Emergency Department Visits Following Joint Replacement Surgery in an Era of Mandatory Bundled Payments

OBJECTIVES

The Center for Medicare & Medicaid Services (CMS) is actively testing bundled payments models. This study sought to identify relevant details for 90-day postdischarge emergency department (ED) visits of Medicare beneficiaries following total joint replacement (TJR) surgery meeting eligibility for a CMS bundled payment program.

METHODS

The CMS research identifiable file for the State of Texas for 2011-2012 was used to identify patients who underwent TJR. Qualifying inpatient claims were linked to 90-day postdischarge ED claims. The claims associated with live discharge were divided into three cohorts: elective total hip replacement (THR), emergent (THR), and total knee replacement. The frequency, distribution, diagnoses, and disposition for these ED visits were identified and stratified by timing within the postdischarge period as well as discharge diagnosis. Visits were correlated with age, sex, joint replaced, and fracture.

RESULTS

There were 50,838 TJR surgeries in Texas in 2011-2012 that would have been eligible for inclusion in the CMS defined CJR program. A total of 12,747 ED visits by 9,299 patients occurred in the 90-day postdischarge period. Visits to the ED by patients 85 and older predominated in the case of THR performed secondary to a hip fracture. Patients 65-74 years predominated in both elective surgery categories. There were 2,370 ED visits within 90 days of 10,786 elective THRs, of which 55.5% were discharged home, 34.6% were hospitalized or transferred, and 6.9% were admitted to observation. Of the 3,438 ED visits among 8,475 emergent hip replacement cases, 22.4% were discharged home, 50.2% were hospitalized or transferred, and 5.3% were admitted to observation. Of the 6,939 visits among 31,387 knee replacement cases, 61.9% were discharged home, 30.6% were readmitted or transferred, and 7.1% were admitted to observation. The discharge diagnoses varied by volume and timing in the postdischarge period. The most prevalent diagnoses across groups included injury/trauma, physiologic decompensation, cardiopulmonary events, and infection.

CONCLUSIONS

ED services are frequent for Medicare TJR bundle-eligible patients within the postdischarge period. ED utilization, discharge diagnosis and disposition varied by age, and elective and emergent surgeries. The ED is an important site for identifying and managing postoperative adverse outcomes.

Care at the End of Life

Objective: To profile communication and recommendations reported by adults with terminal illness and explore differences by patient and physician characteristics.

Method: This pilot was a cross-sectional study sample of 90 patients (39 Caucasian, 51 African American) with advanced heart failure or cancer. Participants completed an in-person, race-matched interview.

Results: Participation was high (94%). Discussion about end-of-life topics was low. For example, only 30% reported discussion of advance directives, and 22% reported their physician inquired about spiritual support. Participants with cancer were significantly more likely to be receiving pain and/or symptom management at home, aware of prognosis, and participating in hospice. African American participants who were under the care of African American physicians were less likely to report pain and/or symptom management than other racial matches.

Discussion: Although additional research on factors related to communication is important, initiation of patient-centered counseling by all physicians with seriously ill patients is essential.

Primary hypertension at a single center: treatment, time to control, and extended follow-up

We present data on presentation, treatment, and follow-up of 65 pediatric patients with primary hypertension treated over the past 12 years, including initial anthropometric data, pharmacologic treatment, time to control for both systolic and diastolic blood pressure (SBP/DBP), and maintenance of control over time. Data was normalized to standard deviation scores (SDS) for mathematical analysis, and antihypertensive medication dosages were converted to dosage equivalents for a single member of each antihypertensive class. We used multiple regression analysis and Kaplan- Meier survival curves to determine the time to control, medication, and dose effectiveness. Patients were seen for an average of seven visits over 25 months. Initial BPs averaged 134/71 mmHg (2.1/0.6 SDS). Patients were taller, heavier, and had higher body mass index than average for age and sex. By the fourth visit, SBP was <90th percentile in 79%. Ninety percent could be controlled, although 32 lost control at some point (at least 16 due to noncompliance). At the last visit, 46 were controlled, and 5/8 patients off medication remained normotensive. Only angiotensin-converting enzyme inhibitors and beta-blockers demonstrated significant association with BP control. This is the first study to document the time to control of BP, and it can serve as an initial standard for quality assessment.

