Hospital characteristics and 30-day all-cause readmission rates

Hospital personnel perspectives on factors influencing acute care patient outcomes: a qualitative approach to model refinement

BACKGROUND

Health systems have long been interested in the best practices for staffing in the acute care setting. Studies on staffing often focus on registered nurses and nurse-to-patient staffing ratios. There were fewer studies on the relationship between interprofessional team members or contextual factors such as hospital and community characteristics and patient outcomes. This qualitative study aimed to refine an explanatory model by soliciting hospital personnel feedback on staffing and patient outcomes.

METHODS

We conducted a qualitative study using semi-structured interviews and thematic analysis to understand hospital personnel's perspectives and experiences of factors that affect acute care inpatient outcomes. Interviews were conducted in 2022 with 38 hospital personnel representing 19 hospitals across Washington state in the United States of America.

RESULTS

Findings support a model of characteristics impacting patient outcomes to include the complex and interconnected relationships between community, hospital, patient, and staffing characteristics. Within the model, patient characteristics were positioned into hospital characteristics, and in turn these were positioned within community characteristics to highlight the importance of setting and context when evaluating outcomes. Together, these factors influenced both staff characteristics and patient outcomes, but these two categories also share a direct relationship.

CONCLUSION

Findings can be applied to hospitals and health systems in a variety of contexts to examine how external factors such as community resource availability impact care delivery. Future research should expand on this work with specific attention to how staffing changes and interprofessional team composition can improve patient outcomes.

A state-level analysis of macro-level factors associated with hospital readmissions

Investigation of the factors that contribute to hospital readmissions has focused largely on individual level factors. We extend the knowledge base by exploring macrolevel factors that may contribute to readmissions. We point to environmental, behavioral, and socioeconomic factors that are emerging as correlates to readmissions. Data were taken from publicly available reports provided by multiple agencies. Partial Least Squares-Structural Equation Modeling was used to test the association between economic stability and environmental factors on opioid use which was in turn tested for a direct association with hospital readmissions. We also tested whether hospital access as measured by the proportion of people per hospital moderates the relationship between opioid use and hospital readmissions. We found significant associations between Negative Economic Factors and Opioid Use, between Environmental Factors and Opioid Use, and between Opioid Use and Hospital Readmissions. We found that Hospital Access positively moderates the relationship between Opioid Use and Readmissions. A priori assumptions about factors that influence hospital readmissions must extend beyond just individualistic factors and must incorporate a holistic approach that also considers the impact of macrolevel environmental factors.

Is there an association between hospital staffing levels and inpatient-COVID-19 mortality rates?

Objective

This study aims to investigate the relationship between RNs and hospital-based medical specialties staffing levels with inpatient COVID-19 mortality rates.

Methods

We relied on data from AHA Annual Survey Database, Area Health Resource File, and UnitedHealth Group Clinical Discovery Database. In phase 1 of the analysis, we estimated the risk-standardized event rates (RSERs) based on 95,915 patients in the UnitedHealth Group Database 1,398 hospitals. We then used beta regression to analyze the association between hospital- and county- level factors with risk-standardized inpatient COVID-19 mortality rates from March 1, 2020, through December 31, 2020.

Results

Higher staffing levels of RNs and emergency medicine physicians were associated with lower COVID-19 mortality rates. Moreover, larger teaching hospitals located in urban settings had higher COVID-19 mortality rates. Finally, counties with greater social vulnerability, specifically in terms of housing type and transportation, and those with high infection rates had the worst patient mortality rates.

Conclusion

Higher staffing levels are associated with lower inpatient mortality rates for COVID-19 patients. More research is needed to determine appropriate staffing levels and how staffing levels interact with other factors such as teams, leadership, and culture to impact patient care during pandemics.

