Effects of introducing a fee for inpatient overstays on the rate of death and readmissions across municipalities in Norway

The Impact of the Swedish Care Coordination Act on Hospital Readmission and Length-of-Stay among Multi-Morbid Elderly Patients: A Controlled Interrupted Time Series Analysis

Coordinating follow-up care after discharge from hospital is critical to ensuring good outcomes for patients, but is difficult when multiple care providers are involved. In 2018, Sweden adopted the Care Coordination Act, which modified economic incentives to reduce discharge delays and mandated a discharge planning process for patients requiring post-discharge social- or primary care services. This study evaluates the impact of this reform on hospital length-of-stay and unplanned readmissions among multi-morbid elderly patients. Interrupted time series analysis of all in-patient care episodes involving multi-morbid elderly patients in Sweden from 2015 - 2019 (n = 2 386 039) was performed. Secondary analyses using case-mix adjustment and controlled interrupted time series analysis were employed to assess for bias. Average length of stay decreased during the post-reform period, corresponding to 248 521 saved care days. Unplanned readmissions meanwhile increased, corresponding to 7 572 excess unplanned readmissions. While reductions in length-of-stay were concentrated among patients targeted by the reform, increases in readmission rates were similar in patients not targeted by the reform, indicating potential confounding. The reform thus appears to have achieved its goal of decreasing in-patient length of stay, but a robust effect on readmissions, outpatient visits, or mortality was not found. This may be due to lackluster implementation or an ineffective mandated intervention.

The Causal Effect of Community Hospitals on General Hospital Admissions. Evaluation of a Natural Experiment Using Register Data

Background

To reduce overall healthcare costs, several countries have attempted to shift services from specialist to primary care. This was also the main strategy of the Coordination Reform introduced in Norway in 2012. An important part of the reform was the introduction of Municipal Acute Wards (MAWs), a type of community hospital aimed at reducing admissions to general hospitals. The main objective of this paper is to investigate whether the implementation of MAWs had a causal effect on hospital admissions.

Methods

Monthly admission rates in total and by age groups for patients admitted with acute or elective conditions at internal medicine or surgical departments were analyzed using panel data regression techniques. We identified causal effects by exploiting the sequential roll out of the MAWs within fixed effect analyses. Our data covered all municipalities from start of 2010 until the end of 2017.

Results

The sequential implementation of the MAWs started during the summer of 2012. By the beginning of 2016 close to all municipalities had an operative MAW. The introduction of MAWs significantly reduced acute hospital admissions. The effect was strongest for patients ≥80 years admitted acutely to internal medicine departments. The effects were even stronger if the MAW had a physician on site 24/7 or was located close to a local emergency center.

Conclusion

Our findings suggest that this type of intermediate care unit is a viable option to alleviate the burden on hospitals by reducing acute secondary care admission volumes.

How do busy hospital circumstances affect mortality and readmission within 60 days: A cohort study of 680 000 acute admissions in Norway

OBJECTIVE

To study mortality and readmissions for older patients admitted during more and less busy hospital circumstances.

DESIGN

Cohort study where we identified patients that were admitted to the same hospital, during the same month and day of the week. We estimated effects of inflow of acute patients and the number of concurrent acute inpatients. Mortality and readmissions were analysed using stratified Cox-regression.

SETTING

All people 80 years and older acutely admitted to Norwegian hospitals between 2008 and 2016.

MAIN OUTCOME MEASURES

Mortality and readmissions within 60 days from admission.

RESULTS

Among 294 653 patients with 685 197 admissions, mean age was 86 years (standard deviation 5). Overall, 13% died within 60 days. An interquartile range difference in inflow of acute patients was associated with a hazard ratio (HR) of 0.99, 95% confidence interval (95% CI) 0.98 to 1.00). There was little evidence of differences in readmissions, but a 7% higher risk (HR 1.07, 95% CI 1.06 to 1.09) of being discharged outside ordinary daytime working hours.

CONCLUSIONS

Older patients admitted during busier circumstances had similar mortality and readmissions to those admitted during less busy periods. Yet, they showed a higher risk of discharge outside daytime working hours. Despite limited effects of busyness on a hospital level, there could still be harmful effects of local situations.

Alternative Payment Models and Associations With Stroke Outcomes, Spending, and Service Utilization: A Systematic Review

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.