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Wahlstedt E, Kelly T, Jung M, Harris A. Unplanned 120-Day ED Visits and Readmission Rates Following Common Stone Procedures. Urology 2023; 176:42-49. [PMID: 36931570 DOI: 10.1016/j.urology.2023.02.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/12/2023] [Accepted: 02/28/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To quantify emergency department (ED) visits and hospital admissions (HA) after common urologic stone procedures including ureteroscopy (URS), shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCL) which are a concern of payors, providers, and patients. MATERIALS AND METHODS This is a retrospective cohort study using claims data from the IBM MarketScan Commercial and Medicare Supplement databases. Adults with a urologic stone diagnosis and no history of stone procedure in prior 12 months who underwent stone procedures between 2012 and 2017 were included. All-cause ED visits and HA were evaluated during 30, 60, 90, and 120-day periods following the index urologic stone procedure. RESULTS A total of 166,287 patients were included in the analytic cohort. For inpatient-indexed procedures, cumulative ED visits rates following stone procedure at 120 days was 18.8% for URS, 19.2% for SWL, and 23.6% for PCL. A similar trend was observed with ED visit rates, following outpatient indexed procedures at 120 days with a cumulative rate of 14.2% of SWL patients, 14.9% of URS patients, and 17.3% of PCL. A similar trend was found when examining HA. ED and HA rates increased steadily through the 120-day time period. CONCLUSION Rates of ED visits and HA following common stone procedures continue to rise at least up to 120 days following the index procedure whether in the outpatient or inpatient settings. While rates of unplanned care are similar for URS and SWL, patients undergoing PCL return to the hospital at higher rates.
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Affiliation(s)
- Eric Wahlstedt
- Department of Urology, University of Kentucky, UK College of Medicine, Lexington KY.
| | - Timothy Kelly
- Department of Health Economics and Outcomes Research, Becton-Dickinson, Atlanta, GA
| | - Molly Jung
- Department of Health Economics and Outcomes Research, Becton-Dickinson, Franklin Lakes, NJ
| | - Andrew Harris
- Department of Urology, University of Kentucky, Medical Center, Lexington KY
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Filippi M, Del Prete E, Aquilini F, Totaro M, Di Serafino F, Civitelli S, Geminale G, Rocchi D, Zotti N, Baggiani A. Evaluation, Description and Magnitude of Readmission Phenomenon in Azienda Ospedaliero Universitaria Pisana (AOUP) for Chronic-Degenerative Diseases in the Period 2018-2021. Healthcare (Basel) 2023; 11:healthcare11050651. [PMID: 36900656 PMCID: PMC10001156 DOI: 10.3390/healthcare11050651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Readmissions are hospitalizations following a previous hospitalization (called index hospitalization) of the same patient that occurred in the same facility or nursing home. They may be a consequence of the progression of the natural history of a disease, but they may also reveal a previous suboptimal stay, or ineffective management of the underlying clinical condition. Preventing avoidable readmissions has the potential to improve both a patient's quality of life, by avoiding exposure to the risks of re-hospitalization, and the financial well-being of health care systems. METHODS We investigated the magnitude of 30 day repeat hospitalizations for the same Major Diagnostic Category (MDC) in the Azienda Ospedaliero Universitaria Pisana (AOUP) over the period from 2018 to 2021. Records were divided into only admissions, index admissions and repeated admission. The length of the stay of all groups was compared using analysis of variance and subsequent multi-comparison tests. RESULTS Results showed a reduction in readmissions over the period examined (from 5.36% in 2018 to 4.46% in 2021), likely due to reduced access to care during the COVID-19 pandemic. We also observed that readmissions predominantly affect the male sex, older age groups, and patients with medical Diagnosis Related Groups (DRGs). The length of stay of readmissions was longer than that of index hospitalization (difference of 1.57 days, 95% CI 1.36-1.78 days, p < 0.001). The length of stay of index hospitalization is longer than that of single hospitalization (difference of 0.62 days, 95% CI 0.52-0.72 days, p < 0.001). CONCLUSIONS A patient who goes for readmission thus has an overall hospitalization duration of almost two and a half times the length of the stay of a patient with single hospitalization, considering both index hospitalization and readmission. This represents a heavy use of hospital resources, about 10,200 more inpatient days than single hospitalizations, corresponding to a 30-bed ward working with an occupancy rate of 95%. Knowledge of readmissions is an important piece of information in health planning and a useful tool for monitoring the quality of models of patient care.
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Affiliation(s)
- Matteo Filippi
- The Azienda Ospedaliero Universitaria Pisana (AOUP), 56100 Pisa, Italy
| | - Erika Del Prete
- Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy
| | | | - Michele Totaro
- Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy
| | - Francesca Di Serafino
- Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy
| | - Sara Civitelli
- Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy
| | - Giulia Geminale
- Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy
| | - David Rocchi
- Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy
| | - Nunzio Zotti
- Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy
| | - Angelo Baggiani
- The Azienda Ospedaliero Universitaria Pisana (AOUP), 56100 Pisa, Italy
- Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy
- Correspondence: ; Tel.: +050-2213583; Fax: +050-2213588
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Abstract
BACKGROUND Discharge planning is a routine feature of health systems in many countries that aims to reduce delayed discharge from hospital, and improve the co-ordination of services following discharge from hospital and reduce the risk of hospital readmission. This is the fifth update of the original review. OBJECTIVES To assess the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two trials registers on 20 April 2021. We searched two other databases up to 31 March 2020. We also conducted reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA Randomised trials that compared an individualised discharge plan with routine discharge that was not tailored to individual participants. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS Two review authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies by older people with a medical condition, people recovering from surgery, and studies that recruited participants with a mix of conditions. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data it was not possible because of differences in the reporting of outcomes, we summarised the reported results for each trial in the text. MAIN RESULTS We included 33 trials (12,242 participants), four new trials included in this update. The majority of trials (N = 30) recruited participants with a medical diagnosis, average age range 60 to 84 years; four of these trials also recruited participants who were in hospital for a surgical procedure. Participants allocated to discharge planning and who were in hospital for a medical condition had a small reduction in the initial hospital length of stay (MD - 0.73, 95% confidence interval (CI) - 1.33 to - 0.12; 11 trials, 2113 participants; moderate-certainty evidence), and a relative reduction in readmission to hospital over an average of three months follow-up (RR 0.89, 95% CI 0.81 to 0.97; 17 trials, 5126 participants; moderate-certainty evidence). There was little or no difference in participant's health status (mortality at three- to nine-month follow-up: RR 1.05, 95% CI 0.85 to 1.29; 8 trials, 2721 participants; moderate certainty) functional status and psychological health measured by a range of measures, 12 studies, 2927 participants; low certainty evidence). There was some evidence that satisfaction might be increased for patients (7 trials), caregivers (1 trial) or healthcare professionals (2 trials) (very low certainty evidence). The cost of a structured discharge plan compared with routine discharge is uncertain (7 trials recruiting 7873 participants with a medical condition; very low certainty evidence). AUTHORS' CONCLUSIONS A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received. The impact on patient health status and healthcare resource use or cost to the health service is uncertain.
