Trends in Hospitalization vs Observation Stay for Ambulatory Care-Sensitive Conditions

Preadmission morbidity and healthcare utilization among older adults with potentially avoidable hospitalizations: a Danish case-control study

PURPOSE

Examine preadmission diagnoses, medication use, and preadmission healthcare utilization among older adults prior to first potentially avoidable hospitalizations.

METHODS

A nationwide population-based case-control study using Danish healthcare data. All Danish adults aged ≥ 65 years who had a first potentially avoidable hospitalization from January 1995 through March 2019 (n = 725,939) were defined as cases, and 1:1 age- and sex-matched general population controls (n = 725,939). Preadmission morbidity and healthcare utilization were assessed based on a complete hospital diagnosis history within 10 years prior, and all medication use and healthcare contacts 1 year prior. Using log-binomial regression, we calculated adjusted prevalence ratios (PR) with 95% confidence intervals (CI).

RESULTS

Included cases and controls had a median age of 78 years and 59% were female. The burden of preadmission morbidity was higher among cases than controls. The strongest associations were observed for preadmission chronic lung disease (PR 3.8, CI 3.7-3.8), alcohol-related disease (PR 3.1, CI 3.0-3.2), chronic kidney disease (PR 2.4, CI 2.4-2.5), psychiatric disease (PR 2.2, CI 2.2-2.3), heart failure (PR 2.2, CI 2.2-2.3), and previous hospital contacts with infections (PR 2.2, CI 2.2-2.3). A high and accelerating number of healthcare contacts was observed during the months preceding the potentially avoidable hospitalization (having over 5 GP contacts 1 month prior, PR 3.0, CI 3.0-3.0).

CONCLUSION

A high number of healthcare contacts and preadmission morbidity and medication use, especially chronic lung, heart, and kidney disease, alcohol-related or psychiatric disease including dementia, and previous infections are strongly associated with potentially avoidable hospitalizations.

Hospital Performance Under Alternative Readmission Measures Incorporating Observation Stays

OBJECTIVE

To determine the extent to which counting observation stays changes hospital performance on 30-day readmission measures.

METHODS

This was a retrospective study of inpatient admissions and observation stays among fee-for-service Medicare enrollees in 2017. We generated 3 specifications of 30-day risk-standardized readmissions measures: the hospital-wide readmission (HWR) measure utilized by the Centers for Medicare and Medicaid Services, which captures inpatient readmissions within 30 days of inpatient discharge; an expanded HWR measure, which captures any unplanned hospitalization (inpatient admission or observation stay) within 30 days of inpatient discharge; an all-hospitalization readmission (AHR) measure, which captures any unplanned hospitalization following any hospital discharge (observation stays are included in both the numerator and denominator of the measure). Estimated excess readmissions for hospitals were compared across the 3 measures. High performers were defined as those with a lower-than-expected number of readmissions whereas low performers had higher-than-expected or excess readmissions. Multivariable logistic regression identified hospital characteristics associated with worse performance under the measures that included observation stays.

RESULTS

Our sample had 2586 hospitals with 5,749,779 hospitalizations. Observation stays ranged from 0% to 41.7% of total hospitalizations. Mean (SD) readmission rates were 16.6% (5.4) for the HWR, 18.5% (5.7) for the expanded HWR, and 17.9% (5.7) in the all-hospitalization readmission measure. Approximately 1 in 7 hospitals (14.9%) would switch from being classified as a high performer to a low performer or vice-versa if observation stays were fully included in the calculation of readmission rates. Safety-net hospitals and those with a higher propensity to use observation would perform significantly worse.

CONCLUSIONS

Fully incorporating observation stays in readmission measures would substantially change performance in value-based programs for safety-net hospitals and hospitals with high rates of observation stays.

Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults: Get With The Guidelines-Heart Failure Registry

Importance

Black adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown.

Objective

To compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals.

Design, Setting, and Participants

Patients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022.

Exposures

Hospitals caring for high proportions of Black patients.

Main Outcomes and Measures

Quality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients.

Results

This study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based β-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02).

Conclusions and Relevance

Quality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.

Racialized economic segregation and potentially preventable hospitalizations among Medicaid/CHIP-enrolled children

OBJECTIVE

To examine geographic variation in preventable hospitalizations among Medicaid/CHIP-enrolled children and to test the association between preventable hospitalizations and a novel measure of racialized economic segregation, which captures residential segregation within ZIP codes based on race and income simultaneously.