The Hospital Value-Based Purchasing Program: Do hospitalists improve health care value

INTRODUCTION

As healthcare organizations examine the associated benefits of employing a larger hospitalist workforce, there is a need to better understand the association with patients' quality, experience, and efficiency. However, there is a lack of information regarding how hospital use of hospitalists over time influences hospital scoring on quality programs, such as the Center for Medicare and Medicaid Services (CMS) Hospital Inpatient Value-Based Purchasing (HVBP) Program. This study examines the association between hospitalist staffing between 2014 and 2019 and HVBP scores.

METHODS

We used a cross-sectional panel study design. Total Performance Score (TPS) and its domains were obtained from CMS from 2014 to 2019 and merged with the American Hospital Association Annual Survey Database. We utilized random-effects multivariable panel regression models and zero-inflated negative binomial regression to examine the association between the hospitalist-staffing ratio and the HVBP Program. All models were adjusted for hospital characteristics.

RESULTS

A total of 2126 hospitals were included in the study. The average ratio of hospitalists per staffed bed was 0.06, with a standard deviation of 0.15. This study suggests that hospitals that employ a higher percentage of hospitalists see improvement in their overall TPS (β = 5.40; p < .001), Patient Experience (β = 2.49; p <.05), and Efficiency (incidence-rate ratio= 1.41; p < .001) domain. However, the Clinical Care domain was no different in organizations employing more hospitalists.

CONCLUSION

There are benefits associated with TPS, Patient Experience, and Efficiency from employing hospitalists. Managers should seek opportunities to leverage hospitalists' expertise in providing care, particularly in improving care processes.

Physician role differentiation: Patients, practice patterns, and performance

BACKGROUND

Multispecialty clinical settings are increasingly prevalent because of the growing complexity in health care, revealing challenges with overlaps in expertise. We study hospitalists and inpatient specialists to gain insights on how physicians with shared expertise may differentiate themselves in practice.

PURPOSE

The aim of this study was to explore how hospitalists differentiate themselves from other inpatient physicians when treating patient cases in areas of shared expertise, focusing on differences in patient populations, practice patterns, and performance on cost and quality metrics.

METHODOLOGY

We use mixed-effects multilevel models and mediation models to analyze medical records and disaggregated billing data for admissions to a large urban pediatric hospital from January 1, 2009, to August 31, 2015.

RESULTS

In areas of shared physician expertise, patients with more ambiguous diagnoses and multiple chronic conditions are more likely to be assigned to a hospitalist. Controlling for differences in patient populations, hospitalists order laboratory tests and medications at lower rates than specialists. Hospitalists' laboratory testing rate had a significant mediating role in their lower total charges and lower odds of their patients experiencing any nonsurgical adverse events compared to specialists, though hospitalists did not differ from specialists in 30- and 90-day readmission rates.

PRACTICE IMPLICATIONS

Physicians with shared expertise, such as hospitalists and inpatient specialists, differentiate their roles through assignment to ambiguous diagnoses and multisystem conditions, and practice patterns such as laboratory and medication orders. Such differentiation can improve care coordination and establish professional identity when roles overlap.

Vertical integration in healthcare: What does literature say about improvements on quality, access, efficiency, and costs containment?

INTRODUCTION

Vertical integration models involve integrating services from different levels of care (e.g., primary care, acute care, post-acute care). Therefore, one of their main objectives is to increase continuity of care, potentially improving outcomes like efficiency, quality, and access or even enabling cost containment.

OBJECTIVES

This study conducts a literature review and aims at contributing to the contentious discussion regarding the effects of vertical integration reforms in terms of efficiency, costs containment, quality, and access.

METHODS

We performed a systematic search of the literature published until February 2020. The articles respecting the conceptual framework were included in an exhaustive analysis to study the impact of vertical integration on costs, prices of care, efficiency, quality, and access.

RESULTS

A sample of 64 papers resulted from the screening process. The impact of vertical integration on costs and prices of care appears to be negative. Decreases in technical efficiency upon vertical integration are practically out of the question. Nevertheless, there is no substantial inclination to visualise a positive influence. The same happens with the quality of care. Regarding access, the lack of available articles on this outcome limits conjectures.