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Affiliation(s)
- Daniela C Gonçalves-Bradley
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Natasha A Lannin
- Brain Recovery and Rehabilitation Group, Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Lindy Clemson
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Sydney Medical School, Northern Clinical School, The University of Sydney, St Leonards, Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Taylor K, Davidson PM. Readmission to the hospital: common, complex and time for a re-think. J Clin Nurs 2021; 30:e56-e59. [PMID: 33394525 DOI: 10.1111/jocn.15631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 12/31/2020] [Indexed: 11/29/2022]
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Fouayzi H, Ash AS. High-frequency hospital users: The tail that wags the readmissions dog. Health Serv Res 2021; 57:579-586. [PMID: 34075581 DOI: 10.1111/1475-6773.13677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/28/2021] [Accepted: 05/04/2021] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To describe the characteristics of high-frequency hospital users (four or more hospitalizations in a year) and the consequences of including or excluding their data from a readmission-based measure. DATA SOURCES 2015 and 2016 Massachusetts Medicaid data. STUDY DESIGN We compare demographics, morbidity burden, and social risk factors for high- and low-frequency hospital users, and membership in 17 accountable care organizations. We evaluate how excluding hospitalizations of high-frequency users from a 30-day readmission measure (with or without risk adjustment) changes its rate and variability and affects performance rankings of accountable care organizations. The outcome is readmission within 30 days; each live discharge from a hospital contributes one observation. DATA COLLECTION/EXTRACTION METHODS We studied 74 706 hospitalizations of 42 794 MassHealth members, 18-64 years old, managed-care-eligible, and ever hospitalized in 2016. PRINCIPAL FINDINGS Among adult managed-care-eligible MassHealth members with at least one acute hospitalization, 8.7% were high-frequency hospital users; they contributed 30.2% of hospitalizations and 69.4% of readmissions. High-frequency users were more often male (77.1% vs. 50.0%; P < 0.001) and sicker (mean medical morbidity score was 3.3 vs. 1.9; P < 0.001) than others. They also had significant social risks: 33.1% with housing problems, 44.1% disabled, 83.2% with serious mental illness, and 77.1% with substance abuse disorder (vs. 22.0%, 27.3%, 60.2%, and 50.0%, respectively, for other hospital users [all P values <0.001]). Fully 50.7% of hospitalizations for high-frequency users led to 30-day readmissions (vs. 9.7%), contributing 72.0% of the variance in 30-day readmission, and substantially affecting judgments about the relative performance of accountable care organizations. CONCLUSIONS A small group of high-frequency hospital users have a disproportionate effect on 30-day readmission rates. This negatively affects some Medicaid ACOs, and more broadly is likely to adversely affect safety net hospitals. How these metrics are used should be reconsidered in this context.
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Affiliation(s)
- Hassan Fouayzi
- Meyers Primary Care Institute, (a joint endeavor of the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health), Worcester, Massachusetts, USA
| | - Arlene S Ash
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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6
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Chen R, Yang C, Zhu M, Chu H, Wang J, Gao B, Liu L, Jiang Y, Lin Y, Wu J, Kong G, Wang F, Zhang L, Zhao M. Association of cardiovascular disease with 30-day hospital readmission in Chinese patients receiving maintenance dialysis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:617. [PMID: 33987315 PMCID: PMC8106029 DOI: 10.21037/atm-20-2367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Previous studies have shown cardiovascular disease (CVD) to be a risk factor in the prediction of 30-day hospital readmission among patients receiving dialysis. However, studies of Asian populations are limited. In the present study, we examined the association between CVD and 30-day hospital readmission in Chinese patients receiving maintenance dialysis. Methods Patients receiving maintenance dialysis were identified by searching a national claims database, the China Health Insurance Research Association (CHIRA) database, using the International Classification of Diseases revision 10 (ICD-10) and items of medical service claims. Patients aged ≥18 years who were discharged after index hospitalization between January 2015 and December 2015 were included in our retrospective analysis. CVD-related diagnoses were divided into three categories: coronary heart disease (CHD), heart failure (HF), and stroke. Thirty-day hospital readmission was defined as any hospital readmission within the 30 days following discharge. Logistic regression models adjusted for logit of propensity scores (PS) were used to assess the association of CVD with 30-day hospital readmission. Results Of 4,700 patients receiving dialysis, the 30-day hospital readmission rate was 10.4%. Compared with patients without CVD, there was an increased risk of 30-day hospital readmission among maintenance dialysis patients with total CVD [odds ratio (OR): 1.33, 95% confidence interval (CI): 1.06–1.66]. Patients with HF (OR: 1.77, CI: 1.27–2.47) and stroke (OR: 2.14, 95% CI: 1.53–2.98) had a greater risk of 30-day hospital readmission. The fully adjusted OR of CHD for the risk of 30-day hospital readmission was 1.22 (95% CI: 0.97–1.55). Conclusions CVDs, especially stroke and HF, are independent predictors of 30-day hospital readmission in Chinese patients receiving dialysis, and could help to guide interventions to improve the quality of care for these patients.
