Hospital readmission rates for cohorts of Medicare beneficiaries in Boston and New Haven

Regional Variation in End-of-Life Care just before Death among the oldest old in Japan : A descriptive study

BACKGROUND

The use of life-sustaining treatment (LST) in the final stage of life is a major policy concern due to increased costs, while its intensity does not correlate with quality. Previous reports have shown declining trends in LST use in Japan. However, regional practice variations remain unclear. This study aims to describe regional variations in LST use before death among the oldest old in Japan.

METHODS

A descriptive study was conducted among patients aged 85 or older who passed away between April 2013 and March 2014. The study utilized health insurance claims from Japan's National Database (NDB) to examine the use of cardiopulmonary resuscitation (CPR), mechanical ventilation (MV), and admission to the acute care ward (ACW) in the last 7 days of life.

RESULTS

Among 224,391 patients, the proportion of patients receiving LST varied by region. CPR ranged from 8.6% (Chubu) to 12.9% (Shikoku), MV ranged from 7.1% (Chubu) to 12.3% (Shikoku), and admission to ACW ranged from 4.5% (Chubu) to 10.1% (Kyushu-Okinawa). The adjusted odds ratios (AOR) for regional variation compared with Kanto were as follows: CPR (in Shikoku, 1.85 [95% CI 1.73 - 1.98]), MV (in Shikoku, 1.75 [1.63 - 1.87]), and ACW admission (in Kyushu-Okinawa, 1.69 [1.52 - 1.88]).

CONCLUSION

The study presents descriptive information regarding regional differences in the utilization of LST for the oldest old. Further research is necessary to identify the factors that contribute to these variations and to address the challenge of improving the quality of end-of-life care.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BACKGROUND

Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.

METHODS

Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.

RESULTS

The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.

CONCLUSIONS

Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Neonatal Intensive Care Utilization and Postdischarge Newborn Outcomes: A Population-based Study of Texas Medicaid Insured Infants

OBJECTIVE

To test the hypothesis that newborn infants cared for in hospitals with greater utilization of neonatal intensive care experienced fewer postdischarge adverse events.

STUDY DESIGN

We developed 3 retrospective population-based cohorts of Texas Medicaid insured singletons born in 2010-2014 (very low birth weight [VLBW n = 11 139], late preterm [n = 57 509], and non-preterm [n = 664 447]) who received care in higher volume hospitals with level III/IV neonatal intensive care units (NICUs). Measures of NICU care were hospital-level risk adjusted NICU admission rates, special care days (days of nonroutine care) per infant, and the percent of intensive (highest billable care code) special care days. The units of analysis were hospitals (n = 80) and the primary outcome was an adverse event, (defined as admission, emergency department visit, or death) within 30 days postdischarge.

RESULTS

Higher use of NICU care at a hospital level was not associated with lower postdischarge 30-day adverse event. Infants cared for in hospitals with above vs below median special care day rates experienced slightly higher postdischarge adverse event per 100 infants (VLBW: 14.01 [95% CI 12.74-15.27] vs 11.84 [10.52-13.16], P < .05; late preterm: 7.33 [6.68-7.97] vs 6.28 [5.87-6.69], P < .01; non-preterm: 4.47 [4.17-4.76] vs 3.97 [3.75-4.18], P < .01). Weak positive associations (Pearson correlations of 0.31-0.37, P < .01) were observed for adverse event with special care days; in no instance was a negative association observed between NICU utilization and adverse event.

CONCLUSION

Higher utilization of NICU care was not associated with lower rates of short-term events suggesting that there may be opportunities to safely decrease admission rates and length of NICU stays.

Geographic variation of hysterectomy rates in the Israeli health care system during the years 2007-2016

Background

In 2014 the OECD published a report regarding inter-regional variation of hysterectomies in 13 countries including Israel. Variance in hospital admission rates were also reported. The Israeli Ministry of Health has set as one of its main goals the reduction in differences in health care, particularly between the country’s periphery and central regions. These variations may reflect differences in characteristics, resource allocation, and medical staff employment, expertise and training. The advances in technology in the last decades including laparoscopic and robotic surgeries and the variance in their implementation emphasize the great regional variance. The aim of this study was to examine hysterectomy trends in the past decade with emphasis on regional differences.

Methods

The study is based on information maintained by the Israeli Ministry of Health and portrays the trend in hysterectomy rates as a factor of indication, surgical approach and length of hospitalization as collected from the years 2007–2016.

Results

Inter-regional significant differences were found between the 7 regions of Israel, though there was a clear trend toward a national 11–24% decrease in hysterectomy rates. A 2–4 time increase in laparoscopic hysterectomies was observed. There was a clear country-wide trend toward shortening hospital stay from 5 to 4 days in total.

Conclusions

Hysterectomy rates have declined in the past decade due to the implementation of new technologies allowing earlier diagnosis and minimally invasive surgery on top of offering alternative, non-surgical treatment modalities. Uneven allocation of resources and manpower allowing technology implementation and optimal medical services may have contributed to the findings.

Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis

BACKGROUND

Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs.

OBJECTIVE

To evaluate the effect of the MSSP on spending and quality while accounting for clinicians' nonrandom exit.

DESIGN

Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants.

SETTING

Fee-for-service Medicare, 2008 through 2014.

PATIENTS

A 20% sample (97 204 192 beneficiary-quarters).

MEASUREMENTS

Total spending, 4 quality indicators, and hospitalization for hip fracture.

RESULTS

In adjusted longitudinal models, the MSSP was associated with spending reductions (change, -$118 [95% CI, -$151 to -$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, -$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (-0.24 hospitalizations for hip fracture [CI, -0.32 to -0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, -0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile).

LIMITATION

The study used an observational design and administrative data.

CONCLUSION

After adjustment for clinicians' nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects-including exit of high-cost clinicians-may drive estimates of savings in the MSSP.

PRIMARY FUNDING SOURCE

Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.

Teaming up census and patient data to delineate fine-scale hospital service areas and identify geographic disparities in hospital accessibility

The number of hospital beds per capita, an important measure of equity in healthcare availability and resource allocation, was found to vary across geographic areas in many countries, including the USA. The hospital service areas (HSAs) have proven to be more meaningful spatial units for studying health-seeking behaviors and health resource allocation and service utilization. However, when evaluating the geographical balance in ratios of hospital beds to population (HBtP), no existing HSA delineation methods directly consider the underlying population distribution. Using Geographic Information Systems (GIS), this study incorporated the State Inpatient Database with census data to develop a population-based HSA delineation method. The census-derived HSAs were produced for Florida and were validated by aggregating and comparing with the traditional flow-based HSAs. The difference in current ratios of HBtP between the most over- and under-served HSAs was approximately 60 times. Significant clusters of high and low ratios were found in Miami and Jacksonville metropolitan areas, respectively. Such results may be of interest to relevant stakeholders and contribute to planning and optimization of hospital resource allocation and healthcare policy-making. Furthermore, the discovery of a strong correlation between the numbers of hospital discharges and the population at ZIP code level holds a remarkable potential for affordable population estimation, especially in non-census years.

