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Chesley CF. Race and Ethnicity Disparities in Management and Outcomes of Critically Ill Adults with Acute Respiratory Failure. Crit Care Clin 2024; 40:671-683. [PMID: 39218480 PMCID: PMC11371359 DOI: 10.1016/j.ccc.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
This article reviews the current evidence base for racial and ethnic disparities related to acute respiratory failure. It discusses the prevailing and most studied mechanisms that underlay these disparities, analytical challenges that face the field, and then uses this discussion to frame future directions to outline next steps for developing disparities-mitigating solutions.
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Affiliation(s)
- Christopher F Chesley
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine; Leonard Davis Institute of Health Economics, University of Pennsylvania; Department of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 839 West Gates Building, Philadelphia, PA 19104, USA.
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Van Wilder A, Bruyneel L, Cox B, Claessens F, De Ridder D, Vanhaecht K. Rates Of Patient Safety Indicators In Belgian Hospitals Were Low But Generally Higher Than In US Hospitals, 2016-18. Health Aff (Millwood) 2024; 43:1274-1283. [PMID: 39226493 DOI: 10.1377/hlthaff.2023.01120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
More than two decades ago, the Agency for Healthcare Research and Quality developed its Patient Safety Indicators (PSIs) to monitor potentially preventable and severe adverse events within hospitals. Application of PSIs outside the US was explored more than a decade ago, but it is uncertain whether they remain relevant within Europe, as no up-to-date assessments of overall PSI-associated adverse event rates or interhospital variability can be found in the literature. This article assesses the nationwide occurrence and variability of thirteen adverse events for a case study of Belgium. We studied 4,765,850 patient stays across all 101 hospitals for 2016-18. We established that although adverse event rates were generally low, with an adverse event observed in 0.1 percent of medical hospital stays and in 1.2 percent of surgical hospital stays, they were higher than equivalent US rates and were prone to considerable between-hospital variability. Failure-to-rescue rates, for example, equaled 23 percent, whereas some hospitals exceeded nationwide central line-associated bloodstream infection rates by a factor of 8. Policy makers and hospital managers can prioritize PSIs that have high adverse event rates or large variability, such as failure to rescue or central line-associated bloodstream infections, to improve the quality of care in Belgian hospitals.
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Brewer A, Hughes MC, Patel KN. Impact of Repeated Reimbursement Penalties on Hospital Total Quality Scores. J Patient Saf 2024; 20:198-201. [PMID: 38197907 DOI: 10.1097/pts.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
OBJECTIVES The incidence of hospital-acquired conditions (HACs) is a serious public health issue with implications ranging from patient morbidity and mortality to negative financial impacts on patients and health care systems. Despite substantial efforts to address and reduce HACs, research into the effect of quality improvement programs is inconclusive. This study seeks to better understand the relationship between repeated reimbursement penalties and improvement in HAC quality scores. METHODS A quantitative comparative analysis of U.S. health care data was conducted. Data on quality outcomes and hospital characteristics were sourced from the Hospital-Acquired Condition Reduction Program from fiscal years 2018 and 2019 and the Centers for Medicare & Medicaid Services Inpatient Prospective Payment System impact files, respectively. RESULTS In total, 3123 U.S. hospitals were analyzed to compare differences between total HAC scores of hospitals with and without penalties in consecutive years. Hospitals with repeated penalties had significantly greater improvement in scores ( t497.262 = -13.00, P < 0.001), and the impact was greatest in small hospitals (<100 beds). Repeated penalties had a smaller impact on disproportionate share hospitals (Cohen d = 0.73). Among all hospitals, the effect of repeated penalties was large (Cohen d = 0.75). CONCLUSIONS This study suggests that repeated penalties can improve quality scores in U.S. hospitals. However, the effect may be exaggerated for smaller hospitals and those that serve patient populations with a relatively higher socioeconomic status. The reason disproportionate share hospitals did not show as much improvement as nondisproportionate hospitals may be because hospitals serving vulnerable populations often have fewer resources.
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Affiliation(s)
- Alice Brewer
- From the College of Health and Human Sciences, Northern Illinois University, DeKalb, Illinois
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Kulasekere DA, Royan R, Shan Y, Reyes AM, Thomas AC, Lundberg AL, Feinglass JM, Stey AM. Appendicitis Hospitalization Care Costs Among Patients With Delayed Diagnosis of Appendicitis. JAMA Netw Open 2024; 7:e246721. [PMID: 38619839 PMCID: PMC11019393 DOI: 10.1001/jamanetworkopen.2024.6721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/17/2024] [Indexed: 04/16/2024] Open
Abstract
Importance Delayed appendicitis diagnosis is associated with worse outcomes. Appendicitis hospital care costs associated with delayed diagnosis are unknown. Objective To determine whether delayed appendicitis diagnosis was associated with increased appendicitis hospital care costs. Design, Setting, and Participants This cohort study used data from patients receiving an appendectomy aged 18 to 64 years in 5 states (Florida, Maryland, Massachusetts, New York, Wisconsin) that were captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases for the years 2016 and 2017 with no additional follow-up. Data were analyzed January through April 2023. Exposures Delayed diagnosis was defined as a previous emergency department or inpatient hospital encounter with an abdominal diagnosis other than appendicitis, and no intervention 7 days prior to appendectomy encounter. Main Outcomes and Measures The main outcome was appendicitis hospital care costs. This was calculated from aggregated charges of encounters 7 days prior to appendectomy, the appendectomy encounter, and 30 days postoperatively. Cost-to-charge ratios were applied to charges to obtain costs, which were then adjusted for wage index, inflation to 2022 US dollar, and with extreme outliers winsorized. A multivariable Poisson regression estimated appendicitis hospital care costs associated with a delayed diagnosis while controlling for age, sex, race and ethnicity, insurance status, care discontinuity, income quartile, hospital size, teaching status, medical school affiliation, percentage of Black and Hispanic patient discharges, core-based statistical area, and state. Results There were 76 183 patients (38 939 female [51.1%]; 2192 Asian or Pacific Islander [2.9%], 14 132 Hispanic [18.5%], 8195 non-Hispanic Black [10.8%], 46 949 non-Hispanic White [61.6%]) underwent appendectomy, and 2045 (2.7%) had a delayed diagnosis. Delayed diagnosis patients had median (IQR) unadjusted cost of $11 099 ($6752-$17 740) compared with $9177 ($5575-$14 481) for nondelayed (P < .001). Patients with delayed diagnosis had 1.23 times (95% CI, 1.16-1.28 times) adjusted increased appendicitis hospital care costs. The mean marginal cost of delayed diagnosis was $2712 (95% CI, $2083-$3342). Even controlling for delayed diagnosis, non-Hispanic Black patients had 1.22 times (95% CI, 1.17-1.28 times) the adjusted increased appendicitis hospital care costs compared with non-Hispanic White patients. Conclusions and Relevance In this cohort study, delayed diagnosis of appendicitis was associated with increased hospital care costs.