A four-system comparison of patients with chronic illness: the Military Health System, Veterans Health Administration, Medicaid, and commercial plans

We compared chronic care utilization in four major health systems in the U.S.: the military health system (TRICARE), the Department of Veterans Affairs (VA), Medicaid, and employer-sponsored commercial plans. Prevalence rates and key performance indicators were constructed from administrative data in federal fiscal year 2003 for eight chronic conditions: hypertension, major depression, diabetes, tobacco dependence, ischemic heart disease, severe mental illness, persistent asthma, and stroke. Continuously enrolled beneficiaries under 65 years old were studied: TRICARE (N = 2,963,987), VA (N = 2,114,739), Medicaid enrollees in five states (N = 5,554,974), and commercial insurance (N = 5,212,833). Condition-specific adjusted prevalence rates and measures were compared using the standardized rate ratio. For the majority of the conditions, the estimated prevalence rates were highest in the VA and Medicaid populations. Prevalence rates were generally lower in TRICARE and commercial plans. Medicaid beneficiaries had the highest hospitalization rates in four of the six conditions where hospitalization rates were measured. These results provide empirical evidence of differences in chronically ill patient populations in several of the major U.S. health insurance systems.

Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial

BACKGROUND

The proper positioning of patients before direct laryngoscopy is a key step that facilitates tracheal intubation. In obese patients, the 25 degree back-up or head-elevated laryngoscopic position, which is better than the supine position for tracheal intubation, is usually achieved by placing blankets or other devices under the patient's head and shoulders. This position can also be achieved by reconfiguring the normally flat operating room (OR) table by flexing the table at the trunk-thigh hinge and raising the back (trunk) portion of the table (OR table ramp). This table-ramp method can be used without the added expense of positioning devices, and it reduces the possibility of injury to the patient or providers that can occur during removal of such devices once tracheal intubation is achieved. In this study, we sought to determine if the table-ramp method of patient positioning was equivalent to the blanket method with regard to the time required for tracheal intubation.

METHODS

Eighty-five adults with a Body Mass Index >30 kg/m(2), scheduled for elective surgery, consented to participate in this prospective randomized equivalence study conducted in a teaching hospital. The randomization scheme used permuted blocks with subjects equally allocated to be positioned using either the blanket method or the table-ramp method. The end-point in either case was to achieve a head-elevated position, where the patient's external auditory meatus and sternal notch were in the same horizontal plane. Although all patients were positioned by the same anesthesiologist, laryngoscopy and tracheal intubation were performed by trainees with various levels of expertise. Standard i.v. induction and tracheal intubation techniques were used. The time from loss of consciousness to the time after tracheal intubation when end-tidal CO(2) was detected was recorded. The effectiveness of mask ventilation and quality of laryngeal exposure were also noted.

RESULTS

The mean time (SD) to tracheal intubation was 175 (66) s in the blanket group, as compared to 163 (71) s in the table-ramp group. Assuming the bounds for equivalence are -55,55 s, our study found a 95% confidence interval of -36.22, 13.52 s using two one-sided tests for equivalence corresponding to a significance level of 0.05. There was no difference in the number of attempts at laryngoscopy (P = 0.21) and tracheal intubation (P = 0.76) required to secure the airway between the two groups.

CONCLUSIONS

Before induction of anesthesia, obese patients can be positioned with their head elevated above their shoulders on the operating table, on a ramp created by placing blankets under their upper body or by reconfiguring the OR table. For the purpose of direct laryngoscopy and tracheal intubation, these two methods are equivalent.

Lack of concordance between physician and patient: reports on end-of-life care discussions

OBJECTIVE

To study the effectiveness of patient physician communications regarding health care choices at the end of life. We studied communications occurring between physicians and their patients who had either terminal cancer or congestive heart failure, with less than 6 months to live.

METHODS

This pilot study used in-person interviews with 22 physicians and 71 of their (matched) patients. Subjects provided paired responses to questions regarding their conversations related to end-of-life care, including resources, attitudes, and preferences. We calculated the concordance of patient and physician reports about these discussions. We examined the physicians' and the patients' agreement on the patient's diagnosis, and on whether a variety of care options were discussed. We then measured whether physicians' were aware of their patients' preferences for pain management and for place of death. Finally, we measured physicians' knowledge of whether religious/spiritual concerns or financial concerns had affected their patients' decisions regarding end-of-life care. Both bivariate and multivariate models were used.