CONCLUSIONS

In summary, it is not clear yet whether vertically integrated healthcare providers positively impact the overall delivery care system. Nevertheless, the recent growing trend in the number of studies suggests a promising future on the analysis of this topic.

Demystifying hospital charges for hospital readmissions in 2017 in the United States for psychosis (DRG = 885)

Existing research on hospital charges is primarily focused on hospital admissions, but not on hospital readmissions. Our research fills this gap. We utilize the 2017 Hospital Readmissions database from the Agency for Healthcare Research and Quality (AHRQ) to empirically study factors that impact hospital charges for hospital readmissions. We focus on psychosis (DRG = 885) which has 609,360 records in 2017 in the AHRQ database. We employ regression analyses using patient demographics, inpatient care variables, and hospital characteristics to explain variance in hospital charges. Results show that inpatient care (diagnoses, procedures, length of stay), hospital ownership, and younger patients result in higher hospital charges.

A systematic review of vertical integration and quality of care, efficiency, and patient-centered outcomes

BACKGROUND

Small independent practices are increasingly giving way to more complex affiliations between provider organizations and hospital systems. There are several ways in which vertically integrated health systems could improve quality and lower the costs of care. But there are also concerns that integrated systems may increase the price and costs of care without commensurate improvements in quality and outcomes.

PURPOSE

Despite a growing body of research on vertically integrated health systems, no systematic review that we know of compares vertically integrated health systems (defined as shared ownership or joint management of hospitals and physician practices) to nonintegrated hospitals or physician practices.

METHODS

We conducted a systematic search of the literature published from January 1996 to November 2016. We considered articles for review if they compared the performance of a vertically integrated health system and examined an outcome related to quality of care, efficiency, or patient-centered outcomes.

RESULTS

Database searches generated 7,559 articles, with 29 articles included in this review. Vertical integration was associated with better quality, often measured as optimal care for specific conditions, but showed either no differences or lower efficiency as measured by utilization, spending, and prices. Few studies evaluated a patient-centered outcome; among those, most examined mortality and did not identify any effects. Across domains, most studies were observational and did not address the issue of selection bias.

PRACTICE IMPLICATIONS

Recent evidence suggests the trend toward vertical integration will likely continue as providers respond to changing payment models and market factors. A growing body of research on comparative health system performance suggests that integration of physician practices with hospitals might not be enough to achieve higher-value care. More information is needed to identify the health system attributes that contribute to improved outcomes, as well as which policy levers can minimize anticompetitive effects and maximize the benefits of these affiliations.

Factors associated with 30-day and 1-year readmission among psychiatric inpatients in Beijing China: a retrospective, medical record-based analysis

BACKGROUND

Psychiatric readmissions negatively impact patients and their families while increasing healthcare costs. This study aimed at investigating factors associated with psychiatric readmissions within 30 days and 1 year of the index admissions and exploring the possibilities of monitoring and improving psychiatric care quality in China.

METHODS

Data on index admission, subsequent admission(s), clinical and hospital-related factors were extracted in the inpatient medical record database covering 10 secondary and tertiary psychiatric hospitals in Beijing, China. Logistic regressions were used to examine the associations between 30-day and 1-year readmissions plus frequent readmissions (≥3 times/year), and clinical variables as well as hospital characteristics.

RESULTS

The 30-day and 1-year psychiatric readmission rates were 16.69% (1289/7724) and 33.79% (2492/7374) respectively. 746/2492 patients (29.34%) were readmitted 3 times or more within a year (frequent readmissions). Factors significantly associated with the risk of both 30-day and 1-year readmission were residing in an urban area, having medical comorbidities, previous psychiatric admission(s), length of stay > 60 days in the index admission and being treated in tertiary hospitals (p < 0.001). Male patients were more likely to have frequent readmissions (OR 1.30, 95%CI 1.04-1.64). Receiving electroconvulsive therapy (ECT) was significantly associated with a lower risk of 30-day readmission (OR 0.72, 95%CI 0.56-0.91) and frequent readmissions (OR 0.60, 95%CI 0.40-0.91).

