Hospital Quality Mediates Impact of Care Fragmentation Following Elective Colectomy

BACKGROUND

Readmission at a non-index hospital, or care fragmentation (CF), has been previously linked to greater morbidity and resource utilization. However, a contemporary evaluation of the impact of CF on readmission outcomes following elective colectomy is lacking. We additionally sought to evaluate the role of hospital quality in mediating the effect of CF.

METHODS

All records for adults undergoing elective colectomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Patients readmitted non-electively within 30 days to a non-index center comprised the CF cohort (others: Non-CF). Hierarchical mixed-effects models were constructed to ascertain risk-adjusted rates of major adverse events (MAEs, a composite of in-hospital mortality and any complication) attributable to center-level effects. Hospitals with risk-adjusted MAE rates ≥50th percentile were considered Low-Quality Hospitals (LQHs) (others: High-Quality Hospitals [HQHs]).

RESULTS

Of 68,185 patients readmitted non-electively within 30 days, 8968 (13.2%) were categorized as CF. On average, CF was older, of greater comorbidity burden, and more often underwent colectomy for cancer, relative to Non-CF. Following risk adjustment, CF remained independently associated with greater likelihood of MAE (adjusted odds ratio [AOR] 1.16, 95% Confidence Interval [CI] 1.05-1.27) and per-patient expenditures (β+$2,280, CI +$1080-3490). Further, readmission to non-index LQH was linked with significantly increased odds of MAE, following initial care at HQH (AOR 1.43, CI 1.03-1.99) and LQH (AOR 1.72, CI 1.30-2.28; Reference: Non-CF).

CONCLUSIONS

Care fragmentation was associated with greater morbidity and resource utilization at readmission following elective colectomy. Further, rehospitalization at non-index LQH conferred significantly inferior outcomes. Novel efforts are needed to improve continuity of care.

Exploring the Potential of a Multi-Level Approach to Advance the Development of the Medical Tourism Industry in Indonesia

Nowadays, the global medical tourism market size has grown quite rapidly, with a projected increase of 21.1% between 2021 and 2028. This study aimed to explore barriers and potential strategies for the development of medical tourism in Indonesia. A qualitative case study design was employed, where 8 respondents were selected using an expert sampling method from various groups according to the helix framework, including academics, government, professional organizations, the private sector, and the media. Data was collected through document analysis and in-depth interviews, and was analyzed manually using an inductive thematic content analysis approach. Limitations to the development of Indonesian medical tourism are related to regulations concerning medical tourism, the number of health services, distribution, supporting resources, public trust, and competition. At the institutional level, the challenges comprise services and products, hospital facilities, supporting facilities, and marketing processes. Furthermore, at the micro level, the low competency of both health and non-health workers persist as an obstacle. The potential strategy at the macro level include the development of robust marketing and branding strategies, health infrastructure, and resources. At the institutional level, it was necessary to develop related products and services provided, improve quality, and focus on branding and marketing strategies. Additionally, improving human resource skills was needed at the micro level.

Characteristics of High Versus Low-Performing Hospitals for Very Preterm Infant Morbidity and Mortality

Objective

To ascertain organizational attributes, policies, and practices that differentiate hospitals with high versus low risk-adjusted rates of very preterm neonatal morbidity and mortality (NMM).

Methods

Using a positive deviance research framework, we conducted qualitative interviews of hospital leadership and frontline clinicians from September-October 2018 in 4 high-performing and 4 low-performing hospitals in New York City, based on NMM measured in previous research. Key interview topics included NICU physician and nurse staffing, professional development, standardization of care, quality measurement and improvement, and efforts to measure and report on racial/ethnic disparities in care and outcomes for very preterm infants. Interviews were audiotaped, professionally transcribed, and coded using NVivo software. In qualitative content analysis, researchers blinded to hospital performance identified emergent themes, highlighted illustrative quotes, and drew qualitative comparisons between hospital clusters.

Results

The following features distinguished high-performing facilities: 1) stronger commitment from hospital leadership to diversity, quality, and equity; 2) better access to specialist physicians and experienced nursing staff; 3) inclusion of nurses in developing clinical policies and protocols, and 4) acknowledgement of the influence of racism and bias in healthcare on racial-ethnic disparities. In both clusters, areas for improvement included comprehensive family engagement strategies, care standardization, and reporting of quality data by patient sociodemographic characteristics.

Conclusions and relevance

Our findings suggest specific organizational and cultural characteristics, from hospital leadership and clinician perspectives, that may yield better patient outcomes, and demonstrate the utility of a positive deviance framework to center equity in quality initiatives for high-risk infant care.

Hospital Discharge Planners Need More Information When Referring Patients to Home Health Care: Insights From the Coronavirus Disease 2019 Pandemic

Hospital discharge planners play an important role in helping patients choose appropriate home health care. However, during the COVID-19 pandemic, they may not have had enough information to make the best decisions for their patients. A study of 58 discharge planners from Michigan hospitals found that 90% of them wanted information about the quality of home health agencies and whether they were prepared for COVID-19. However, only about 20% had this information readily available. The study also found that discharge planners varied in how they incorporated quality information. Some did not incorporate any quality information at all, while others provided it to patients without explaining its significance. Only about 25% of discharge planners helped patients interpret different sources of information. These findings suggest that hospital discharge planners had an unmet need for quality information, and they also provided limited assistance to patients. This may have led to some patients receiving suboptimal care. Thus, we proposed that hospital discharge planners need more information about the quality of home health agencies. Discharge planners should be more transparent about the quality of information they have, and they should help patients interpret it.

Predicting Hospital Readmissions in a Commercially Insured Population over Varying Time Horizons

BACKGROUND

Reducing hospital readmissions is a federal policy priority, and predictive models of hospital readmissions have proliferated in recent years; however, most such models tend to focus on the 30-day readmission time horizon and do not consider readmission over shorter (or longer) windows.

OBJECTIVES

To evaluate the performance of a predictive model of hospital readmissions over three different readmission timeframes in a commercially insured population.

DESIGN

Retrospective multivariate logistic regression with an 80/20 train/test split.

PARTICIPANTS

A total of 2,213,832 commercially insured inpatient admissions from 2016 to 2017 comprising 782,768 unique patients from the Health Care Cost Institute.

MAIN MEASURES

Outcomes are readmission within 14 days, 15-30 days, and 31-60 days from discharge. Predictor variables span six different domains: index admission, condition history, demographic, utilization history, pharmacy, and environmental controls.

KEY RESULTS

Our model generates C-statistics for holdout samples ranging from 0.618 to 0.915. The model's discriminative power declines with readmission time horizon: discrimination for readmission predictions within 14 days following discharge is higher than for readmissions 15-30 days following discharge, which in turn is higher than predictions 31-60 days following discharge. Additionally, the model's predictive power increases nonlinearly with the inclusion of successive risk factor domains: patient-level measures of utilization and condition history add substantially to the discriminative power of the model, while demographic information, pharmacy utilization, and environmental risk factors add relatively little.

CONCLUSION

It is more difficult to predict distant readmissions than proximal readmissions, and the more information the model uses, the better the predictions. Inclusion of utilization-based risk factors add substantially to the discriminative ability of the model, much more than any other included risk factor domain. Our best-performing models perform well relative to other published readmission prediction models. It is possible that these predictions could have operational utility in targeting readmission prevention interventions among high-risk individuals.

Why Did New York State Hospitals Rank So Poorly?

BACKGROUND

According to the Centers for Medicare and Medicaid Services star ratings, New York State (NYS) hospitals are relatively poor performers, with 33% achieving 1 star compared with 5% of hospitals across the United States.

OBJECTIVES

We compared NYS hospitals to all United States hospitals using Centers for Medicare and Medicaid Services Hospital Value-Based Purchasing (HVBP) and star ratings component measures. We perform risk adjustment for hospital and market characteristics associated poor performance.

RESEARCH DESIGN

This was a cross-sectional observational study.

SUBJECTS

All acute care hospitals in the United States which had HVBP scores for 2019 in April 21, 2021, Hospital Care Compare database.