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Affiliation(s)
- Rui Chen
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Chao Yang
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Ming Zhu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Hong Chu
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Jinwei Wang
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Bixia Gao
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Lili Liu
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Yifang Jiang
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Yu Lin
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Jingyi Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Guilan Kong
- National Institute of Health Data Science at Peking University, Beijing, China.,Center for Data Science in Health and Medicine, Peking University, Beijing, China
| | - Fang Wang
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Luxia Zhang
- Department of Medicine, Peking University First Hospital, Beijing, China.,National Institute of Health Data Science at Peking University, Beijing, China.,Center for Data Science in Health and Medicine, Peking University, Beijing, China
| | - Minghui Zhao
- Department of Medicine, Peking University First Hospital, Beijing, China.,Peking-Tsinghua Center for Life Science, Beijing, China
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7
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Unplanned 30-day readmission rates after plastic and reconstructive surgery procedures: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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8
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Kaya S, Sain Guven G, Teleş M, Aydan S, Kar A, Bahcecioglu AB, Firat Senturk E. Emergency department visits following discharge: Implications for healthcare management. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2020. [DOI: 10.1080/20479700.2020.1762050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Sıdıka Kaya
- Department of Health Care Management, Faculty of Economics and Administrative Sciences, Hacettepe University, Ankara, Turkey
| | - Gulay Sain Guven
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mesut Teleş
- Department of Health Management, Niğde Zübeyde Hanım School of Health, Niğde Ömer Halisdemir University, Niğde, Turkey
| | - Seda Aydan
- Department of Health Care Management, Faculty of Economics and Administrative Sciences, Hacettepe University, Ankara, Turkey
| | - Ahmet Kar
- Department of Health Care Management, Faculty of Health Sciences, Kırıkkale University, Kırıkkale, Turkey
| | - A. Begum Bahcecioglu
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Esra Firat Senturk
- Taşköprü State Hospital, Kastamonu, Turkey
- Present address: Cincinnati Children Hospital, Cincinnati, Ohio, USA
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9
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Hospital Readmissions to Nonindex Hospitals: Patterns and Determinants Following the Medicare Readmission Reduction Penalty Program. J Healthc Qual 2020; 42:e10-e17. [DOI: 10.1097/jhq.0000000000000199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Ambugo EA, Hagen TP. Effects of introducing a fee for inpatient overstays on the rate of death and readmissions across municipalities in Norway. Soc Sci Med 2019; 230:309-317. [PMID: 31027865 DOI: 10.1016/j.socscimed.2019.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 02/19/2019] [Accepted: 04/06/2019] [Indexed: 11/29/2022]
Abstract
The Norwegian healthcare coordination reform (Samhandlingsreformen) was implemented from January 1, 2012. In addition to providing municipalities with funding to strengthen their health infrastructure, it required municipalities to pay hospitals a daily fee for patients who, having been declared ready for discharge and in need of municipal health services, were not received by the municipalities on time. This study examines the effects of the reform on the rate of death and readmissions occurring within 60 days of hospitalization. We use aggregated municipal data for years 2009, 2010, 2012-2014 (N = 1646) for Norwegian patients (age 18+) hospitalized in the same years for COPD/asthma, heart failure, hip fracture, and stroke. We stratify our analyses of the municipal data by these patient groups. Our linear regression models test for moderated (interaction) effects whereby associations between the reform and the rate of death and readmissions vary by whether or not patients were classified as ready for discharge and in need of follow-up care in the municipality. The models adjust for municipal sociodemographic and health characteristics. We found no statistically significant moderated effects of the reform across the patient groups, except for patients with stroke (b = .027, SE = 0.109, p < .05). Specifically, compared to the pre-reform period (2009-2010), the post-reform period (2012-2014) was associated with a higher rate of readmissions at high predicted values of needing follow-up care. Even though our analyses of municipal data suggest that patients with stroke are vulnerable to the reform and its incentive scheme, there is no strong evidence overall to suggest that the Norwegian healthcare coordination reform is functioning in a manner that exacerbates the risk of death and readmissions.
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Affiliation(s)
- Eliva Atieno Ambugo
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Postboks 1089 Blindern, 0318, Oslo, Norway.
| | - Terje P Hagen
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Postboks 1089 Blindern, 0318, Oslo, Norway
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Wagner TH, Almenoff P, Francis J, Jacobs J, Pal Chee C. Assessment of the Medicare Advantage Risk Adjustment Model for Measuring Veterans Affairs Hospital Performance. JAMA Netw Open 2018; 1:e185993. [PMID: 30646300 PMCID: PMC6324352 DOI: 10.1001/jamanetworkopen.2018.5993] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Policymakers and consumers are eager to compare hospitals on performance metrics, such as surgical complications or unplanned readmissions, measured from administrative data. Fair comparisons depend on risk adjustment algorithms that control for differences in case mix. OBJECTIVE To examine whether the Medicare Advantage risk adjustment system version 21 (V21) adequately risk adjusts performance metrics for Veterans Affairs (VA) hospitals. DESIGN, SETTING, AND PARTICIPANTS This cohort analysis of administrative data from all 5.5 million veterans who received VA care or VA-purchased care in 2012 was performed from September 8, 2015, to October 22, 2018. Data analysis was performed from January 22, 2016, to October 22, 2018. EXPOSURES A patient's risk as measured by the V21 model. MAIN OUTCOMES AND MEASURES The main outcome was total cost, and the key independent variable was the V21 risk score. RESULTS Of the 5 472 629 VA patients (mean [SD] age, 63.0 [16.1] years; 5 118 908 [93.5%] male), the V21 model identified 694 706 as having a mental health or substance use condition. In contrast, a separate classification system for psychiatric comorbidities identified another 1 266 938 patients with a mental health condition. The V21 model missed depression not otherwise specified (396 062 [31.3%]), posttraumatic stress disorder (345 338 [27.3%]), and anxiety (129 808 [10.2%]). Overall, the V21 model underestimated the cost of care by $2314 (6.7%) for every person with a mental health diagnosis. CONCLUSIONS AND RELEVANCE The findings suggest that current aspirations to engender competition by comparing hospital systems may not be appropriate or fair for safety-net hospitals, including the VA hospitals, which treat patients with complex psychiatric illness. Without better risk scores, which is technically possible, outcome comparisons may potentially mislead consumers and policymakers and possibly aggravate inequities in access for such vulnerable populations.