One-year costs of medical admissions with and without a 30-day readmission and enhanced risk adjustment

BACKGROUND

To overcome the limitations of administrative data in adequately adjusting for differences in patients' risk of readmissions, recent studies have added supplemental data from patient surveys and other sources (e.g., electronic health records). However, judging the adequacy of enhanced risk adjustment for use in assessment of 30-day readmission as a hospital quality indicator is not straightforward. In this paper, we evaluate the adequacy of risk adjustment by comparing the one-year costs of those readmitted within 30 days to those not after excluding the costs of the readmission.

METHODS

In this two-step study, we first used comprehensive administrative and survey data on a nationally representative Medicare cohort of hospitalized patients to compare patients with a medical admission who experienced a 30-day readmission to patients without a readmission in terms of their overall Medicare payments during 12 months following the index discharge. We then examined the extent to which a series of enhanced risk adjustment models incorporating code-based comorbidities, self-reported health status and prior healthcare utilization, reduced the payment differences between the admitted and not readmitted groups.

RESULTS

Our analytic cohort consisted 4684 index medical hospitalization of which 842 met the 30-day readmission criteria. Those readmitted were more likely to be older, White, sicker and with higher healthcare utilization in the previous year. The unadjusted subsequent one-year Medicare spending among those readmitted ($56,856) was 60% higher than that among the non-readmitted ($35,465). Even with enhanced risk adjustment, and across a variety of sensitivity analyses, one-year Medicare spending remained substantially higher (46.6%, p < 0.01) among readmitted patients.

CONCLUSIONS

Enhanced risk adjustment models combining health status indicators from administrative and survey data with previous healthcare utilization are unable to substantially reduce the cost differences between those medical admission patients readmitted within 30 days and those not. The unmeasured patient severity that these cost differences most likely reflect raises the question of the fairness of programs that place large penalties on hospitals with higher than expected readmission rates.

ACOs' Impact on Hospitalization Rates of Rural Older Adults With Diabetes: Early Indications

The purpose of this study was to examine the impact of Medicare Shared Savings Program Accountable Care Organizations (SSP ACOs), along with other factors, on diabetes-related hospitalization rates for rural older adults. Using an early year of the SSP ACO program, we conducted multiple linear regressions to examine the effect of ACO participation on African American and white older adults. In neither model was ACO affiliation found to have a statistically significant impact on diabetes-related hospitalization rates. This study provides baseline measures for patient outcomes during the initial years of ACO formation.

Rates of Hospital Readmission Among Medicare Beneficiaries With Gastrointestinal Bleeding Vary Based on Etiology and Comorbidities

BACKGROUND & AIMS

Gastrointestinal bleeding results in significant morbidity, mortality, and healthcare costs in the United States. The Center for Medicare and Medicaid Services' payment reform programs assess quality and value based on rates of hospital readmission for patients with gastrointestinal bleeding, but they identify these patients using Medicare Severity Diagnosis Related Groups (MS-DRGs), which include many types of gastrointestinal bleeding and do not account for the clinical heterogeneity among these patients. We aimed to characterize heterogeneity in outcomes of subgroups of patients with gastrointestinal bleeding.

METHODS

We performed was a cross-sectional, claims-based retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding in 2014 (159,000 hospitalizations). The primary outcome was unplanned readmission within 30 days of discharge from the hospital (30-day readmission). Secondary outcomes included length of stay, inpatient mortality, and death within 30 days of admission to the hospital (30-day mortality). Analyses were adjusted for age, sex, race, and Elixhauser comorbidities using logistic and Poisson regression, adjusting for clustering within hospitals.

RESULTS

The 30-day readmission rate was 16.0%. Readmission rates varied among patients with different types of gastrointestinal bleeding, ranging from 13.5% for diverticular bleeding to 18.6% for small bowel bleeding. The mean length of stay was 4.2 days and 30-day mortality was 6.9% (ranging from 3.4% for diverticular bleeding to 12.1% for upper gastrointestinal bleeding not otherwise specified). When hospitalizations were stratified by MS-DRGs, the main source of variation in rates of readmission and mortality was MS-DRGs.

CONCLUSIONS

In a retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding, we found that 16% of these patients are readmitted to the hospital. Rates of hospital readmission, length of stay, and mortality vary with type of gastrointestinal bleeding, but MS-DRGs account for the largest source of variation. Policies focused on quality and value should account for this heterogeneity.

Racial/Ethnic Disparities in Readmissions in US Hospitals: The Role of Insurance Coverage

We examine differences in rates of 30-day readmissions across patients by race/ethnicity and the extent to which these differences were moderated by insurance coverage. We use hospital discharge data of patients in the 18 years and above age group for 5 US states, California, Florida, Missouri, New York, and Tennessee for 2009, the latest year prior to the start of Centers for Medicare & Medicaid Services’ Hospital Compare program of public reporting of hospital performance on 30-day readmissions. We use logistic regression models by state to estimate the association between insurance status, race, and the likelihood of a readmission within 30 days of an index hospital admission for any cause. Overall in 5 states, non-Hispanic blacks had a slightly higher risk of 30-day readmissions relative to non-Hispanic whites, although this pattern varied by state and insurance coverage. We found higher readmission risk for non-Hispanic blacks, compared with non-Hispanic whites, among those covered by Medicare and private insurance, but lower risk among uninsured and similar risk among Medicaid. Hispanics had lower risk of readmissions relative to non-Hispanic whites, and this pattern was common across subgroups with private, Medicaid, and no insurance coverage. Uninsurance was associated with lower risk of readmissions among minorities but higher risk of readmissions among non-Hispanic whites relative to private insurance. The study found that risk of readmissions by racial ethnic groups varies by insurance status, with lower readmission rates among minorities who were uninsured compared with those with private insurance or Medicare, suggesting that lower readmission rates may not always be construed as a good outcome, because it could result from a lack of insurance coverage and poor access to care, particularly among the minorities.

Self-Reported Physical Function As a Predictor of Hospitalization in the Lifestyle Interventions and Independence for Elders Study

OBJECTIVES

To explore whether baseline scores on the Mobility Assessment Tool-short form (MAT-sf), a brief, animated, computer-based means of assessing mobility that predicts mobility disability, are associated with number of hospitalizations and time to first hospitalization over a median follow-up of 2.7 years.

DESIGN

Post hoc analysis of prospectively gathered data from the Lifestyle Interventions and Independence for Elders (LIFE) Study, a randomized clinical trial of lifestyle interventions to preserve mobility in older adults.