MEASURES

Analysis of variance was used to compare NYS hospitals to all United States hospitals. Multivariable-based risk adjustment was applied to NYS hospitals with adjustment for hospital characteristics (eg, occupancy, size), hospital fiscal ratios (eg, operating margin), and market characteristics (eg, percent of hospital market that has a high school diploma).

RESULTS

NYS hospitals averaged lower patient satisfaction and higher readmissions. These domains were statistically significantly associated with lower socioeconomic status in the hospital market area. Risk adjustment reduced but did not eliminate these differences. NYS also performed poorly on pressure ulcers and deep vein thrombosis/pulmonary embolism prevention. NYS hospitals were similar to the United States in mortality and hospital-acquired infections.

CONCLUSIONS

Differences in the demographic makeup of hospital markets account for some of the poor performance of NYS hospitals. Some aspects, such as long length of stay, may be associated with wider regional trends.

Relative Productivity of For-Profit Hospitals: A Big or a Little Deal?

This study asks: Does the empirical evidence support the conclusion that for-profit (FP) hospitals are more productive or efficient than private not-for-profit (NFP) hospitals or non-federal public (PUB) hospitals? Alternative theories of NFP behavior are described. Our review of individual empirical hospital studies of quality, service mix, community benefit, and cost/efficiency in the United States published since 2000 indicates that no systematic difference exists in cost/efficiency, provision of uncompensated care, and quality of care. But FPs are more likely to provide profitable services, higher service intensity, have lower shares of uninsured and Medicaid patients, and are more responsive to external financial incentives. That FP hospitals are not more efficient runs counter to property rights theory, but their relative responsiveness to financial incentives supports it. There is little evidence that FP market presence changes NFP behaviors. Observed differences between FP and NFP hospitals are mostly a "little deal."

The development and implementation of a new hospital performance measure to assess hospital contributions to community health and equity

OBJECTIVE

To develop and implement a measure of how US hospitals contribute to community health with a focus on equity.

DATA SOURCES

Primary data from public comments and hospital surveys and secondary data from the IBM Watson Top 100 Hospitals program collected in the United States in 2020 and 2021.

STUDY DESIGN

A thematic analysis of public comments on the proposed measure was conducted using an iterative grounded approach for theme identification. A cross-sectional survey of 207 hospitals was conducted to assess self-attestation to 28 community health best practice standards in the revised measure. An analysis of hospital rankings before and after inclusion of the new measure was performed.

DATA COLLECTION/EXTRACTION METHODS

Public comment on the proposed measure was collected via an online survey, email, and virtual meetings in 2020. The survey of hospitals was conducted online by IBM in 2021. The analysis of hospital ranking compared the 2020 and 2021 IBM Watson Top 100 Hospitals program results.

PRINCIPAL FINDINGS

More than 650 discrete comments from 83 stakeholders were received and analyzed during measure development. Key themes identified in thematic analysis included equity, fairness, and community priorities. Hospitals that responded to a cross-sectional survey reported meeting on average 76% of applicable best practice standards. Least met standards included providing emergent buprenorphine treatment for opioid use disorder (53%), supporting an evidence-based home visiting program (53%), and establishing a returning citizens employment program (27%). Thirty-seven hospitals shifted position in the 100 Top Hospital rankings after the inclusion of the new measure.

CONCLUSIONS

There is broad interest in measuring hospital contributions to community health with a focus on equity. Many highly ranked hospitals report meeting best practice standards, but significant gaps remain. Improving measurement to incentivize greater hospital contributions to community health and equity is an important priority.

Hospital Price Transparency in the United States: An Examination of Chargemaster, Cash, and Negotiated, Price Variation for 14 Common Procedures

BACKGROUND

Effective January 1, 2021, US hospitals were required to upload information on their chargemaster prices (database of list prices), discounted cash prices (commonly charged to self-pay patients), and payer-specific negotiated prices.

OBJECTIVE

Examine how prices vary and are associated with hospital characteristics, market competition, and hospital quality.

DESIGN SETTING AND PARTICIPANTS

This observational study used data on 14 common medical services across 1599 hospitals in 2021. Descriptive and regression analyses were used to study price variation. Analyses adjust for hospital characteristics, market competition and state fixed effects.

RESULTS

Ninetieth -to-10th-percentile price markups factors (ratios) range between 3.2 and 11.5 for chargemaster; 6.1 and 19.7 for cash; and 6.6 and 30.0 for negotiated prices. Adjusted regression results indicate that hospitals' cash prices are on average 60% ( P <0.01) higher, and list prices are on average 164% ( P <0.01) higher, than negotiated prices. Systematic pricing differences across hospitals were noted, with urban hospitals having 14% ( P <0.01) lower prices than rural hospitals, teaching hospitals having 3% ( P <0.01) higher prices than nonteaching hospitals, and nonprofit hospitals pricing 9% ( P <0.01), and for-profit hospitals 39% ( P <0.01), higher than government owned hospitals. In addition, hospitals that contract with more insurance plans have higher prices, hospitals in more competitive markets have lower prices, and higher quality hospitals have on average 5% ( P <0.01) lower prices than lower quality hospitals.

CONCLUSIONS

Prices all vary considerably across US hospitals. High quality hospitals are associated with lower pricing across all three sets of prices examined. Hospital price transparency may help consumers better identify hospitals that provide both high quality, and low cost, care.

New evidence on geographic disparities in United States hospital capacity

OBJECTIVE

To characterize the quantity and quality of hospital capacity across the United States.

DATA SOURCES

We combine a 2017 near-census of US hospital inpatient discharges from the Healthcare Cost and Utilization Project (HCUP) with American Hospital Association Survey, Hospital Compare, and American Community Survey data.

STUDY DESIGN

This study produces local hospital capacity quantity and care quality measures by allocating capacity to zip codes using market shares and population totals. Disparities in these measures are examined by race and ethnicity, income, age, and urbanicity.

DATA COLLECTION/EXTRACTION METHODS

All data are derived from pre-existing sources. All hospitals and zip codes in states, including the District of Columbia, contributing complete data to HCUP in 2017 are included.

PRINCIPAL FINDINGS

Non-Hispanic Black individuals living in zip codes supplied, on average, 0.11 more beds per 1000 population (SE = 0.01) than places where non-Hispanic White individuals live. However, the hospitals supplying this capacity have 0.36 fewer staff per bed (SE = 0.03) and perform worse on many care quality measures. Zip codes in the most urban parts of America have the least hospital capacity (2.11 beds per 1000 persons; SEM = 0.01) from across the rural-urban continuum. While more rural areas have markedly higher capacity levels, urban areas have advantages in staff and capital per bed. We do not find systematic differences in care quality between rural and urban areas.

CONCLUSIONS

This study highlights the importance of lower hospital care quality and resource intensity in driving racial and ethnic, as well as income, disparities in hospital care-related outcomes. This study also contributes an alternative approach for measuring local hospital capacity that accounts for cross-hospital service area flows. Adjusting for these flows is necessary to avoid underestimating the supply of capacity in rural areas and overestimating it in places where non-Hispanic Black individuals tend to live.

Wisdom of the Experts Versus Opinions of the Crowd in Hospital Quality Ratings: Analysis of Hospital Compare Star Ratings and Google Star Ratings

Background

Popular web-based portals provide free and convenient access to user-generated hospital quality reviews. The Centers for Medicare & Medicaid Services (CMS) also publishes Hospital Compare Star Ratings (HCSR), a comprehensive expert rating of US hospital quality that aggregates multiple measures of quality. CMS revised the HCSR methods in 2021. It is important to analyze the degree to which web-based ratings reflect expert measures of hospital quality because easily accessible, crowdsourced hospital ratings influence consumers’ hospital choices.

Objective

This study aims to assess the association between web-based, Google hospital quality ratings that reflect the opinions of the crowd and HCSR representing the wisdom of the experts, as well as the changes in these associations following the 2021 revision of the CMS rating system.

Methods

We extracted Google star ratings using the Application Programming Interface in June 2020. The HCSR data of April 2020 (before the revision of HCSR methodology) and April 2021 (after the revision of HCSR methodology) were obtained from the CMS Hospital Compare website. We also extracted scores for the individual components of hospital quality for each of the hospitals in our sample using the code provided by Hospital Compare. Fractional response models were used to estimate the association between Google star ratings and HCSR as well as individual components of quality (n=2619).