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Affiliation(s)
- Todd H. Wagner
- Stanford University School of Medicine, Palo Alto, California
- Center for Innovation to Implementation, VA Palo Alto, Menlo Park, California
- Health Economics Resource Center, VA Palo Alto, Menlo Park, California
| | - Peter Almenoff
- Office of Secretary, Department of Veterans Affairs, Washington, DC
- Center of Innovation, Department of Veterans Affairs, Washington, DC
- Program for Quality Improvement/Patient Safety, School of Medicine, University of Missouri–Kansas City, Kansas City
- Office of Reporting, Analytics, Performance, Improvement, and Deployment, Department of Veterans Affairs, Washington, DC
| | - Joseph Francis
- Office of Reporting, Analytics, Performance, Improvement, and Deployment, Department of Veterans Affairs, Washington, DC
| | - Josephine Jacobs
- Center for Innovation to Implementation, VA Palo Alto, Menlo Park, California
- Health Economics Resource Center, VA Palo Alto, Menlo Park, California
| | - Christine Pal Chee
- Health Economics Resource Center, VA Palo Alto, Menlo Park, California
- Department of Public Policy, Stanford University, Palo Alto, California
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12
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Beck AC, Goffredo P, Hassan I, Sugg SL, Lal G, Howe JR, Weigel RJ. Risk factors for 30-day readmission after adrenalectomy. Surgery 2018; 164:766-773. [PMID: 30097166 DOI: 10.1016/j.surg.2018.04.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Readmissions represent a substantial burden to the health care system. Risk factors for 30-day readmission after adrenalectomy were examined. METHODS Patients who underwent adrenalectomy were selected from the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2015. RESULTS Among 4,221 patients who underwent adrenalectomy, 216 (5.1%) were readmitted. On multivariate analysis, pre-operative predictive factors associated with readmission were American Society of Anesthesiologists classification (odds ratio [OR] 1.4, confidence interval [CI] 1.1-1.8), disseminated cancer (OR 1.6, CI 1.1-2.5), and adrenal injury (OR 10.9, CI 1.8-68.9). Elective procedures had fewer readmissions (OR 0.50, CI 0.33-0.76). and procedures with greater relative value units had greater readmission rates (OR 1.01, CI 1.004-1.02). An open adrenalectomy (21% of patients) had a higher rate of readmission than a laparoscopic approach (8.0% vs 4.3%, OR 1.5, CI 1.1-2.0). Postoperative risk factors affecting readmission included reoperations (OR 3.2, CI 1.3-8.0), wound complications (OR 6.6, CI 3.8-11.7), systemic infection (OR 6.5, CI 3.9-10.7), renal complications (OR 7.1, CI 2.6-19.2), venous thrombotic events (OR 11.3, CI 5.6-22.6), and discharge to home (OR 0.40, CI 0.22-0.73). CONCLUSION Encouraging the appropriate use of laparoscopic adrenalectomy, preventing venous thrombotic events and surgical infections, and improving early post-operative follow-up in high-risk patients may decrease readmissions.
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Affiliation(s)
- Anna C Beck
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Paolo Goffredo
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Imran Hassan
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Sonia L Sugg
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Geeta Lal
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - James R Howe
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Ronald J Weigel
- From the Department of Surgery, University of Iowa, Iowa City, Iowa..
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Socwell CP, Bucci L, Patchell S, Kotowicz E, Edbrooke L, Pope R. Utility of Mayo Clinic's early screen for discharge planning tool for predicting patient length of stay, discharge destination, and readmission risk in an inpatient oncology cohort. Support Care Cancer 2018; 26:3843-3849. [PMID: 29777381 DOI: 10.1007/s00520-018-4252-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/06/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE To examine the feasibility of using the Mayo Clinic's Early Screen for Discharge Planning (ESDP) tool in determining its predictive ability in an inpatient oncology hospital setting for variables including length of stay (LOS), discharge destination, and readmission risk. METHODS A prospective observational study was conducted at a metropolitan tertiary cancer centre in Melbourne, Australia. The ESDP score, along with patient outcomes and characteristics, were collected to examine the relationships between positive and negative ESDP scores and patient outcomes. RESULTS A total of 136 participants met inclusion criteria for this study. The proportion with positive ESDP scores was greater in those with unplanned hospital admissions compared with planned admissions (χ2(1, n = 136) = 3.94, p = 0.047). The ESDP status was not a significant predictor of oncology hospital LOS (rpb = 0.116, p = 0.178); however, the ESDP scores did predict discharge destination (χ2(2, n = 136) = 20.22, p < .001). Those re-admitted within 14 days were more likely to have negative ESDP scores than those not readmitted within this time period (χ2(1, n = 136) = 5.22, p = 0.022). Those with positive ESDP scores received a greater number of hospital services whilst admitted than those with negative scores (rpb = 0.388, p < .001) and were more likely to receive particular types of services. CONCLUSION The findings from this study suggest that the ESDP tool could be useful in an adult inpatient oncology population in a hospital with defined specialised hospital discharge planning services (SHDCPS). The ESDP may be beneficial for early identification of service types likely to be required in care and likely discharge destination, both of which can assist discharge planning (DP); however, the ESDP was not useful for predicting LOS or readmission risk in the adult inpatient oncology population without a SHDCPS model in place.