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Affiliation(s)
| | - Regina Royan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Ying Shan
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ana M. Reyes
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | | | - Alexander L. Lundberg
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Joe M. Feinglass
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anne M. Stey
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Serpa JA, Gemeinhardt G, Arias CA, Morgan RO, Russell H, Miao H, Ganduglia Cazaban CM. Teaching and Safety-Net Hospital Penalization in the Hospital-Acquired Condition Reduction Program. JAMA Netw Open 2024; 7:e2356196. [PMID: 38363569 PMCID: PMC10873765 DOI: 10.1001/jamanetworkopen.2023.56196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/21/2023] [Indexed: 02/17/2024] Open
Abstract
Importance The Hospital-Acquired Condition Reduction Program (HACRP) evaluates acute care hospitals on the occurrence of patient safety events and health care-associated infections. Since its implementation, several studies have raised concerns about the overpenalization of teaching and safety-net hospitals, and although several changes in the program's methodology have been applied in the last few years, whether these changes reversed the overpenalization of teaching and safety-net hospitals is unknown. Objective To determine hospital characteristics associated with HACRP penalization and penalization reversal. Design, Setting, and Participants This retrospective cross-sectional study assessed data from 3117 acute care hospitals participating in the HACRP. The HACRP penalization and hospital characteristics were obtained from Hospital Compare (2020 and 2021), the Inpatient Prospective Payment System impact file (2020), and the American Hospital Association annual survey (2018). Exposures Hospital characteristics, including safety-net status and teaching intensity (no teaching and very minor, minor, major, and very major teaching levels). Main Outcomes and Measures The primary outcome was HACRP penalization (ie, hospitals that fell within the worst quartile of the program's performance). Multivariable models initially included all covariates, and then backward stepwise variable selection was used. Results Of 3117 hospitals that participated in HACRP in 2020, 779 (25.0%) were safety-net hospitals and 1090 (35.0%) were teaching institutions. In total, 771 hospitals (24.7%) were penalized. The HACRP penalization was associated with safety-net status (odds ratio [OR], 1.41 [95% CI, 1.16-1.71]) and very major teaching intensity (OR, 1.94 [95% CI, 1.15-3.28]). In addition, non-federal government hospitals were more likely to be penalized than for-profit hospitals (OR, 1.62 [95% CI, 1.23-2.14]), as were level I trauma centers (OR, 2.05 [95% CI, 1.43-2.96]) and hospitals located in the New England region (OR, 1.65 [95% CI, 1.12-2.43]). Safety-net hospitals with major teaching levels were twice as likely to be penalized as non-safety-net nonteaching hospitals (OR, 2.15 [95% CI, 1.14-4.03]). Furthermore, safety-net hospitals penalized in 2020 were less likely (OR, 0.64 [95% CI, 0.43-0.96]) to revert their HACRP penalization status in 2021. Conclusions and Relevance Findings from this cross-sectional study indicated that teaching and safety-net hospital status continued to be associated with overpenalization in the HACRP despite recent changes in its methodology. Most of these hospitals were also less likely to revert their penalization status. A reevaluation of the program methodology is needed to avoid depleting resources of hospitals caring for underserved populations.
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Affiliation(s)
- Jose A. Serpa
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Gretchen Gemeinhardt
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston
| | - Cesar A. Arias
- Center for Infectious Diseases, Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, Texas
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Robert O. Morgan
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston
| | - Heidi Russell
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston
| | - Hongyu Miao
- Department of Statistics, and College of Nursing, Florida State University, Tallahassee
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Deboever N, Correa AM, Feldman H, Mathur U, Hofstetter WL, Mehran RJ, Rice DC, Roth JA, Sepesi B, Swisher SG, Walsh GL, Vaporciyan AA, Antonoff MB, Rajaram R. Disparities in early-stage lung cancer outcomes at minority-serving hospitals compared with nonminority serving hospitals. J Thorac Cardiovasc Surg 2024; 167:329-337.e4. [PMID: 37116780 DOI: 10.1016/j.jtcvs.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/05/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVES Disparities in cancer care are omnipresent and originate from a multilevel set of barriers. Our objectives were to describe the likelihood of undergoing surgery for early-stage non-small cell lung cancer at minority-serving hospitals (MSHs), and evaluate the association of race/ethnicity with resection based on MSH status. METHODS A retrospective study using the National Cancer Database (2008-2016) was conducted including patients with clinical stage I non-small cell lung cancer. MSHs were defined as hospitals in the top decile of providing care to Hispanic or African American patients. The primary outcome evaluated was receipt of definitive surgery at MSHs vs non-MSHs. Outcomes related to race/ethnicity stratified by hospital type were also investigated. RESULTS A total of 142,580 patients were identified from 1192 hospitals (120 MSHs and 1072 non-MSHs). Most patients (85% [n = 121,240]) were non-Hispanic White, followed by African American (9% [n = 12,772]), and Hispanic (3%, [n= 3749]). MSHs cared for 7.4% (n = 10,491) of the patients included. In adjusted analyses, patients treated at MSHs were resected less often than those at non-MSHs (odds ratio, 0.87; 95% CI, 0.76-1.00; P = .0495). African American patients were less likely to receive surgery in the overall analysis (P < .01), and at MSHs specifically (P < .01), compared with non-Hispanic White patients. Hispanic patients had similar rates of resection in the overall analysis (P = .11); however, at MSHs, they underwent surgery more often compared with non-Hispanic White patients (P = .02). Resected patients at MSHs had similar overall survival (median, 91.7 months; 95% CI, 86.6-96.8 months) compared with those resected at non-MSHs (median, 85.7 months; 95% CI, 84.5-86.8 months). CONCLUSIONS Patients with early-stage non-small cell lung cancer underwent resection less often at MSHs compared with non-MSHs. Disparities related to underutilization of surgery for African American patients continue to persist, regardless of hospital type.
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Affiliation(s)
- Nathaniel Deboever
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Arlene M Correa
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Hope Feldman
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Urvashi Mathur
- University of Texas Rio Grande Valley Medical School, Edinburg, Tex
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Garrett L Walsh
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Ravi Rajaram
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex.
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Coaston TN, Sakowitz S, Chervu NL, Branche C, Shuch BM, Benharash P, Revels S. Persistent racial disparities in refusal of resection in non-small cell lung cancer patients at high-volume and Black-serving institutions. Surgery 2023; 174:1428-1435. [PMID: 37821266 DOI: 10.1016/j.surg.2023.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Surgical resection is the standard of care for early-stage non-small cell lung cancer. Black patients have higher surgical refusal rates than White patients. We evaluated factors associated with the refusal of resection and subsequent non-small cell lung cancer outcomes. METHODS We identified patients with non-small cell lung cancer stages IA to IIIA eligible for surgical resection (lobectomy or pneumonectomy) listed between 2004 and 2017 in the National Cancer Database. We stratified hospitals by the proportion of Black patients served and lung cancer resection volume. We used multivariable regression models to identify factors associated with refusal of resection and assessed 5-year mortality using Kaplan-Meier analysis and Cox proportional hazard modeling. RESULTS Of 221,396 patients identified, 7,753 (3.5%) refused surgery. Black race was associated with increased refusal (adjusted odds ratio 2.06, 95% confidence interval 1.90-2.22). Compared to White race, Black race was associated with increased refusal across the highest (adjusted odds ratio 2.29, 95% confidence interval 1.94-2.54), intermediate (adjusted odds ratio 2.05, 95% confidence interval 1.78-2.37), and lowest (adjusted odds ratio 1.77, 95% confidence interval 1.58-1.99) volume tertiles. Similarly, Black race was associated with increased refusal across the highest (adjusted odds ratio 1.97, 95% confidence interval 1.78-2.17), intermediate (adjusted odds ratio 2.08, 95% confidence interval 1.80-2.40), and lowest (adjusted odds ratio 1.53, 95% confidence interval 1.13-2.06) Black-serving tertiles. However, surgical resection yielded similar 5-year survival for Black and White patients. CONCLUSION Racial disparities in non-small cell lung cancer surgery refusal persist regardless of hospital volume or proportion of Black patients served. These findings suggest that a better understanding of patient and patient-provider level interventions could facilitate a better understanding of treatment decision-making.