CONCLUSION

More than 30% of the psychiatric inpatients were readmitted within 1 year. Urban residents, those with medical comorbidities and previous psychiatric admission(s) or a longer length of stay were more likely to be readmitted, and men are more likely to be frequently readmitted. ECT treatment may reduce the likelihood of 30-day readmission and frequent admissions. Targeted interventions should be designed and piloted to effectively monitor and reduce psychiatric readmissions.

Comparison of Risk-Standardized Readmission Rates of Surgical Patients at Safety-Net and Non-Safety-Net Hospitals Using Agency for Healthcare Research and Quality and American Hospital Association Data

Importance

Medical patients discharged from safety-net hospitals (SNHs) experience higher readmission rates compared with those discharged from non-SNHs. However, little is known about whether this association persists for surgical patients.

Objectives

To examine differences in readmission rates between SNHs and non-SNHs among surgical patients after discharge and determine whether hospital characteristics might account for some of the variation.

Design, Setting, and Participants

This observational retrospective study linked the Healthcare Cost and Utilization Project State Inpatient Databases of the Agency for Healthcare Research and Quality from January 1, 2011, through December 31, 2014, for 4 states (New York, Florida, Iowa, and Washington) with data from the 2014 American Hospital Association annual survey. After identifying surgical discharges, SNHs were defined as those with the top quartile of inpatient stays paid by Medicaid or self-paid. Hospital-level risk-standardized readmission rates (RSRRs) for surgical discharges were calculated. The association between hospital RSRRs and hospital characteristics was evaluated with bivariate analyses. An estimated multivariable hierarchical linear regression model was used to examine variation in hospital RSRRs, adjusting for hospital characteristics, state, year, and SNH status. Data were analyzed from June 1, 2017, through March 1, 2018.

Exposures

Surgical care at an SNH.

Main Outcomes and Measures

Readmission after an index surgical admission.

Results

A total of 1 252 505 patients across all 4 years and states were included in the analysis (51.7% women; mean [SD] age, 52.7 [18.1] years). Bivariate analyses found that SNHs had higher mean (SD) surgical RSRRs compared with non-SNHs; significant differences were found for New York (9.6 [0.1] vs 10.9 [0.1]; P < .001) and Florida (11.6 [0.1] vs 12.1 [0.1]; P = .001). The SNHs also had higher RSRRs in these 2 states when stratified by hospital funding (nonfederal government SNHs in New York, 11.9 [0.2]; for-profit, private SNHs in Florida, 13.1 [0.2]; P < .001 for both); however, bed size was a significant factor for higher mean (SD) RSRRs only for New York (200 to 399 beds, 12.0 [0.4]; P = .006). Similar results were found for multivariable linear regression models; RSRRs were 1.02% higher for SNHs compared with non-SNHs (95% CI, 0.75%-1.29%; P < .001). Increased RSRRs were observed for hospitals in New York and Florida, teaching hospitals, and investor-owned hospitals. Factors associated with reduced RSRRs included presence of an ambulatory surgery center, cardiac catheterization capabilities, and high surgical volume.

Conclusions and Relevance

According to results of this study, surgical patients treated at SNHs experienced slightly higher RSRRs compared with those treated at non-SNHs. This association persisted after adjusting for year, state, and hospital factors, including teaching status, hospital bed size, and hospital volume.

Associations between Medicaid expansion and nurse staffing ratios and hospital readmissions

OBJECTIVE

To examine the associations between Medicaid expansion and nurse staffing ratios and hospital-wide readmission rates.

DATA SOURCES

Secondary data from the 2011-2016 Healthcare Cost Report Information System, the American Hospital Association Annual Survey, and the Hospital Compare data.

STUDY DESIGN

Difference-in-difference models are used to compare outcomes in hospitals located in states that expanded Medicaid with those located in nonexpansion states. The changes in nurse staffing ratios and hospital-wide readmission rates are calculated in each one of the postexpansion years (2014, 2015, and 2016), compared to pre-expansion.