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Affiliation(s)
- Caitlyn P Socwell
- Doctor of Physiotherapy Program, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4226, Australia.
| | - Lucy Bucci
- Physiotherapy Department, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
| | - Sharni Patchell
- Physiotherapy Department, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
| | - Erika Kotowicz
- Physiotherapy Department, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
| | - Lara Edbrooke
- Physiotherapy Department, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
| | - Rodney Pope
- Doctor of Physiotherapy Program, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4226, Australia.,School of Community Health, Charles Sturt University, Albury, NSW, 2640, Australia
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Vuagnat A, Yilmaz E, Roussot A, Rodwin V, Gadreau M, Bernard A, Creuzot-Garcher C, Quantin C. Did case-based payment influence surgical readmission rates in France? A retrospective study. BMJ Open 2018; 8:e018164. [PMID: 29391376 PMCID: PMC5829593 DOI: 10.1136/bmjopen-2017-018164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To determine whether implementation of a case-based payment system changed all-cause readmission rates in the 30 days following discharge after surgery, we analysed all surgical procedures performed in all hospitals in France before (2002-2004), during (2005-2008) and after (2009-2012) its implementation. SETTING Our study is based on claims data for all surgical procedures performed in all acute care hospitals with >300 surgical admissions per year (740 hospitals) in France over 11 years (2002-2012; n=51.6 million admissions). INTERVENTIONS We analysed all-cause 30-day readmission rates after surgery using a logistic regression model and an interrupted time series analysis. RESULTS The overall 30-day all-cause readmission rate following discharge after surgery increased from 8.8% to 10.0% (P<0.001) for the public sector and from 5.9% to 8.6% (P<0.001) for the private sector. Interrupted time series models revealed a significant linear increase in readmission rates over the study period in all types of hospitals. However, the implementation of case-based payment was only associated with a significant increase in rehospitalisation rates for private hospitals (P<0.001). CONCLUSION In France, the increase in the readmission rate appears to be relatively steady in both the private and public sector but appears not to have been affected by the introduction of a case-based payment system after accounting for changes in care practices in the public sector.
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Affiliation(s)
- Albert Vuagnat
- Department of Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France
- Division of Research and Statistics, Ministry of Health, Paris, France
| | - Engin Yilmaz
- Division of Research and Statistics, Ministry of Health, Paris, France
- School of Economics, University of Sorbonne, Paris, France
| | - Adrien Roussot
- Department of Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France
| | - Victor Rodwin
- The Robert F. Wagner School of Public Service, New York University, New York, USA
| | - Maryse Gadreau
- Laboratoire d’Economie de Dijon, Université Bourgogne/Franche-Comté, Inserm U1200, CNRS UMR 6307, Dijon, France
| | - Alain Bernard
- Department of Thoracic Surgery, University Hospital, Dijon, France
| | - Catherine Creuzot-Garcher
- Department of Ophthalmology, University Hospital, Dijon, France
- Eye and Nutrition Research Group, Bourgogne Franche-Comté University, Dijon, France
| | - Catherine Quantin
- Department of Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France
- Clinical Investigation Center, Dijon University Hospital, Dijon, France
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), INSERM, UVSQ, Institut Pasteur, Université Paris-Saclay, Paris, France
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15
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Izón GM, Pardini CA. Association Between Medicare's Mandatory Hospital Value-Based Purchasing Program and Cost Inefficiency. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:79-90. [PMID: 29081000 DOI: 10.1007/s40258-017-0357-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND The Patient Protection and Affordable Care Act instituted pay-for-performance programs, including Hospital Value-Based Purchasing (HVBP), designed to encourage hospital quality and efficiency. OBJECTIVE AND METHOD While these programs have been evaluated with respect to their implications for care quality and financial viability, this is the first study to assess the relationship between hospitals' cost inefficiency and their participation in the programs. We estimate a translog specification of a stochastic cost frontier with controls for participation in the HVBP program and clinical and outcome quality for California hospitals for 2012-2015. RESULTS The program-participation indicators' parameters imply that participants were more cost inefficient than their peers. Further, the estimated coefficients for summary process of care quality indexes for three health conditions (acute myocardial infarction, pneumonia, and heart failure) suggest that higher quality scores are associated with increased operating costs. CONCLUSION The estimated coefficients for the outcome quality variables suggest that future determination of HVBP payment adjustments, which will depend solely on mortality rates as measures of clinical care quality, may not only be aligned with increasing healthcare quality but also reducing healthcare costs.
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Affiliation(s)
- Germán M Izón
- Department of Economics, Eastern Washington University, 311 Patterson Hall, Cheney, WA, 99004-2429, USA.