SETTING

Eight U.S. academic medical centers.

PARTICIPANTS

Of 1,635 sedentary community-dwelling older adults enrolled in LIFE, 1,574 completed baseline physical function screening including the MAT-sf, with baseline scores ranging from 30.2 (low function) to 69.8 (high function) on a scale from 30 to 80.

MEASUREMENTS

Number of hospitalizations and time to first hospitalization, adjusted for age, sex, race, living alone, clinical site, baseline comorbidities, number of prescription medications, and cognition.

RESULTS

Of the 1,557 participants with data regarding hospitalization status, 726 (47%) had at least 1 hospitalization; 78% of these had 1 or 2 hospitalizations. For every 10-point lower MAT-sf score, the rate of all hospitalizations was 19% higher in those with lower scores (adjusted rate ratio=1.20, 95% confidence interval (CI)=1.08-1.32, p<.001). Lower baseline MAT-sf scores were also associated with greater risk of first hospitalization (adjusted hazard ratio=1.20, 95% CI=1.09-1.32, p<.01, per 10-point lower MAT-sf score).

CONCLUSION

Low MAT-sf scores identify older adults at risk of hospitalization; further study is needed to test interventions to reduce hospitalizations in these individuals.

Multiple Chronic Conditions and Disparities in 30-Day Hospital Readmissions Among Nonelderly Adults

This study examines the patterns of 30-day hospital readmissions by race/ethnicity and multiple chronic conditions (MCC) burden among nonelderly adult patients. We used hospital discharge data of patients in the 18- to 64-year age group in 5 US states, California, Florida, Missouri, New York, and Tennessee, for 2009 from the Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) of the Agency for Healthcare Research and Quality, linked to contextual and provider data from the Health Resources and Services Administration. A multilevel logistic regression model was used for data pooled over 5 states, adjusting for patient, hospital, and community characteristics. Controlling for other covariates, the study found that a higher MCC burden was associated with a higher all-cause 30-day readmission risk. We found considerable heterogeneity in levels of readmission risk among racial/ethnic subgroups stratified by chronic conditions. Among patients with a lowest MCC burden, African Americans had the highest risk of readmission, but with a higher MCC burden, the risk of readmission increased most for Hispanics.

Meaningful Use and Hospital Performance on Post-Acute Utilization Indicators

OBJECTIVES

To examine trends in hospital post-acute utilization indicators and to determine whether improvement in these indicators is associated with attesting to meaningful use (MU).

DATA SOURCES

Medicare claims-based, repeated measures on 30-day hospital-wide all-cause readmission and emergency department (ED) utilization rates for 160 short-stay hospitals (2009-2012); Medicare EHR Incentive Program Payments files (2011-2012); and other hospital and market data.

STUDY DESIGN

Interrupted time series with concurrent comparison group.

PRINCIPAL FINDINGS

Propensity score-weighted multilevel models for change demonstrate that 30-day readmission rates (unadjusted) fell from 13.4 percent in 2009 to 12.1 percent in 2012. Similarly, 30-day ED utilization declined from 18.9 percent to 17.3 percent during the same period. However, MU and non-MU hospitals were indistinguishable vis-à-vis performance. Controlling for hospital and market characteristics, MU was unrelated to 30-day readmission. In contrast, 30-day ED utilization deteriorated.

CONCLUSIONS

Hospitals with MU Stage 1 designation did not show significantly higher improvement on post-acute utilization compared to their counterparts without. To achieve gains in quality and safety, potentially associated with EHRs, and to advance care coordination and patient engagement, the regulators should strengthen accountability by linking comprehensive, outcomes-based performance measures to specific MU objectives.

Association of hospice utilization and publicly reported outcomes following hospitalization for pneumonia or heart failure: a retrospective cohort study

Background

The Center for Medicare and Medicaid Services (CMS) and the Hospital Quality Alliance began collecting and reporting United States hospital performance in the treatment of pneumonia and heart failure in 2008. Whether the utilization of hospice might affect CMS-reported mortality and readmission rates is not known.

Methods

Hospice utilization (mean days on hospice per decedent) for 2012 from the Dartmouth Atlas (a project of the Dartmouth Institute that reports a variety of public health and policy-related statistics) was merged with hospital-level 30-day mortality and readmission rates for pneumonia and heart failure from CMS. The association between hospice use and outcomes was analyzed with multivariate quantile regression controlling for quality of care metrics, acute care bed availability, regional variability and other measures.

Results

2196 hospitals reported data to both CMS and the Dartmouth Atlas in 2012. Higher rates of hospice utilization were associated with lower rates of 30-day mortality and readmission for pneumonia but not for heart failure. Higher quality of care was associated with lower rates of mortality for both pneumonia and heart failure. Greater acute care bed availability was associated with increased readmission rates for both conditions (p < 0.05 for all).

Conclusions

Higher rates of hospice utilization were associated with lower rates of 30-day mortality and readmission for pneumonia as reported by CMS. While causality is not established, it is possible that hospice referrals might directly affect CMS outcome metrics. Further clarification of the relationship between hospice referral patterns and publicly reported CMS outcomes appears warranted.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2801-3) contains supplementary material, which is available to authorized users.

Decreasing Hospital Readmission in Ileostomy Patients: Results of Novel Pilot Program

BACKGROUND

Nearly 30% of patients with newly formed ileostomies require hospital readmission from severe dehydration or associated complications. This contributes to significant morbidity and rising healthcare costs associated with this procedure. Our aim was to design and pilot a novel program to decrease readmissions in this patient population.

STUDY DESIGN

An agreement was established with Visiting Nurse Health System (VNHS) in March 2015 that incorporated regular home visits with clinical triggers to institute surgeon-supervised corrective measures aimed at preventing patient decompensation associated with hospital readmissions. Thirty-day readmission data for patients managed with and without VNHS support for 10.5 months before and after implementation of this new program were collected.

RESULTS

Of 833 patients with small bowel procedures, 162 were ileostomies with 47 in the VNHS and 115 in the non-VNHS group. Before program implementation, VNHS (n = 24) and non-VNHS patients (n = 54) had similar readmission rates (20.8% vs 16.7%). After implementation, VNHS patients (n = 23) had a 58% reduction in hospital readmission (8.7%) and non-VNHS patient hospital readmissions (n = 61) increased slightly (24.5%). Total cost of readmissions per patient in the cohort decreased by >80% in the pilot VNHS group.

CONCLUSIONS

Implementation of a novel program reduced the 30-day readmission rate by 58% and cost of readmissions per patient by >80% in a high risk for readmission patient population with newly created ileostomies. Future efforts will expand this program to a greater number of patients, both institutionally and systemically, to reduce the readmission-rate and healthcare costs for this high-risk patient population.

Geographic variation in selected hospital procedures and services in the Israeli health care system

Background

Medical practice variation refers to differences in health service utilization among regions in the same country. It is used as a tool for studying health inequities.

