for chromosomes 13, 18, 21, X or Y. Ninety-five (0.7%) cases were screen-positive for subchromosomal aberration (SA), rare autosomal trisomy (RAT) or multiple abnormalities (MA), with 10 of these cases having a fetal genetic abnormality. The incidence of a false-positive RAT, MA or SA result was significantly higher in participants with fibroids (20/1017 (2.0%)) than in those without fibroids (64/12 167 (0.5%)). Women with fibroids were approximately six times as likely to have a false-positive result for SA, and this was associated positively with both fibroid number and volume.

CONCLUSIONS

Most women with fibroids do not have an abnormal result on genome-wide cfDNA screening. However, CNVs due to fibroids are associated with false-positive SA findings, although fibroids do not appear to influence cfDNA screening accuracy for the common autosomal trisomies or sex-chromosomal abnormalities. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Quality and Cost in Community Health Centers

BACKGROUND

Quantifying health care quality has long presented a challenge to identifying the relationship between provider level quality and cost. However, growing focus on quality improvement has led to greater interest in organizational performance, prompting payers to collect various indicators of quality that can be combined at the provider level.

OBJECTIVE

To explore the relationship between quality and average cost of medical visits provided in US Community Health Centers (CHCs) using composite measures of quality.

RESEARCH DESIGN

Using the Uniform Data System collected by the Bureau of Primary Care, we constructed composite measures by combining 9 process and 2 outcome indicators of primary care quality provided in 1331 US CHCs during 2015-2018. We explored different weighting schemes and different combinations of individual quality indicators constructed at the intermediate domain levels of chronic condition control, screening, and medication management. We used generalized linear modeling to regress average cost of a medical visit on composite quality measures, controlling for patient and health center factors. We examined the sensitivity of results to different weighting schemes and to combining individual quality indicators at the overall level compared with the intermediate domain level.

RESULTS

Both overall and domain level composites performed well in the estimations. Average cost of a medical visit was negatively associated with quality, although the magnitude of the effect varied across weighting schemes.

CONCLUSION

Efforts toward improvement of primary health care quality delivered in CHCs need not involve greater cost.

The Effect of Telehealth Services on Provider Productivity

BACKGROUND

Telehealth services historically have played a small role in the provision of health care in the United States. However during the coronavirus disease 2019 (COVID-19) pandemic, public and private insurers rapidly expanded access to telehealth in order to reduce exposure and avoid transmission. It is unknown whether telehealth will become a more regular substitute for in-person care beyond the pandemic.

OBJECTIVE

Our objective was to provide evidence on the value of telehealth by comparing the productivity of physicians and other specialized clinicians who provide telehealth with the productivity of those who do not.

RESEARCH DESIGN

We conducted a retrospective data analysis of 17,705 unique providers in the areas of internal medicine, cardiology, dermatology, psychiatry, psychology, and optometry practicing in the US veterans affairs health care system during the period 2015 to 2018. For each year, we measured individual providers productivity by the total number of relative value units (RVUs) per full-time equivalent (FTE). We estimated the impact of providing telehealth on RVUs/FTE using fixed effects regression models estimated on a panel dataset of 58,873 provider-year observations and controlling for provider and patient characteristics.

RESULTS

Overall provider productivity increased in veterans affairs over the period, particularly in cardiology and dermatology. Providers of telehealth had above average productivity by 124 RVUs/FTE, or ∼4% of average total provider productivity. For the highest quartile of telehealth providers, average productivity was 188 RVUs/FTE higher than productivity of other providers.

CONCLUSION

Strategies that encourage long-term integration of telehealth into provider practices may contribute to overall health care value.

Do accountable care organizations differ according to physician-hospital integration?: A retrospective observational study

Physician-hospital integration among accountable care organizations (ACOs) has raised concern over impacts on prices and spending. However, characteristics of ACOs with greater integration between physicians and hospitals are unknown. We examined whether ACOs systematically differ by physician-hospital integration among 16 commercial ACOs operating in Massachusetts.Using claims data linked to information on physician affiliation, we measured hospital integration with primary care physicians for each ACO and categorized them into high-, medium-, and low-integrated ACOs. We conducted cross-sectional descriptive analysis to compare differences in patient population, organizational characteristics, and healthcare spending between the three groups. In addition, using multivariate generalized linear models, we compared ACO spending by integration level, adjusting for organization and patient characteristics. We identified non-elderly adults (aged 18-64) served by 16 Massachusetts ACOs over the period 2009 to 2013.High- and medium-integrated ACOs were more likely to be an integrated delivery system or an organization with a large number of providers. Compared to low-integrated ACOs, higher-integrated ACOs had larger inpatient care capacity, smaller composition of primary care physicians, and were more likely to employ physicians directly or through an affiliated hospital or physician group. A greater proportion of high-/medium-integrated ACO patients lived in affluent neighborhoods or areas with a larger minority population. Healthcare spending per enrollee in high-integrated ACOs was higher, which was mainly driven by a higher spending on outpatient facility services.This study shows that higher-integrated ACOs differ from their counterparts with low integration in many respects including higher healthcare spending, which persisted after adjusting for organizational characteristics and patient mix. Further investigation into the effects of integration on expenditures will inform the ongoing development of ACOs.