DATA SOURCES

We supplement claims and enrollment data from the Transformed Medicaid Statistical Information System (T-MSIS) representing over 12 million Medicaid/CHIP enrollees in 24 states with data from the Public Health Disparities Geocoding Project measuring racialized economic segregation.

STUDY DESIGN

We measure preventable hospitalizations by ZIP code among children. We use logistic regression to estimate the association between ZIP code-level measures of racialized economic segregation and preventable hospitalizations, controlling for sex, age, rurality, eligibility group, managed care plan type, and state.

DATA EXTRACTION METHODS

We include children ages 0-17 continuously enrolled in Medicaid/CHIP throughout 2018. We use validated algorithms to identify preventable hospitalizations, which account for characteristics of the pediatric population and exclude children with certain underlying conditions.

PRINCIPAL FINDINGS

Preventable hospitalizations vary substantially across ZIP codes, and a quarter of ZIP codes have rates exceeding 150 hospitalizations per 100,000 Medicaid-enrolled children per year. Preventable hospitalization rates vary significantly by level of racialized economic segregation: children living in the ZIP codes that have the highest concentration of low-income, non-Hispanic Black residents have adjusted rates of 181 per 100,000 children, compared to 110 per 100,000 for children in ZIP codes that have the highest concentration of high-income, non-Hispanic white residents (p < 0.01). This pattern is driven by asthma-related preventable hospitalizations.

CONCLUSIONS

Medicaid-enrolled children's risk of preventable hospitalizations depends on where they live, and children in economically and racially segregated neighborhoods-specifically those with higher concentrations of low-income, non-Hispanic Black residents-are at particularly high risk. It will be important to identify and implement Medicaid/CHIP and other policies that increase access to high-quality preventive care and that address structural drivers of children's health inequities.

Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings

BACKGROUND

Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown.

OBJECTIVE

To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures.

DESIGN

Cross-sectional.

SETTING

Population-based.

PARTICIPANTS

Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program.

MEASUREMENTS

Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated.

RESULTS

Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings.

LIMITATION

Hospital performance measurement and risk adjustment differed slightly from those used by Medicare.

CONCLUSION

Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance.

PRIMARY FUNDING SOURCE

Laura and John Arnold Foundation.

Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare

Importance

Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care-sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges.

Objective

To determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare.

Design, Setting, and Participants

Cross-sectional study of US Medicare Advantage vs traditional Medicare beneficiaries from January 1 to December 31, 2018. Poisson regression models were used to compare risk-adjusted rates of Medicare Advantage vs traditional Medicare, controlling for patient demographic characteristics and clinical risk and including county fixed-effects. Data were analyzed between April 2021 and November 2022.

Main Outcomes and Measures

Hospitalizations, observation stays, and ED direct discharges for ACSCs.

Results

The study sample comprised 2 665 340 Medicare Advantage patients (mean [SD] age, 72.7 [9.8] years; 1 504 519 [56.4%] women; 1 859 067 [69.7%] White individuals) and 7 981 547 traditional Medicare patients (mean [SD] age, 71.2 [11.8] years; 4 232 201 [53.0%] women; 6 176 239 [77.4%] White individuals). Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94; 95% CI, 0.93-0.95), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44; 95% CI, 1.43-1.45) and observation stays (RR, 2.38; 95% CI, 2.34-2.41) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30; 95% CI, 1.30-1.31). Within the Medicare Advantage population, patients in health maintenance organizations (HMOs) were at lower risk of ACSC-related hospitalization compared with patients in its preferred provider organizations (RR, 0.96; 95% CI, 0.95-0.98); however, those in the HMOs had a higher risk of ED direct discharge (RR, 1.08; 95% CI, 1.07-1.09) and observation stay (overall RR, 1.10; 95% CI, 1.02-1.12).

Conclusions and Relevance

The findings of this cross-sectional study of Medicare Advantage and traditional Medicare patients with ACSCs indicate that apparent gains in lowering rates of potentially avoidable acute care have been associated with shifting inpatient care to settings such as ED direct discharges and observation stays.

Accounting for the Growth of Observation Stays in the Assessment of Medicare's Hospital Readmissions Reduction Program

IMPORTANCE

Decreases in 30-day readmissions following the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP) have occurred against the backdrop of increasing hospital observation stay use, yet observation stays are not captured in readmission measures.