In 2011, the OECD launched a Medical Practice Variation Project which examines regional differences within countries and explores the sources of the inter-regional differences. The aim of this study is to examine the patterns and trends in geographic variation for selected health services in Israel.

Methods

The analysis is based on data from the National Hospital Discharges Database (NHDD) of the Israeli Ministry of Health. The eight procedures and services studied were: medical admissions (i.e. admissions without surgical procedures); hip fractures; caesarian sections; diagnostic cardiac catheterization; cardiac angioplasty (PTCA); cardiac bypass surgery (CABG); hysterectomy; and knee replacement surgery. The data are presented for the 7 districts in Israel, determined by address of residence.

Results

The procedures and services with the lowest variation across the seven districts were medical admissions (RR between regions-maximum/minimum 1.3) and hip fractures (RR 1.44), while the one with the highest variation was CABG (RR 1.98). The Israeli periphery, and the northern district in particular, had higher rates of medical admissions, knee replacement and cardiac procedures. When studying the trend over time, we found a decrease in use rates for most procedures, such as coronary bypass (R. 04) and CABG (R 0.8). Medical admissions decreased by 8%, with the highest decline (16%) observed in the central districts.

Conclusions

This study provides Israeli policy makers with information which is vital for the strategic planning of service development, such as strengthening preventive medical services in the community, reducing cardiovascular risk factors in the periphery and expanding the national publication of clinical quality scores.

Electronic supplementary material

The online version of this article (doi:10.1186/s13584-016-0127-y) contains supplementary material, which is available to authorized users.

Geographic variation in potentially avoidable hospitalizations in France

Potentially avoidable hospitalizations are studied as an indirect measure of access to primary care. Understanding the determinants of these hospitalizations can help improve the quality, efficiency, and equity of health care delivery. Few studies have tackled the issue of potentially avoidable hospitalizations in France, and none has done so at the national level. We assessed disparities in potentially avoidable hospitalizations in France in 2012 and analyzed their determinants. The standardized rate of potentially avoidable hospitalizations ranged from 0.1 to 44.4 cases per 1,000 inhabitants, at the ZIP code level. Increased potentially avoidable hospitalizations were associated with higher mortality, lower density of acute care beds and ambulatory care nurses, lower median income, and lower education levels. This study unveils considerable variation in the rate of potentially avoidable hospitalizations in spite of France's mandatory, publicly funded health insurance system. In addition to epidemiological and sociodemographic factors, this study suggests that primary care organization plays a role in geographic disparities in potentially avoidable hospitalizations that might be addressed by increasing the number of nurses and enhancing team work in primary care. Policy makers should consider measuring potentially avoidable hospitalizations in France as an indicator of primary care organization.

Medical practice variations: changing the theoretical approach

Variations in medical practice are well documented, but there has been less progress in explaining these variations. This paper discusses the existing theories and hypotheses and concludes that a change in theoretical approach is required, to one that more directly highlights the social context influencing the behaviour of doctors in their daily practice. An initial alternative model for explaining variation in practice style is presented. The paper illustrates how (combinations of) important structural factors, such as the availability of hospital resources, the way the doctor is reimbursed, the availability of patients, professional uncertainty, and the way the hospital is financed, lead to hypotheses about when different local standards of medical care emerge. It is concluded that theoretical progress in research on variations in medical practice is possible and that empirical research needs to be driven by hypotheses that emphasize the role of social contexts in the doctor's decision behaviour. Some suggestions for future lines of research are outlined.

Variation in Physician Practice Styles within and across Emergency Departments

Despite the significant responsibility that physicians have in healthcare delivery, we know surprisingly little about why physician practice styles vary within or across institutions. Estimating variation in physician practice styles is complicated by the fact that patients are rarely randomly assigned to physicians. This paper uses the quasi-random assignment of patients to physicians in emergency departments (EDs) to show how physicians vary in their treatment of patients with minor injuries. The results reveal a considerable degree of variation in practice styles within EDs; physicians at the 75th percentile of the spending distribution spend 20% more than physicians at the 25th percentile. Observable physician characteristics do not explain much of the variation across physicians, but there is a significant degree of sorting between physicians and EDs over time, with high-cost physicians sorting into high-cost EDs as they gain experience. The results may shed light on why some EDs remain persistently higher-cost than others.

Hospital Re-Admissions: An Empirical Analysis of Quality Management in Taiwan

This retrospective study uses discharge-level data to analyse and assess the situation of re-admissions within 15 days of discharge, for quality evaluation. The re-admission rate of the study period was 3.22%. Among those re-admission cases, 45.7% patients were re-admitted within five days of discharge, and 33.5% cases returned to hospital six to 10 days after discharge. The average length of stays of re-admissions (9.86 days for previous stay and 8.10 days for re-admitted stay) were both longer than the hospital's overall average (7.63 days) at the same period. Paediatric patients comprised the greatest number of re-admissions. Re-admissions were more likely to have higher percentage of emergency admission. Significant relationships were found between factors for re-admissions and patient characteristics (e.g. age and insurance status), admitted department, and diagnosis. Further investigation and strategies, combined with the application of severity adjustment technique to better monitor and avoid unnecessary re-admissions, need to be developed.

Risk-standardized Acute Admission Rates Among Patients With Diabetes and Heart Failure as a Measure of Quality of Accountable Care Organizations: Rationale, Methods, and Early Results

BACKGROUND

Population-based measures of admissions among patients with chronic conditions are important quality indicators of Accountable Care Organizations (ACOs), yet there are challenges in developing measures that enable fair comparisons among providers.

METHODS

On the basis of consensus standards for outcome measure development and with expert and stakeholder input on methods decisions, we developed and tested 2 models of risk-standardized acute admission rates (RSAARs) for patients with diabetes and heart failure using 2010-2012 Medicare claims data. Model performance was assessed with deviance R; score reliability was tested with intraclass correlation coefficient. We estimated RSAARs for 114 Shared Savings Program ACOs in 2012 and we assigned ACOs to 3 performance categories: no different, worse than, and better than the national rate.

RESULTS

The diabetes and heart failure cohorts included 6.5 and 2.6 million Medicare Fee-For-Service beneficiaries aged 65 years and above, respectively. Risk-adjustment variables were age, comorbidities, and condition-specific severity variables, but not socioeconomic status or other contextual factors. We selected hierarchical negative binomial models with the outcome of acute, unplanned hospital admissions per 100 person-years. For the diabetes and heart failure measures, respectively, the models accounted for 22% and 12% of the deviance in outcomes and score reliability was 0.89 and 0.81. For the diabetes measure, 51 (44.7%) ACOs were no different, 45 (39.5%) were better, and 18 (15.8%) were worse than the national rate. The distribution of performance for the heart failure measure was 61 (53.5%), 37 (32.5%), and 16 (14.0%), respectively.