Payments for outpatient joint replacement surgery: A comparison of hospital outpatient departments and ambulatory surgery centers

OBJECTIVE

To compare commercial insurance payments for outpatient total knee and hip replacement surgeries performed in hospital outpatient departments (HOPDs) and in ambulatory surgery centers (ASCs).

DATA SOURCES

A large national claims database that contains information on actual prices paid to providers over the period 2014-2017.

DATA COLLECTION

We identified all patients receiving total knee replacement surgery and total hip replacement surgery in HOPDs and in ASCs for each of the 4 years.

STUDY DESIGN

For each year, we conducted descriptive and statistical patient-level analyses of the facility component of payments to HOPDs and to ASCs.

PRINCIPAL FINDINGS

For each procedure and for each year, ASC payments exceeded HOPD payments by a wide margin; however, the gap across settings declined over time. In 2014, knee replacement payments to HOPDs (n = 67) were $6016 compared to $23 244 in ASCs (n = 68). By 2017, payments to HOPDs (n = 223) had grown to $10 060 compared to $18 234 in ASCs (n = 602). Similarly, for hip replacements, HOPD payments (n = 43) rose from $6980 in 2014 to $11 139 in 2017 (n = 206) and in ASCs fell from $28 485 in 2014 (n = 82) to $18 595 in 2017 (n = 465).

CONCLUSIONS

Results suggest that for total joint replacement, common perceptions of cost savings from transition of services from hospitals to ASCs may be misguided.

Patient Outcomes Following Total Joint Replacement Surgery: A Comparison of Hospitals and Ambulatory Surgery Centers

BACKGROUND

For several years, many orthopedic surgeons have been performing total joint replacements in hospital outpatient departments (HOPDs) and more recently in ambulatory surgery centers (ASCs). In a recent shift, the Centers for Medicare and Medicaid Services began reimbursing for total knee replacement surgery in HOPDs. Some observers have expressed concerns over patient safety for the Medicare population particularly if Centers for Medicare and Medicaid Services extends the policy to include total hip replacement surgery and coverage in ASCs.

METHODS

This study used a large claims database of non-Medicare patients to examine inpatient and outpatient total knee replacement and total hip replacement surgery performed on a near-elderly population during 2014-2016. We applied propensity score methods to match inpatients with ASC patients and HOPD patients with ASC patients adjusting for risk using the HHS Hierarchical Condition Categories risk adjustment model. We conducted statistical tests comparing clinical outcomes across the 3 settings and examined relative costs.

RESULTS

Readmissions, postsurgical complications, and payments were lower for outpatients than for inpatients. Within outpatient settings, readmissions and postsurgical complications were lower in ASCs than in HOPDs but payments for ASC patients were higher than payments for HOPD patients.

CONCLUSION

Our findings support the argument that outpatient total joint replacement is appropriate for select patients treated in both HOPDs and ASCs, although in the commercially insured population, the latter services may come at a cost. Until further study of outpatient total joint replacement in the Medicare population becomes available, how this will extrapolate to the Medicare population is unknown.

Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use

OBJECTIVE

This study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP).

DESIGN

A retrospective cohort study of patients with new-onset LBP from 2008 to 2013.

SETTING

The study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP.

PARTICIPANTS

216 504 individuals aged 18 years or older across the USA who were diagnosed with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance.

EXPOSURES

The primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists).

MAIN OUTCOME MEASURES

Short-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days' supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months).

RESULTS

Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).

CONCLUSIONS

Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Health insurance design and conservative therapy for low back pain

OBJECTIVES

To determine the association of health insurance benefit design features with choice of early conservative therapy for patients with new-onset low back pain (LBP).

STUDY DESIGN

Observational study of 117,448 commercially insured adults 18 years or older presenting with an outpatient diagnosis of new-onset LBP between 2008 and 2013 as recorded in the OptumLabs Data Warehouse.