RESULTS

As a whole, the concordance scores were poor; however, concordance varied across domains of issues discussed. Patients with less education had significantly lower concordance scores.

DISCUSSION

We have identified domains in which the physicians and patients may be least effective in discussing end-of-life care options. Findings may help in designing interventions to improve communication, especially for patients with less education.

A system for interactive assessment and management in palliative care

The availability of psychometrically sound and clinically relevant screening, diagnosis, and outcome evaluation tools is essential to high-quality palliative care assessment and management. Such data will enable us to improve patient evaluations, prognoses, and treatment selections, and to increase patient satisfaction and quality of life. To accomplish these goals, medical care needs more precise, efficient, and comprehensive tools for data acquisition, analysis, interpretation, and management. We describe a system for interactive assessment and management in palliative care (SIAM-PC), which is patient centered, model driven, database derived, evidence based, and technology assisted. The SIAM-PC is designed to reliably measure the multiple dimensions of patients' needs for palliative care, and then to provide information to clinicians, patients, and the patients' families to achieve optimal patient care, while improving our capacity for doing palliative care research. This system is innovative in its application of the state-of-the-science approaches, such as item response theory and computerized adaptive testing, to many of the significant clinical problems related to palliative care.

Physician perspectives on end-of-life care: factors of race, specialty, and geography

OBJECTIVES

To describe physicians' end-of-life practices, perceptions regarding end-of-life care and characterize differences based upon physician specialty and demographic characteristics. To illuminate physicians' perceptions about differences among their African-American and Caucasian patients' preferences for end-of-life care.

DESIGN AND METHODS

Twenty-four African-American and 16 Caucasian physicians (N=40) participated in an in-person interview including 23 primary care physicians, 7 cardiologists, and 10 oncologists. Twenty-four practices were in urban areas and 16 were in rural counties.

RESULTS

Physicians perceived racial differences in preferences for end-of-life care between their Caucasian and African-American patients. Whereas oncologists and primary care physicians overwhelmingly reported having working relationships with hospice, only 57% of cardiologists reported having those contacts. African-American physicians were more likely than Caucasian physicians to perceive racial differences in their patients preferences for pain medication.

SIGNIFICANCE OF RESULTS

Demographic factors such as race of physician and patient may impact the provider's perspective on end-of-life care including processes of care and communication with patients.

Compliance with breast-conservation standards for patients with early-stage breast carcinoma

BACKGROUND

Multiple treatment guidelines and practice standards have been developed regarding the management of patients with breast carcinoma. Few evaluations of the penetration and utility of these practice standards have been performed. In 1992, the American College of Surgeons (ACOS), the American College of Radiology, the College of American Pathologists, and the Society of Surgical Oncology collaborated in establishing standards for breast-conservation treatment (BCT). The authors sought to determine whether practice patterns for patients with breast carcinoma who underwent BCT were consistent with these standards 2 years after their dissemination and to establish whether compliance varied by the same patient and hospital variables that predicted for the amount of BCT performed.

METHODS

A study specific questionnaire was circulated to cancer registrars through the Commission on Cancer of the ACOS asking them to submit reports on patients with Stage I and II breast carcinoma who were diagnosed in 1994. Eight hundred forty-two predominantly community hospitals throughout the United States responded, yielding a total of 16,643 analyzable patients. The frequency of compliance to the 1992 published practice standards for 7097 patients who received BCT was determined. The variation in compliance rates by patient age, race, and insurance status and the treating hospital's geographic locations and cancer programs were evaluated.

RESULTS

Of the 22 standards that were evaluated in the areas of preoperative mammography (2 standards), labeling of the surgical specimen (3 standards), pathology report content (10 standards), radiation after lumpectomy (6 standards), and systemic therapy for patients with positive lymph nodes (1 standard), treatment adherence was > or = 80% for 16 standards (73%). Poor compliance was demonstrated for six standards: the documentation of an abnormality's size in the mammogram report, labeling the lumpectomy specimen with the affected quadrant of the breast, spatial orientation of the lumpectomy specimen and inclusion of lymphatic/vascular invasion, ductal carcinoma in situ, and macroscopic margin assessment in the pathology report. Variation in compliance to a standard occurred frequently across the type of hospital cancer program and geographic region (77% for both), and variation occurred less across the patient variables of age (32%), race (41%), and payer (23%). There was not a pattern of more frequent compliance among variables associated with more BCT use.