CONCLUSION

Measures of RSAARs for patients with diabetes and heart failure meet criteria for scientific soundness and reveal important variation in quality across ACOs.

Do Non-Clinical Factors Improve Prediction of Readmission Risk?: Results From the Tele-HF Study

OBJECTIVES

This study sought to determine whether a model that included self-reported socioeconomic, health status, and psychosocial characteristics obtained from patients recently discharged from hospitalizations for heart failure substantially improved 30-day readmission risk prediction compared with a model that incorporated only clinical and demographic factors.

BACKGROUND

Existing readmission risk models have poor discrimination and it is unknown whether they would be markedly improved by the inclusion of patient-reported information.

METHODS

As part of the Tele-HF (Telemonitoring to Improve Heart Failure Outcomes) trial, we conducted medical record abstraction and telephone interviews in a sample of 1,004 patients recently hospitalized for heart failure to obtain clinical, functional, and psychosocial information within 2 weeks of discharge. Candidate risk factors included 110 variables divided into 2 groups: demographic and clinical variables generally available from the medical record; and socioeconomic, health status, adherence, and psychosocial variables from patient interview.

RESULTS

The 30-day readmission rate was 17.1%. Using the 3-level risk score derived from the restricted medical record variables, patients with a score of 0 (no risk factors) had a readmission rate of 10.9% (95% confidence interval [CI]: 8.2% to 14.2%), and patients with a score of 2 (all risk factors) had a readmission rate of 32.1% (95% CI: 22.4% to 43.2%), a C-statistic of 0.62. Using the 5-level risk score derived from all variables, patients with a score of 0 (no risk factors) had a readmission rate of 9.6% (95% CI: 6.1% to 14.2%), and patients with a score of 4 (all risk factors) had a readmission rate of 55.0% (95% CI: 31.5% to 76.9%), a C-statistic of 0.65.

CONCLUSIONS

Self-reported socioeconomic, health status, adherence, and psychosocial variables are not dominant factors in predicting readmission risk for patients with heart failure. Patient-reported information improved model discrimination and extended the predicted ranges of readmission rates, but the model performance remained poor. (Telemonitoring to Improve Heart Failure Outcomes [Tele-HF]; NCT00303212).

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

PURPOSE

We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration.

RESULTS

We identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87-0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51-0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious.

CONCLUSIONS

Clinicians and managers who implement TCIs in primary care can incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option.

The outcomes of psychiatric inpatients by proportion of experienced psychiatrists and nurse staffing in hospital: New findings on improving the quality of mental health care in South Korea

Readmission rates for mental health care are higher in South Korea than other Organization for Economic Development (OECD) countries. Therefore, it is worthwhile to continue investigating how to reduce readmissions. Taking a novel approach, we determined the relationship between psychiatrist experience and mental health care readmission rates. We used National Health Insurance claim data (N=21,315) from 81 hospitals to analyze readmissions within 30 days of discharge for "mood disorders" or "schizophrenia, schizotypal and delusional disorders" during 2010-2013. In this study, multilevel models that included both patient and hospital-level variables were analyzed to examine associations with readmission. Readmissions within 30 days of discharge accounted for 1079 (5.1%) claims. Multilevel analysis demonstrated that the proportion of experienced psychiatrists at a hospital was inversely associated with risk of readmission (OR: 0.79, 95% CI: 0.74-0.84 per 10% increase in experienced psychiatrists). Readmission rates for psychiatric disorders within 30 days of discharge were lower in hospitals with a higher number of nurses (OR: 0.95, 95% CI: 0.94-0.96 per 10 nurses). In conclusion, health policymakers and hospital managers should make an effort to reduce readmissions for psychiatric disorders and other diseases by considering the role that physician experience plays and nurse staffing.

Associations Between Mild Cognitive Impairment and Hospitalization and Readmission

OBJECTIVES

To determine whether older adults with mild cognitive impairment (MCI), a condition not previously explored as a risk factor, have more hospitalizations and 30-day readmissions than those with normal cognition.

DESIGN

Post hoc analysis of prospectively gathered data on incident hospitalization and readmission from the Ginkgo Evaluation of Memory Study (GEMS), a randomized, double-blind, placebo-controlled trial designed to assess the effect of Ginkgo biloba on incidence of dementia.

SETTING

GEMS was conducted in five academic medical centers in the United States.

PARTICIPANTS

Community-dwelling adults aged 75 and older with normal cognition (n = 2,314) or MCI (n = 428) at baseline cognitive testing (N = 2,742).

MEASUREMENTS

Index hospitalization and 30-day hospital readmission, adjusted for age, sex, race, education, clinic site, trial assignment status, comorbidities, number of prescription medications, and living with an identified proxy.

RESULTS

MCI was associated with a 17% greater risk of index hospitalization than normal cognition (adjusted hazard ratio (aHR) = 1.17, 95% confidence interval (CI) = 1.02-1.34)). In participants who lived with a proxy, MCI was associated with a 39% greater risk of index hospitalization (aHR = 1.39, 95% CI = 1.17-1.66). Baseline MCI was not associated with greater odds of 30-day hospital readmission (adjusted odds ratio = 0.90, 95% CI = 0.60-1.36).

CONCLUSION

MCI may represent a target condition for healthcare providers to coordinate support services in an effort to reduce hospitalization and subsequent disability.

Practice Arrangement and Medicare Physician Payment in Otolaryngology

Objective

Medicare Part B physician payment indicates a cost to Medicare beneficiaries for a physician service and connotes physician clinical productivity. The objective of this study was to determine whether there was an association between practice arrangement and Medicare physician payment.

Study Design

Cross-sectional study.

Setting

Medicare provider utilization and payment data.

Subjects and Methods

Otolaryngologists from 1 metropolitan area were included as part of a pilot study. A generalized linear model was used to determine the effect of practice-specific variables including patient volumes on physician payment.

Results

Of 67 otolaryngologists included, 23 (34%) provided services through an independent practice, while others were employed by 1 of 3 local academic centers. Median payment was $58,895 per physician for the year, although some physicians received substantially higher payments. Reimbursements to faculty at 1 academic department were higher than to those at other institutions or to independent practitioners. After adjustments were made for patient volumes, physician subspecialty, and gender, payments to each faculty at Hospital C were 2 times higher than to those at Hospital A (relative ratio [RR] 2.03; 95% CI, 1.27-3.27; P = .003); 2 times higher than to faculty at Hospital B (RR 2.04; 95% CI, 1.4-2.7; P = .0001); and 1.6 times higher than to independent practitioners (RR 1.6; 95% CI, 1.04-2.7; P = .03). Payments to physicians in the other groups were not significantly different. Differences in reimbursement corresponded to an emphasis on procedures over office visits but not Medicare case mix adjustments for patient discharges from associated institutions.