OBJECTIVE

To examine whether the HRRP was associated with decreases in 30-day readmissions after accounting for observation stays.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included a 20% sample of inpatient admissions and observation stays among Medicare fee-for-service beneficiaries from January 1, 2009, to December 31, 2015. Data analysis was performed from November 2021 to June 2022. A differences-in-differences analysis assessed changes in 30-day readmissions after the announcement of the HRRP and implementation of penalties for target conditions (heart failure, acute myocardial infarction, and pneumonia) vs nontarget conditions under scenarios that excluded and included observation stays.

MAIN OUTCOMES AND MEASURES

Thirty-day inpatient admissions and observation stays.

RESULTS

The study included 8 944 295 hospitalizations (mean [SD] age, 78.7 [8.2] years; 58.6% were female; 1.3% Asian; 10.0% Black; 2.0% Hispanic; 0.5% North American Native; 85.0% White; and 1.2% other or unknown). Observation stays increased from 2.3% to 4.4% (91.3% relative increase) of index hospitalizations among target conditions and 14.1% to 21.3% (51.1% relative increase) of index hospitalizations for nontarget conditions. Readmission rates decreased significantly after the announcement of the HRRP and returned to baseline by the time penalties were implemented for both target and nontarget conditions regardless of whether observation stays were included. When only inpatient hospitalizations were counted, decreasing readmissions accrued into a -1.48 percentage point (95% CI, -1.65 to -1.31 percentage points) absolute reduction in readmission rates by the postpenalty period for target conditions and -1.13 percentage point (95% CI, -1.30 to -0.96 percentage points) absolute reduction in readmission rates by the postpenalty period for nontarget conditions. This reduction corresponded to a statistically significant differential change of -0.35 percentage points (95% CI, -0.59 to -0.11 percentage points). Accounting for observation stays more than halved the absolute decrease in readmission rates for target conditions (-0.66 percentage points; 95% CI, -0.83 to -0.49 percentage points). Nontarget conditions showed an overall greater decrease during the same period (-0.76 percentage points; 95% CI, -0.92 to -0.59 percentage points), corresponding to a differential change in readmission rates of 0.10 percentage points (95% CI, -0.14 to 0.33 percentage points) that was not statistically significant.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the reduction of readmissions associated with the implementation of the HRRP was smaller than originally reported. More than half of the decrease in readmissions for target conditions appears to be attributable to the reclassification of inpatient admission to observation stays.

The association between primary care use and potentially-preventable hospitalization among dual eligibles age 65 and over

Background

Individuals dually-enrolled in Medicare and Medicaid (dual eligibles) are disproportionately sicker, have higher health care costs, and are hospitalized more often for ambulatory care sensitive conditions (ACSCs) than other Medicare beneficiaries. Primary care may reduce ACSC hospitalizations, but this has not been well studied among dual eligibles. We examined the relationship between primary care and ACSC hospitalization among dual eligibles age 65 and older.

Methods

In this observational study, we used 100% Medicare claims data for dual eligibles ages 65 and over from 2012 to 2018 to estimate the likelihood of ACSC hospitalization as a function of primary care visits and other factors. We used linear probability models stratified by rurality, with subgroup analyses for dual eligibles with diabetes or congestive heart failure.

Results

Each additional primary care visit was associated with an 0.05 and 0.09 percentage point decrease in the probability of ACSC hospitalization among urban (95% CI: − 0.059, − 0.044) and rural (95% CI: − 0.10, − 0.08) dual eligibles, respectively. Among dual eligibles with CHF, the relationship was even stronger with decreases of 0.09 percentage points (95% CI: − 0.10, − 0.08) and 0.15 percentage points (95% CI: − 0.17, − 0.13) among urban and rural residents, respectively.

Conclusions

Increased primary care use is associated with lower rates of preventable hospitalizations for dual eligibles age 65 and older, especially for dual eligibles with diabetes and congestive heart failure. In turn, efforts to reduce preventable hospitalizations for this dual-eligible population should consider how to increase access to and use of primary care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08326-2.