METHODS

We identified patients who chose a primary care physician (PCP), physical therapist, or chiropractor as their entry-point provider. The main analyses were logistic regression models that estimated the likelihood of choosing a physical therapist versus a PCP and choosing a chiropractor versus a PCP. Key independent variables were health plan type, co-payment, deductible, and participation in a health reimbursement account (HRA) or health savings account (HSA). Models controlled for patient demographic and clinical characteristics.

RESULTS

Selection of entry-point provider was moderately responsive to the incentives that patients faced. Those covered under plan types with greater restrictions on provider choice were less likely to choose conservative therapy compared with those covered under the least restrictive plan type. Results also indicated a general pattern of higher likelihood of treatment with physical therapy at lower levels of patient cost sharing. We did not observe consistent associations between participation in HRAs or HSAs and choice of conservative therapy.

CONCLUSIONS

Modification of health insurance benefit designs offers an opportunity for creating greater value in treatment of new-onset LBP by encouraging patients to choose noninvasive conservative management that will result in long-term economic and social benefits.

44 Misregulation of ten-eleven translocation 3 CXXC domain leads to abnormal formation of 5-hydroxymethylcytosine and expression of pluripotency genes in pig embryos

Ten-eleven translocation (TET) methylcytosine dioxygenases are considered to play an important role in regulation of DNA methylation patterns by converting 5-methylcytosine (5mC) to 5-hydroxymethylcytosine (5hmC). TET3 protein, a member of TET family, is enriched in mature oocytes and early stage embryos and contributes to DNA demethylation of the paternal genome in zygotes. N-terminal CXXC domain of TET3 is thought to be important in catalysing 5mC oxidation through its DNA binding potential. However, it is not clear whether specific DNA binding of CXXC domain is required for 5hmC conversion in mammalian embryos. Here, we investigated the role of TET3 CXXC domain in controlling 5hmC formation in fertilized pig embryos by injecting TET3 CXXC domain into mature pig oocytes as a dominant negative to inhibit the direct binding of TET3 to the genome through the CXXC domain. The CXXC domain of pig TET3 was identified through bioinformatics comparison of TET3 sequences among different species and cloned from mature pig oocyte-derived cDNA. To construct the green fluorescent protein (GFP)-CXXC fusion protein, CXXC sequence was subcloned into N-terminal GFP fusion vector, and then mRNA was synthesised by in vitro transcription. The GFP-CXXC mRNA (100 ng/µL) was injected into oocytes matured in vitro for 36 to 37h. Then, the oocytes were fertilized at 42h post-maturation. Water-injected oocytes served as a control. At 17h post-fertilization, zygotes were collected to analyse 5hmC level by immunocytochemistry. The level of 5hmC was analysed using ImageJ (https://imagej.nih.gov/ij/). Expression of pluripotency-related genes at Day 7 blastocysts was examined through quantitative RT-PCR; ΔΔCt method was used to analyse the quantitative RT-PCR data and Student’s t-test was used for statistical analysis. All experiments were conducted at least three times and P-values of less than 0.05 were considered significant. The GFP-CXXC was exclusively localised in pronuclei, indicating that the CXXC domain may lead to nuclear localization of TET3. The level of 5hmC in zygotes was not altered by the overexpression of GFP-CXXC. Interestingly, in 2-cell stage embryos, the 5hmC level was reduced in GFP-CXXC injected embryos compared with the control group, suggesting that CXXC domain is important for 5hmC formation post-DNA replication. There was an increase in transcript abundance of NANOG and ESRRB in blastocysts developed from GFP-CXXC injected oocytes compared with control blastocysts (P<0.05). There was no difference in the expression of POU5F1 and SOX2. In this study, we found that CXXC domain of TET3 is critical in maintaining the level of 5hmC formation at 2-cell stage and proper level of pluripotency-related genes (NANOG and ESRRB) in blastocysts. Future studies will focus on elucidating mechanisms behind the changes after overexpression of GFP-CXXC in pig embryos.