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Affiliation(s)
- Troy N Coaston
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Corynn Branche
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Brian M Shuch
- Institute of Urologic Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sha'Shonda Revels
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Elshami M, Hoehn RS, Ammori JB, Hardacre JM, Selfridge JE, Bajor D, Mohamed A, Chakrabarti S, Mahipal A, Winter JM, Ocuin LM. Disparities in guideline-compliant care for patients with pancreatic ductal adenocarcinoma at minority-versus non-minority-serving hospitals. HPB (Oxford) 2023; 25:1502-1512. [PMID: 37558565 DOI: 10.1016/j.hpb.2023.07.903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND We examined disparities in guideline-compliant care at minority-serving hospitals (MSH) versus non-MSH among patients with localized or metastatic pancreatic adenocarcinoma (PDAC). METHODS Patients with PDAC were identified within the National Cancer Database (2004-2018). Guideline-compliant care was defined as surgery + chemotherapy ± radiation therapy for localized and chemotherapy for metastatic disease. Facilities in the top decile of minority patients treated were considered MSH. RESULTS A total of 190,950 patients were identified and most (59.6%) had metastatic disease. Overall, 6.4% of patients with localized and 8.2% of patients with metastatic disease were treated at MSH. Patients treated at MSH were less likely to receive guideline-compliant care (localized: OR = 0.78, 95% CI: 0.67-0.91; metastatic: OR = 0.77, 95% CI: 0.67-0.88). Minority patients were less likely to receive guideline-compliant care at non-MSH (localized: OR = 0.71, 95% CI: 0.67-0.75; metastatic: OR = 0.85, 95% CI: 0.82-0.89) or MSH (localized: OR = 0.85, 95% CI: 0.74-0.98; metastatic: OR = 0.91, 95% CI: 0.82-0.99). Patients treated at non-MSH or MSH who received guideline-compliant care were more likely to have higher OS regardless of stage or race. CONCLUSIONS MSH patients were less likely to receive guideline-compliant care and minority patients were less likely to receive guideline-compliant care regardless of MSH status. Guideline-compliant care was associated with improved OS.
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Affiliation(s)
- Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer E Selfridge
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - David Bajor
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - Amr Mohamed
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - Sakti Chakrabarti
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - Amit Mahipal
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Zogg CK, Cooper Z, Peduzzi P, Falvey JR, Castillo-Angeles M, Kodadek LM, Staudenmayer KL, Davis KA, Tinetti ME, Lichtman JH. Changes in Older Adult Trauma Quality When Evaluated Using Longer-Term Outcomes vs In-Hospital Mortality. JAMA Surg 2023; 158:e234856. [PMID: 37792354 PMCID: PMC10551815 DOI: 10.1001/jamasurg.2023.4856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/11/2023] [Indexed: 10/05/2023]
Abstract
Importance Lack of knowledge about longer-term outcomes remains a critical blind spot for trauma systems. Recent efforts have expanded trauma quality evaluation to include a broader array of postdischarge quality metrics. It remains unknown how such quality metrics should be used. Objective To examine the utility of implementing recommended postdischarge quality metrics as a composite score and ascertain how composite score performance compares with that of in-hospital mortality for evaluating associations with hospital-level factors. Design, Setting, and Participants This national hospital-level quality assessment evaluated hospital-level care quality using 100% Medicare fee-for-service claims of older adults (aged ≥65 years) hospitalized with primary diagnoses of trauma, hip fracture, and severe traumatic brain injury (TBI) between January 1, 2014, and December 31, 2015. Hospitals with annual volumes encompassing 10 or more of each diagnosis were included. The data analysis was performed between January 1, 2021, and December 31, 2022. Exposures Reliability-adjusted quality metrics used to calculate composite scores included hospital-specific performance on mortality, readmission, and patients' average number of healthy days at home (HDAH) within 30, 90, and 365 days among older adults hospitalized with all forms of trauma, hip fracture, and severe TBI. Main Outcomes and Measures Associations with hospital-level factors were compared using volume-weighted multivariable logistic regression. Results A total of 573 554 older adults (mean [SD] age, 83.1 [8.3] years; 64.8% female; 35.2% male) from 1234 hospitals were included. All 27 reliability-adjusted postdischarge quality metrics significantly contributed to the composite score. The most important drivers were 30- and 90-day readmission, patients' average number of HDAH within 365 days, and 365-day mortality among all trauma patients. Associations with hospital-level factors revealed predominantly anticipated trends when older adult trauma quality was evaluated using composite scores (eg, worst performance was associated with decreased older adult trauma volume [odds ratio, 0.89; 95% CI, 0.88-0.90]). Results for in-hospital mortality showed inverted associations for each considered hospital-level factor and suggested that compared with nontrauma centers, level 1 trauma centers had a 17 times higher risk-adjusted odds of worst (highest quantile) vs best (lowest quintile) performance (odds ratio, 17.08; 95% CI, 16.17-18.05). Conclusions and Relevance The study results challenge historical notions about the adequacy of in-hospital mortality as the single measure of older adult trauma quality and suggest that, when it comes to older adults, decisions about how quality is evaluated can profoundly alter understandings of what constitutes best practices for care. Composite scores appear to offer a promising means by which postdischarge quality metrics could be used.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Peter Peduzzi
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Manuel Castillo-Angeles
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lisa M. Kodadek
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Kimberly A. Davis
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Mary E. Tinetti
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
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Jacobs MA, Schmidt S, Hall DE, Stitzenberg KB, Kao LS, Wang CP, Manuel LS, Shireman PK. Differentiating Urgent from Elective Cases Matters in Minority Populations: Developing an Ordinal "Desirability of Outcome Ranking" to Increase Granularity and Sensitivity of Surgical Outcomes Assessment. J Am Coll Surg 2023; 237:545-555. [PMID: 37288840 PMCID: PMC10417256 DOI: 10.1097/xcs.0000000000000776] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Surgical analyses often focus on single or binary outcomes; we developed an ordinal Desirability of Outcome Ranking (DOOR) for surgery to increase granularity and sensitivity of surgical outcome assessments. Many studies also combine elective and urgent procedures for risk adjustment. We used DOOR to examine complex associations of race/ethnicity and presentation acuity. STUDY DESIGN NSQIP (2013 to 2019) cohort study assessing DOOR outcomes across race/ethnicity groups risk-adjusted for frailty, operative stress, preoperative acute serious conditions, and elective, urgent, and emergent cases. RESULTS The cohort included 1,597,199 elective, 340,350 urgent, and 185,073 emergent cases with patient mean age of 60.0 ± 15.8, and 56.4% of the surgeries were performed on female patients. Minority race/ethnicity groups had increased odds of presenting with preoperative acute serious conditions (adjusted odds ratio [aORs] range 1.22 to 1.74), urgent (aOR range 1.04 to 2.21), and emergent (aOR range 1.15 to 2.18) surgeries vs the White group. Black (aOR range 1.23 to 1.34) and Native (aOR range 1.07 to 1.17) groups had increased odds of higher/worse DOOR outcomes; however, the Hispanic group had increased odds of higher/worse DOOR (aOR 1.11, CI 1.10 to 1.13), but decreased odds (aORs range 0.94 to 0.96) after adjusting for case status; the Asian group had better outcomes vs the White group. DOOR outcomes improved in minority groups when using elective vs elective/urgent cases as the reference group. CONCLUSIONS NSQIP surgical DOOR is a new method to assess outcomes and reveals a complex interplay between race/ethnicity and presentation acuity. Combining elective and urgent cases in risk adjustment may penalize hospitals serving a higher proportion of minority populations. DOOR can be used to improve detection of health disparities and serves as a roadmap for the development of other ordinal surgical outcomes measures. Improving surgical outcomes should focus on decreasing preoperative acute serious conditions and urgent and emergent surgeries, possibly by improving access to care, especially for minority populations.