Conclusions

Variation in the cost of academic otolaryngology care may be subject in part to institutional factors.

Ninety-day readmissions after degenerative cervical spine surgery: A single-center administrative database study

BACKGROUND

Unplanned hospital readmissions result in significant clinical and financial burdens to patients and the healthcare system. Readmission rates and causes have been investigated using large administrative databases which have certain limitations in data reporting and coding. The objective of this study was to provide a description of 90 day post-discharge readmissions following surgery for common degenerative cervical spine pathologies at a large-volume tertiary hospital. The study also compared the readmission rates of patients who underwent anterior- and posterior-approach procedures.

METHODS

The administrative records from a single-center, high-volume tertiary institution were queried using ICD-9 codes for common cervical pathology over a three year period to determine the rate and causes of readmissions within the 90 days following the index surgery.

RESULTS

A total of 768 patients underwent degenerative cervical spine surgery during the three year study period. Within 90 days of discharge, 24 (3.13%) patients were readmitted; 16 (2.06%) readmissions were planned for lumbar surgery; 8 (1.04%) readmissions were unplanned. 640 patients underwent procedures involving an anterior approach and 128 patients underwent procedures involving a posterior approach. There were 14 (2.17%) planned readmissions in the anterior group and 2 (1.5%) in the posterior group. The unplanned readmission rate was 0.63% (4 patients) and 3.13% (4 patients) in the anterior and posterior groups, respectively. (p=0.0343).

CONCLUSION

The 90 day post-discharge unplanned readmission rate that followed elective degenerative cervical spine surgery was 1.04%. The unplanned readmission rate associated with posterior-approach procedures (3.13%) was significantly higher than that of anterior-approach procedures (0.63%).

LEVEL OF EVIDENCE

IV.

Measuring Returns to Hospital Care: Evidence from Ambulance Referral Patterns

Medicare spending exceeds 4% of GDP in the US each year, and there are concerns that moral hazard problems have led to overspending. This paper considers whether hospitals that treat patients more aggressively and receive higher payments from Medicare improve health outcomes for their patients. An innovation is a new lens to compare hospital performance for emergency patients: plausibly exogenous variation in ambulance-company assignment among patients who live near one another. Using Medicare data from 2002-2010, we show that ambulance company assignment importantly affects hospital choice for patients in the same ZIP code. Using data for New York State from 2000-2006 that matches exact patient addresses to hospital discharge records, we show that patients who live very near each other but on either side of ambulance service area boundaries go to different types of hospitals. Both identification strategies show that higher-cost hospitals achieve better patient outcomes for a variety of emergency conditions. Using our Medicare sample, the estimates imply that a one standard deviation increase in Medicare reimbursement leads to a 4 percentage point reduction in mortality (10% compared to the mean). Taking into account one-year spending after the health shock, the implied cost per at least one year of life saved is approximately $80,000. These results are found across different types of hospitals and patients, as well across both identification strategies.

Can Caesarean section improve child and maternal health? The case of breech babies

This paper examines the health effects of Caesarean section (CS) for children and their mothers. We use exogenous variation in the probability of CS in a fuzzy regression discontinuity design. Using administrative Danish data, we exploit an information shock for obstetricians that sharply altered CS rates for breech babies. We find that CS decreases the child's probability of having a low APGAR score and the number of family doctor visits in the first year of life. We find no significant effects for severe neonatal morbidity or hospitalizations. While mothers are hospitalized longer after birth, we find no effects of CS for maternal post-birth complications or infections. Although the change in mode of delivery for the marginal breech babies increases direct costs, the health benefits show that CS is the safest option for these children.

Profile of St. Jude Medical's Allure Quadra quadripolar pacemaker system for cardiac resynchronization therapy

Congestive heart failure is a major public health epidemic and economic burden in the USA and worldwide. Cardiac resynchronization therapy is an effective therapy for treating congestive heart failure in conjunction with pharmacologic therapy. The average congestive heart failure admission costs approximately US$ 8 billion annually. Current cardiac resynchronization therapy pacemaker systems from various manufacturers deliver therapy-utilizing bipolar leads including the left ventricle, with electrode spacing ranging from 8 to 22 mm. The Quartet LV™ lead model 1458Q (St. Jude Medical Sylmar, CA) is a quadripolar lead with a 4.0 Fr. tip electrode and three 4.7 Fr. ring electrodes located 20, 30 and 47 mm from the tip. The Quartet lead and Allure Quadra TM allows 14 pacing configurations, providing benefits, including reductions in phrenic nerve stimulation, reduced pacing thresholds, improved battery longevity and potential reductions, in non-responders to cardiac resynchronization therapy. In addition, there is cost benefit data from utilizing quadripolar technology compared with traditional bipolar cardiac resynchronization therapy.

Variation in the risk of readmission among hospitals: the relative contribution of patient, hospital and inpatient provider characteristics

BACKGROUND

The risk of readmission varies among hospitals. This variation has led the Centers of Medicare and Medicaid services to reduce payments to hospitals with excess readmissions. The contribution of patient characteristics, hospital characteristics and provider type to the variation in risk of readmission among hospitals has not been determined.

OBJECTIVE

To describe the variation in risk of readmission among hospitals and partition it by patient characteristics, hospital characteristics and provider type.

DESIGN

Retrospective research design of 100% Texas Medicare data using multilevel, multivariable models.

SUBJECTS

A total of 514,064 admissions of Medicare beneficiaries to 272 hospitals in Texas for medical diagnoses during the years 2008 and 2009.

MAIN MEASURES

Using hierarchical generalized linear models, we describe the hospital-specific variation in risk of readmission that is attributable to patients characteristics, hospital characteristics and provider type by measuring the variance and intraclass correlation coefficients.

KEY RESULTS

Of the total variation in risk of readmission, only a small amount (0.84%) is attributed to hospitals. In further analyses modeling the components of this variation among hospitals, differences in patient characteristics in the hospitals explained 56.2% of the variation. Hospital characteristics and the type of provider explained 9.3% of the variation among hospitals and 0.08% of the total variation in risk of readmission.

CONCLUSIONS

Patient characteristics are the largest contributor to variation in risk of readmission among hospitals. Measurable hospital characteristics and the type of inpatient provider contribute little to variation in risk of readmission among hospitals.

Risk factors associated with 30-day postoperative readmissions in major gastrointestinal resections

PURPOSE

Preventable readmissions represent a major burden on the health care system and risk stratification of patients can help direct costly resources. This study examines patient characteristics, surgical factors, and postoperative complications associated with 30-day postoperative readmissions in gastrointestinal (GI) resections.