| | - Chelsea A Pardini
- Department of Economics, Eastern Washington University, 311 Patterson Hall, Cheney, WA, 99004-2429, USA
- Department of Economics, Washington State University, Pullman, WA, 99164, USA
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16
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Horwitz LI, Bernheim SM, Ross JS, Herrin J, Grady JN, Krumholz HM, Drye EE, Lin Z. Hospital Characteristics Associated With Risk-standardized Readmission Rates. Med Care 2017; 55:528-534. [PMID: 28319580 PMCID: PMC5426655 DOI: 10.1097/mlr.0000000000000713] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Safety-net and teaching hospitals are somewhat more likely to be penalized for excess readmissions, but the association of other hospital characteristics with readmission rates is uncertain and may have relevance for hospital-centered interventions. OBJECTIVE To examine the independent association of 8 hospital characteristics with hospital-wide 30-day risk-standardized readmission rate (RSRR). DESIGN This is a retrospective cross-sectional multivariable analysis. SUBJECTS US hospitals. MEASURES Centers for Medicare and Medicaid Services specification of hospital-wide RSRR from July 1, 2013 through June 30, 2014 with race and Medicaid dual-eligibility added. RESULTS We included 6,789,839 admissions to 4474 hospitals of Medicare fee-for-service beneficiaries aged over 64 years. In multivariable analyses, there was regional variation: hospitals in the mid-Atlantic region had the highest RSRRs [0.98 percentage points higher than hospitals in the Mountain region; 95% confidence interval (CI), 0.84-1.12]. For-profit hospitals had an average RSRR 0.38 percentage points (95% CI, 0.24-0.53) higher than public hospitals. Both urban and rural hospitals had higher RSRRs than those in medium metropolitan areas. Hospitals without advanced cardiac surgery capability had an average RSRR 0.27 percentage points (95% CI, 0.18-0.36) higher than those with. The ratio of registered nurses per hospital bed was not associated with RSRR. Variability in RSRRs among hospitals of similar type was much larger than aggregate differences between types of hospitals. CONCLUSIONS Overall, larger, urban, academic facilities had modestly higher RSRRs than smaller, suburban, community hospitals, although there was a wide range of performance. The strong regional effect suggests that local practice patterns are an important influence. Disproportionately high readmission rates at for-profit hospitals may highlight the role of financial incentives favoring utilization.
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Affiliation(s)
- Leora I Horwitz
- *Department of Population Health, Division of Healthcare Delivery Science, New York University School of Medicine †Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center ‡Department of Medicine, Division of General Internal Medicine and Clinical Innovation, New York University School of Medicine, New York, NY §Center for Outcomes Research and Evaluation, Yale New Haven Health ∥Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine ¶Department of Medicine, Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine #Department of Health Policy and Management, Yale School of Public Health **Department of Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT ††Health Research and Educational Trust, Chicago, IL ‡‡Department of Pediatrics, Yale School of Medicine, New Haven, CT
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17
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Chin DL, Bang H, Manickam RN, Romano PS. Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators Of Quality Of Care. Health Aff (Millwood) 2016; 35:1867-1875. [PMID: 27702961 PMCID: PMC5457284 DOI: 10.1377/hlthaff.2016.0205] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Public reporting and payment programs in the United States have embraced thirty-day readmissions as an indicator of between-hospital variation in the quality of care, despite limited evidence supporting this interval. We examined risk-standardized thirty-day risk of unplanned inpatient readmission at the hospital level for Medicare patients ages sixty-five and older in four states and for three conditions: acute myocardial infarction, heart failure, and pneumonia. The hospital-level quality signal captured in readmission risk was highest on the first day after discharge and declined rapidly until it reached a nadir at seven days, as indicated by a decreasing intracluster correlation coefficient. Similar patterns were seen across states and diagnoses. The rapid decay in the quality signal suggests that most readmissions after the seventh day postdischarge were explained by community- and household-level factors beyond hospitals' control. Shorter intervals of seven or fewer days might improve the accuracy and equity of readmissions as a measure of hospital quality for public accountability.
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Affiliation(s)
- David L Chin
- David L. Chin is a postdoctoral scholar at the Center for Healthcare Policy and Research, University of California, Davis, in Sacramento
| | - Heejung Bang
- Heejung Bang is a professor of biostatistics in the Department of Public Health Sciences, University of California, Davis
| | - Raj N Manickam
- Raj N. Manickam is a graduate student researcher in the Graduate Group in Epidemiology, University of California, Davis
| | - Patrick S Romano
- Patrick S. Romano is a professor of medicine and pediatrics in the Division of General Medicine at the University of California, Davis, School of Medicine and at the Center for Healthcare Policy and Research
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18
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Gilman M, Adams EK, Hockenberry JM, Wilson IB, Milstein AS, Becker ER. California safety-net hospitals likely to be penalized by ACA value, readmission, and meaningful-use programs. Health Aff (Millwood) 2016; 33:1314-22. [PMID: 25092831 DOI: 10.1377/hlthaff.2014.0138] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Affordable Care Act includes provisions to increase the value obtained from health care spending. A growing concern among health policy experts is that new Medicare policies designed to improve the quality and efficiency of hospital care, such as value-based purchasing (VBP), the Hospital Readmissions Reduction Program (HRRP), and electronic health record (EHR) meaningful-use criteria, will disproportionately affect safety-net hospitals, which are already facing reduced disproportionate-share hospital (DSH) payments under both Medicare and Medicaid. We examined hospitals in California to determine whether safety-net institutions were more likely than others to incur penalties under these programs. To assess quality, we also examined whether mortality outcomes were different at these hospitals. Our study found that compared to non-safety-net hospitals, safety-net institutions had lower thirty-day risk-adjusted mortality rates in the period 2009-11 for acute myocardial infarction, heart failure, and pneumonia and marginally lower adjusted Medicare costs. Nonetheless, safety-net hospitals were more likely than others to be penalized under the VBP program and the HRRP and more likely not to meet EHR meaningful-use criteria. The combined effects of Medicare value-based payment policies on the financial viability of safety-net hospitals need to be considered along with DSH payment cuts as national policy makers further incorporate performance measures into the overall payment system.