209 Overexpression of WAVE1 activates pluripotency-related genes in porcine somatic cells

Despite extensive efforts, cellular reprogramming in livestock species has had limited success. Induced pluripotent stem cells (iPSC) have been established; however, these cells often show incomplete reprogramming status, and constitutive expression of exogenous reprogramming factors is required due to inactivation of endogenous pluripotency-related genes. A previous study reported that overexpression of the Xenopus egg-derived WAVE1 gene assists reprogramming of murine somatic cells into the pluripotent state. The WAVE1 gene is also required for oocyte-mediated reprogramming by transcriptional activation of embryonic genes. In this study, we investigated the role of porcine WAVE1 in cellular reprogramming by inducing overexpression of WAVE1 in porcine fetal fibroblasts (PFF). Previously, we cloned the coding sequences (CDS) of porcine WAVE1 using porcine expressed sequence tags (EST) and predicted porcine WAVE1 sequences. The WAVE1 CDS, derived from porcine mature oocytes, was overexpressed in PFF by transfection using the Neon system. Then, G418-based antibiotic selection was performed to enrich cells constitutively overexpressing WAVE1. After cell culture for 4 weeks, RNA was extracted from the WAVE1 transfected and control PFF, and cDNA was synthesised from the RNA using random hexamers. The cDNAs were used for quantitative reverse transcription PCR to analyse the expression pattern of pluripotency- and reprogramming-related genes: POU5F1, NANOG, KLF2, SOX2, DPPA3, ZFP42, ESRRB, TET1, TET2, and TET3. The expression of target genes were normalized to GAPDH level and the ΔΔCt algorithm was used for analysis. Three technical replications and 4 biological replications were performed. Student’s t-test was used for the comparison and P-values<0.05 were considered significant. On average, a 20-fold increase of WAVE1 was observed in the transfected cells compared with control cells. Interestingly, overexpression of WAVE1 activated some of the pluripotency-related genes in porcine PFF. Specifically, transcript levels of NANOG, KLF2, and SOX2 were increased compared with those in the control cells (P<0.05). In addition, levels of POU5F1 and DPPA3 tended to be higher in WAVE1-overexpressing cells compared with those in the control cells (P<0.1). However, transcript levels of other pluripotency-related genes (ZFP42, DPPA3, and ESRRB) did not change in WAVE1-overexpressing cells. The expression level of TET family (TET1, TET2, and TET3), which is enriched in pluripotent stem cells and a key regulator of DNA methylation, was not changed in WAVE1-overexpressing cells. These results indicate that WAVE1 can be a novel factor in porcine cellular reprogramming. Considering that a key defect of current porcine iPSC generation is insufficient expression of endogenous pluripotency genes, application of WAVE1 may enhance quality of porcine iPSC. We intend to evaluate expression of pluripotency markers at the protein level in WAVE1-overexpressing cells and investigate mechanisms underpinning WAVE1-mediated reprogramming process in future studies.

Assessing the Appearance and Fluorescence of Resin-Infiltrated White Spot Lesions With Caries Detection Devices

OBJECTIVE

This in vitro study examined the effectiveness of caries detector devices in assessing the ability of resin infiltration (RI) (Icon, DMG-Hamburg, Hamburg, Germany) to improve the optical properties of enamel white spot lesions (WSLs).

METHODS AND MATERIALS

Ten caries-free third molars were used. Photographs, a subjective visual assessment of the photographs, fluorescent camera (FC) images using the Spectra (Air Techniques, Melville, NY, USA), and laser fluorescent (LF) readings using the DIAGNOdent (KaVo, Biberach, Germany) were obtained from each tooth's buccal surface. Specimens were coated with nail polish leaving a rectangular window on the buccal surface and placed in pH 4.5 lactic acid gel for two weeks to create a WSL. The WSLs were analyzed by the same methods. RI was applied to half of each WSL; final photographs were then taken, and caries detector assessments were conducted. FC images were converted to grayscale, and the fluorescent image's brightness intensity was measured using ImageJ. Data were analyzed with analysis of variance and Tukey-Kramer honestly significant difference test. Significance was set at α=0.05.

RESULTS

Subjective assessment of the photographs showed that RI improved the appearance of the WSLs so that they resembled intact enamel. Mean FC-brightness intensities for intact, demineralized, and demineralized RI-treated areas were 159.6 ± 9.2, 123.4 ± 7.2, and 160.9 ± 11.5, respectively. There were no significant differences in fluorescent intensity between the intact and RI areas ( p=0.58). The demineralized areas had significantly lower fluorescent intensity than both the RI-treated and intact areas ( p<0.001). LF values did not differ significantly between intact, demineralized, or RI-treated areas.

CONCLUSIONS

This study demonstrates the ability of RI to restore artificial WSLs to the esthetics and fluorescence of intact enamel. The FC can be used to assess the optical properties of WSLs and the impact of RI on these properties.

