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Oddleifson DA, Xu X, Wiznia D, Gibson D, Spatz ES, Desai NR. Healthcare Market-Level and Hospital-Level Disparities in Access to and Utilization of High-Quality Hip and Knee Replacement Hospitals Among Medicare Beneficiaries. J Am Acad Orthop Surg 2023; 31:e961-e973. [PMID: 37543752 DOI: 10.5435/jaaos-d-23-00183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/11/2023] [Indexed: 08/07/2023] Open
Abstract
INTRODUCTION This study aimed to determine whether healthcare markets with higher social vulnerability have lower access to high-quality hip and knee replacement hospitals and whether hospitals that serve a higher percentage of low-income patients are less likely to be designated as high-quality. METHODS This cross-sectional study used 2021 Centers for Medicare and Medicaid Services outcome measures and 2022 Joint Commission (JC) process-of-care measures to identify hospitals performing high-quality hip and knee replacement. A total of 2,682 hospitals and 304 healthcare markets were included. For the market-level analysis, we assessed the association of social vulnerability with the presence of a high-quality hip and knee replacement center. For the hospital-level analysis, we assessed the association of disproportionate share hospital (DSH) percentage with each high-quality designation. Healthcare markets were approximated by hospital referral regions. All associations were assessed with fractional regressions using generalized linear models with binomial family and logit links. RESULTS We found that healthcare markets in the most vulnerable quartile were less likely to have a hip and knee replacement hospital that did better than the national average (odds ratio [OR] 0.22, P = 0.02) but not more or less likely to have a hospital certified as advanced by JC (OR 0.41, P = 0.16). We found that hip and knee replacement hospitals in the highest DSH quartile were less likely to be designated by the Centers for Medicare and Medicaid Services as better than the national average (OR 0.18, P = 0.001) but not more or less likely to be certified as advanced by JC (OR 1.40, P = 0.28). DISCUSSION Geographic distribution of high-quality hospitals may contribute to socioeconomic disparities in patients' access to and utilization of high-quality hip and knee replacement. Equal access to and utilization of hospitals with high-quality surgical processes does not necessarily indicate equitable access to and utilization of hospitals with high-quality outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH.
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Byrd JN, Chung KC. The Hand Surgeon's Practice and the Evolving Merit-Based Incentive Payment System. J Hand Surg Am 2022; 47:890-893. [PMID: 35717421 DOI: 10.1016/j.jhsa.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 03/10/2022] [Accepted: 04/27/2022] [Indexed: 02/02/2023]
Abstract
The Merit-Based Incentive Payment System began scoring physicians in 2017, with implementation of payment adjustments started in 2019. The program continues to evolve, with adjustments to measures, score weighting and consideration of patient complexity. However, there remain concerns about unintended consequences of this latest value-based payment program. This review summarizes the roll-out of the program in the first performance year (2017) and changes that will have an impact on payment adjustments in the 2022 performance year. Further, it explains the need for policy informed by clinical experience to protect access for vulnerable patients.
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Affiliation(s)
- Jacqueline N Byrd
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
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Lekarczyk A, Sinha H, Dvir D, Goyert J, Airhart A, Reddy RM. Similar hospital profits with robotic-assisted paraesophageal hiatal hernia repair, despite higher or supply costs. Surg Endosc 2022; 37:3952-3955. [PMID: 35999312 DOI: 10.1007/s00464-022-09513-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/26/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Robotic-assisted laparoscopic surgery has emerged as an alternative to traditional laparoscopy and may offer some clinical benefits when performing complex hiatal hernia repairs. Many institutions may choose to not invest in robotic surgery because of perceived higher costs, and when they already have proficient laparoscopic surgeons. We hypothesized that the robotic approach would yield lower profits overall due to higher supply costs, while offering comparable outcomes to the traditional laparoscopic approach. METHODS Financial and outcomes data from a single quaternary academic center was retrospectively reviewed from a prospectively collected database from July 2020 to May 2021. Laparoscopic hiatal hernia repairs and robotic-assisted repairs were compared for metrics including length of stay, operative time, hospital and supply cost, payments, and profits. Metrics of these two groups were compared using t-test analyses with significance set to p < 0.05. RESULTS Seventy-three patients were included with 31 in the robotic group (42.5%) and 42 in the laparoscopic group (57.5%). There were no significant differences in length of stay (robotic mean 2.0 days, laparoscopic 2.55 days, p = 0.09) or operative time (257.6 min vs 256.7 min, p = 0.48) between the two approaches. The robotic approach was associated with higher supply costs ($2,655 vs $2,028, p < 0.001) and patient charges ($63,997 vs $56,276, p < 0.05). Despite higher costs associated with robotics, hospital profits were not different between the two groups ($7,462 vs $7,939, p = 0.42). CONCLUSION Despite higher supply costs and charges for robotic-assisted hiatal hernia repair, hospital profits were similar when comparing robotic and laparoscopic approaches. Short-term clinical outcomes were also similar. Programs should do their own analysis to understand their individual cost issues.