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Affiliation(s)
- Michael A Jacobs
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX (Jacobs, Shireman)
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX (Schmidt, Wang)
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA (Hall)
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA (Hall)
- Wolff Center, UPMC, Pittsburgh, PA (Hall)
| | - Karyn B Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, NC (Stitzenberg)
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Kao)
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX (Schmidt, Wang)
| | - Laura S Manuel
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio, TX (Manuel)
| | - Paula K Shireman
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX (Jacobs, Shireman)
- University Health, San Antonio, TX (Shireman)
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX (Shireman)
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11
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McLaughlin CC, Boscoe FP. The geography of Medicare's hospital value-based purchasing in relation to market demographics. Health Serv Res 2023; 58:844-852. [PMID: 36755373 PMCID: PMC10315389 DOI: 10.1111/1475-6773.14141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVE To illustrate the association between the sociodemographic characteristics of hospital markets and the geographic patterns of Medicare hospital value-based purchasing (HVBP) scores. DATA SOURCES AND STUDY SETTING This is a secondary analysis of United States hospitals with a HVBP Total Performance Score (TPS) for 2019 in the Centers for Medicare and Medicaid Services (CMS) Hospital Compare database (4/2021 release) and American Community Survey (ACS) data for 2015-2019. STUDY DESIGN This is a cross-sectional study using spatial multivariable autoregressive models with HVBP TPS and component domain scores as dependent variables and hospital market demographics as the independent variables. DATA COLLECTION/EXTRACTION METHODS We calculated hospital market demographics using ZIP code level data from the ACS, weighted the 2019 CMS inpatient Hospital Service Area file. PRINCIPAL FINDINGS Spatial autoregressive models using eight nearest neighbors with diversity index, race and ethnicity distribution, families in poverty, unemployment, and lack of health insurance among residents ages 19-64 years provided the best model fit. Diversity index had the highest statistically significant contribution to lower TPS (ß = -12.79, p < 0.0001), followed by the percent of the population coded to "non-Hispanic, some other race" (ß = -2.59, p < 0.0023), and the percent of families in poverty (ß = -0.26, p < 0.0001). Percent of the population was non-Hispanic American Indian/Alaskan Native (ß = 0.35, p < 0.0001) and percent non-Hispanic Asian (ß = 0.12, p < 0.02071) were associated with higher TPS. Lower predicted TPS was observed in large urban cities throughout the US as well as in states throughout the Southeastern US. Similar geographic patterns were observed for the predicted Patient Safety, Person and Community Engagement, and Efficiency and Cost Reduction domain scores but are not for predicted Clinical Outcomes scores. CONCLUSIONS The lower predicted scores seen in cities and in the Southeastern region potentially reflect an inherent-that is, structural-association between market sociodemographics and HVBP scores.
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Affiliation(s)
- Colleen C. McLaughlin
- Department of Population Health SciencesAlbany College of Pharmacy and Health SciencesAlbanyNew YorkUSA
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12
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Gangopadhyaya A, Zuckerman S, Rao N. Assessing the difference in racial and ethnic disparities in access to and use of care between Traditional Medicare and Medicare Advantage. Health Serv Res 2023; 58:914-923. [PMID: 36894493 PMCID: PMC10315374 DOI: 10.1111/1475-6773.14150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE Test whether racial-ethnic disparities in the access and use of care differ between Traditional Medicare (TM) and Medicare Advantage (MA). DATA SOURCE Secondary data from the 2015-2018 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN Measure Black-White and Hispanic-White disparities in access to care and use of preventive services within TM, within MA, and assess the difference-in-disparities between the two programs with and without controls for factors that could influence enrollment, access, and use. DATA COLLECTION/EXTRACTION Pool 2015-2018 MCBS data and restrict to non-Hispanic Black, non-Hispanic White, or Hispanic respondents. PRINCIPAL FINDINGS Black enrollees have worse access to care relative to White enrollees in TM and MA, particularly for cost-related measures such as not having problems paying medical bills (11-13 pp. lower for Black enrollees; p < 0.05) and satisfaction with out-of-pocket costs (5-6 pp. lower; p < 0.05). We find no difference in Black-White disparities between TM and MA. Hispanic enrollees have worse access to care relative to White enrollees in TM but similar access relative to White enrollees in MA. Hispanic-White disparities in not delaying care due to cost and not reporting problems paying medical bills are narrower in MA relative to TM by about 4 pp (significant at the p < 0.05 level) each. We find no consistent evidence that Black-White or Hispanic-White differences in the use of preventive services differ between TM and MA. CONCLUSIONS Across the measures of access and use studied here, racial and ethnic disparities in MA are not substantially narrower than in TM for Black and Hispanic enrollees relative to White enrollees. For Black enrollees, this study suggests that system-wide reforms are required to reduce existing disparities. For Hispanic enrollees, MA does narrow some disparities in access to care relative to White enrollees but, in part, because White enrollees do not do as well in MA as they do in TM.
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Affiliation(s)
- Anuj Gangopadhyaya
- Health Policy CenterUrban Institute Health Policy Center500 L'Enfant Plaza SWWashingtonDC20024USA
| | - Stephen Zuckerman
- Health Policy CenterUrban Institute Health Policy Center500 L'Enfant Plaza SWWashingtonDC20024USA
| | - Nikhil Rao
- Health Policy CenterUrban Institute Health Policy Center500 L'Enfant Plaza SWWashingtonDC20024USA
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13
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Frego N, D'Andrea V, Labban M, Trinh QD. An ecological framework for racial and ethnic disparities in surgery. Curr Probl Surg 2023; 60:101335. [PMID: 37316107 DOI: 10.1016/j.cpsurg.2023.101335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Nicola Frego
- Department of Urology, Istituto Clinico Humanitas IRCCS, Milan, Italy
| | - Vincent D'Andrea
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA
| | - Muhieddine Labban
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA; Brigham and Women's Faulkner Hospital, Jamaica Plain, MA.
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14
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Jacobs MA, Tetley JC, Kim J, Schmidt S, Brimhall BB, Mika V, Wang CP, Manuel LS, Damien P, Shireman PK. Association of Cumulative Colorectal Surgery Hospital Costs, Readmissions, and Emergency Department/Observation Stays with Insurance Type. J Gastrointest Surg 2023; 27:965-979. [PMID: 36690878 PMCID: PMC10133377 DOI: 10.1007/s11605-022-05576-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/17/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND/PURPOSE Medicare's Hospital Readmission Reduction Program disproportionately penalizes safety-net hospitals (SNH) caring for vulnerable populations. This study assessed the association of insurance type with 30-day emergency department visits/observation stays (EDOS), readmissions, and cumulative costs in colorectal surgery patients. METHODS Retrospective inpatient cohort study using the National Surgical Quality Improvement Program (2013-2019) with cost data in a SNH. The odds of EDOS and readmissions and cumulative variable (index hospitalization and all 30-day EDOS and readmissions) costs were modeled adjusting for frailty, case status, presence of a stoma, and open versus laparoscopic surgery. RESULTS The cohort had 245 private, 195 Medicare, and 590 Medicaid/uninsured cases, with a mean age 55.0 years (SD = 13.3) and 52.9% of the cases were performed on male patients. Most cases were open surgeries (58.7%). Complication rates were 41.8%, EDOS 12.0%, and readmissions 20.1%. Medicaid/uninsured had increased odds of urgent/emergent surgeries (aOR = 2.15, CI = 1.56-2.98, p < 0.001) and complications (aOR = 1.43, CI = 1.02-2.03, p = 0.042) versus private patients. Medicaid/uninsured versus private patients had higher EDOS (16.6% versus 4.1%) and readmissions (22.9% versus 14.3%) rates and higher odds of EDOS (aOR = 4.81, CI = 2.57-10.06, p < 0.001), and readmissions (aOR = 1.62, CI = 1.07-2.50, p = 0.025), while Medicare patients had similar odds versus private. Cumulative variable cost %change was increased for Medicare and Medicaid/uninsured, but Medicaid/uninsured was similar to private after adjusting for urgent/emergent cases. CONCLUSIONS Increased urgent/emergent cases in Medicaid/uninsured populations drive increased complications odds and higher costs compared to private patients, suggesting lack of access to outpatient care. SNH care for higher cost populations, receive lower reimbursements, and are penalized by value-based programs. Increasing healthcare access for Medicaid/uninsured patients could reduce urgent/emergent surgeries, resulting in fewer complications, EDOS/readmissions, and costs.