PRINCIPAL FINDINGS

Results indicate that nurse staffing ratios increased, whereas hospital-wide readmission rates declined in expansion states relative to nonexpansion states. Nurse staffing ratios increased by 0.33, 0.42, and 0.46 registered nurses hours per adjusted patient days in 2014, 2015, and 2016 in hospitals located in expansion states, compared with hospitals in nonexpansion states after expansion. This increase was statistically significant (P < .001) in 2015 and 2016, but marginally significant (P = .016) in 2014. Hospital-wide readmission rates statistically significantly decreased by 9, 16, and 18 per 10 000 patients (P < .001) in 2014, 2015, and 2016, respectively, in expansion vs nonexpansion states hospitals after expansion.

CONCLUSIONS

Medicaid expansion was associated with gradually improved hospitals' nurse staffing ratios and hospital-wide readmission rates from 2014 through 2016. The continued monitoring of quality measures of hospitals can help assess the impact of Medicaid expansion over a longer period of time.

Hospitalists staffing levels and hospital performance

OBJECTIVE (OR STUDY QUESTION)

To examine the association between hospitalists staffing levels and contract type with CMS Total Performance Score (TPS).

DATA SOURCES/STUDY SETTING

Total performance scores were obtained from CMS, hospital-level data from the 2015 American Hospital Association Annual Survey Database, and unemployment rates from the Area Resource Health File.

STUDY DESIGN

We used cluster analysis to classify hospitals based on the distribution of various hospitalist contracts, and we used regression analysis to examine the association between TPS and hospitalist staffing levels and contract distributions. Hospital-level predictors included hospitalists staffing levels, RN staffing levels, and Magnet status. Market-level variables were unemployment rates and competition.

PRINCIPAL FINDINGS

Higher staffing levels of employed hospitalists or hospitalists with a group contract are associated with higher TPS (with coefficient estimates of 0.85 and 0.83, respectively, and the same standard error of 0.22). Higher staffing levels of hospitalists under individual contract are negatively associated with TPS (with coefficient estimate of -0.43 and standard error of 0.21). Based on the regression analysis using hospital clusters as independent variables, hospitals with individual contracts or without hospitalists providing care had significantly worse TPS compared to hospitals that predominantly employ hospitalists (with coefficient estimate of -1.80 and standard error of 0.61). Magnet status, RN staffing levels, and small and medium size were positively associated with TPS. Medicare share of inpatient days, teaching status, AMCs, and for-profit and public nonfederal ownership were negatively associated with TPS.

CONCLUSIONS

Adequate hospitalist staffing level is important for hospitals to achieve better performance. Hospitals need to consider the mix of arrangements or contracts that they have with hospitalists.

Medical-surgical readmissions in patients with co-occurring serious mental illness: A systematic review and meta-analysis

OBJECTIVE

To estimate the relationship between comorbid serious mental illness (SMI) diagnosis and 30-day medical-surgical readmissions.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) we searched five databases (2012 to 2017) to identify relevant articles on the relationship between SMI diagnosis and readmissions. We used the National Institute of Health's Quality Appraisal Tool for Observational Cohort and Cross-Sectional Studies guidelines to appraise studies and assess risk of bias. Data were narratively synthesized and a pooled random effects unadjusted odds ratio was estimated using meta-analysis. Heterogeneity was investigated using subgroup analysis and meta-regression.

RESULTS

Our search yielded 424 articles after removing duplicates. Nine met inclusion criteria. All studies were retrospective observational cohort studies. The meta-analysis showed that people with SMI have greater odds of readmission than people without SMI (pooled OR 1.38, CI 1.23-1.56, I² = 98.6%). There was heterogeneity in patient cohorts, study methodology, and definition of SMI. No significant possibility of publication bias was detected (Classic fail-safe N = 3480).

CONCLUSION

There is a meaningful relationship between SMI diagnosis and medical-surgical readmissions. Given the prevalence of SMI in patients hospitalized for medical-surgical problems and the heterogeneity of evidence, further research on sources of variation in outcomes is critically needed.