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Affiliation(s)
- Andrew Lekarczyk
- University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Hana Sinha
- University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Danielle Dvir
- University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Joshua Goyert
- University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Austin Airhart
- University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Rishindra M Reddy
- University of Michigan Medical School, Ann Arbor, MI, 48109, USA.
- Section of Thoracic Surgery, Department of Surgery, University of Michigan-Comprehensive Robotic Surgery Program, Jose Jose Alvarez Research Professor in Thoracic Surgery, University of Michigan, TC2120/5344, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.
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Bonner SN, Kunnath N, Dimick JB, Ibrahim AM. Neighborhood deprivation and Medicare expenditures for common surgical procedures. Am J Surg 2022; 224:1274-1279. [PMID: 35750504 DOI: 10.1016/j.amjsurg.2022.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The Center of Medicare and Medicaid Services valued based payments for inpatient surgical hospitalizations are adjusted for clinical but not social risk factors. While research has shown that social risk is associated with worse surgical patient outcomes, it is unknown if inpatient surgical episode Medicare payments are affected by social risk factors. METHODS Retrospective review of Medicare beneficiaries, age 65-99, undergoing appendectomy, colectomy, hernia repair, or cholecystectomy between 2014 and 2018. Neighborhood deprivation measured by Area Deprivation Index for beneficiary census tract. We evaluated Medicare payments for a total episode of surgical care comprised of index hospitalization, physician fees, post-acute care, and readmission by beneficiary neighborhood deprivation. RESULTS A total of 809,059 patients (Women, 56.0%) and mean (SD) age of 75.7 (7.4 years were included. A total of 145,351 beneficiaries lived in the least deprived neighborhoods and 134,188 who lived in the most deprived neighborhoods. Total surgical episode spending was $2654 higher among beneficiaries from the most deprived neighborhoods compared to those from the least after risk adjustment for clinical and hospital factors. These differences were driven in part by higher rates of readmissions (12.9% vs 10.8%, P < 0.001) and post-acute care (67.8% vs. 61.2%, P < 0.001) among beneficiaries living in the most deprived neighborhoods. CONCLUSION These findings suggest that value-based payment models with inclusion of social risk adjustment may be needed for surgical cohorts. Moreover, efforts focused on investing in deprived communities may be aligned with surgical quality improvement.
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Affiliation(s)
- Sidra N Bonner
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; National Clinician Scholars Program, University of Michigan, Ann Arbor, MI, USA.
| | - Nicholas Kunnath
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Andrew M Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
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Taylor K, Diaz A, Nuliyalu U, Ibrahim A, Nathan H. Association of Dual Medicare and Medicaid Eligibility With Outcomes and Spending for Cancer Surgery in High-Quality Hospitals. JAMA Surg 2022; 157:e217586. [PMID: 35195684 PMCID: PMC8867385 DOI: 10.1001/jamasurg.2021.7586] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Although dual eligibility (DE) status for Medicare and Medicaid has been used for social risk stratification in value-based payment programs, little is known about the interplay between hospital quality and disparities in outcomes and spending by social risk. OBJECTIVE To assess whether treatment at high-quality hospitals mitigates DE-associated disparities in outcomes and spending for cancer surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study from January 1, 2014, to December 31, 2018, evaluating inpatient surgery at acute care hospitals. A total of 119 757 Medicare beneficiaries aged 65 years or older who underwent colectomy, rectal resection, lung resection, or pancreatectomy were evaluated. Data were analyzed between November 1, 2020, and April 30, 2021. EXPOSURES Medicare and Medicaid DE status and hospital quality. MAIN OUTCOMES AND MEASURES Postoperative complications, readmission, and mortality by DE status and hospital quality. RESULTS Overall, 119 757 Medicare beneficiaries underwent colectomy, rectal resection, lung resection, or pancreatectomy. The mean (SD) age was 75.3 (6.7) years, 61 617 (51.5%) were women, 7677 (6.4%) were Black, 106 099 (88.6%) were White, and 5981 (5.0%) identified as another race or ethnicity; 11.3% had DE status. Dually eligible patients were more likely to be discharged to a facility (colectomy, 15.0% [95% CI, 14.7%-15.3%] vs 23.9% [95% CI, 22.9%-24.9%]; proctectomy, 18.7% [95% CI, 18.0%-19.3%] vs 26.9% [95% CI, 24.9%-28.9%]; lung resection, 11.0% [95% CI, 10.7%-11.3%] vs 17.9% [95% CI, 16.8%-18.9%]; pancreatectomy, 23.5% [95% CI, 22.5%-24.4%] vs 30.0% [95% CI, 26.5%-33.5%]). Differences in postacute care use persisted even after accounting for postoperative complications and contributed to variation in spending. Compared with the lowest-quality hospitals, DE patients had improved rates of discharge to a facility (22.7% vs 19.3%) and spending ($22 577 vs $20 100) but rates remained increased compared with Medicare patients even at the highest-quality hospitals. CONCLUSIONS AND RELEVANCE The findings of this study indicate that, even among the highest-quality hospitals, DE patients had poorer outcomes and higher spending. Dually eligible patients were more likely to be discharged to a facility and therefore incurred higher postacute care costs. Although treatment at high-quality hospitals is associated with reduced differences in outcomes, DE patients remain at high risk for adverse postoperative outcomes and increased readmissions and postacute care use.