Results

The Google star ratings are statistically associated with HCSR (P<.001) after controlling for hospital-level effects; however, they are not associated with clinical components of HCSR that require medical expertise for evaluation such as safety of care (P=.30) or readmission (P=.52). The revised CMS rating system ameliorates previous partial inconsistencies in the association between Google star ratings and quality component scores of HCSR.

Conclusions

Crowdsourced Google star hospital ratings are informative regarding expert CMS overall hospital quality ratings and individual quality components that are easier for patients to evaluate. Improvements in hospital quality metrics that require expertise to assess, such as safety of care and readmission, may not lead to improved Google star ratings. Hospitals can benefit from using crowdsourced ratings as timely and easily available indicators of their quality performance while recognizing their limitations and biases.

Changes in hospital quality at hospitals serving black and hispanic newborns below 30 weeks' gestation

OBJECTIVE

Examine whether the quality of Black and Hispanic serving (BHS) compared with not BHS (NBHS) NICUs has changed differentially over time.

STUDY DESIGN

Infants 24-29 weeks' gestation born at U.S. Vermont Oxford Network centers (2006-2018) were studied. We calculated adjusted hospital quality scores as the predicted probabilities of composite in-hospital mortality and morbidities from a logistic model. We regressed hospital quality scores on birth year to estimate the linear temporal slope by BHS-serving status for hospitals within each Census division.

RESULTS

Hospital quality improved similarly over time for BHS and NBHS hospitals across all divisions except West South Central where a mean change in the composite score was -18.8 (95% CI: -24.1, -13.5) for NBHS and -9.3 (95% CI: -14.1, -4.6) for BHS hospitals (p-value = 0.009).

CONCLUSION

Hospital quality improved similarly for BHS and NBHS hospitals across most divisions. Variation within and between divisions should be a focus for quality improvement.

Did the Hospital Readmissions Reduction Program Reduce Readmissions? An Assessment of Prior Evidence and New Estimates

In this article, we provide a comprehensive, empirical assessment of the hypothesis that the Hospital Readmissions Reduction Program (HRRP) affected hospital readmissions. In doing so, we provide evidence as to the validity of prior empirical approaches used to evaluate the HRRP and we present results from a previously unused approach to study this research question-a regression-kink design. Results of our analysis document that the empirical approaches used in most prior research assessing the efficacy of the HRRP often lack internal validity. Therefore, results from these studies may not be informative about the causal consequences of the HRRP. Results from our regression-kink analysis, which we validate, suggest that the HRRP had little effect on hospital readmissions. This finding contrasts with the results of most prior studies, which report that the HRRP significantly reduced readmissions. Our finding is consistent with conceptual considerations related to the assumptions underlying HRRP penalty: in particular, the difficulty of identifying preventable readmissions, the highly imperfect risk adjustment that affects the penalty determination, and the absence of proven tools to reduce readmissions.

Comparing the dangers of a stay in English and German hospitals for high-need patients

OBJECTIVE

To estimate the risk of an avoidable adverse event for high-need patients in England and Germany and the causal impact that has on outcomes.

DATA SOURCES

We use administrative, secondary data for all hospital inpatients in 2018. Patient records for the English National Health Service are provided by the Hospital Episode Statistics database and for the German health care system accessed through the Research Data Center of the Federal Statistical Office.

STUDY DESIGN

We calculated rates of three hospital-acquired adverse events and their causal impact on mortality and length of stay through propensity score matching and estimation of average treatment effects.

DATA COLLECTION/EXTRACTION METHODS

Patients were identified based on diagnoses codes and translated Patient Safety Indicators developed by the Agency for Healthcare Research and Quality.

PRINCIPAL FINDINGS

For the average hospital stay, the risk of an adverse event was 5.37% in the English National Health Service and 3.26% in the German health care system. High-need patients are more likely to experience an adverse event, driven by hospital-acquired infections (2.06%-4.45%), adverse drug reactions (2.37%-2.49%), and pressure ulcers (2.25%-0.45%). Adverse event risk is particularly high for patients with advancing illnesses (10.50%-27.11%) and the frail elderly (17.75%-28.19%). Compared to the counterfactual, high-need patients with an adverse event are more likely to die during their hospital stay and experience a longer length of stay.

CONCLUSIONS

High-need patients are particularly vulnerable with an adverse event risking further deterioration of health status and adding resource use. Our results indicate the need to assess the costs and benefits of a hospital stay, particularly when care could be provided in settings considered less hazardous.

Value of Nurse Practitioner Inpatient Hospital Staffing

BACKGROUND

Evidence indicates hospitals with better registered nurse (RN) staffing have better patient outcomes. Whether involving more nurse practitioners (NPs) in inpatient care produces better outcomes is largely unknown.

OBJECTIVE

The objective of this study was to determine whether the presence of more NPs produces better inpatient outcomes net of RN staffing.

RESEARCH DESIGN

This was a 2015-2016 cross-sectional data on 579 hospitals linked from: (1) RN4CAST-US nurse surveys; (2) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys; (3) surgical patient discharge abstracts; (4) Medicare Spending per Beneficiary (MSPB) reports; (5) American Hospital Association (AHA) Annual Survey. Hospitals were grouped according to their NP/beds ratios [<1 NP/100 beds (N=132), 1-2.99 NPs/100 beds (N=279), and 3+ NPs/100 beds (N=168)].

SUBJECTS

RNs randomly sampled nurses from licensure lists yielded 22,273 RNs in study hospitals; discharge data for 1.4 million surgical patients; HCAHPS data for 86% of study hospitals.

MEASURES

Mortality, readmissions, lengths of stay, MSPB, patient experience, and quality reported by patients and nurses.

RESULTS

After adjustments, patients in hospitals with 3+ NPs/100 beds had lower odds than patients in hospitals with <1 NP/100 beds of 30-day mortality [odds ratio (OR)2=0.76; 95% confidence interval (CI)=0.67-0.82; P<0.001] and 7-day readmissions (OR2=0.90; 95% CI=0.86-0.96; P<0.001), shorter average length of stay (incident rate ratio2=0.92; 95% CI=0.88-0.96; P<0.001) and 5.4% lower average MSPB (95% CI=3.8%-7.1%). Patients and nurses in the hospitals with higher NP/bed ratios were significantly more likely to report better care quality and safety, and nurses reported lower burnout, higher job satisfaction, greater intentions of staying in their jobs.

CONCLUSIONS

Having more NPs in hospitals has favorable effects on patients, staff nurse satisfaction, and efficiency. NPs add value to existing labor resources.

Racial and Economic Neighborhood Segregation, Site of Delivery, and Morbidity and Mortality in Neonates Born Very Preterm

OBJECTIVE

To assess the influence of racial and economic residential segregation of home or hospital neighborhood on very preterm birth morbidity and mortality in neonates born very preterm.

STUDY DESIGN

We constructed a retrospective cohort of n = 6461 infants born <32 weeks using 2010-2014 New York City vital statistics-hospital data. We calculated racial and economic Index of Concentration at the Extremes for home and hospital neighborhoods. Neonatal mortality and morbidity was defined as death and/or severe neonatal morbidity. We estimated relative risks for Index of Concentration at the Extremes measures and neonatal mortality and morbidity using log binomial regression and the risk-adjusted contribution of delivery hospital using Fairlie decomposition.

RESULTS

Infants whose mothers live in neighborhoods with the greatest relative concentration of Black residents had a 1.6 times greater risk of neonatal mortality and morbidity than those with the greatest relative concentration of White residents (95% CI 1.2-2.1). Delivery hospital explained more than one-half of neighborhood differences. Infants with both home and hospital in high-concentration Black neighborhoods had a 38% adjusted risk of neonatal mortality and morbidity compared with 25% of those with both home and hospital high-concentration White neighborhoods (P = .045).

CONCLUSIONS

Structural racism influences very preterm birth neonatal mortality and morbidity through both the home and hospital neighborhood. Quality improvement interventions should incorporate a framework that includes neighborhood context.