Emergency departments in the United States treating high proportions of patients with ambulatory care sensitive conditions: a retrospective cross-sectional analysis

BACKGROUND

One in nine emergency department (ED) visits by Medicare beneficiaries are for ambulatory care sensitive conditions (ACSCs). This study aimed to examine the association between ACSC ED visits to hospitals with the highest proportion of ACSC visits ("high ACSC hospitals) and safety-net status.

METHODS

This was a cross-sectional study of ED visits by Medicare fee-for-service beneficiaries ≥ 65 years using 2013-14 claims data, Area Health Resources File data, and County Health Rankings. Logistic regression estimated the association between an ACSC ED visit to high ACSC hospitals, accounting for individual, hospital, and community factors, including whether the visit was to a safety-net hospital. Safety net status was measured by Disproportionate Share Hospital (DSH) index patient percentage; public hospital status; and proportion of dual-eligible beneficiaries. Hospital-level correlation was calculated between ACSC visits, DSH index, and dual-eligible patients. We stratified by type of ACSC visit: acute or chronic.

RESULTS

Among 5,192,729 ACSC ED visits, the odds of visiting a high ACSC hospital were higher for patients who were Black (1.37), dual-eligible (1.18), and with the highest comorbidity burden (1.26, p < 0.001 for all). ACSC visits had increased odds of being to high ACSC hospitals if the hospitals were high DSH (1.43), served the highest proportion of dual-eligible beneficiaries (2.23), and were for-profit (relative to non-profit) (1.38), and lower odds were associated with public hospitals (0.64) (p < 0.001 for all). This relationship was similar for visits to high chronic ACSC hospitals (high DSH: 1.59, high dual-eligibility: 2.60, for-profit: 1.41, public: 0.63, all p < 0.001) and to a lesser extent, high acute ACSC hospitals (high DSH: 1.02; high dual-eligibility: 1.48, for-profit: 1.17, public: 0.94, p < 0.001). The proportion of ACSC visits at all hospitals was weakly correlated with DSH proportion (0.2) and the proportion of dual-eligible patients (0.29), and this relationship was also seen for both chronic and acute ACSC visits, though stronger for the chronic ACSC visits.

CONCLUSION

Visits to hospitals with a high proportion of acute ACSC ED visits may be less likely to be to hospitals classified as safety net hospitals than those with a high proportion of chronic ACSC visits.

Underlying Factors of Health Insurance Use Among Blacks and Hispanics With Ambulatory Care-Sensitive Conditions

This study examined satisfaction with and confidence in understanding health insurance use among Blacks and Hispanic Americans with ambulatory care-sensitive conditions. Using the 2013-2016 Health Reform Monitoring Survey data sets, descriptive statistics and ordinary least-square regressions estimated the association between satisfaction and confidence scores and racial or ethnic groups with ambulatory care-sensitive conditions. Compared with their White counterparts, Black (β = -.13; 95% confidence interval [CI], -0.19 to -0.06) and Hispanic (β = -0.41; 95% CI, -0.48 to -0.33) participants' standardized confidence scores were significantly lower. Research is needed to identify factors that may enhance this population's confidence level.

A mixed-methods evaluation of home-based primary care in dementia within an integrated system

BACKGROUND

No prior studies have examined the effects of home-based primary care (HBPC) in persons living with dementia (PLWD), within an ecosystem of serious illness care in an integrated healthcare system. Our objectives were to compare the characteristics of PLWD receiving HBPC and their hospital utilization and end-of-life care, with those of a matched comparison group, and to understand the experiences of family caregivers of PLWD receiving HBPC.

METHODS

This mixed-methods study used a retrospective observational cohort design with PLWD receiving HBPC (n = 287) from 2015 to 2020 and a strata-matched comparison group (n = 861), and qualitative phone interviews with 16 HBPC family caregivers in 2020. Inverse probability of treatment weighting propensity score-adjusted models were used to compare time-to-first hospital-based utilization and, for decedents, home palliative and hospice care and place of death. Care experience was captured through caregiver interviews.

RESULTS

Patients receiving HBPC had a similar risk of hospital utilization [adjusted hazard ratio, 1.06 (95% CI: 0.89-1.26), p = 0.51] as a matched non-HBPC comparison group after a median follow-up of 199 days. However, HBPC decedents (n = 159) were more likely to receive home palliative care or hospice [rate ratio, RR: 1.23 (95% CI: 1.07-1.42), p < 0.01] and to die at home [RR: 1.66 (95% CI: 1.35-2.05), p < 0.001] than were non-HBPC decedents (n = 423). Caregivers reported that HBPC provided coordinated, continuous, and convenient care that was aligned with families' priorities and goals; however, some expressed unmet needs, especially for help paying for personal care and medical supplies/equipment, and a desire for clearer communication about program operations and more quality oversight for contract services.