CONCLUSIONS

Large-scale evaluation of the penetration of treatment standards is feasible. For patients who underwent lumpectomy, practice appeared to be consistent (> or = 80% compliance), with 73% of 22 treatment standards evaluated. The standards with poor compliance represent areas for targeted physician education and reevaluation. Significant differences in adherence to a standard were seen frequently based on a hospital's geographic location and type of cancer program. This emphasizes the importance of adequate dissemination of treatment standards to ensure penetration into medical practices of all types.

A tale of two bounties: the impact of competing fees on physician behavior

This study examines how the volume of privately insured services provided in hospital inpatient and outpatient departments changes in response to reductions in Medicare physician payments. We hypothesize that physicians consider relative payment rates when choosing which patients to treat in their practices. When Medicare reduces its payments for surgical procedures, as it did in the late 1980s, physicians are predicted to treat more privately insured patients because they become more lucrative. We use data from 182 hospitals for seventeen major procedures groups, covering a forty-five-month period between 1988 and 1991 that encom passes a twenty-four-month period before the reduction in Medicare fees and twenty-one months after the reduction. Our findings are consistent with the predictions for a number of procedure groups, but not for all of them. One implication of the findings is that societal savings from Medicare fee reductions are overstated if one does not also consider spillover effects in the private insurance market.

Community perceptions of the effects of rural hospital closure on access to care

The purpose of this case study was to ascertain the perceptions of health professionals who were located in six rural communities where hospital closure occurred, regarding the impact of closure on community residents. These health professionals were asked to respond to questions about effects of hospital closures on the availability of medical services such as emergency care, physician services, hospital services and nursing home care. To control for trends in medical services utilization that were unrelated to hospital closure, the study design included comparison areas where similar hospitals remained open. A standardized questionnaire was administered to three health professionals in each of the areas that experienced a hospital closure and also in the matched comparison areas. Interviews of the health professionals in closure areas provide evidence suggestive of some perceived negative effects of hospital closure on these communities. These negative effects include difficulty recruiting and retaining physicians, concern of residents about the loss of their local emergency room, and increased travel times to receive hospital services. The perceived effects of closure appeared to be mediated by the distance required for travel to the nearest hospital. Respondents perceived increased travel times to most significantly affect vulnerable populations, such as the elderly, the disabled and the economically disadvantaged. Respondents in the majority of comparison areas also reported access barriers for vulnerable populations. These barriers primarily center on problems of obtaining transportation and enduring the rigors of travel. Improvements in the availability of transportation to medical care may offer some stabilization to communities where hospitals closed; however, it also is the case that transportation improvements are needed to increase access to care in rural communities where hospitals remained open.

Variations in practice patterns: antiviral drug use in hospitalized patients with herpes infections

This study describes patterns of antiviral drug use for patients hospitalized with chickenpox, herpes simplex, and herpes zoster infections, and also for a subgroup of herpes patients with severe infections (systemic infections, eye infections, encephalitis, hemorrhagic pneumonitis, and other severe conditions). Our findings demonstrate that there is great deal of variation in the use of antiviral drugs for these herpes patients, and that much of this variation is apparently unrelated to medical indications for antiviral drug use. Instead, patterns of use are associated with patient characteristics (age, race) and with hospital characteristics (location, teaching status, number of beds). Because these drugs are effective when used properly, treatment guidelines and protocols may be needed so that improved drug use will produce better patient outcomes.

Do physicians cost shift?

This study analyzes whether physicians charge their privately insured patients more-a practice known as cost shifting-in response to Medicare payment reductions. As part of congressional legislation in 1989 and 1990, Medicare reduced its payment rates for selected procedures by as much as 30 percent. Here we examine whether reductions in Medicare rates increase how much physicians charge privately insured patients. Our data provide no evidence that physicians respond to Medicare payment reductions by shifting costs to their privately insured patients.

Information management in the age of managed competition

BACKGROUND

Today's information requirements differ from those of the past, in terms of both the internal and external reporting needs of health care organizations. Demands for information are currently generated by physicians, quality managers, total quality management (TQM) teams, marketing staff, financial managers, regulators, insurance plans, accreditation agencies, purchasers, coalitions, and other customers.