Palliative Care Specialist Access is Associated With Rankings of Hospital Quality

CONTEXT

Increasing evidence has shown that access to specialty palliative care, particularly outpatient palliative care clinics, can yield improved health outcomes and be a marker of hospital quality.

OBJECTIVE

To determine whether an association exists between access to specialty palliative care programs and hospital rankings found in the 2020-2021 U.S. News & World Report Best Hospitals.

METHODS

This study used publicly available data from the Center to Advance Palliative Care (CAPC) Provider Directory to determine access to in-patient and out-patient palliative care in the 2020-2021 U.S. News & World Report Best Hospitals Rankings. Descriptive statistics and chi-squares were performed. Data were also analyzed across the four U.S. Census Bureau regions (Northeast, South, Midwest, West).

RESULTS

Around 100% of the Top 20 hospitals include hospital-based palliative care consultation teams, and 95% offered outpatient palliative care. Of the second cohort of 83 hospitals, 99% offered inpatient palliative care, and 65% offered outpatient palliative care. Of the third cohort of 75 hospitals ranked, 96% had inpatient palliative care services, while only 41.3% offered outpatient palliative care. This represents a significant association between rank position and access to outpatient palliative care (P < 0.01). Ranked hospitals also have significantly higher access to hospital-based palliative care teams compared to the national prevalence rate (P < 0.01).

CONCLUSION

These findings reflect the association of access to specialty palliative care with USNWR rankings for hospital quality. Further study is necessary to determine the specific influence of access to palliative care and USNWR rank position.

Predicting Hospital Overall Quality Star Ratings in the USA

The U.S. Centers for Medicare and Medicaid Services (CMS) assigns quality star ratings to hospitals upon assessing their performance across 57 measures. Ratings can be used by healthcare consumers for hospital selection and hospitals for quality improvement. We provide a simpler, more intuitive modeling approach, aligned with recent criticism by stakeholders. An ordered logistic regression approach is proposed to assess associations between performance measures and ratings across eligible (n = 4519) U.S. hospitals. Covariate selection reduces the double counting of information from highly correlated measures. Multiple imputation allows for inference of star ratings when information on all measures is not available. Twenty performance measures were found to contain all the relevant information to formulate star rating predictions upon accounting for performance measure correlation. Hospitals can focus their efforts on a subset of model-identified measures, while healthcare consumers can predict quality star ratings for hospitals ineligible under CMS criteria.

Public Hospital Quality Assessment. Evidence from Greek Health Setting Using SERVQUAL Model

(1) Background: Health care service quality has been equated with preparedness to provide, accessibility, suitability, adequacy, friendliness and ongoing support and has been connected to service excellence. The main aim of this study was to investigate patients' perceptions and expectations regarding the quality of health services. (2) Materials and Methods: A cross-sectional analysis was carried out in 5 public general hospitals and convenience sampling was used as the sampling technique. Questionnaires were distributed to inpatients and outpatients and 700 valid questionnaires were returned. The SERVQUAL questionnaire was used for data collection in this survey. (3) Results: Overall, in this study, it became apparent that patients' expectations as regarding the quality of the provided services were not met. All of the five quality dimensions had a negative gap between patients' expectations and perceptions. (4) Conclusions: The findings suggested that hospital managers and health care professionals should be interested about patient expectations and subsequently they should search out ways and means to meet them. Open communication with patients, individualized attention, as well as responsiveness to their requirements, polite behavior, trustful atmosphere across the hospital and better physical facilities are the key elements that determine the patient's judgment about quality.

Hospital Readmission and Emergency Department Revisits of Homeless Patients Treated at Homeless-Serving Hospitals in the USA: Observational Study

BACKGROUND

As the U.S. homeless population grows, so has the challenge of providing effective care to homeless individuals. Understanding hospitals that achieve better outcomes after hospital discharge for homeless patients has important implications for making our health system more sustainable and equitable.

OBJECTIVE

To determine whether homeless patients experience higher rates of readmissions and emergency department (ED) visits after hospital discharge than non-homeless patients, and whether the homeless patients exhibit lower rates of readmissions and ED visits after hospital discharge when they were admitted to hospitals experienced with the treatment of the homeless patients ("homeless-serving" hospitals-defined as hospitals in the top decile of the proportion of homeless patients).

DESIGN

A population-based longitudinal study, using the data including all hospital admissions and ED visits in FL, MA, MD, and NY in 2014.

PARTICIPANTS

Participants were 3,527,383 patients (median age [IQR]: 63 [49-77] years; 1,876,466 [53%] women; 134,755 [4%] homeless patients) discharged from 474 hospitals.

MAIN MEASURES

Risk-adjusted rates of 30-day all-cause readmissions and ED visits after hospital discharge.

KEY RESULTS

After adjusting for potential confounders, homeless patients had higher rates of readmissions (adjusted rate, 27.3% vs. 17.5%; adjusted odds ratio [aOR], 1.93; 95% CI, 1.69-2.21; p < 0.001) and ED visits after hospital discharge (37.1% vs. 23.6%; aOR, 1.98; 95% CI, 1.74-2.25; p < 0.001) compared with non-homeless patients. Homeless patients treated at homeless-serving hospitals exhibited lower rates of readmissions (23.9% vs. 33.4%; p < 0.001) and ED visits (31.4% vs. 45.4%; p < 0.001) after hospital discharge than homeless patients treated at non-homeless-serving hospitals.

CONCLUSIONS

Homeless patients were more likely to be readmitted or return to ED within 30 days after hospital discharge, especially when they were treated at hospitals that treat a small proportion of homeless patients. These findings suggest that homeless patients may receive better discharge planning and care coordination when treated at hospitals experienced with caring for homeless people.

The Impact of Nursing Staff on Satisfaction Scores for U.S. Hospitals: A Production Function Approach

Hospitals have increasingly relied on nurse assistants to support nurses in the provision of patient care, yet knowledge about their contributions to the patient experience in U.S. hospitals is limited. We address this issue by exploring the impact of nurse assistants and registered nurses on an array of patient satisfaction measures from the Medicare Hospital Consumer Assessment of Healthcare Providers and Systems. Using linked data for 2,807 hospitals from 2008 to 2016, we employ a production function approach to estimate and plot marginal impact curves for both nurse assistants and registered nurses. We find that although registered nurses are more impactful, nurse assistants are the more underdeployed staffing category. We also find that after meeting certain thresholds for minimal hours, nurse assistants have a comparative advantage in improving patient satisfaction scores in the housekeeping and patient support domain. Given their lower labor costs, further employment of nurse assistants may be warranted.

Fixed effects analysis of the incidence of cardiovascular outcomes under managed care following the managed care backlash

To examine the impact of increased managed care activity on 30-day readmission and mortality for acute myocardial infarctions and congestive heart failure in U.S. hospitals following the managed care backlash against managed care cost containment practices.The Centers for Medicare and Medicaid Services (CMS) Hospital Compare files, CMS Hospital Cost Report, CMS Medicare Advantage Enrollment files, and Health Resources and Services Administration Area Resource File data for the period 2008 to 2011 were used to construct the study sample. Multivariate fixed effects regression with robust standard errors, hospital fixed effects, and year fixed effects were used to estimate the impact of managed care penetration on adverse cardiovascular outcomes. Our primary outcome measures were readmission and mortality for patients discharged with acute myocardial infarction and congestive heart failure for acute, non-federal hospitals with emergency rooms. To examine effects of hospital ownership status, not-for-profit hospitals were compared to proprietary hospitals.The main analysis revealed that an increase in managed care penetration was associated with a decline in both 30-day readmission and mortality for acute myocardial infarction and congestive heart failure. In the hospital ownership analysis, only the acute myocardial infarction results for proprietary hospitals was statistically significant. All hospital types reported similar congestive heart failure trends as the full sample; however, proprietary hospitals reported greater declines in readmission and mortality.Increased managed care activity is associated with reductions in hospital readmission and mortality following the legislative and consumer backlash against managed care, with differential impacts across hospital ownership type. These finding highlights the important role of managed care in creating quality improvements in the delivery of care in the hospital setting.