Challenges faced in rural hospitals: the experiences of nurse managers in Uganda

AIM

The aim of this study was to understand nurse ward managers perceived challenges in the rural healthcare setting in Uganda.

BACKGROUND

The health workforce, essential medicines and equipment and political unrest are the main factors affecting the international community in addressing the hefty disease burden in World Health Organization African regions. Nurse ward managers have an important role to play to mitigate these factors in health facilities in these regions through leadership, supervision and support for staff.

METHODS

This study utilized interpretive phenomenology based on Gadamer's hermeneutical principles. Eleven nurse managers from two rural public hospitals in Uganda were interviewed. Those with more than a 2-year experience in their management role were invited to participate in the study.

RESULTS

Nurse managers pointed out four major challenges with staffing, while they worked in the rural healthcare settings. These are summarized into themes: 'Numbers do matter'; 'I cannot access them when I need them at work'; 'Challenges in dealing with negative attitudes'; and 'Questioning own ability to manage health services'.

DISCUSSION

Health facilities in rural areas face extremely low staff-to-patient ratio, a high level of workload, lack of essential medicines and equipment, low salaries and delayed payment for staff.

CONCLUSION

Nurse managers demonstrated situation-based performance to minimize the impact of these challenges on the quality and safety of patient care, but they had less influence on policy and resource development.

IMPLICATIONS FOR NURSING POLICY

It is imperative to mobilize education for nurse ward managers to enable them to improve leadership, management skills and to have a greater impact on policy and resource development.

Era of hospitalists

Hospitalists, known as physicians, are an emerging group in the medical field that is focused on the general medical care of hospitalized patients. Specializing in hospital medicine, they often attract a mix of appreciation and criticism. In the present manuscript, we review the pros and cons of a hospitalist in the health-care system. Although experts agree that hospitalists add value to the health-care system by reducing costs, streamlining administrative processes, and contributing to improved health-care outcomes, there is a large degree of disagreement regarding the extent of hospitalist contribution to overall improvements on health-care outcomes. In this paper, new strategies to overcome reported shortcomings and to further improve the quality of health care are discussed. Abbreviations: SHM: Society of Hospital Medicine; BOOST: Better Outcomes by Optimizing Safe Transitions; RED: Re-Engineered Discharge; CHF: chronic heart failure; MI: myocardial infarction; ICU: intensive care unit; PACT: post-acute care transitions; MRSA: methicillin-resistant Staphylococcus aureus; CINAHL: The Cumulative Index to Nursing and Allied Health Literature; PCP: primary care physician.

Is the effectiveness of memory assessment services associated with their structural and process characteristics?

OBJECTIVES

The aim of this study was to investigate whether structural and process characteristics of memory assessment services (MASs) are associated with outcomes (changes in patients' health-related quality of life (HRQL), carers' HRQL and carers' burden) over the first 6 months following the first appointment.

METHODS

Data from 785 patients referred to 69 MASs and 511 of their lay carers, collected at the first appointment and 6 months later. Data on MAS characteristics were collected using a questionnaire at baseline. We used multilevel linear regression models to explore the associations of patients' HRQL and carers' outcomes with structural and process characteristics of MASs. Analyses were conducted on the full sample of patients and carers, and separately on those patients diagnosed with dementia.

RESULTS

None of the structural (skill mix, workload, volume, provision of clinical assessments and provision of psychosocial support) or process (waiting time, length and number of appointments, anti-dementia drug use and psychosocial interventions use) characteristics included in the analyses were associated with patients' or carers' outcomes at 6 months, apart from the presence of allied health professionals (AHPs), which was associated with a DEMQOL score 2.7 points higher. When only those with a diagnosis of dementia were considered, the association with presence of AHPs was no longer observed.

CONCLUSIONS

Apart from involving AHPs, alterations to the way MASs are structured or function appear unlikely to improve their effectiveness in improving patients' and carers' HRQL. It is possible that the characteristics of MASs may influence patients' and carers' experience, but this was not studied. Copyright © 2017 John Wiley & Sons, Ltd.