DISCUSSION

Health care organizations respond to these demands in different ways, depending on their size and type. Six aspects of information needs that would be relevant under managed competition are analyzed: standardization, linkages among data banks, risk adjustment, comprehensive institution-based indicators and information systems, comprehensive population-based indicators and information systems, and methods for protecting confidentiality of patient records.

RECOMMENDATIONS

Six recommendations to hospitals/managed care plans that decide to establish information management systems are made: set goals, set priorities, describe current system, identify external data sources, develop (a plan), and check back (reassess).

HQEF update: master's degree program guidelines for a concentration in healthcare quality management

The Healthcare Quality Educational Foundation (HQEF), in its quest to identify formal educational opportunities for healthcare quality leaders, determined that academia lacked a standardized curriculum for healthcare quality management. Because a majority of the members of the National Association for Healthcare Quality (NAHQ) expressed a need for master's degree programs, the foundation appointed a committee composed of academicians and quality management professionals to define a curriculum appropriate for a master's degree program with a concentration in healthcare quality management. This article identifies the HQEF's goals and outlines the activities undertaken by the committee to define guidelines for colleges and universities interested in developing master's degree programs.

Applications for risk-adjusted outcome measures

This paper reports on the development and application of multiple risk-adjusted measures of hospital performance (mortality, readmission, complications). The indices are based on patient-level data so they can be aggregated at any level (hospital, specialty, physician), are easy to use and interpret by hospitals, and provide an inexpensive method for evaluating hospital performance using existing databases. This paper focuses on the development of practical applications of these measures in the quality improvement process.

Measuring outcomes of hospital care using multiple risk-adjusted indexes

Using existing data sources, we developed three risk-adjusted measures of hospital quality: the risk-adjusted mortality index (RAMI), the risk-adjusted readmissions index (RARI), and the risk-adjusted complication index (RACI). We describe the construction and validation of each of these indexes. After these measures were developed, we tested the relationships among the three indexes using a sample of 300 hospitals. Actual numbers of adverse events were observed for each hospital and compared to the number predicted by the RAMI, RARI, and RACI models. Then each hospital was ranked on each index. Our results showed that no relationship existed between a hospital's ranking on any one of these indexes and its ranking on the other two indexes. This result provides some evidence that no measure of quality should be used by itself to represent different aspects of the quality of hospital care. Adequate overall measures of hospital quality will need to include multiple measures in order to be credible and to reflect the complexity of hospital care. The findings suggest that consumers, payers, and policymakers cannot simply choose one hospitalwide measure, such as the mortality rate, to validly represent a hospital's performance: those hospitals with high rankings on their mortality rates do not necessarily rank high on their readmission rates or complication rates.

Changes in rates of unscheduled hospital readmissions and changes in efficiency following the introduction of the Medicare prospective payment system. An analysis using risk-adjusted data

The purpose of this study was to analyze changes in rates of unscheduled readmissions and changes in technical efficiency following the introduction of the Medicare Prospective Payment System (PPS). We developed the Risk-Adjusted Readmissions Index (RARI), which allowed us to make comparisons in rates of unanticipated readmissions across hospitals and over time. Data envelopment analysis (DEA), a linear programming technique, was used to measure changes in technical efficiency by comparing the inputs used and the outputs produced across a cohort of hospitals, while adjusting for changes over time in case mix and case complexity. Rates of unscheduled readmissions and efficiency scores were computed for a sample of 245 hospitals for each year. Although both readmission rates and efficiency scores increased for most hospitals, there was no evidence that those hospitals that experienced the greatest increases in efficiency had the largest increases in their rates of unscheduled readmissions.

Current uses of large data sets to assess the quality of providers. Construction of risk-adjusted indexes of hospital performance

This article examines how large data sets can be used for evaluating the effects of health policy changes and for flagging providers with potential quality problems. An example is presented, illustrating how three risk-adjusted measures of hospital performance were developed using patient discharge abstracts. Advantages and disadvantage of this approach are discussed.

Computed tomography: the cost-benefit dilemma

Although cost-benefit analysis is used for most systems of health care planning, its use in evaluating CT scanning is not appropriate. The authors suggest that cost-effectiveness is a more reasonable approach to the economic analysis of CT installations. Cost effectiveness attempts to assure that disease is treated with the most effective means available which minimizes the cost of such treatment. This method involves such factors as the impact of CT on the existing health care system, health outcome of patients, and reduction of hospital occupancy.