Neighborhood Disadvantage and Hospital Quality Ratings in the Medicare Hospital Compare Program

BACKGROUND

The Centers for Medicare and Medicaid Services provide nationwide hospital ratings that may influence reimbursement. These ratings do not account for the social risk of communities and may inadvertently penalize hospitals that service disadvantaged neighborhoods.

OBJECTIVE

This study examines the relationship between neighborhood social risk factors (SRFs) and hospital ratings in Medicare's Hospital Compare Program.

RESEARCH DESIGN

2017 Medicare Hospital Compare ratings were linked with block group data from the 2015 American Community Survey to assess hospital ratings as a function of neighborhood SRFs.

SUBJECTS

A total of 3608 Medicare-certified hospitals in 50 US states.

MEASURES

Hospital summary scores and 7 quality group scores (100 percentile scale), including effectiveness of care, efficiency of care, hospital readmission, mortality, patient experience, safety of care, and timeliness of care.

RESULTS

Lower hospital summary scores were associated with caring for neighborhoods with higher social risk, including a reduction in hospital score for every 10% of residents who reported dual-eligibility for Medicare/Medicaid [-3.3%; 95% confidence interval (CI), -4.7 to -2.0], no high-school diploma (-0.8%; 95% CI, -1.5 to -0.1), unemployment (-1.2%; 95% CI, -1.9 to -0.4), black race (-1.2%; 95% CI, -1.7 to -0.8), and high travel times to work (-2.5%; 95% CI, -3.3 to -1.6). Associations between neighborhood SRFs and hospital ratings were largest in the timeliness of care, patient experience, and hospital readmission groups; and smallest in the safety, efficiency, and effectiveness of care groups.

CONCLUSIONS

Hospitals serving communities with higher social risk may have lower ratings because of neighborhood factors. Failing to account for neighborhood social risk in hospital rating systems may reinforce hidden disincentives to care for medically underserved areas in the United States.

Readmission treatment price and product quality in the hospital sector

In this paper, we study the effect of readmission treatment payment in a dynamic framework characterised by competition among hospitals and sluggish beliefs of patients concerning the service quality. We find that the effect of readmission treatment payment depends on the interplay between the effect of quality in lowering readmissions and its effect on future demand. When the readmission occurrence strongly depends on the service quality, the higher the readmission treatment payment for hospitals, the lower the incentive to provide quality. Instead, when readmission depends barely on quality, the readmission payment acts as the treatment price for first admissions, and thus it reinforces the incentive to provide quality. We also show that the detrimental effect of readmission payments on quality are fed by a high degree of demand sluggishness, that is, by situation where current quality has modest effect on future demand changes. Our findings are robust to different equilibrium concepts of the differential game (i.e., open-loop and state-feedback). The results suggest that a discounted regulated price for readmission can be an effective (and cost-free) policy tool to improve health care quality, especially when the market is characterised by sluggish beliefs about quality.

Experiences of Older Persons in Seeking Care at a Private Hospital in Urban India

Objective: The study aims to describe the experiences of older persons in seeking health care in a private hospital in urban India. Methods: Semi-structured interviews were conducted with 50 older persons admitted in or visiting a private hospital in Hyderabad city in India between the period November 2017 and April 2018. The data were analyzed using Content Analysis. Results: Dimensions related to payment mechanisms, quality of health care staff, and hospital quality were reported to be important for the older persons. Payment mechanisms were related to discounts, insurance support, and reducing out-of-pocket expenditure. Quality of care was related to optimizing hospital operational processes like discharge time, standard of treatment, and trustworthiness of the medical staff. Discussion: Payment mechanism can be made friendly for the older persons. Quality of hospital including its staff can be enhanced by developing geriatric-specific competencies which can help them to understand and treat complex health problems specific for the older population.

Hospital Factors Associated With Interhospital Transfer Destination for Stroke in the Northeast United States

Background

We aimed to determine if there is an association between hospital quality and the likelihood of a given hospital being a preferred transfer destination for stroke patients.

Methods and Results

Data from Medicare claims identified acute ischemic stroke transferred between 394 northeast US hospitals from 2007 to 2011. Hospitals were categorized as transferring (n=136), retaining (n=241), or receiving (n=17) hospitals based on the proportion of acute ischemic stroke encounters transferred or received. We identified all 6409 potential dyads of sending and receiving hospitals, and categorized dyads as connected if ≥5 patients were transferred between the hospitals annually (n=82). We used logistic regression to identify hospital characteristics associated with establishing a connected dyad, exploring the effect of adjusting for different quality measures and outcomes. We also adjusted for driving distance between hospitals, receiving hospital stroke volume, and the number of hospitals in the receiving hospital referral region. The odds of establishing a transfer connection increased when rate of alteplase administration increased at the receiving hospital or decreased at the sending hospital, however this finding did not hold after applying a potential strategy to adjust for clustering. Receiving hospital performance on 90‐day home time was not associated with likelihood of transfer connection.

Conclusions

Among northeast US hospitals, we found that differences in hospital quality, specifically higher levels of alteplase administration, may be associated with increased likelihood of being a transfer destination. Further research is needed to better understand acute ischemic stroke transfer patterns to optimize stroke transfer systems.

Examining the Multi-Scalar Unevenness of High-Quality Healthcare Resources Distribution in China

Healthcare disparity is, to a large extent, ascribable to the uneven distribution of high-quality healthcare resources, which remains insufficiently examined, largely due to data unavailability. To overcome this barrier, we synthesized multiple sources of data, employed integrated methods and made a comprehensive analysis of government administrative structures and the socio-economic environment to build probably the most inclusive dataset of Chinese 3-A hospitals thus far. Calibrated on a sample of 379 hospitals rated by a reputable organization, we developed a realistic and viable evaluation framework for assessing hospital quality in China. We then calculated performance scores for 1246 3-A hospitals, which were aggregated and further analyzed at multiple scales (cities, provinces, regions, and economic zones) using general entropy indexes. This research shows that the fragmented governance and incoordination of "kuai" and "tiao" is rooted deeply in China's legacy of centrally-planned systems, and has had a far-reaching yet partially contradictory influence over the contemporary distribution and performance of healthcare resources. Additionally, the unevenness in the distribution of healthcare resources is related closely to a city's administrative rank and power. This study thus suggests that the policy design of healthcare systems should be coordinated with external socio-economic transformation in a sustainable manner.

Facts and Fears in Public Reporting: Patients' Information Needs and Priorities When Selecting a Hospital for Cancer Care

Objective. Public reporting on the quality of provider care has the potential to empower patients to make evidence-based decisions. Yet patients seldom consult resources such as provider report cards in part because they perceive the information as irrelevant. To inform more effective public reporting, we investigated patients' information priorities when selecting a hospital for cancer treatment. We hypothesized that patients would be most interested in data on clinical outcomes. Methods. An experienced moderator led a series of focus groups using a semistructured discussion guide. Separate sessions were held with patients aged 18 to 54 years and those older than 54 years in Philadelphia, Pennsylvania; Phoenix, Arizona; and Indianapolis, Indiana, in 2017. All 38 participants had received treatment for cancer within the past 2 years and had a choice of hospitals. Results. In selecting hospitals for cancer treatment, many participants reported that they considered factors such as reputation, quality of the facilities, and experiences of other patients. For most, however, decisions were guided by trusted advisors, with the majority agreeing that a physician's opinion would sway them to disregard objective data about hospital quality. Nonetheless, nearly all expressed interest in having comparative data. Participants varied in selecting from a hypothetical list, "the top 3 things you would want to know when choosing a hospital for cancer care." The most commonly preferred items were overall care quality, timeliness, and patient satisfaction. Contrary to our hypothesis, many preferred to avoid viewing comparative clinical outcomes, particularly survival. Conclusions. Patients' information preferences are diverse. Fear or other emotional responses might deter patients from viewing outcomes data such as survival. Additional research should explore optimal ways to help patients incorporate comparative data on the components of quality they value into decision making.