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Affiliation(s)
- Kathryn Taylor
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Department of Surgery, Stanford University, Stanford, California,Department of Surgery, University of Michigan, Ann Arbor
| | - Adrian Diaz
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Department of Surgery, The Ohio State University, Columbus
| | - Usha Nuliyalu
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Department of Surgery, University of Michigan, Ann Arbor
| | - Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Department of Surgery, University of Michigan, Ann Arbor
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Sharma A, Farley KX, Schwartz AM, Wilson JM, Bradbury TL, Guild GN. Medicaid Payer Status Is Associated With Increased 90-Day Resource Utilization, Reoperation, and Infection Following Aseptic Revision Total Hip Arthroplasty. THE IOWA ORTHOPAEDIC JOURNAL 2022; 42:66-74. [PMID: 36601230 PMCID: PMC9769354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Prior literature has demonstrated increased resource utilization and perioperative complications in patients with a Medicaid payor status undergoing primary total hip and knee arthroplasty. This relationship has yet to be explored in patients undergoing revision total hip arthroplasty (rTHA). Methods The National Readmissions Database was queried from 2010 to 2015 for all patients undergoing aseptic rTHA. 90-day complication data were collected, and patients were separated into two cohorts based on insurance payor type: Medicaid and non-Medicaid. Patients were propensity score matched 2:1 on a number of comorbid and operative characteristics. The relationship between Medicaid payor status and postoperative outcomes was then assessed using binomial logistic regression analysis. Results 3,110 Medicaid patients were identified and matched to 6,175 non-Medicaid patients. Medicaid patients had increased odds of an early prosthetic joint infection (Odds Ratio [OR] 1.29, p=0.019), superficial surgical site infection (OR: 1.48, p=0.003), and early reoperation (OR: 1.18, p=0.045). Medicaid patients also experienced higher odds of readmissions, extended length of stay, non-home discharge status, and medical complications. Finally, the Medicaid cohort had a $3,332 (95% CI: 2,412-4,253, p<0.001) increased adjusted total cost of care when compared to the non-Medicaid cohort. Conclusion This study identifies the Medicaid payor status as an independent risk factor for increased resource utilization, reoperation, and infection in the early postoperative period for patients undergoing rTHA. This relationship is likely due to an interplay of multiple variables, including socioeconomic status and access to care. Level of Evidence: IV.