The relationship between nursing home quality and costs: Evidence from the VA

Ensuring quality of care in nursing homes is a public health priority, yet how nursing home quality relates to cost is not well understood. This paper addresses this relationship for 132 VA community living centers (nursing homes), for fiscal years 2014 and 2015. We estimated cost models using the VA Decision Support System which tracks total direct costs and nursing direct costs for individual resident segments of care. We summed residents’ total costs and nursing costs to the community living center level for each year. Annual facility costs then were regressed on quality of care measured with composite scores based on 13 distinct adverse events. Results indicated that higher quality was associated with higher predicted cost. However, we did not find evidence that higher costs were driven by high nurse staffing levels.

Specialization and production cost efficiency: evidence from ambulatory surgery centers

In the U.S. health care sector, the economic logic of specialization as an organizing principle has come under active debate in recent years. An understudied case is that of ambulatory surgery centers (ASCs), which recently have become the dominant provider of specific surgical procedures. While the majority of ASCs focus on a single specialty, a growing number are diversifying to offer a wide range of surgical services. We take a multiple output cost function approach to an empirical investigation that compares production economies in single specialty ASCs with those in multispecialty ASCs. We applied generalized estimating equation techniques to a sample of Pennsylvania ASCs for the period 2004-2014, including 73 ASCs that specialized in gastrointestinal procedures and 60 ASCs that performed gastrointestinal as well as other specialty procedures. Results indicated that both types of ASC had small room for expansion. In simulation analysis, production of GI services in specialized ASCs had a cost advantage over joint production of GI with other specialty procedures. Our results provide support for the focused factory model of production in the ASC sector.

Radiographic and clinical changes of the patellar tendon after tibial plateau leveling osteotomy

Patellar tendon thickening (PTT) and patellar tendinosis (PTS) have been discussed in the veterinary literature as a post-operative complication of tibial plateau leveling osteotomy (TPLO). The purpose of this study was to define radiographic PTT, determine the frequency of and risk factors for PTT and PTS, and describe the clinical and histopathological findings of PTS after TPLO. We hypothesized that the location of the osteotomy alters forces placed on the patellar tendon resulting in PTT or PTS. Radiographs and medical records from 83 dogs undergoing 94 TPLO procedures were retrospectively evaluated. Two months post-operatively, 19 dogs (20.2%) had a normal patellar tendon or mild PTT, 51 (54.3%) had moderate PTT, and 24 (25.5%) had severe PTT. Seven of the 24 dogs (7.4%) with severe PTT had clinical signs consistent with PTS. Only dogs with severe PTT developed PTS (p < 0.0001). The risk factors for the development of PTT include: a cranial osteotomy, a partially intact cranial cruciate ligament (CCL) in conjunction with a cranial osteotomy, and post-operative tibial tuberosity fracture. The only risk factor identified for the development of PTS was a partially intact CCL. Four dogs with PTS improved with conservative therapy and one improved with surgical treatment. Two dogs had tendon biopsies with histopathological review that showed tendon degeneration with lack of inflammation. As only the dogs with severe PTT develop PTS, a caudal osteotomy for the prevention of PTT and subsequent PTS is recommended.

Specialization as an Organizing Principle: The Case of Ambulatory Surgery Centers

Ambulatory surgery centers (ASCs) recently have grown to become the dominant provider of specific surgical procedures in the United States. While the majority of ASCs focus primarily on a single specialty, many have diversified to offer a wide range of surgical specialties. We exploited a unique data set from Pennsylvania for the years 2004 to 2014 to conduct an empirical investigation of the relative cost of production in ASCs over varying degrees of specialization. We found that for the majority of ASCs, focus on a specialty was associated with lower facility costs. In addition, ASCs appeared to be capturing economies of scale over a broad range of service volume. In contrast to studies of cost efficiency in specialty hospitals, our results provide evidence that supports the focused factory model of production in the ASC sector.

Readmissions To New York Hospitals Fell For Three Target Conditions From 2008 To 2012, Consistent With Medicare Goals

The Medicare Hospital Readmissions Reduction Program (HRRP), an initiative of the Affordable Care Act, imposes considerable financial penalties on hospitals with excess thirty-day readmissions for patients with selected high-volume conditions. We investigated the intended impact of the program by examining changes in thirty-day readmissions among Medicare patients admitted for three conditions targeted by the program in New York State, compared to Medicare patients with other conditions and with privately insured patients, before and after the program's introduction. We also examined potential unintended strategic responses by hospitals that might allow them to continue to treat target-condition patients while avoiding the readmission penalty. We found that thirty-day readmissions fell for the three conditions targeted by the HRRP, consistent with the goals of the program. Second, there also was a substantial fall in readmissions for a comparison group although not as large as for the target group, which suggests modest spillover effects in Medicare for other conditions. We did not find strong evidence of unintended effects associated with the program. These early findings suggest that the HRRP is affecting hospitals in the direction intended by the Affordable Care Act.