Consumers' Perceptions And Choices Related To Three Value-Based Insurance Design Approaches

The burden of rising health care costs is being shifted to consumers, and 30 percent of health care costs are attributed to wasteful spending on low- or no-value services. Value-based insurance design (VBID) is intended to encourage the use of high-value services or discourage the use of low-value services by aligning cost with quality. During the summer and fall of 2016, this mixed-methods study used focus groups and a quantitative analysis of survey data to explore consumer decision making in Northern California. When presented with three common VBID approaches, the focus groups favored value-based benefit design the most (41 percent), followed by reference pricing (28 percent) and narrow networks (21 percent). When presented with VBID scenarios, participants were skeptical of the value-based trade-offs and reported seeking information they wanted instead of relying on information that health plans provide. Engaging consumers to successfully reduce waste through VBID will require clarifying trade-offs to support consumers' processes for arriving at high-value decisions as well as reaching out to consumers through trusted sources and networks.

Consumers' Perceptions And Choices Related To Three Value-Based Insurance Design Approaches

The burden of rising health care costs is being shifted to consumers, and 30 percent of health care costs are attributed to wasteful spending on low- or no-value services. Value-based insurance design (VBID) is intended to encourage the use of high-value services or discourage the use of low-value services by aligning cost with quality. During the summer and fall of 2016, this mixed-methods study used focus groups and a quantitative analysis of survey data to explore consumer decision making in Northern California. When presented with three common VBID approaches, the focus groups favored value-based benefit design the most (41 percent), followed by reference pricing (28 percent) and narrow networks (21 percent). When presented with VBID scenarios, participants were skeptical of the value-based trade-offs and reported seeking information they wanted instead of relying on information that health plans provide. Engaging consumers to successfully reduce waste through VBID will require clarifying trade-offs to support consumers' processes for arriving at high-value decisions as well as reaching out to consumers through trusted sources and networks.

Patient Perspectives in Comparing Hospitals for Childbirth: Insights from Hawai'i

Childbirth is a national priority area for healthcare quality improvement. Patient perspectives are increasingly valued in healthcare, yet Asian American and Pacific Islander (AAPI) perspectives of healthcare quality are often understudied, particularly from individuals with limited English proficiency (LEP). Our study goal was to understand factors that consumers in Hawai'i, including AAPI and those with LEP, use to compare patient care in hospitals, especially for childbirth. A total of 400 women ages 18 years and older with a recent childbirth completed an in-person interview in English (n=291), Tagalog (n=42), Chinese (n=36), or Marshallese (n=31) on O'ahu, Hawai'i. Participants described if (yes/no), and how (open-ended), they believed hospitals in the state varied in providing patient care. Open-ended responses were coded by two independent raters using the framework approach. Respondents were 53.3% Asian, 30.8% Pacific Islander, 13.5% White, and 2.5% other race/ethnicity; 17.8% reported limited English proficiency. Overall, 66.8% of respondents affirmed that local hospitals varied in patient care; Marshallese, other Pacific Islanders, and non-English speakers were significantly less likely to say that Hawai'i hospitals varied in patient care. Among those who endorsed hospital variation, commonly reported themes about this variation were: (1) patient experience, (2) patient overall impression, (3) childbirth options (eg, waterbirths), (4) staff, (5) facilities (eg, "emergency capabilities"), (6) high-tech levels of care, and (7) the hospital's area of focus (eg, "women and children"). We provide insights into factors that diverse patients use to compare patient care in hospitals in Hawai'i to add value, relevance, and engagement to healthcare quality research and dissemination efforts.

Thirty-day readmissions in aneurysmal subarachnoid hemorrhage: A good metric for hospital quality?

Thirty-day readmission rates has been increasingly used by clinicians, hospital administrators, and policy makers as a metric for the quality of care. However, the 30-day readmission rates may be affected by other factors intrinsic to the patient and may not be a good measure of the quality of care provided by the hospital. In this review, we examined the quality of the 30-day readmissions rate as a quality metric for the quality of care provided to patients with aneurysmal subarachnoid hemorrhage (SAH). It has been shown that in this patient population, 30-day readmission rate primarily captures values, such as the number of comorbidities, disease severity, and discharge dispositions. There is little association between SAH 30-day readmission rates and mortality. However, 30-day readmissions may be reduced by increasing early discharge surveillance, providing readmission reduction programs to patients discharged to medical facilities as well as to home, and identifying patients most at risk for readmission.

Decreasing Room Traffic in Orthopedic Surgery: A Quality Improvement Initiative

Operating room (OR) traffic and door openings increase potential for air contamination in the OR and create distractions for surgical teams. A multidisciplinary intervention was developed among OR staff, surgical staff, vendors, radiology, and anesthesia and approved by the hospital system's patient and quality safety department for implementation. Interventions included education, OR signage, and team-based accountability and behavioral interventions. After interventions were implemented, a second prospective, observational data collection was performed and compared to preintervention OR traffic. A total of 35 cases were observed over the 3-month period in the preintervention group; 42 cases were observed in the postintervention group. Average door openings per minute decreased by 22% (P = .0011) after intervention. All surgical groups excluding anesthesia had significant reductions in OR traffic following the intervention. Behavioral interventions that focus on education, awareness, and efficiency strategies can decrease overall OR traffic for orthopedic cases.

Global Advances in Value-Based Payment and Their Implications for Global Health Management Education, Development, and Practice

Global advances in health policy reform, health system improvement and health management education and practice need to be closely aligned to successfully change national health policies and improve the performance of health care delivery organizations. This paper describes the globally acknowledged need for incentive-based organizational performance and relevant implications for health care management education (HCME) and practice. It also outlines the major rationale underlying Value-Based Payment (VBP) or Pay for Performance (P4P) health policy initiatives and their basic elements. Clearly, the major global health policy shift that is underway will likely ultimately have major impacts on the strategic and operational management and performance of health care delivery organizations. Thus, practical specific suggestions are made regarding changes that need to be introduced and strengthened in contemporary health care management education and development programs to help organizational managers in the future.

Hospital uncompensated care and patient experience: An instrumental variable approach

OBJECTIVE

Examine the endogenous relationship between uncompensated care and hospital patient experience scores.

DATA SOURCES/STUDY SETTING

The Hospital Consumer Assessment of Healthcare Providers and Systems Survey, CMS Healthcare Cost Report Information System, and the US Census Bureau.

STUDY DESIGN

The exogenous change in uncompensated care caused by the 2014 Medicaid expansion was exploited to measure the effect of uncompensated care on patient experience scores using a 2SLS regression with instrumental variables approach.

DATA COLLECTION/EXTRACTION METHODS

U.S. general, short-term hospitals whose DSH status remained constant and had nonmissing data for 2011-2015, which totaled 969 unique hospitals per year.

PRINCIPAL FINDINGS

The effect of uncompensated care on patient experience was in the predicted direction, with three of the 10 measures being statistically significant. A one percentage point increase in uncompensated care costs resulted in a 0.25-0.50 percentage point decrease in select patient experience scores.

CONCLUSIONS

Results indicate a weak relationship between uncompensated care and patient experience scores, as a reduction in uncompensated care is related to quality improvement for some hospitals. These findings have implications for hospitals as they navigate changing reimbursement structures and policy makers considering changes to Obama-era health care reforms.

Do German public reporting websites provide information that office-based physicians consider before referring patients to hospital? A four-step analysis

BACKGROUND

In recent years, many different performance frameworks and quality assurance systems have been developed to measure health care quality. In Germany, an external quality assurance system for hospitals was introduced in 2005. The data of these systems are often reported by public reporting websites (PRWs) to inform patients and other stakeholders interested in health care systems about health care providers' quality. However, publication is obligatory (at least in Germany) for most of the existing quality assurance measures; some may be reported voluntarily. An important target group for this information is the group of all office-based physicians as they are crucial for patients' hospital choice. However, public reporting initiatives in Germany and other countries have not increased the use of quality reports for hospital choice.

OBJECTIVES

(1) To summarize the criteria that office-based physicians consider to be of high, medium, and low importance for hospital selection when referring patients and (2) to examine whether German public reporting websites (PRWs) provide these hospital-related criteria.