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Affiliation(s)
- Michael A Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Jasmine C Tetley
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- University Health, San Antonio, TX, USA
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Laura S Manuel
- Business Intelligence and Data Analytics, University of Texas Health Physicians, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Paul Damien
- Department of Information, Risk, and Operations Management, School of Business, University of Texas, Red McCombs, Austin, TX, USA
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA.
- University Health, San Antonio, TX, USA.
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX, USA.
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15
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Schmidt S, Kim J, Jacobs MA, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Independent Associations of Neighborhood Deprivation and Patient-level Social Determinants of Health with Textbook Outcomes after Inpatient Surgery. ANNALS OF SURGERY OPEN 2023; 4:e237. [PMID: 37588414 PMCID: PMC10427124 DOI: 10.1097/as9.0000000000000237] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Objective Assess associations of Social Determinants of Health (SDoH) using Area Deprivation Index (ADI), race/ethnicity and insurance type with Textbook Outcomes (TO). Summary Background Data Individual- and contextual-level SDoH affect health outcomes, but only one SDoH level is usually included. Methods Three healthcare system cohort study using National Surgical Quality Improvement Program (2013-2019) linked with ADI risk-adjusted for frailty, case status and operative stress examining TO/TO components (unplanned reoperations, complications, mortality, Emergency Department/Observation Stays and readmissions). Results Cohort (34,251 cases) mean age 58.3 [SD=16.0], 54.8% females, 14.1% Hispanics, 11.6% Non-Hispanic Blacks, 21.6% with ADI>85, and 81.8% TO. Racial and ethnic minorities, non-Private insurance, and ADI>85 patients had increased odds of urgent/emergent surgeries (aORs range: 1.17-2.83, all P<.001). Non-Hispanic Black patients, ADI>85 and non-Private insurances had lower TO odds (aORs range: 0.55-0.93, all P<.04), but ADI>85 lost significance after including case status. Urgent/emergent versus elective had lower TO odds (aOR=0.51, P<.001). ADI>85 patients had higher complication and mortality odds. Estimated reduction in TO probability was 9.9% (CI=7.2%-12.6%) for urgent/emergent cases, 7.0% (CI=4.6%-9.3%) for Medicaid, and 1.6% (CI=0.2%-3.0%) for non-Hispanic Black patients. TO probability difference for lowest-risk (White-Private-ADI≤85-elective) to highest-risk (Black-Medicaid-ADI>85-urgent/emergent) was 29.8% for very frail patients. Conclusion Multi-level SDoH had independent effects on TO, predominately affecting outcomes through increased rates/odds of urgent/emergent surgeries driving complications and worse outcomes. Lowest-risk versus highest-risk scenarios demonstrated the magnitude of intersecting SDoH variables. Combination of insurance type and ADI should be used to identify high-risk patients to redesign care pathways to improve outcomes. Risk adjustment including contextual neighborhood deprivation and patient-level SDoH could reduce unintended consequences of value-based programs.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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Bercow AS, Rauh-Hain JA, Melamed A, Mazina V, Growdon WB, Del Carmen MG, Goodman A, Bouberhan S, Randall T, Sisodia R, Bregar A, Eisenhauer EL, Minami C, Molina G. Association of hospital-level factors with utilization of sentinel lymph node biopsy in patients with early-stage vulvar cancer. Gynecol Oncol 2023; 169:47-54. [PMID: 36508758 DOI: 10.1016/j.ygyno.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate utilization of sentinel lymph node biopsy (SLNB) for early-stage vulvar cancer at minority-serving hospitals and low-volume facilities. METHODS Between 2012-2018, individuals with T1b vulvar squamous cell carcinoma were identified using the National Cancer Database. Patient, facility, and disease characteristics were compared between patients undergoing SLNB or inguinofemoral lymph node dissection (IFLD). Multivariable logistic regression, adjusted for patient, facility, and disease characteristics, was used to evaluate factors associated with SLNB. Kaplan-Meier survival analysis using log rank test and Cox regression was performed. RESULTS Of the 3,532 patients, 2,406 (68.1%) underwent lymph node evaluation, with 1,704 (48.2%) undergoing IFLD and 702 (19.8%) SLNB. In a multivariable analysis, treatment at minority-serving hospitals (OR 0.39, 95% CI 0.19-0.78) and low-volume hospitals (OR 0.44, 95% CI 0.28-0.70) were associated with significantly lower odds of undergoing SLNB compared to receiving care at non-minority-serving and high-volume hospitals, respectively. While SLNB utilization increased over time for the entire cohort and stratified subgroups, use of the procedure did not increase at minority-serving hospitals. After controlling for patient and tumor characteristics, SLNB was not associated with worse OS compared to IFLD in patients with positive (HR 1.02, 95% CI 0.63-1.66) or negative (HR 0.92, 95% CI 0.70-1.21) nodal pathology. CONCLUSIONS For patients with early-stage vulvar cancer, treatment at minority-serving or low-volume hospitals was associated with significantly decreased odds of undergoing SLNB. Future efforts should be concentrated toward ensuring that all patients have access to advanced surgical techniques regardless of where they receive their care.
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Affiliation(s)
- Alexandra S Bercow
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America.
| | - J Alejandro Rauh-Hain
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Alexander Melamed
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Varvara Mazina
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, New York University Langone Medical Center, New York, NY, United States of America
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Sara Bouberhan
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Thomas Randall
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Rachel Sisodia
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Amy Bregar
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Eric L Eisenhauer
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Christina Minami
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Breast Surgery, Department of Surgery, Dana-Farber/Brigham and Women's Hospital, Boston, MA, United States of America
| | - George Molina
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America
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Simon RC, Kim J, Schmidt S, Brimhall BB, Salazar CI, Wang CP, Wang Z, Sarwar ZU, Manuel LS, Damien P, Shireman PK. Association of Insurance Type With Inpatient Surgery 30-Day Complications and Costs. J Surg Res 2023; 282:22-33. [PMID: 36244224 DOI: 10.1016/j.jss.2022.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/10/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Safety-net hospitals (SNHs) have higher postoperative complications and costs versus low-burden hospitals. Do low socioeconomic status/vulnerable patients receive care at lower-quality hospitals or are there factors beyond providers' control? We studied the association of private, Medicare, and vulnerable insurance type with complications/costs in a high-burden SNH. METHODS Retrospective inpatient cohort study using National Surgical Quality Improvement Program (NSQIP) data (2013-2019) with cost data risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status, and expanded operative stress score (OSS) to evaluate 30-day unplanned reoperations, any complication, Clavien-Dindo IV (CDIV) complications, and hospitalization variable costs. RESULTS Cases (Private 1517; Medicare 1224; Vulnerable 3648) with patient mean age 52.3 y [standard deviation = 14.7] and 47.3% male. Adjusting for frailty and OSS, vulnerable patients had higher odds of PASC (aOR = 1.71, CI = 1.39-2.10, P < 0.001) versus private. Adjusting for frailty, PASC and OSS, Medicare (aOR = 1.27, CI = 1.06-1.53, P = 0.009), and vulnerable (aOR = 2.44, CI = 2.13-2.79, P < 0.001) patients were more likely to undergo urgent/emergent surgeries. Vulnerable patients had increased odds of reoperation and any complications versus private. Variable cost percentage change was similar between private and vulnerable after adjusting for case status. Urgent/emergent case status increased percentage change costs by 32.31%. We simulated "switching" numbers of private (3648) versus vulnerable (1517) cases resulting in an estimated variable cost of $49.275 million, a 25.2% decrease from the original $65.859 million. CONCLUSIONS Increased presentation acuity (PASC and urgent/emergent surgeries) in vulnerable patients drive increased odds of complications and costs versus private, suggesting factors beyond providers' control. The greatest impact on outcomes may be from decreasing the incidence of urgent/emergent surgeries by improving access to care.