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Affiliation(s)
- Aman Sharma
- Emory University Orthopaedics & Spine Hospital, Tucker, Georgia, USA.,Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kevin X Farley
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrew M Schwartz
- Emory University Orthopaedics & Spine Hospital, Tucker, Georgia, USA.,Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jacob M Wilson
- Emory University Orthopaedics & Spine Hospital, Tucker, Georgia, USA.,Emory University School of Medicine, Atlanta, Georgia, USA
| | - Thomas L Bradbury
- Emory University Orthopaedics & Spine Hospital, Tucker, Georgia, USA.,Emory University School of Medicine, Atlanta, Georgia, USA
| | - George N Guild
- Emory University Orthopaedics & Spine Hospital, Tucker, Georgia, USA.,Emory University School of Medicine, Atlanta, Georgia, USA
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Herrel LA, Zhu Z, Ryan AM, Hollenbeck BK, Miller DC. Intensity of end-of-life care for dual-eligible beneficiaries with cancer and the impact of delivery system affiliation. Cancer 2021; 127:4628-4635. [PMID: 34428311 PMCID: PMC9199351 DOI: 10.1002/cncr.33874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/13/2021] [Accepted: 08/03/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Dual-eligible beneficiaries, who qualify for Medicare and Medicaid, are a vulnerable population with much to gain from efforts to improve quality. Integrated delivery networks and cancer centers, with their emphasis on care coordination and communication, may improve quality of care for dual-eligible patients with cancer at the end of life. METHODS This study used Surveillance, Epidemiology, and End Results registry data linked with Medicare claims to evaluate quality for beneficiaries who died of cancer and were diagnosed from 2009 to 2014. High-intensity care was evaluated with 7 end-of-life quality measures according to dual-eligible status with multivariable logistic regression models. Regression-based techniques were used to assess the effect of delivery system affiliation (ie, cancer center or integrated delivery network vs no affiliation). RESULTS Among 100,549 beneficiaries who died during the study interval, 22% were dually eligible. Inferior outcomes were identified for dual-eligible beneficiaries in comparison with nondual beneficiaries across nearly every quality measure assessed, including >1 hospitalization in the last 30 days (12.6% vs 11.3%; P < .001) and a greater proportion of deaths occurring in a hospital setting (30.2% vs 26.2%; P < .001). Receipt of care in an affiliated delivery system was associated with reduced deaths in a hospital setting and increased hospice utilization for dual-eligible beneficiaries. CONCLUSIONS Dual-eligible status is associated with higher intensity care at the end of life. Delivery system affiliation has a modest impact on quality at the end of life, and this suggests that targeted efforts may be needed to optimize quality for this group of vulnerable patients.
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Affiliation(s)
- Lindsey A Herrel
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Ziwei Zhu
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Andrew M Ryan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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Byrd JN, Chung KC. Evaluation of the Merit-Based Incentive Payment System and Surgeons Caring for Patients at High Social Risk. JAMA Surg 2021; 156:1018-1024. [PMID: 34379100 DOI: 10.1001/jamasurg.2021.3746] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance The latest step in the Centers for Medicaid & Medicare transformation to pay-for-value is the Medicare Merit-Based Incentive Payment System (MIPS). Value-based payment designs often do not account for uncaptured clinical status and social determinants of health in patients at high social risk, and the consequences for clinicians and patients associated with their use have not been explored. Objective To evaluate MIPS scoring of surgeons caring for patients at high social risk to determine whether this implementation threatens disadvantaged patients' access to surgical care. Design, Setting, and Participants A retrospective cohort study of US general surgeons participating in MIPS during its first year in outpatient surgical practices across the US and territories. The study was conducted from September 1, 2020, to May 1, 2021. Data were analyzed from November 1, 2020, to March 30, 2021 (although data were collected during the 2017 calendar year and reported ahead of 2019 payment adjustments). Main Outcomes and Measures Characteristics of surgeons participating in MIPS, overall MIPS score assigned to clinician. and practice-level disadvantage measures. The MIPS scores can range from 0 to 100. For the first year, a score of less than 3 led to negative payment adjustment; a score of greater than 3 but less than 70 to a positive adjustment; and a score of 70 or higher to the exceptional performance bonus. Results Of 20 593 general surgeons, 10 252 participated in the first year of MIPS. Surgeons with complete patient data (n = 9867) were evaluated and a wide range of dual-eligible patient caseloads from 0% to 96% (mean [SD], 27.1% [14.5%]) was identified. Surgeons in the highest quintile of dual eligibility cared for a Medicare patient caseload ranging from 37% to 96% dual eligible for Medicare and Medicaid. Surgeons caring for the patients at highest social risk had the lowest final mean (SD) MIPS score compared with the surgeons caring for the patients at least social risk (66.8 [37.3] vs 71.2 [35.9]; P < .001). Conclusions and Relevance Results of this cohort study suggest that implementation of MIPS value-based care reimbursement without adjustment for caseload of patients at high social risk may penalize surgeons who care for patients at highest social risk.
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Affiliation(s)
- Jacqueline N Byrd
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor.,Department of Surgery, The University of Texas Southwestern Medical School, Dallas
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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Nerenz DR, Austin JM, Deutscher D, Maddox KEJ, Nuccio EJ, Teigland C, Weinhandl E, Glance LG. Adjusting Quality Measures For Social Risk Factors Can Promote Equity In Health Care. Health Aff (Millwood) 2021; 40:637-644. [PMID: 33819097 DOI: 10.1377/hlthaff.2020.01764] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Risk adjustment of quality measures using clinical risk factors is widely accepted; risk adjustment using social risk factors remains controversial. We argue here that social risk adjustment is appropriate and necessary in defined circumstances and that social risk adjustment should be the default option when there are valid empirical arguments for and against adjustment for a given measure. Social risk adjustment is an important way to avoid exacerbating inequity in the health care system.