METHODS

The analysis comprised four steps: 1) Five databases were systematically searched for peer-reviewed English- and German-language literature. 2) The selection of articles was based on compliance with inclusion criteria, and all the criteria relevant to the referral of patients to hospital were extracted. 3) The criteria were then divided into five main categories: structural quality, process quality, outcome quality, patient experience, and referring physicians' experience. In addition, the criteria were classified into three importance categories (high-, medium-, and low-priority criteria) according to their relevance to the referral decision. 4) We investigated whether German PRWs publicly report high-priority criteria.

RESULTS

A total of N=11 articles published in peer-reviewed journals met our inclusion criteria. The studies were published in Germany (n=4), the Netherlands (n=3), Denmark, France, Norway, and the USA (n=1 each). In total, N=86 criteria were identified, most of them relating to structural quality (n=43) and process quality (n=26). We found just n=3 outcome quality criteria, only one of which fell in the high-priority category (breast cancer indicators with clinically relevant differences). In total, n=25 low-, n=40 medium-, and n=34 high-priority criteria could be established, which is due to the fact that some criteria had been investigated in several studies evaluating the importance of some criteria differently. Most of the high-priority criteria were related to process quality. All the high-priority structural quality criteria and high-priority outcome quality criteria were available on German PRWs, whereas just 38.5 % of those relating to process quality could be identified on these portals. We also identified 66.7 % of the high-priority criteria regarding patient experience and 50.0 % concerning the referring physicians' experience. Overall, a larger amount of low- and medium-priority criteria are available on German PRWs than high-priority criteria.

DISCUSSION

A substantial amount of hospital information regarding structural quality and outcome quality is available on German PRWs. However, the development of further process quality criteria (which are currently underrepresented) should be considered, for example whether hospital physicians continue the medication initiated by office-based doctors. Also, hospital quality reports should be tailored for specific user groups, for instance for referring gynecologists or referring general practitioners (GPs).

Adoption of high technology medical imaging and hospital quality and efficiency: Towards a conceptual framework

Measuring the value of medical imaging is challenging, in part, due to the lack of conceptual frameworks underlying potential mechanisms where value may be assessed. To address this gap, this article proposes a framework that builds on the large body of literature on quality of hospital care and the classic structure-process-outcome paradigm. The framework was also informed by the literature on adoption of technological innovations and introduces 2 distinct though related aspects of imaging technology not previously addressed specifically in the literature on quality of hospital care: adoption (a structural hospital characteristic) and use (an attribute of the process of care). The framework hypothesizes a 2-part causality where adoption is proposed to be a central, linking factor between hospital structural characteristics, market factors, and hospital outcomes (ie, quality and efficiency). The first part indicates that hospital structural characteristics and market factors influence or facilitate the adoption of high technology medical imaging within an institution. The presence of this technology, in turn, is hypothesized to improve the ability of the hospital to deliver high quality and efficient care. The second part describes this ability throughout 3 main mechanisms pointing to the importance of imaging use on patients, to the presence of staff and qualified care providers, and to some elements of organizational capacity capturing an enhanced clinical environment. The framework has the potential to assist empirical investigations of the value of adoption and use of medical imaging, and to advance understanding of the mechanisms that produce quality and efficiency in hospitals.

The Volume-Outcome Relationship Revisited: Practice Indeed Makes Perfect

OBJECTIVE

To examine the causal effect of a hospital's experience with treating hip fractures (volume) on patient treatment outcomes.

DATA SOURCES

We use a full sample of administrative data from German hospitals for 2007. The data provide detailed information on patients and hospitals. We also reference the hospitals' addresses and the zip codes of patients' place of residence.

STUDY DESIGN

We apply an instrumental variable approach to address endogeneity concerns due to reverse causality and unobserved patient heterogeneity. As instruments for case volume, we use the number of potential patients and number of other hospitals in the region surrounding each hospital.

PRINCIPAL FINDINGS

Our results indicate that after applying an instrumental variables (IV) regression of volume on outcome, volume significantly increases quality.

CONCLUSIONS

We provide evidence for the practice-makes-perfect hypothesis by showing that volume is a driving factor for quality.

Are Facebook user ratings associated with hospital cost, quality and patient satisfaction? A cross-sectional analysis of hospitals in New York State

BACKGROUND

Hospital care costs are high while quality varies across hospitals. Patient satisfaction may be associated with better clinical quality, and social media ratings may offer another opportunity to measure patient satisfaction with care.

OBJECTIVES

To test if Facebook user ratings of hospitals are associated with existing measures of patient satisfaction, cost and quality.

RESEARCH DESIGN

Data were obtained from Centers for Medicare and Medicaid Services Hospital Compare, the Hospital Inpatient Prospective Payment System impact files and the Area Health Resource File for 2015. Information from hospitals' Facebook pages was collected in July 2016. Multivariate linear regression was used to test if there is an association between Facebook user ratings (star rating and adjusted number of 'likes') and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction measures, the 30-day all-cause readmission rate, and the Medicare spending per beneficiary (MSPB) ratio.

SUBJECTS

One hundred and thirty-six acute care hospitals in New York State in 2015.

RESULTS

An increase in the Facebook star rating is associated with significant increases in 21/23 HCAHPS measures (p≤0.003). An increase in the adjusted number of 'likes' is associated with very small increases in 3/23 HCAHPS measures (p<0.05). Facebook user ratings are not associated with the 30-day all-cause readmission rate or the Medicare spending per beneficiary ratio.

CONCLUSIONS

Results demonstrate an association between HCAHPS patient satisfaction measures and Facebook star ratings. Adjusted number of 'likes' may not be a useful measure of patient satisfaction.

Characteristics of High- and Low-Efficiency Hospitals

We compared performance, operating characteristics, and market environments of low- and high-efficiency hospitals in the 37 states that supplied inpatient data to the Healthcare Cost and Utilization Project from 2006 to 2010. Hospital cost-inefficiency estimates using stochastic frontier analysis were generated. Hospitals were then grouped into the 100 most- and 100 least-efficient hospitals for subsequent analysis. Compared with the least efficient hospitals, high-efficiency hospitals tended to have lower average costs, higher labor productivity, and higher profit margins. The most efficient hospitals tended to be nonteaching, investor-owned, and members of multihospital systems. Hospitals in the high-efficiency group were located in areas with lower health maintenance organization penetration and less competition, and they had a higher share of Medicaid and Medicare admissions. Results of the analysis suggest there are opportunities for public policies to support improved efficiency in the hospital sector.

Healthy Life-Years Lost and Excess Bed-Days Due to 6 Patient Safety Incidents: Empirical Evidence From English Hospitals

BACKGROUND

There is little satisfactory evidence on the harm of safety incidents to patients, in terms of lost potential health and life-years.

OBJECTIVE

To estimate the healthy life-years (HLYs) lost due to 6 incidents in English hospitals between the years 2005/2006 and 2009/2010, to compare burden across incidents, and estimate excess bed-days.

RESEARCH DESIGN

The study used cross-sectional analysis of the medical records of all inpatients treated in 273 English hospitals. Patients with 6 types of preventable incidents were identified. Total attributable loss of HLYs was estimated through propensity score matching by considering the hypothetical remaining length and quality of life had the incident not occurred.

RESULTS

The 6 incidents resulted in an annual loss of 68 HLYs and 934 excess bed-days per 100,000 population. Preventable pressure ulcers caused the loss of 26 HLYs and 555 excess bed-days annually. Deaths in low-mortality procedures resulted in 25 lost life-years and 42 bed-days. Deep-vein thrombosis/pulmonary embolisms cost 12 HLYs, and 240 bed-days. Postoperative sepsis, hip fractures, and central-line infections cost <6 HLYs and 100 bed-days each.

DISCUSSION

The burden caused by the 6 incidents is roughly comparable with the UK burden of Multiple Sclerosis (80 DALYs per 100,000), HIV/AIDS and Tuberculosis (63 DALYs), and Cervical Cancer (58 DALYs). There were marked differences in the harm caused by the incidents, despite the public attention all of them receive. Decision makers can use the results to prioritize resources into further research and effective interventions.

Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter?

BACKGROUND

Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation.

METHODS

Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit amputation and after complicated thumb amputation injuries only.