CONCLUSIONS

Although HBPC for PLWD was associated with a similar risk of hospital utilization compared to a matched non-HBPC comparison group, HBPC resulted in more patient-centered end-of-life care for decedents. Prospective studies of HBPC that further elicit and address unmet needs are warranted.

Comparing Preventable Acute Care Use of Rural Versus Urban Americans: an Observational Study of National Rates During 2008-2017

BACKGROUND

Rural Americans have less access to care than urban Americans. Preventable acute care use is a marker of unmet ambulatory healthcare needs, but little is known about how such utilization has differed between rural and urban areas over time.

OBJECTIVE

Compare preventable emergency department (ED) visit and hospitalization rates among rural versus urban residents over the past decade.

DESIGN

Observational study using a validated algorithm to compute age-sex-adjusted rates per 100,000 individuals of preventable ED visits and hospitalizations. Differences in overall, annual, and condition-specific rates for rural versus urban residents were assessed and linear regression was used to assess 10-year trends.

SETTING

Nationwide Emergency Department Sample, National Inpatient Sample, and US Census, 2008-2017.

PARTICIPANTS

US adults, an annual average of 241.3 million individuals.

MEASUREMENTS

Preventable ED visits and hospitalizations.

RESULTS

Compared to urban residents, rural residents had 45% higher rates of preventable ED visits in 2008 (3003 vs. 2070 per 100,000, adjusted difference [AD]: 933; 95% CI: 928-938) and 44% higher rates of preventable ED visits in 2017 (3911 vs. 2708 per 100,000, AD: 1202; 95% CI: 1196-1208). Rural residents had 26% higher rates of preventable hospitalizations in 2008 (2104 vs. 1666 per 100,000, AD: 439; 95% CI: 434-443) and 13% higher rates in 2017 (1634 vs. 1440 per 100,000, AD: 194; 95% CI: 190-199). Preventable ED visits increased more in absolute terms in rural versus urban residents, but the percentage increase was similar (30% vs. 31%) because rural residents started at a higher baseline. Preventable hospitalizations decreased at a faster rate (22% vs. 14%) among rural versus urban residents.

LIMITATIONS

Observational study; unable to infer causality.

CONCLUSIONS

Rural disparities in acute care use are narrowing for preventable hospitalizations but have persisted for all preventable acute care use, suggesting unmet demand for high-quality ambulatory care in rural areas.

Trends and Variation in the Use of Observation Stays at Children's Hospitals

BACKGROUND

Observation status could improve efficiency of healthcare resource use but also might shift financial burdens to patients and hospitals. Although the use of observation stays has increased for adult patient populations, the trends are unknown among hospitalized children.

OBJECTIVE

The goal of this study was to describe recent trends in observation stays for pediatric populations at children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Both observation and inpatient stays for all conditions were retrospectively studied using the Pediatric Health Information System database (2010 to 2019).

EXPOSURE, MAIN OUTCOMES, AND MEASURES

Patient type was classified as inpatient or observation status. Main outcomes included annual percentage of observation stays, annual percentage of observation stays having prolonged length of stay (>2 days), and growth rates of observation stays for the 20 most common conditions. Risk adjusted hospital-level use of observation stays was estimated using generalized linear mixed-effects models.

RESULTS

The percentage of observation stays increased from 23.6% in 2010 to 34.3% in 2019 (P < .001), and the percentage of observation stays with prolonged length of stay rose from 1.1% to 4.6% (P < .001). Observation status was expanded among a diverse group of clinical conditions; diabetes mellitus and surgical procedures showed the highest growth rates. Adjusted hospital-level use ranged from 0% to 67% in 2019, indicating considerable variation among hospitals.

CONCLUSION

Based on the increase in observation stays, future studies should explore the appropriateness of observation care related to efficient use of healthcare resources and financial implications for hospitals and patients.