METHODS

Inpatients undergoing major GI surgery were selected from the 2011 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Resections were classified into foregut, small bowel, colorectal, liver, and pancreatic using Current Procedural Terminology (CPT) codes. Postoperative complications were divided into pre- and post-discharge groups using time to complication and discharge. Univariate analysis compared patient and surgical characteristics and pre-discharge complications with 30-day unplanned readmission rates. Factors with a p value <0.1 were included in multivariate logistic regression. A p value <0.05 was considered statistically significant.

RESULTS

For 42,609 patients undergoing GI resection, the overall 30-day unplanned readmission rate was 12.3 % ranging from 11.8 % for colorectal resections to 16.3 % for pancreatic resections. Major predictors of 30-day readmissions included pre-discharge major complications (odds ratio [OR] = 1.28, 95 % confidence interval [CI] 1.18-1.39, p < 0.0001), chronic steroid use (OR = 1.67, 95 % CI 1.50-1.86, p < 0.0001), operative time ≥4 h (OR = 1.45, 95 % CI 1.35-1.56, p < 0.0001) and discharge to a facility other than home (OR = 1.37, 95 % CI 1.23-1.50, p < 0.0001).

CONCLUSIONS

Unplanned 30-day readmissions represent a major clinical and financial concern, but some may be foreseeable and potentially modifiable. This model provides insight into factors that could inform resource utilization and postoperative care to help prevent readmissions in select GI surgical patients.

Impact of case exposures on physician behavior responses in childhood poisoning: quality and cost implications

OBJECTIVES

When measuring physicians' competencies, there is no consensus as to what would constitute an optimum exposure in unintentional pediatric poisoning. In the absence of universal protocols and poison centers' support, the behavior responses of the physicians can vary depending on their exposure to cases. We sought to determine if there was a correlation between the case exposure and physicians' behavior choices that could affect quality and cost of care.

METHODS

A cross-sectional study was conducted in 2010, and a self-reporting survey questionnaire was given to the physicians in the pediatric emergency departments and primary care centers in the city of Al Ain. The physicians' responses were plotted against (a) the number of cases the physicians have had managed in the preceding 12 months and (b) the number of years the physicians have had been in practice

RESULTS

One hundred seven physicians partook in the survey. We found that the physicians who had managed more than 2 cases of childhood poisoning in the preceding year chose significantly more positive behavior responses when compared with those who had managed 2 cases or less. There was no significant difference when the responses were measured against the physicians' number of years of practice.

CONCLUSIONS

Physicians' practice effectiveness may improve if they manage at least 3 cases of childhood poisoning in a year. Physicians training modules could be developed for those physicians who do not get the optimum exposure necessary in improving physicians' behaviors associated with effective quality and cost efficiency.

Multidisciplinary intervention reducing readmissions in medical inpatients: a prospective, non-randomized study

BACKGROUND

The purpose of this study was to examine whether a multidisciplinary intervention targeting drug-related problems, cognitive impairment, and discharge miscommunication could reduce readmissions in a general hospital population.

METHODS

This prospective, non-randomized intervention study was carried out at the department of general internal medicine at a tertiary university hospital. Two hundred medical inpatients living in the community and aged over 60 years were included. Ninety-nine patients received interventions and 101 received standard care. Control/intervention allocation was determined by geographic selection. Interventions consisted of a comprehensive medication review, improved discharge planning, post-discharge telephone follow-up, and liaison with the patient's general practitioner. The main outcome measures recorded were readmissions and hospital nights 12 months after discharge. Separate analyses were made for 12-month survivors and from an intention-to-treat perspective. Comparative analyses were made between groups as well as within groups over time.

RESULTS

After 12 months, survivors in the control group had 125 readmissions in total, compared with 58 in the intervention group (Mann-Whitney U test, P = 0.02). For hospital nights, the numbers were 1,228 and 492, respectively (P = 0.009). Yearly admissions had increased from the previous year in the control group from 77 to 125 (Wilcoxon signed-rank test, P = 0.002) and decreased from 75 to 58 in the intervention group (P = 0.25). From the intention-to-treat perspective, the same general pattern was observed but was not significant (1,827 versus 1,008 hospital nights, Mann-Whitney test, P = 0.054).

CONCLUSION

A multidisciplinary approach, targeting several different areas, could substantially lower readmissions and hospital costs in a non-terminal general hospital population.

A systematic review of medical practice variation in OECD countries

BACKGROUND

Major variations in medical practice have been documented internationally. Variations raise questions about the quality, equity, and efficiency of resource allocation and use, and have important implications for health care and health policy.

OBJECTIVE

To perform a systematic review of the peer-reviewed literature on medical practice variations in OECD countries.

METHODS

We searched MEDLINE to find publications on medical practice variations in OECD countries published between 2000 and 2011. We present an overview of the characteristics of published studies as well as the magnitude of variations for select high impact conditions.

RESULTS

A total of 836 studies were included. Consistent with the gray literature, there were large variations across regions, hospitals and physician practices for almost every condition and procedure studied. Many studies focused on high-impact conditions, but very few looked at the causes or outcomes of medical practice variations.

CONCLUSION

While there were an overwhelming number of publications on medical practice variations the coverage was broad and not often based on a theoretical construct. Future studies should focus on conditions and procedures that are clinically important, policy relevant, resource intensive, and have high levels of public awareness. Further study of the causes and consequences of variations is important.

Unplanned readmissions following surgery for colorectal cancer

SUMMARY Unplanned 30-day readmission rates following surgery for colorectal cancer range from 8.4 to 17.1% and have an obvious impact on patient outcomes and the overall cost of treating this population. Bowel obstruction, ileus, surgical infections, operative complications and dehydration are consistently the primary causes for readmission following colorectal surgery; however, finding a reliable set of predictors among many risk factors for readmissions has proven elusive. With a recent shift in focus towards reducing hospital readmissions, interventions to reduce them must be developed. These should be based on a nuanced understanding of the patient, operative and systematic factors driving readmissions and aim to decrease the patient’s unmet needs and challenges following discharge after surgery for colorectal cancer.

Effect of collaborative care on cost variation in an intensive care unit

BACKGROUND

Improving the cost-effectiveness of health care requires an understanding of the genesis of health care costs and in particular the sources of cost variation. Little is known about how multiple physicians, caring collaboratively for patients, contribute to costs.

OBJECTIVE

To explore the effect of collaborative care by physicians on variation in discretionary costs in an intensive care unit (ICU) by determining the contributions of the attending intensivists and ICU fellows.

METHODS

Prospective, observational study using a multivariable model of median discretionary costs for the first day in the ICU, adjusting for confounding variables. Analysis included 3514 patients who spent more than 2 hours in the ICU on the initial day. Impact of the physicians was assessed via variables representing the specific intensivist and ICU fellow responsible on the first ICU day and allowing for interaction terms.