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Affiliation(s)
- Richard C Simon
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Zhu Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Zaheer U Sarwar
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas
| | - Laura S Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, Texas
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas; Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas.
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Spivack SB, Qin L, Herrin J, Goutos DB, Schreiber M, Fleisher LA, Venkatesh AB, Bernheim S. Assessing Hospital Quality Scores By Proportion Of Patients Dually Eligible For Medicare And Medicaid. Health Aff (Millwood) 2023; 42:35-43. [PMID: 36623224 DOI: 10.1377/hlthaff.2022.00362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The Centers for Medicare and Medicaid Services has been reporting hospital star ratings since 2016. Some stakeholders have criticized the star ratings methodology for not adjusting for social risk factors. We examined the relationship between 2021 star rating scores and hospitals' proportion of Medicare patients dually eligible for Medicaid. We found that, on average, hospitals caring for a greater proportion of dually eligible patients had lower star ratings, but there was significant overlap in performance among hospitals when we stratified them by quintile of dually eligible patients. Hospitals in the highest quintile (those with the greatest proportion of dually eligible patients) had the best mean mortality scores (0.28) but the worst readmission (-0.44) and patient experience (-0.78) scores. We assigned star ratings after stratifying the readmission measure group by proportion of dually eligible patients and found that a total of 142 hospitals gained a star and 161 hospitals lost a star, of which 126 (89 percent) and 1 (<1 percent) were in the highest quintile, respectively. Adjusting public reporting tools such as star ratings for social risk factors is ultimately a policy decision, and views on the appropriateness of accounting for factors such as proportion of dually eligible patients are mixed, depending on the organization and stakeholder.
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Affiliation(s)
| | | | | | | | - Michelle Schreiber
- Michelle Schreiber, Centers for Medicare and Medicaid Services, Baltimore, Maryland
| | - Lee A Fleisher
- Lee A. Fleisher, Centers for Medicare and Medicaid Services
| | - Arjun B Venkatesh
- Arjun B. Venkatesh, Yale-New Haven Hospital, New Haven, Connecticut, and Yale University
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Tetley JC, Jacobs MA, Kim J, Schmidt S, Brimhall BB, Mika V, Wang CP, Manuel LS, Damien P, Shireman PK. Association of Insurance Type With Colorectal Surgery Outcomes and Costs at a Safety-Net Hospital: A Retrospective Observational Study. ANNALS OF SURGERY OPEN 2022; 3:e215. [PMID: 36590892 PMCID: PMC9780053 DOI: 10.1097/as9.0000000000000215] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/02/2022] [Indexed: 11/09/2022] Open
Abstract
Association of insurance type with colorectal surgical complications, textbook outcomes (TO), and cost in a safety-net hospital (SNH). Background SNHs have higher surgical complications and costs compared to low-burden hospitals. How does presentation acuity and insurance type influence colorectal surgical outcomes? Methods Retrospective cohort study using single-site National Surgical Quality Improvement Program (2013-2019) with cost data and risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status and open versus laparoscopic to evaluate 30-day reoperations, any complication, Clavien-Dindo IV (CDIV) complications, TO, and hospitalization variable costs. Results Cases (Private 252; Medicare 207; Medicaid/Uninsured 619) with patient mean age 55.2 years (SD = 13.4) and 53.1% male. Adjusting for frailty, open abdomen, and urgent/emergent cases, Medicaid/Uninsured patients had higher odds of presenting with PASC (adjusted odds ratio [aOR] = 2.02, 95% confidence interval [CI] = 1.22-3.52, P = 0.009) versus Private. Medicaid/Uninsured (aOR = 1.80, 95% CI = 1.28-2.55, P < 0.001) patients were more likely to undergo urgent/emergent surgeries compared to Private. Medicare patients had increased odds of any and CDIV complications while Medicaid/Uninsured had increased odds of any complication, emergency department or observations stays, and readmissions versus Private. Medicare (aOR = 0.51, 95% CI = 0.33-0.88, P = 0.003) and Medicaid/Uninsured (aOR = 0.43, 95% CI = 0.30-0.60, P < 0.001) patients had lower odds of achieving TO versus Private. Variable cost %change increased in Medicaid/Uninsured patients to 13.94% (P = 0.005) versus Private but was similar after adjusting for case status. Urgent/emergent cases (43.23%, P < 0.001) and any complication (78.34%, P < 0.001) increased %change hospitalization costs. Conclusions Decreasing the incidence of urgent/emergent colorectal surgeries, possibly by improving access to care, could have a greater impact on improving clinical outcomes and decreasing costs, especially in Medicaid/Uninsured insurance type patients.
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Affiliation(s)
- Jasmine C. Tetley
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Michael A. Jacobs
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Jeongsoo Kim
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, TX
| | - Paula K. Shireman
- From the Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX
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Kim H, Mahmood A, Hammarlund NE, Chang CF. Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives. Front Public Health 2022; 10:882715. [PMID: 36299751 PMCID: PMC9589294 DOI: 10.3389/fpubh.2022.882715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/12/2022] [Indexed: 01/21/2023] Open
Abstract
Beginning in the early 2010s, an array of Value-Based Purchasing (VBP) programs has been developed in the United States (U.S.) to contain costs and improve health care quality. Despite documented successes in these efforts in some instances, there have been growing concerns about the programs' unintended consequences for health care disparities due to their built-in biases against health care organizations that serve a disproportionate share of disadvantaged patient populations. We explore the effects of three Medicare hospital VBP programs on health and health care disparities in the U.S. by reviewing their designs, implementation history, and evidence on health care disparities. The available empirical evidence thus far suggests varied impacts of hospital VBP programs on health care disparities. Most of the reviewed studies in this paper demonstrate that hospital VBP programs have the tendency to exacerbate health care disparities, while a few others found evidence of little or no worsening impacts on disparities. We discuss several policy options and recommendations which include various reform approaches and specific programs ranging from those addressing upstream structural barriers to health care access, to health care delivery strategies that target service utilization and health outcomes of vulnerable populations under the VBP programs. Future studies are needed to produce more explicit, conclusive, and consistent evidence on the impacts of hospital VBP programs on disparities.
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Affiliation(s)
- Hyunmin Kim
- School of Health Professions, The University of Southern Mississippi, Hattiesburg, MS, United States
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, United States
| | - Asos Mahmood
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, United States
- Center for Health System Improvement, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Medicine-General Internal Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Noah E. Hammarlund
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, United States
| | - Cyril F. Chang
- Department of Economics, Fogelman College of Business and Economics, The University of Memphis, Memphis, TN, United States
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21
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Boamah SA, Hamadi HY, Spaulding AC. Hospital-Acquired Conditions Reduction Program, Racial and Ethnic Diversity, and Magnet Designation in the United States. J Patient Saf 2022; 18:e1090-e1095. [PMID: 35532988 DOI: 10.1097/pts.0000000000001014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A key quality indicator in any health system is its ability to reduce morbidity and mortality. In recent years, healthcare organizations in the United States have been held to stricter measures of accountability to provide safe, quality care. This study aimed to explore the contextual factors driving racial disparities in hospital-acquired conditions incident rates among Medicare recipients in Magnet and non-Magnet hospitals. METHODS A cross-sectional observational study was performed using data from Hospital-Acquired Condition Reduction Program. Performance from 1823 hospitals were used to examine the association between Magnet recognition and community's racial and ethnic differences in hospital performance on the Hospital-Acquired Condition Reduction Program. The unit of analysis was the hospital level. A propensity score matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals. The outcome measures were risk-standardized hospital performance on the Hospital-Acquired Condition Reduction Program domains and overall performance. RESULTS Study findings show that Magnet hospitals had decreased methicillin-resistant Staphylococcus aureus (MRSA) rate (β = -0.22; 95% confidence interval, -0.36 to -0.08) compared with non-Magnet hospitals. No other statistical difference was identified. CONCLUSIONS Results from this study show community's racial and ethnic differences in hospital-acquired conditions occurrence differ between Magnet and non-Magnet hospitals for MRSA, indicating its association with nursing practice. However, because this improvement is limited to only MRSA, there are likely opportunities for Magnet hospitals to continue process improvements focused on additional Hospital-Acquired Condition Reduction Program measures.