The Hospital Readmissions Reduction Program and Observation Hospitalizations

The Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP) penalizes hospitals having excess inpatient rehospitalizations within 30 days of index inpatient stays for targeted conditions. Observation hospitalizations are increasing in frequency and may clinically resemble inpatient hospitalizations, yet HRRP excludes observation in index and 30-day rehospitalization counts. Using 100% 2014 Medicare fee-for-service claims and CMS's 30-day rehospitalization methodology, we modeled how observation hospitalizations impact HRRP metrics when counted as index (denominator) and 30-day (numerator) rehospitalizations. Of 3,806,772 index hospitalizations for HRRP conditions, 418,923 (11%) were observation; 18% (155,553/876,033) of rehospitalizations were invisible to HRRP due to observation hospitalization as index (34%; 63,740/188,430), 30-day outcome (53%; 100,343/188,430), or both (13%; 24,347/188,430). By ignoring observation hospitalizations as index and 30-day events, nearly one of five HRRP rehospitalizations is missed. Policymakers might consider this an opportunity to address broad challenges of the two-tiered observation and inpatient hospital billing distinction.

Hospitalization Trajectories and Risks of ESKD and Death in Individuals With CKD

INTRODUCTION

Management of chronic kidney disease (CKD) entails high medical complexity and often results in high hospitalization burden. There are limited data on the associations of longitudinal hospital utilization patterns with adverse clinical outcomes in individuals with CKD.

METHODS

We derived cumulative all-cause hospitalization trajectory groups using latent class trajectory analysis in 3012 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study who were alive and did not reach end-stage kidney disease (ESKD) within 4 years of study entry. Cox proportional hazards models tested the associations between hospitalization trajectory groups and risks of ESKD and death prior to the onset of ESKD (ESKD-censored death).

RESULTS

Within 4 years of study entry, there were 5658 hospitalizations among 3012 participants. We identified 3 distinct subgroups of individuals with CKD based on cumulative all-cause hospitalization trajectories over 4 years: low-utilizer (n = 1066), intermediate-utilizer (n = 1802), and high-utilizer (n = 144). High-utilizers represented a patient population of lower socioeconomic status who had a greater prevalence of comorbid conditions and lower kidney function compared with intermediate- and low-utilizers. After the 4-year ascertainment period to form the trajectory subgroups, there were 544 ESKD events and 437 ESKD-censored deaths during a median follow-up time of 5.1 years. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.49-fold (95% confidence interval [CI] 1.22-1.84) and 1.75-fold (95% CI 1.20-2.56) higher risk of ESKD in adjusted analyses, respectively. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.48-fold (95% CI 1.17-1.87) and 2.58-fold (95% CI 1.74-3.83) higher risk of ESKD-censored death in adjusted analyses, respectively.

CONCLUSIONS

Trajectories of cumulative all-cause hospitalization identify subgroups of individuals with CKD who are at high risk of ESKD and death.

Avoidable Hospitalizations And Observation Stays: Shifts In Racial Disparities

Racial disparities in hospitalization rates for ambulatory care-sensitive conditions are concerning and may signal differential access to high-quality ambulatory care. Whether racial disparities are improving as a result of better ambulatory care versus artificially narrowing because of increased use of observation status is unclear. Using Medicare data for 2011-15, we sought to determine whether black-white disparities in avoidable hospitalizations were improving and evaluated the degree to which changes in observations for ambulatory care-sensitive conditions may be contributing to changes in these gaps. We found that while the racial gap in avoidable hospitalizations due to such conditions has decreased, that seems to be explained by a concomitant increase in the gap of avoidable observation stays. This suggests that changes from inpatient admissions to observation status seem to be driving the reduction in racial disparities in avoidable hospitalizations, rather than changes in the ambulatory setting.

Thirty-Day Re-observation, Chronic Re-observation, and Neighborhood Disadvantage

OBJECTIVE

To determine whether neighborhood socioeconomic disadvantage, as determined by the Area Deprivation Index, increases 30-day hospital re-observation risk.

PARTICIPANTS AND METHODS

This retrospective study of 20% Medicare fee-for-service beneficiary observation stays from January 1, 2014, to November 30, 2014, included 319,980 stays among 273,308 beneficiaries. We evaluated risk for a 30-day re-observation following an index observation stay for those living in the 15% most disadvantaged compared with the 85% least disadvantaged neighborhoods.