RESULTS

On the initial day, patients spent a median of 10.6 hours (interquartile range, 6.3-16.5) in the ICU, with median discretionary costs of $1343 (interquartile range, $788-2208). There was large variation in adjusted costs attributable to both the intensivists ($359; 95% CI, $244-$474) and the fellows ($756; 95% CI, $550-$965). The interaction terms were not significant (P = .12-.79).

CONCLUSIONS

In an ICU care model with intensivists and subspecialty fellows, both types of physicians contributed significantly to the observed variation in discretionary costs. However, even in the presence of a hierarchical arrangement of clinical responsibilities, the influences on costs of the 2 types of physicians were independent.

Do more hospital beds lead to higher hospitalization rates? a spatial examination of Roemer's Law

BACKGROUND

Roemer's Law, a widely cited principle in health care policy, states that hospital beds that are built tend to be used. This simple but powerful expression has been invoked to justify Certificate of Need regulation of hospital beds in an effort to contain health care costs. Despite its influence, a surprisingly small body of empirical evidence supports its content. Furthermore, known geographic factors influencing health services use and the spatial structure of the relationship between hospital bed availability and hospitalization rates have not been sufficiently explored in past examinations of Roemer's Law. We pose the question, "Accounting for space in health care access and use, is there an observable association between the availability of hospital beds and hospital utilization?"

METHODS

We employ an ecological research design based upon the Anderson behavioral model of health care utilization. This conceptual model is implemented in an explicitly spatial context. The effect of hospital bed availability on the utilization of hospital services is evaluated, accounting for spatial structure and controlling for other known determinants of hospital utilization. The stability of this relationship is explored by testing across numerous geographic scales of analysis. The case study comprises an entire state system of hospitals and population, evaluating over one million inpatient admissions.

RESULTS

We find compelling evidence that a positive, statistically significant relationship exists between hospital bed availability and inpatient hospitalization rates. Additionally, the observed relationship is invariant with changes in the geographic scale of analysis.

CONCLUSIONS

This study provides evidence for the effects of Roemer's Law, thus suggesting that variations in hospitalization rates have origins in the availability of hospital beds. This relationship is found to be robust across geographic scales of analysis. These findings suggest continued regulation of hospital bed supply to assist in controlling hospital utilization is justified.

Higher health care quality and bigger savings found at large multispecialty medical groups

The belief that integrated delivery systems offer better care at lower cost has contributed to growing interest in accountable care organizations. These provider-led delivery systems would accept responsibility for their primary care populations and would have financial incentives for improving care and reducing costs. We investigated this belief by comparing the costs and quality of care provided to Medicare beneficiaries in twenty-two health care markets by physicians who did and did not work within large multispecialty group practices affiliated with the Council of Accountable Physician Practices. In most markets, and after adjustment for patient factors, group physicians affiliated with the council provided higher-quality care at a 3.6 percent lower annual cost ($272 per patient).

Hospital readmission prevalence and analysis of those potentially avoidable in southern Italy

Background

One quality indicator of hospital care, which can be used to judge the process of care, is the prevalence of hospital readmission because it reflects the impact of hospital care on the patient’s condition after discharge. The purposes of the study were to measure the prevalence of hospital readmissions, to identify possible factors that influence such readmission and to measure the prevalence of readmissions potentially avoidable in Italy.

Methods

A sample of 2289 medical records of patients aged 18 and over admitted for medical or surgical illness at one 502-bed community non-teaching hospital were randomly selected.

Results

A total of 2252 patients were included in the final analysis, equaling a response rate of 98.4%. The overall hospital readmission prevalence within 30 days of discharge was 10.2%. Multivariate logistic regression analysis revealed that the proportion of patients readmitted within 30 days of discharge significantly increased regardless of Charlson et al. comorbidity score, among unemployed or retired patients, and in patients in general surgery. A total of 43.7% hospital readmissions were judged to be potentially avoidable. Multivariate logistic regression analysis showed that potentially avoidable readmissions were significantly higher in general surgery, in patients referred to hospital by an emergency department physician, and in those with a shortened time between discharge and readmission.

Conclusion

Additional research on intervention or bundle of interventions applicable to acute inpatient populations that aim to reduce potentially avoidable readmissions is strongly needed, and health care providers are urged to implement evidence-based programs for more cost-effective delivery of health care.

Spending differences associated with the Medicare Physician Group Practice Demonstration

CONTEXT

The Centers for Medicare & Medicaid Services (CMS) recently launched accountable care organization (ACO) programs designed to improve quality and slow cost growth. The ACOs resemble an earlier pilot, the Medicare Physician Group Practice Demonstration (PGPD), in which participating physician groups received bonus payments if they achieved lower cost growth than local controls and met quality targets. Although evidence indicates the PGPD improved quality, uncertainty remains about its effect on costs.

OBJECTIVE

To estimate cost savings associated with the PGPD overall and for beneficiaries dually eligible for Medicare and Medicaid.

DESIGN

Quasi-experimental analyses comparing preintervention (2001-2004) and postintervention (2005-2009) trends in spending of PGPD participants to local control groups. We compared estimates using several alternative approaches to adjust for case mix.

SETTING

Ten physician groups from across the United States.

PATIENTS AND PARTICIPANTS

The intervention group was composed of fee-for-service Medicare beneficiaries (n = 990,177) receiving care primarily from the physicians in the participating medical groups. Controls were Medicare beneficiaries (n = 7,514,453) from the same regions who received care largely from non-PGPD physicians. Overall, 15% of beneficiaries were dually eligible for Medicare and Medicaid.

MAIN OUTCOME MEASURE

Annual spending per Medicare fee-for-service beneficiary.

RESULTS

Annual savings per beneficiary were modest overall (adjusted mean $114, 95% CI, $12-$216). Annual savings were significant in dually eligible beneficiaries (adjusted mean $532, 95% CI, $277-$786), but were not significant among nondually eligible beneficiaries (adjusted mean $59, 95% CI, $166 in savings to $47 in additional spending). The adjusted mean spending reductions were concentrated in acute care (overall, $118, 95% CI, $65-$170; dually eligible: $381, 95% CI, $247-$515; nondually eligible: $85, 95% CI, $32-$138). There was significant variation in savings across practice groups, ranging from an overall mean per-capita annual saving of $866 (95% CI, $815-$918) to an increase in expenditures of $749 (95% CI, $698-$799). Thirty-day medical readmissions decreased overall (-0.67%, 95% CI, -1.11% to -0.23%) and in the dually eligible (-1.07%, 95% CI, -1.73% to -0.41%), while surgical readmissions decreased only for the dually eligible (-2.21%, 95% CI, -3.07% to -1.34%). Estimates were sensitive to the risk-adjustment method.

CONCLUSIONS

Substantial PGPD savings achieved by some participating institutions were offset by a lack of saving at other participating institutions. Most of the savings were concentrated among dually eligible beneficiaries.