RESULTS

For patients with simple and complicated thumb amputation injuries, and patients with complicated thumb amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated thumb amputation injuries only, there was no association between patients' minority or insurance status and replantation.

CONCLUSION

Variation in emergency department wait time and its effects on treatment of traumatic digit amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Achieving Kaiser Permanente quality

BACKGROUND

The Kaiser Permanente model of integrated health delivery is highly regarded for high-quality and efficient health care. Efforts to reproduce Kaiser's success have mostly failed. One factor that has received little attention and that could explain Kaiser's advantage is its commitment to and investment in nursing as a key component of organizational culture and patient-centered care.

PURPOSE

The aim of this study was to investigate the role of Kaiser's nursing organization in promoting quality of care.

METHODOLOGY

This was a cross-sectional analysis of linked secondary data from multiple sources, including a detailed survey of nurses, for 564 adult, general acute care hospitals from California, Florida, Pennsylvania, and New Jersey in 2006-2007. We used logistic regression models to examine whether patient (mortality and failure-to-rescue) and nurse (burnout, job satisfaction, and intent-to-leave) outcomes in Kaiser hospitals were better than in non-Kaiser hospitals. We then assessed whether differences in nursing explained outcomes differences between Kaiser and other hospitals. Finally, we examined whether Kaiser hospitals compared favorably with hospitals known for having excellent nurse work environments-Magnet hospitals.

FINDINGS

Patient and nurse outcomes in Kaiser hospitals were significantly better compared with non-Magnet hospitals. Kaiser hospitals had significantly better nurse work environments, staffing levels, and more nurses with bachelor's degrees. Differences in nursing explained a significant proportion of the Kaiser outcomes advantage. Kaiser hospital outcomes were comparable with Magnet hospitals, where better outcomes have been largely explained by differences in nursing.

IMPLICATIONS

An important element in Kaiser's success is its investment in professional nursing, which may not be evident to systems seeking to achieve Kaiser's advantage. Our results suggest that a possible strategy for achieving outcomes like Kaiser may be for hospitals to consider Magnet designation, a proven and cost-effective strategy to improve process of care through investments in nursing.

Modern Management Practices and Hospital Admissions

We investigate whether the modern management practices and publicly reported performance measures are associated with choice of hospital for patients with acute myocardial infarction (AMI). We define and measure management practices at approximately half of US cardiac care units using a novel survey approach. A patient's choice of a hospital is modeled as a function of the hospital's performance on publicly reported quality measures and the quality of its management. The estimates, based on a grouped conditional logit specification, reveal that higher management scores and better performance on publicly reported quality measures are positively associated with hospital choice. Management practices appear to have a direct correlation with admissions for AMI--potentially through reputational effects--and indirect association, through better performance on publicly reported measures. Overall, a one standard deviation change in management practice scores is associated with an 8% increase in AMI admissions.

Prolonged Length of Stay Is Not an Acceptable Alternative to Coded Complications in Assessing Hospital Quality in Elective Joint Arthroplasty

We sought to determine if prolonged length of stay (pLOS) is an accurate measure of quality in total hip and knee arthroplasty (THA and TKA). Coded complications and pLOS for 5967 TKA and 4518 THA patients in our hospital discharged between 2009 and 2011 were analyzed. Of 727 patients with pLOS, only 170 also had a complication, yielding a sensitivity of 41.4% (95% CI: 36.7, 46.2) with a positive predictive value (PPV) of just 23.4% (95% CI: 20.3, 26.4). Specificity (94.5% [95% CI: 94.0, 94.9]) and negative predictive value (NPV) (97.5% [95% CI: 97.2, 97.8]) were high, due to the large number of patients without complications or pLOS. This suggests that risk-adjusted pLOS is an inadequate measure of patient safety in primary THA and TKA.

Development and Validation of an Algorithm to Identify Planned Readmissions From Claims Data

BACKGROUND

It is desirable not to include planned readmissions in readmission measures because they represent deliberate, scheduled care.

OBJECTIVES

To develop an algorithm to identify planned readmissions, describe its performance characteristics, and identify improvements.

DESIGN

Consensus-driven algorithm development and chart review validation study at 7 acute-care hospitals in 2 health systems.

PATIENTS

For development, all discharges qualifying for the publicly reported hospital-wide readmission measure. For validation, all qualifying same-hospital readmissions that were characterized by the algorithm as planned, and a random sampling of same-hospital readmissions that were characterized as unplanned.

MEASUREMENTS

We calculated weighted sensitivity and specificity, and positive and negative predictive values of the algorithm (version 2.1), compared to gold standard chart review.

RESULTS

In consultation with 27 experts, we developed an algorithm that characterizes 7.8% of readmissions as planned. For validation we reviewed 634 readmissions. The weighted sensitivity of the algorithm was 45.1% overall, 50.9% in large teaching centers and 40.2% in smaller community hospitals. The weighted specificity was 95.9%, positive predictive value was 51.6%, and negative predictive value was 94.7%. We identified 4 minor changes to improve algorithm performance. The revised algorithm had a weighted sensitivity 49.8% (57.1% at large hospitals), weighted specificity 96.5%, positive predictive value 58.7%, and negative predictive value 94.5%. Positive predictive value was poor for the 2 most common potentially planned procedures: diagnostic cardiac catheterization (25%) and procedures involving cardiac devices (33%).

CONCLUSIONS

An administrative claims-based algorithm to identify planned readmissions is feasible and can facilitate public reporting of primarily unplanned readmissions.

The volume-outcome relationship and minimum volume standards--empirical evidence for Germany

For decades, there is an ongoing discussion about the quality of hospital care leading i.a. to the introduction of minimum volume standards in various countries. In this paper, we analyze the volume-outcome relationship for patients with intact abdominal aortic aneurysm and hip fracture. We define hypothetical minimum volume standards in both conditions and assess consequences for access to hospital services in Germany. The results show clearly that patients treated in hospitals with a higher case volume have on average a significant lower probability of death in both conditions. Furthermore, we show that the hypothetical minimum volume standards do not compromise overall access measured with changes in travel times.

Hospital diagnostic aggregation and risk-adjusted quality

OBJECTIVE

To demonstrate the importance of diagnostic aggregation when assessing hospitals.

DATA SOURCES

Patient data from the Victorian Admitted Episodes Database (VAED), 1999/2000 to 2004/2005. Financial statements from public hospitals, 2002/2003 to 2004/2005.

STUDY DESIGN

Risk-adjusted quality computed for each hospital using two aggregation levels. Each is then used to estimate the relationship between hospital efficiency and quality using two-stage DEA/Tobit model by Wilson and Simar (2006).

DATA COLLECTION

Selected variables from the VAED were obtained from the Department of Health in Victoria, then linked anonymously with financial statements.

PRINCIPAL FINDINGS

Hospital quality and, in some cases, its relationship with efficiency differs depending on aggregations.

CONCLUSIONS

Patient risk adjustment should be conducted using more than one aggregation level whenever possible.

On the Hospital Volume and Outcome Relationship: Does Specialization Matter More Than Volume?

OBJECTIVE

To evaluate the relationship between hospital volume and outcome by focusing on alternative measures of volume that capture specialization and overall throughput of hospitals.

DATA SOURCES/STUDY SETTING

Hospital administrative data from the state of Victoria, Australia; data contain 1,798,474 admitted episodes reported by 135 public and private acute-care hospitals.

STUDY DESIGN

This study contrasts the volume-outcome relationship using regression models with different measures of volume; two-step and single-step risk-adjustment methods are used.

DATA COLLECTION/EXTRACTION METHODS

The sample is restricted to ischemic heart disease (IHD) patients (ICD-10 codes: I20-I25) admitted during 2001/02 to 2004/05.

PRINCIPAL FINDINGS

Overall hospital throughput and degree of specialization display more substantive implications for the volume-outcome relationship than conventional caseload volume measure. Two-step estimation when corrected for heteroscedasticity produces comparable results to single-step methods.

CONCLUSIONS

Different measures of volume could lead to vastly different conclusions about the volume-outcome relationship. Hospital specialization and throughput should both be included as measures of volume to capture the notion of size, focus, and possible congestion effects.