RESULTS

Overall, 4.5% (270,600 of 6,080,664) of beneficiaries had index observation stays, which varied by disadvantage (4.3% [232,568 of 5,398,311] in the least disadvantaged 85% compared with 5.6% [38,032 of 682,353] in the most disadvantaged 15%). Patients in the most disadvantaged neighborhoods had a higher 30-day re-observation rate (2857 of 41,975; 6.8%) compared with least disadvantaged neighborhoods (13,543 of 278,005; 4.9%); a 43% increased risk (unadjusted odds ratio [OR], 1.43; 95% CI, 1.31 to 1.55). After adjustment, this risk remained (adjusted OR, 1.13; 95% CI, 1.04 to 1.22). Discharge to a skilled nursing facility reduced 30-day re-observation risk (OR, 0.63; 95% CI, 0.57 to 0.69), whereas index observation length of stay of 4 or more days (3 midnights) conferred increased risk (OR, 1.29; 95% CI, 1.09 to 1.52); those living in disadvantaged neighborhoods were less likely to discharge to skilled nursing facilities and more likely to have long index stays. Beneficiaries with more than one 30-day re-observation (chronic re-observation) had progressively greater disadvantage by number of stays (adjusted incident rate ratio, 1.08; 95% CI, 1.02 to 1.14). Observation prevalence varied nationally.

CONCLUSION

Thirty-day re-observation, especially chronic re-observation, is highly associated with socioeconomic neighborhood disadvantage, even after accounting for factors such as race, disability, and Medicaid eligibility. Beneficiaries least able to pay are potentially most vulnerable to costs from serial re-observations and challenges of Medicare observation policy, which may discourage patients from seeking necessary care.

National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia

BACKGROUND/OBJECTIVES

Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking.

DESIGN

Retrospective cohort study using the National Inpatient Sample from 2012 to 2016.

SETTING

U.S. acute care hospitals.

PARTICIPANTS

A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia.

MEASUREMENTS

Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs.

RESULTS

The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community.

CONCLUSION

The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.

Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations

IMPORTANCE

Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population.

OBJECTIVE

To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019.

MAIN OUTCOMES AND MEASURES

The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained.

RESULTS

The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.

Changes in Emergency Department Care Intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey

INTRODUCTION

Emergency departments (ED) in the United States (US) have increasingly taken the central role for the expedited diagnosis and treatment of acute episodic illnesses and exacerbations of chronic diseases, allowing outpatient management to be possible for many conditions that traditionally required hospitalization and inpatient care. The goal of this analysis was to examine the changes in ED care intensity in this context through the changes in ED patient population and ED care provided.

METHODS

We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007-2016. Incorporating survey design and weight, we calculated the changes in ED patient characteristics and ED care provided between 2007 and 2016. We also calculated changes in the proportion of visits with low-severity illnesses that may be safely managed at alternative settings. Lastly, we compared ED care received and final ED dispositions by calculating adjusted relative risk (aRR) comparing ED visits in 2007 to 2016, using survey weighted multivariable logistic regression.

RESULTS

NHAMCS included 35,490 visits in 2007 and 19,467 visits in 2016, representing 117 million and 146 million ED visits, respectively. Between 2007 and 2016, there was an increase in the proportion of ED patients aged 45-64 (21.0% to 23.6%) and 65-74 (5.9% to 7.5%), while visits with low-severity illnesses decreased from 37.3% to 30.4%. There was a substantial increase in the proportion of Medicaid patients (22.2% to 34.0%) with corresponding decline in the privately insured (36.2% to 28.3%) and the uninsured (15.4% to 8.6%) patients. After adjusting for patient and visit characteristics, there was an increase in the utilization of advanced imaging (aRR 1.29; 95% confidence interval [CI], 1.17-1.41), blood tests (aRR 1.16; 95% CI, 1.10-1.22), urinalysis (aRR 1.22; 95% CI, 1.13-1.31), and visits where the patient received four or more medications (aRR 2.17; 95% CI, 1.88-2.46). Lastly, adjusted hospitalization rates declined (aRR 0.74; 95% CI, 0.64-0.84) while adjusted discharge rates increased (aRR 1.06; 95%CI 1.03-1.08).

CONCLUSION

From 2007 to 2016, ED care intensity appears to have increased modestly, including aging of patient population, increased illness severity, and increased resources utilization. The role of increased care intensity in the decline of ED hospitalization rate requires further study.