Hospital Readmissions Reduction Program: Safety-Net Hospitals Show Improvement, Modifications To Penalty Formula Still Needed

Many observers are calling for modification of Medicare's Hospital Readmissions Reduction Program (HRRP) to relieve an unfair burden on safety-net hospitals, which serve low-income populations and consequently have relatively high readmission rates. To broaden the perspective on this issue, we addressed the fundamental question of whether the HRRP has been an effective tool for reducing thirty-day readmissions in safety-net hospitals. In the first three years of the program, these hospitals reduced readmissions for heart attack by 2.86 percentage points, heart failure by 2.78 percentage points, and pneumonia by 1.77 percentage points, and they also reduced the disparity between their readmission rates and those of other hospitals. While the fairness issue remains unresolved, it appears that safety-net hospitals have been able to respond to HRRP incentives.

Ambulatory Surgery Centers and Prices in Hospital Outpatient Departments

Specialty providers claim to offer a new competitive benchmark for efficient delivery of health care. This article explores this view by examining evidence for price competition between ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs). I studied the impact of ASC market presence on actual prices paid to HOPDs during 2007-2010 for four common surgical procedures that were performed in both provider types. For the procedures examined, HOPDs received payments from commercial insurers in the range of 3.25% to 5.15% lower for each additional ASC per 100,000 persons in a market. HOPDs may have less negotiating leverage with commercial insurers on price in markets with high ASC market penetration, resulting in relatively lower prices.

Measuring the hospital length of stay/readmission cost trade-off under a bundled payment mechanism

If patients are discharged from the hospital prematurely, many may need to return within a short period of time. This paper investigates the relationship between length of stay and readmission within 30 days of discharge from an acute care hospitalization. It applies a two-part model to data on Medicare patients treated for heart attack in New York state hospitals during 2008 to obtain the expected cost of readmission associated with length of stay. The expected cost of a readmission is compared with the marginal cost of an additional day in the initial stay to examine the cost trade-off between an extra day of care and the expected cost of readmission. The cost of an additional day of stay was offset by expected cost savings from an avoided readmission in the range of 15% to 65%. Results have implications for payment reform based on bundled payment reimbursement mechanisms.

Diffuse skeletal muscle metastases from sacral chordoma

Chordomas are rare, slow-growing tumors arising from cellular remnants of the notochord. They account for 1-4% of primary malignant bone tumors and usually occur in the axial skeleton, most commonly the sacrum. Although typically locally recurrent, chordoma metastasis rates as high as 10-42% have been reported. While spread to multiple organ systems has been documented, metastatic disease to skeletal muscle is extremely rare. We present a case of extensive, multifocal skeletal muscle metastases developing in the setting of recurrent sacral chordoma. Our literature search found only one additional case of metastatic chordoma to a single skeletal muscle.

Peritoneal and mediastinal highly differentiated follicular carcinoma of ovarian origin

A 70-year-old female patient presented to her primary care doctor with persistent elevated alkaline phosphatase of suspected metastatic etiology. Computed tomography demonstrated epicardial and peritoneal nodules. Biopsy of one of the peritoneal nodules revealed thyroid tissue and extraovarian struma ovarii was considered. The patient had a history of remote total abdominal hysterectomy and bilateral salpingo-oophorectomy 31 years prior for endometriosis with no available pathology from that surgery. The patient recalls being told that she had a left ovarian cyst. A thyroid ultrasound was performed that demonstrated multiple nodules without concerning features; however, due to high clinical suspicion, a total thyroidectomy was performed. Upon full histological evaluation a 0.5 cm papillary microcarcinoma was found. Given the rarity of metastatic papillary cancer to the peritoneum and the small size and grade of the tumor, a diagnosis of highly differentiated follicular carcinoma of ovarian origin was favored. The patient was subsequently treated with radioiodine therapy.

Non-contrast CT at comparable dose to an abdominal radiograph in patients with acute renal colic; impact of iterative reconstruction on image quality and diagnostic performance

OBJECTIVES

The aim was to assess the performance of low-dose non-contrast CT of the urinary tract (LD-CT) acquired at radiation exposures close to that of abdominal radiography using adaptive statistical iterative reconstruction (ASiR).