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Affiliation(s)
- David R Nerenz
- David R. Nerenz is the director emeritus of the Center for Health Policy and Health Services Research, Henry Ford Health System, in Detroit, Michigan
| | - J Matthew Austin
- J. Matthew Austin is an assistant professor at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, in Baltimore, Maryland
| | - Daniel Deutscher
- Daniel Deutscher is a senior research scientist at Net Health Systems, Inc., in Pittsburgh, Pennsylvania, and the director of patient reported outcome measures at the MaccabiTech Institute for Research and Innovation, Maccabi Healthcare Services, in Tel Aviv, Israel
| | - Karen E Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine in the Department of Internal Medicine, Washington University School of Medicine, in St. Louis, Missouri
| | - Eugene J Nuccio
- Eugene J. Nuccio is an assistant professor of medicine at the University of Colorado, Anschutz Medical Campus, in Denver, Colorado
| | - Christie Teigland
- Christie Teigland is a principal in the health economics and advanced analytics practice at Avalere Health, in Washington, D.C
| | - Eric Weinhandl
- Eric Weinhandl is a senior epidemiologist in the Chronic Disease Research Group at the Hennepin Healthcare Research Institute, in Minneapolis, Minnesota
| | - Laurent G Glance
- Laurent G. Glance is vice chair for research and a professor in the Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, in Rochester, New York
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Brown CS, Montgomery JR, Neiman PU, Wakam GK, Tsai TC, Dimick JB, Scott JW. Assessment of Potentially Preventable Hospital Readmissions After Major Surgery and Association With Public vs Private Health Insurance and Comorbidities. JAMA Netw Open 2021; 4:e215503. [PMID: 33847752 PMCID: PMC8044735 DOI: 10.1001/jamanetworkopen.2021.5503] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Rehospitalization after major surgery is common and represents a significant cost to the health care system. Little is known regarding the causes of these readmissions and the degree to which they may be preventable. OBJECTIVE To evaluate the degree to which readmissions after major surgery are potentially preventable. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used a weighted sample of 1 937 354 patients from the 2017 National Readmissions Database to evaluate all adult inpatient hospitalizations for 1 of 7 common major surgical procedures. Statistical analysis was performed from January 14 to November 30, 2020. MAIN OUTCOMES AND MEASURES The study calculated 90-day readmission rates as well as rates of readmissions that were considered potentially preventable. Potentially preventable readmissions (PPRs) were defined as those with a primary diagnosis code for superficial surgical site infection, acute kidney injury, aspiration pneumonitis, or any of the Agency for Healthcare Research and Quality-defined ambulatory care sensitive conditions. Multivariable logistic regression was used to identify factors associated with PPRs. RESULTS A total weighted sample of 1 937 354 patients (1 048 046 women [54.1%]; mean age, 66.1 years [95% CI, 66.0-66.3 years]) underwent surgical procedures; 164 755 (8.5%) experienced a readmission within 90 days. Potentially preventable readmissions accounted for 29 321 (17.8%) of all 90-day readmissions, for an estimated total cost to the US health care system of approximately $296 million. The most common reasons for PPRs were congestive heart failure exacerbation (34.6%), pneumonia (12.0%), and acute kidney injury (22.5%). In a multivariable model of adults aged 18 to 64 years, patients with public health insurance (Medicare or Medicaid) had more than twice the odds of PPR compared with those with private insurance (adjusted odds ratio, 2.09; 95% CI, 1.94-2.25). Among patients aged 65 years or older, patients with private insured had 18% lower odds of PPR compared with patients with Medicare as the primary payer (adjusted odds ratio, 0.82; 95% CI, 0.74-0.90). CONCLUSIONS AND RELEVANCE This study suggests that nearly 1 in 5 readmissions after surgery are potentially preventable and account for nearly $300 million in costs. In addition to better inpatient care, improved access to ambulatory care may represent an opportunity to reduce costly readmissions among surgical patients.
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Affiliation(s)
- Craig S. Brown
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - John R. Montgomery
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Pooja U. Neiman
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- National Clinician Scholars Program, University of Michigan, Ann Arbor
| | - Glenn K. Wakam
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Thomas C. Tsai
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - John W. Scott
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
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12
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Affiliation(s)
- Linda Diem Tran
- Stanford-Surgery Policy Improvement Research & Education (S-SPIRE) Center, Stanford University School of Medicine, Palo Alto, California
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