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Affiliation(s)
- Matlin Gilman
- Matlin Gilman is a research assistant in the Department of Health Policy and Management Rollins School of Public Health, at Emory University, in Atlanta, Georgia
| | - E Kathleen Adams
- E. Kathleen Adams is a professor in the Department of Health Policy and Management, Rollins School of Public Health
| | - Jason M Hockenberry
- Jason M. Hockenberry is an assistant professor in the Department of Health Policy and Management, Rollins School of Public Health, and a faculty research fellow in the National Bureau of Economic Research in Cambridge, Massachusetts
| | - Ira B Wilson
- Ira B. Wilson is a professor of community health at the Brown University School of Public Health, in Providence, Rhode Island
| | - Arnold S Milstein
- Arnold S. Milstein is director of the Clinical Excellence Research Center and a professor of medicine at the Stanford University School of Medicine, in California
| | - Edmund R Becker
- Edmund R. Becker is a professor in the Department of Health Policy and Management, Rollins School of Public Health
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Abstract
BACKGROUND Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review. OBJECTIVES To assess the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov). SELECTION CRITERIA Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text. MAIN RESULTS We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials). AUTHORS' CONCLUSIONS A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.
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Affiliation(s)
| | - Natasha A Lannin
- Alfred HealthOccupational TherapyThe Alfred55 Commercial RoadPrahranVictoriaAustralia3004
| | - Lindy M Clemson
- University of SydneyFaculty of Health SciencesJ005, East St. LidcombeLidcombeNSWAustralia1825
| | - Ian D Cameron
- Kolling Institute, Northern Sydney Local Health DistrictJohn Walsh Centre for Rehabilitation ResearchSt LeonardsNSWAustralia2065
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthOxfordUK
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20
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Colla CH, Lewis VA, Bergquist SL, Shortell SM. Accountability across the Continuum: The Participation of Postacute Care Providers in Accountable Care Organizations. Health Serv Res 2016; 51:1595-611. [PMID: 26799992 DOI: 10.1111/1475-6773.12442] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine the extent to which accountable care organizations (ACOs) formally incorporate postacute care providers. DATA SOURCES The National Survey of ACOs (N = 269, response rate 66 percent). STUDY DESIGN We report statistics on ACOs' formal inclusion of postacute care providers and the organizational characteristics and clinical capabilities of ACOs that have postacute care. PRINCIPAL FINDINGS Half of ACOs formally include at least one postacute service, with inclusion at higher rates in ACOs with commercial (64 percent) and Medicaid contracts (70 percent) compared to ACOs with Medicare contracts only (45 percent). ACOs that have a formal relationship with a postacute provider are more likely to have advanced transition management, end of life planning, readmission prevention, and care management capabilities. CONCLUSIONS Many ACOs have not formally engaged postacute care, which may leave room to improve service integration and care management.
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Affiliation(s)
- Carrie H Colla
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Valerie A Lewis
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | | | - Stephen M Shortell
- Division of Health Policy and Management, Haas School of Business, University of California-Berkeley School of Public Health, Berkeley, CA
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21
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Moran V, Jacobs R, Mason A. Variations in Performance of Mental Health Providers in the English NHS: An Analysis of the Relationship Between Readmission Rates and Length-of-Stay. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2016; 44:188-200. [PMID: 26749002 DOI: 10.1007/s10488-015-0711-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Length-of-stay (LOS) for inpatient mental health care is a major driver of variation in resource use internationally. We explore determinants of LOS in England, focusing on the impact of emergency readmission rates which can serve as a measure of the quality of care. Data for 2009/2010 and 2010/2011 are analysed using hierarchical and non-hierarchical models. Unexplained residual variation among providers is quantified using Empirical Bayes techniques. Diagnostic, treatment and patient-level demographic variables are key drivers of LOS. Higher emergency readmission rates are associated with shorter LOS. Ranking providers by residual variation reveals significant differences, suggesting some providers can improve performance.
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Affiliation(s)
- Valerie Moran
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Rowena Jacobs
- Centre for Health Economics and Department of Economics and Related Studies, University of York, Alcuin A Block, Heslington, York, YO10 5DD, UK
| | - Anne Mason
- Centre for Health Economics and Department of Economics and Related Studies, University of York, Alcuin A Block, Heslington, York, YO10 5DD, UK
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22
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Harel Z, Wald R, McArthur E, Chertow GM, Harel S, Gruneir A, Fischer HD, Garg AX, Perl J, Nash DM, Silver S, Bell CM. Rehospitalizations and Emergency Department Visits after Hospital Discharge in Patients Receiving Maintenance Hemodialysis. J Am Soc Nephrol 2015; 26:3141-50. [PMID: 25855772 PMCID: PMC4657827 DOI: 10.1681/asn.2014060614] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 02/20/2015] [Indexed: 12/13/2022] Open
Abstract
Clinical outcomes after a hospital discharge are poorly defined for patients receiving maintenance in-center (outpatient) hemodialysis. To describe the proportion and characteristics of these patients who are rehospitalized, visit an emergency department, or die within 30 days after discharge from an acute hospitalization, we conducted a population-based study of all adult patients receiving maintenance in-center hemodialysis who were discharged between January 1, 2003, and December 31, 2011, from 157 acute care hospitals in Ontario, Canada. For patients with more than one hospitalization, we randomly selected a single hospitalization as the index hospitalization. Of the 11,177 patients included in the final cohort, 1926 (17%) were rehospitalized, 2971 (27%) were treated in the emergency department, and 840 (7.5%) died within 30 days of discharge. Complications of type 2 diabetes mellitus were the most common reason for rehospitalization, whereas heart failure was the most common reason for an emergency department visit. In multivariable analysis using a cause-specific Cox proportional hazards model, the following characteristics were associated with 30-day rehospitalization: older age, the number of hospital admissions in the preceding 6 months, the number of emergency department visits in the preceding 6 months, higher Charlson comorbidity index score, and the receipt of mechanical ventilation during the index hospitalization. Thus, a large proportion of patients receiving maintenance in-center hemodialysis will be readmitted or visit an emergency room within 30 days of an acute hospitalization. A focus on improving care transitions from the inpatient setting to the outpatient dialysis unit may improve outcomes and reduce healthcare costs.