METHODS

Thirty-three patients with clinically suspected renal colic were prospectively included. Conventional dose (CD-CT) and LD-CT data sets were contemporaneously acquired. LD-CT images were reconstructed with 40 %, 70 % and 90 % ASiR. Image quality was subjectively and objectively measured. Images were also clinically interpreted.

RESULTS

Mean ED was 0.48 ± 0.07 mSv for LD-CT compared with 4.43 ± 3.14 mSv for CD-CT. Increasing the percentage ASiR resulted in a step-wise reduction in mean objective noise (p < 0.001 for all comparisons). Seventy % ASiR LD-CT images had higher diagnostic acceptability and spatial resolution than 90 % ASiR LD-CT images (p < 0.001). Twenty-seven calculi (diameter = 5.5 ± 1.7 mm), including all ureteric stones, were correctly identified using 70 % ASiR LD-CT with two false positives and 16 false negatives (diameter = 2.3 ± 0.7 mm) equating to a sensitivity and specificity of 72 % and 94 %. Seventy % ASiR LD-CT had a sensitivity and specificity of 87 % and 100 % for detection of calculi >3 mm.

CONCLUSION

Reconstruction of LD-CT images with 70 % ASiR resulted in superior image quality than FBP, 40 % ASIR and 90 % ASIR. LD-CT with ASIR demonstrates high sensitivity and specificity for detection of calculi >3 mm.

TEACHING POINTS

• Low-dose CT studies for urinary calculus detection were performed with a mean dose of 0.48 ± 0.07 mSv • Low-dose CT with 70 % ASiR detected calculi >3 mm with a sensitivity and specificity of 87 % and 100 % • Reconstruction with 70 % ASiR was superior to filtered back projection, 40 % ASiR and 90 % ASiR images.

Hospital length of stay and readmission: an early investigation

This article is an investigation into the relationship between length of stay and readmission within 30 days of discharge from an acute care hospitalization. We estimated probability models for heart attack and for heart failure patients using generalized estimating techniques applied to hospital administrative data from California for calendar year 2008. The key independent variable was length of stay in the initial hospitalization. We found negative associations between length of stay and readmission probability, particularly in the case of heart attack. Simulated values of predicted readmissions based on a 1-day increase in length of stay yielded estimated reductions in readmission rates in the 7% to 18% range for heart attack patients and the 1% to 8% range for heart failure patients. Increasing length of stay for some patients may be a means of improving quality of care by reducing readmission during the 30-day postdischarge period.

The association between serious psychological distress and emergency department utilization among young adults in the USA

PURPOSE

Psychological problems could lead to several adverse health outcomes and were strongly correlated with cigarette smoking and alcohol consumption. In addition, patients treated in EDs were vulnerable to psychological problems. We therefore examined the population-level association between serious psychological distress (SPD) and emergency department (ED) use among young adults in the USA. We also studied the additive effects of SPD, cigarette smoking, and alcohol consumption on the ED presentation.

METHODS

The study sample contains 16,873 individuals, using data from the National Health Interview Survey, from 2004 to 2006. Bivariate analyses with chi-square tests and logistic regression analyses are performed.

RESULTS

Young adults having SPD were 2.05 times more likely to go to an ED. People having SPD and being a current smoker were 2.52 times more likely to use services in an ED. However, people having SPD and being a heavy drinker did not have a significantly elevated risk of ED use.

CONCLUSION

An association between SPD and ED use among US young adults is established in this study. Attempts to decrease excess ED use and the development of strategies to improve mental health among young adults are needed to improve patient health and reduce the health-care burden of high costs and deteriorating ED care quality.

Use of abdominopelvic computed tomography in emergency departments and rates of urgent diagnoses in Crohn's disease

BACKGROUND & AIMS

In the United States, the use of abdominopelvic computed tomography (APCT) by emergency departments for patients with abdominal pain has increased, despite stable admission rates and diagnosis requiring urgent intervention. We proposed that trends would be similar for patients with Crohn's disease (CD).

METHODS

We conducted a retrospective study of data from 648 adults with CD who presented at 2 emergency departments (2001-2009; 1572 visits). Trends in APCT use were assessed with Spearman correlation coefficient. We compared patient characteristics and APCT findings during 2001-2003 and 2007-2009.

RESULTS

APCT use increased from 2001 (used for 47% of encounters) to 2009 (used for 78% of encounters; P = .005), whereas admission rates were relatively stable at 68% in 2001 and 71% in 2009 (P = .06). The overall proportion of APCTs with findings of intestinal perforation, obstruction, or abscess was 29.0%; 34.9% of APCTs were associated with urgent diagnoses, including those unrelated to CD. Between 2001-2003 and 2007-2009, the proportions of APCTs that detected intestinal perforation, obstruction, or abscess were similar (30% vs 29%, P = .92), as were the proportions used to detect any diagnosis requiring urgent intervention, including those unrelated to CD (36% vs 34%, P = .91).