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Affiliation(s)
- Sheila A Boamah
- From the School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Hanadi Y Hamadi
- Department of Health Administration, Brooks College of Health (Building 39), University of North Florida
| | - Aaron C Spaulding
- Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern, Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida
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22
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Chen A, Ghosh A, Gwynn KB, Newby C, Henry TL, Pearce J, Fleurant M, Schmidt S, Bracey J, Jacobs EA. Society of General Internal Medicine Position Statement on Social Risk and Equity in Medicare's Mandatory Value-Based Payment Programs. J Gen Intern Med 2022; 37:3178-3187. [PMID: 35768676 PMCID: PMC9485310 DOI: 10.1007/s11606-022-07698-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/02/2022] [Indexed: 11/30/2022]
Abstract
The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major mandatory pay-for-performance programs have been implemented since 2012 with increasing positive and negative payment adjustments over time. A growing body of evidence indicates that these programs are inequitable and financially penalize safety-net systems and systems that care for a higher proportion of racial and ethnic minority patients. Payments from penalized systems are often redistributed to those with higher performance scores, which are predominantly better-financed, large, urban systems that serve less vulnerable patient populations - a "Reverse Robin Hood" effect. This inequity may be diminished by adjusting for social risk factors in payment policy. In this position statement, we review the literature evaluating equity across Medicare value-based payment programs, major policy reports evaluating the use of social risk data, and provide recommendations on behalf of the Society of General Internal Medicine regarding how to address social risk and unmet health-related social needs in these programs. Immediate recommendations include implementing peer grouping (stratification of healthcare systems by proportion of dual eligible Medicare/Medicaid patients served, and evaluation of performance and subsequent payment adjustments within strata) until optimal methods for accounting for social risk are defined. Short-term recommendations include using census-based, area-level indices to account for neighborhood-level social risk, and developing standardized approaches to collecting individual socioeconomic data in a robust but sensitive way. Long-term recommendations include implementing a research agenda to evaluate best practices for accounting for social risk, developing validated health equity specific measures of care, and creating policies to better integrate healthcare and social services.
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Affiliation(s)
- Anders Chen
- Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Arnab Ghosh
- Department of Medicine, Weill Cornell Medical College of Columbia University, New York, NY, USA
| | - Kendrick B Gwynn
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Celeste Newby
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tracey L Henry
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Jackson Pearce
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Stacie Schmidt
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Jennifer Bracey
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Bonner SN, Kunnath N, Dimick JB, Ibrahim AM. Neighborhood deprivation and Medicare expenditures for common surgical procedures. Am J Surg 2022; 224:1274-1279. [PMID: 35750504 DOI: 10.1016/j.amjsurg.2022.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The Center of Medicare and Medicaid Services valued based payments for inpatient surgical hospitalizations are adjusted for clinical but not social risk factors. While research has shown that social risk is associated with worse surgical patient outcomes, it is unknown if inpatient surgical episode Medicare payments are affected by social risk factors. METHODS Retrospective review of Medicare beneficiaries, age 65-99, undergoing appendectomy, colectomy, hernia repair, or cholecystectomy between 2014 and 2018. Neighborhood deprivation measured by Area Deprivation Index for beneficiary census tract. We evaluated Medicare payments for a total episode of surgical care comprised of index hospitalization, physician fees, post-acute care, and readmission by beneficiary neighborhood deprivation. RESULTS A total of 809,059 patients (Women, 56.0%) and mean (SD) age of 75.7 (7.4 years were included. A total of 145,351 beneficiaries lived in the least deprived neighborhoods and 134,188 who lived in the most deprived neighborhoods. Total surgical episode spending was $2654 higher among beneficiaries from the most deprived neighborhoods compared to those from the least after risk adjustment for clinical and hospital factors. These differences were driven in part by higher rates of readmissions (12.9% vs 10.8%, P < 0.001) and post-acute care (67.8% vs. 61.2%, P < 0.001) among beneficiaries living in the most deprived neighborhoods. CONCLUSION These findings suggest that value-based payment models with inclusion of social risk adjustment may be needed for surgical cohorts. Moreover, efforts focused on investing in deprived communities may be aligned with surgical quality improvement.
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Affiliation(s)
- Sidra N Bonner
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; National Clinician Scholars Program, University of Michigan, Ann Arbor, MI, USA.
| | - Nicholas Kunnath
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Andrew M Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
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24
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Makic MBF, Stevens KR, Gritz RM, Wald H, Ouellet J, Morrow CD, Rodrick D, Reeder B. Dashboard Design to Identify and Balance Competing Risk of Multiple Hospital-Acquired Conditions. Appl Clin Inform 2022; 13:621-631. [PMID: 35675838 DOI: 10.1055/s-0042-1749598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Hospital-acquired conditions (HACs) are common, costly, and national patient safety priority. Catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure injury (HAPI), and falls are common HACs. Clinicians assess each HAC risk independent of other conditions. Prevention strategies often focus on the reduction of a single HAC rather than considering how actions to prevent one condition could have unintended consequences for another HAC. OBJECTIVES The objective of this study is to design an empirical framework to identify, assess, and quantify the risks of multiple HACs (MHACs) related to competing single-HAC interventions. METHODS This study was an Institutional Review Board approved, and the proof of concept study evaluated MHAC Competing Risk Dashboard to enhance clinicians' management combining the risks of CAUTI, HAPI, and falls. The empirical model informing this study focused on the removal of an indwelling urinary catheter to reduce CAUTI, which may impact HAPI and falls. A multisite database was developed to understand and quantify competing risks of HACs; a predictive model dashboard was designed and clinical utility of a high-fidelity dashboard was qualitatively tested. Five hospital systems provided data for the predictive model prototype; three served as sites for testing and feedback on the dashboard design and usefulness. The participatory study design involved think-aloud methods as the clinician explored the dashboard. Individual interviews provided an understanding of clinician's perspective regarding ease of use and utility. RESULTS Twenty-five clinicians were interviewed. Clinicians favored a dashboard gauge design composed of green, yellow, and red segments to depict MHAC risk associated with the removal of an indwelling urinary catheter to reduce CAUTI and possible adverse effects on HAPI and falls. CONCLUSION Participants endorsed the utility of a visual dashboard guiding clinical decisions for MHAC risks preferring common stoplight color understanding. Clinicians did not want mandatory alerts for tool integration into the electronic health record. More research is needed to understand MHAC and tools to guide clinician decisions.