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Affiliation(s)
- Ziv Harel
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada;
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Shai Harel
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Gruneir
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Hadas D Fischer
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Nephrology, London Health Sciences Centre, Western University, London, Ontario, Canada; and
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Danielle M Nash
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Samuel Silver
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Chaim M Bell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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23
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Jacobs R, Gutacker N, Mason A, Goddard M, Gravelle H, Kendrick T, Gilbody S. Determinants of hospital length of stay for people with serious mental illness in England and implications for payment systems: a regression analysis. BMC Health Serv Res 2015; 15:439. [PMID: 26424408 PMCID: PMC4590310 DOI: 10.1186/s12913-015-1107-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 09/23/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Serious mental illness (SMI), which encompasses a set of chronic conditions such as schizophrenia, bipolar disorder and other psychoses, accounts for 3.4 m (7 %) total bed days in the English NHS. The introduction of prospective payment to reimburse hospitals makes an understanding of the key drivers of length of stay (LOS) imperative. Existing evidence, based on mainly small scale and cross-sectional studies, is mixed. Our study is the first to use large-scale national routine data to track English hospitals' LOS for patients with a main diagnosis of SMI over time to examine the patient and local area factors influencing LOS and quantify the provider level effects to draw out the implications for payment systems. METHODS We analysed variation in LOS for all SMI admissions to English hospitals from 2006 to 2010 using Hospital Episodes Statistics (HES). We considered patients with a LOS of up to 180 days and estimated Poisson regression models with hospital fixed effects, separately for admissions with one of three main diagnoses: schizophrenia; psychotic and schizoaffective disorder; and bipolar affective disorder. We analysed the independent contribution of potential determinants of LOS including clinical and socioeconomic characteristics of the patient, access to and quality of primary care, and local area characteristics. We examined the degree of unexplained variation in provider LOS. RESULTS Most risk factors did not have a differential effect on LOS for different diagnostic sub-groups, however we did find some heterogeneity in the effects. Shorter LOS in the pooled model was associated with co-morbid substance or alcohol misuse (4 days), and personality disorder (8 days). Longer LOS was associated with older age (up to 19 days), black ethnicity (4 days), and formal detention (16 days). Gender was not a significant predictor. Patients who self-discharged had shorter LOS (20 days). No association was found between higher primary care quality and LOS. We found large differences between providers in unexplained variation in LOS. CONCLUSIONS By identifying key determinants of LOS our results contribute to a better understanding of the implications of case-mix to ensure prospective payment systems reflect accurately the resource use within sub-groups of patients with SMI.
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Affiliation(s)
- Rowena Jacobs
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Nils Gutacker
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Anne Mason
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Maria Goddard
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Hugh Gravelle
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, UK.
| | - Simon Gilbody
- Department of Health Sciences, University of York, Heslington, York, UK.
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24
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Gilman M, Hockenberry JM, Adams EK, Milstein AS, Wilson IB, Becker ER. The Financial Effect of Value-Based Purchasing and the Hospital Readmissions Reduction Program on Safety-Net Hospitals in 2014: A Cohort Study. Ann Intern Med 2015; 163:427-36. [PMID: 26343790 DOI: 10.7326/m14-2813] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Medicare's value-based purchasing (VBP) and the Hospital Readmissions Reduction Program (HRRP) could disproportionately affect safety-net hospitals. OBJECTIVE To determine whether safety-net hospitals incur larger financial penalties than other hospitals under VBP and HRRP. DESIGN Cross-sectional analysis. SETTING United States in 2014. PARTICIPANTS 3022 acute care hospitals participating in VBP and the HRRP. MEASUREMENTS Safety-net hospitals were defined as being in the top quartile of the Medicare disproportionate share hospital (DSH) patient percentage and Medicare uncompensated care (UCC) payments per bed. The differences in penalties in both total dollars and dollars per bed between safety-net hospitals and other hospitals were estimated with the use of bivariate and graphical regression methods. RESULTS Safety-net hospitals in the top quartile of each measure were more likely to be penalized under VBP than other hospitals (62.9% vs. 51.0% under the DSH definition and 60.3% vs. 51.5% under the UCC per-bed definition). This was also the case under the HRRP (80.8% vs. 69.0% and 81.9% vs. 68.7%, respectively). Safety-net hospitals also had larger payment penalties ($115 900 vs. $66 600 and $150 100 vs. $54 900, respectively). On a per-bed basis, this translated to $436 versus $332 and $491 versus $314, respectively. Sensitivity analysis setting the cutoff at the top decile rather than the top quartile decile led to similar conclusions with somewhat larger differences between safety-net and other hospitals. The quadratic fit of the data indicated that the larger effect of these penalties is in the middle of the distribution of the DSH and UCC measures. LIMITATION Only 2 measures of safety-net status were included in the analyses. CONCLUSION Safety-net hospitals were disproportionately likely to be affected under VBP and the HRRP, but most incurred relatively small payment penalties in 2014. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute.
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Affiliation(s)
- Matlin Gilman
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Clinical Excellence Research Center, Stanford School of Medicine, Palo Alto, California; and Brown University School of Public Health, Providence, Rhode Island
| | - Jason M. Hockenberry
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Clinical Excellence Research Center, Stanford School of Medicine, Palo Alto, California; and Brown University School of Public Health, Providence, Rhode Island
| | - E. Kathleen Adams
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Clinical Excellence Research Center, Stanford School of Medicine, Palo Alto, California; and Brown University School of Public Health, Providence, Rhode Island
| | - Arnold S. Milstein
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Clinical Excellence Research Center, Stanford School of Medicine, Palo Alto, California; and Brown University School of Public Health, Providence, Rhode Island
| | - Ira B. Wilson
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Clinical Excellence Research Center, Stanford School of Medicine, Palo Alto, California; and Brown University School of Public Health, Providence, Rhode Island
| | - Edmund R. Becker
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Clinical Excellence Research Center, Stanford School of Medicine, Palo Alto, California; and Brown University School of Public Health, Providence, Rhode Island
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