CONCLUSIONS

Despite the increased use of APCT by emergency departments for patients with CD, there were no significant changes in admission rates between the periods of 2001-2003 and 2007-2009. The proportion of APCTs that detected intestinal perforation, obstruction, abscess, or other urgent conditions not related to CD remained high.

Measuring the cost of hospital adverse patient safety events

This paper estimates the excess cost of hospital inpatient care due to adverse safety events in the U.S. Department of Veterans Affairs (VA) hospitals during fiscal year 2007. We measured adverse events according to the Patient Safety Indicator (PSI) algorithms of the Agency for Healthcare Research and Quality. Patient level cost regression analyses were performed using generalized linear modeling techniques. Accounting for the heavily skewed distribution of costs among patients having adverse safety events, results suggested that the excess cost of nine different PSIs for VA patients are much higher than previously estimated. We tested sensitivity of results to whether costs were measured by VA's Decision Support System (DSS) that uses local costs of specific inputs, or by the average costing system developed by VA's Health Economics Resource Center. DSS costing appeared to better characterize the high cost patients.

Excess Costs Attributable to Postoperative Complications

This article estimates excess costs associated with postoperative complications among inpatients treated in Veterans Health Administration (VA) hospitals. The authors conducted an observational study on 43,822 hospitalizations involving inpatient surgery in one of 104 VA hospitals during fiscal year 2007. Hospitalization-level cost regression analyses were performed to estimate the excess cost of each of 18 unique postoperative complications. The authors used generalized linear modeling techniques to account for the heavily skewed cost distribution. Costs were measured using an activity-based cost accounting system and complications were assessed based on medical chart review conducted by the VA ‘National Surgical Quality Improvement Program. The authors found excess costs associated with postoperative complications ranging from $8,338 for “superficial surgical site infection” to $29,595 for “failure to wean within 24 hours in the presence of respiratory complications.” The results obtained suggest that quality improvement efforts aimed at reducing postoperative complications can contribute significantly to lowering of hospital costs.

Hospital competition and financial performance: the effects of ambulatory surgery centers

Ambulatory surgery centers (ASCs), limited-service alternatives for treating surgery patients not requiring an overnight stay, are a health-care service innovation that has proliferated in the U.S. and other countries in recent years. This paper examines the effects of ASC competition on revenues, costs, and profit margins of hospitals that also provided these services as a subset of their general services in Arizona, California, and Texas during the period 1997-2004. We identified all ASCs operating during the period in the 49 Dartmouth Hospital Referral Regions in the three states. The results of fixed effects models suggested that ASCs are meaningful competitors to general hospitals. We found downward pressure on revenues, costs, and profits in general hospitals associated with ASC presence.

Emergency department visits: the cost of trauma centers

Crowded emergency departments (EDs) have become a serious problem in the current U.S. healthcare system. Patient wait times and periods of ED diversion have increased, raising concerns about the timeliness, efficiency, and quality of ED treatment. This study addresses the question of whether there are economies of scale (EOS) in ED care, and the extent to which such economies vary across different types of EDs. A hospital cost function approach is taken to evaluate average and marginal costs of EDs designated as trauma centers. Data comes from acute care hospitals in Texas for the period 1998-2004. Cost functions corresponding to four different levels of ED trauma care are estimated using a translog panel data model with hospital fixed effects. The marginal costs (in 2004 dollars) of each trauma center level are: $53 (Level I), $177 (Level II), $119 (Level III), and $258 (Level IV). Average cost per ED visit for trauma centers exceeds marginal cost at all Levels, indicating the presence of EOS. The results support a possible expansion of ED size policy in order to improve the cost efficiency of ED services.

Single Specialty Hospitals and Service Competition

Advocates for physician-owned hospitals specializing in cardiac, orthopedic, and surgical services claim that these facilities induce healthy competition, stimulating improved performance among acute care hospitals. This paper examines the effect of specialty hospital entry on one indicator of competition among hospitals: changes in service provision by general hospitals in local markets. Results suggest that general hospitals are stepping up their own offerings of services that are in direct competition with those of specialty hospitals. Entry of specialty hospitals is also associated with significantly higher growth in high-technology diagnostic imaging services in the general hospitals in those markets.