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Affiliation(s)
| | - Kathleen R Stevens
- School of Nursing, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States
| | - R Mark Gritz
- Division of Health Care Policy and Research, School of Medicine, University of Colorado Denver, Aurora, Colorado, United States
| | - Heidi Wald
- SCL Health, Denver, Colorado, United States
| | - Judith Ouellet
- Division of Health Care Policy and Research, School of Medicine, University of Colorado Denver, Aurora, Colorado, United States
| | - Cynthia Drake Morrow
- Health Systems, Management and Policy, Colorado School of Public Health, Aurora, Colorado, United States
| | - David Rodrick
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland, United States
| | - Blaine Reeder
- University of Missouri Health, Sinclair School of Nursing and MU Institute for Data Science and Informatics, School of Nursing, Columbia, Missouri, United States
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25
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Shashikumar SA, Waken RJ, Aggarwal R, Wadhera RK, Joynt Maddox KE. Three-Year Impact Of Stratification In The Medicare Hospital Readmissions Reduction Program. Health Aff (Millwood) 2022; 41:375-382. [PMID: 35254934 DOI: 10.1377/hlthaff.2021.01448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with high readmission rates. In fiscal year 2019 the program was changed to account for the association between social risk and high readmission rates. The new approach stratifies hospitals into five groups by hospitals' proportion of patients dually enrolled in Medicare and Medicaid, and it evaluates performance within each stratum instead of within the national cohort. Its impact on hospitals caring for vulnerable populations has not been studied. We calculated the change in average annual penalty percentage, before and after stratification, for safety-net hospitals, rural hospitals, and hospitals caring for a high share of Black and Hispanic or Latino patients. We found that stratification by proportion of dual enrollees was associated with a decrease in penalties by -0.09 percentage points at hospitals with the highest proportion of dual enrollees, -0.08 percentage points at rural hospitals, and -0.06 percentage points at hospitals with a large share of Black and Hispanic or Latino patients. Fully adjusted analyses suggest that these patterns were driven by penalty reductions at rural hospitals and hospitals disproportionately serving Black and Hispanic or Latino patients. Given the allocation of fewer penalties to these hospitals, we conclude that the stratification mandate was a modest step toward equity within the HRRP.
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Affiliation(s)
| | - R J Waken
- R. J. Waken, Washington University in St. Louis
| | - Rahul Aggarwal
- Rahul Aggarwal, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Rishi K Wadhera
- Rishi K. Wadhera, Beth Israel Deaconess Medical Center and Harvard Medical School
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Zogg CK, Lichtman JH, Dalton MK, Learn PA, Schoenfeld AJ, Perez Koehlmoos T, Weissman JS, Cooper Z. In defense of Direct Care: Limiting access to military hospitals could worsen quality and safety. Health Serv Res 2021; 57:723-733. [PMID: 34608642 PMCID: PMC9264466 DOI: 10.1111/1475-6773.13885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 07/24/2021] [Accepted: 09/20/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Ongoing health care reforms within the US Military Health System (MHS) are expected to shift >1.9 million MHS beneficiaries from military treatment facilities (MTFs) into local civilian hospitals over the next 1-2 years. The objective of this study was to examine how such health care reforms are likely to affect the quality of MHS care. DATA SOURCES Adult MHS beneficiaries, aged 18-64 years, treated in MTFs (under a program known as Direct Care) were compared against (1) MHS beneficiaries treated in locally available civilian hospitals (under a program known as Purchased Care) and (2) similarly-aged adult civilian patients across the United States. MHS beneficiaries in Direct and Purchased Care were identified from fiscal-year 2016-2018 MHS inpatient claims. National inpatients were identified in the 2017 Nationwide Readmissions Database. STUDY DESIGN Retrospective cohort. DATA COLLECTION Differences in quality were compared using two sets of quality metrics endorsed by the US Agency for Healthcare Research and Quality (AHRQ): Inpatient Quality Indicators, 19 quality metrics that look at differences in in-hospital mortality, and Patient Safety Indicators, 18 quality metrics that look at differences in in-hospital morbidity and adverse events. Among MHS beneficiaries (Direct and Purchased Care), we further simulated what changes in quality indicators might look like under various proposed scenarios of reduced access to Direct Care. PRINCIPAL FINDINGS A total of 502,252 MHS admissions from 37 MTFs and surrounding civilian hospitals were included (326,076 Direct Care, 179,176 Purchased Care). Nationwide, 9.34 million adult admissions from 2453 hospitals were included. On average, MHS beneficiaries treated in MTFs experienced better inpatient quality and improved patient safety compared with MHS beneficiaries treated in locally available civilian hospitals (e.g., summary observed-to-expected ratio for medical mortality: 0.98 vs. 1.03, p < 0.001) and adult patients across the United States (0.98 vs. 1.02, p < 0.001). Simulations of proposed changes resulted in consistently worse outcomes for MHS patients, whether reducing MTF access by 10%, 20%, or 50% nationwide; limiting MTF access to active-duty beneficiaries; or closing MTFs with the worst performance on patient safety (p < 0.001 for overall quality indicators for each). CONCLUSIONS Reducing access to MTFs could result in significant harm to MHS patients. The results underscore the importance of health-policy planning based on evidence-based evaluation and the need to consider the consequential downstream effects caused by changes in access to care.
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Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, New Haven, Connecticut, USA.,Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Judith H Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Peter A Learn
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Tracey Perez Koehlmoos
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
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27
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Chao GF, Emlaw J, Chiu AS, Yang J, Thumma J, Brackett A, Pei KY. Asian American Pacific Islander Representation in Outcomes Research: NSQIP Scoping Review. J Am Coll Surg 2021; 232:682-689.e5. [PMID: 33705984 DOI: 10.1016/j.jamcollsurg.2021.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND If Asian American and Pacific Islanders (AAPIs) are not recognized within patients in health services research, we miss an opportunity to ensure health equity in patient outcomes. However, it is unknown what the rates are of AAPIs inclusion in surgical outcomes research. STUDY DESIGN Through a scoping review, we used Covidence to search MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, and CINAHL for studies published in 2008-2018 using NSQIP data. NSQIP was chosen because of its national scope, widespread use in research, and coding inclusive of AAPI patients. We examined the proportion of studies representing AAPI patients in the demographic characteristics and Methods, Results, or Discussion section. We then performed multivariable logistic regression to examine associations between study characteristics and AAPI inclusion. RESULTS In 1,264 studies included for review, 62% included race. Overall, only 22% (n = 278) of studies included AAPI patients. Of studies that included race, 35% represented AAPI patients in some component of the study. We found no association between sample size or publication year and inclusion. Studies were significantly more likely to represent AAPI patients when there was a higher AAPI population in the region of the first author's institution (lowest vs highest tercile; p < 0.001). Studies with a focus on disparities were more likely to include AAPI patients (p = 0.001). CONCLUSIONS Our study is the first to examine AAPI representation in surgical outcomes research. We found < 75% of studies examine race, despite availability within NSQIP. Little more than one-third of studies including race reported on AAPI patients as a separate group. To provide the best care, we must include AAPI patients in our research.
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Affiliation(s)
- Grace F Chao
- National Clinician Scholars Program, Veterans Affairs Ann Arbor, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Surgery, New Haven, CT.
| | - Jonel Emlaw
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | | | - Jie Yang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Jyothi Thumma
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, CT
| | - Kevin Y Pei
- Department of Surgery, Houston Methodist Hospital, Houston, TX
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Shashikumar SA, Waken RJ, Luke AA, Nerenz DR, Joynt Maddox KE. Association of Stratification by Proportion of Patients Dually Enrolled in Medicare and Medicaid With Financial Penalties in the Hospital-Acquired Condition Reduction Program. JAMA Intern Med 2021; 181:330-338. [PMID: 33346779 PMCID: PMC7754078 DOI: 10.1001/jamainternmed.2020.7386] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/17/2020] [Indexed: 02/05/2023]
Abstract
Importance The Hospital-Acquired Condition Reduction Program (HACRP) is a value-based payment program focused on safety events. Prior studies have found that the program disproportionately penalizes safety-net hospitals, which may perform more poorly because of unmeasured severity of illness rather than lower quality. A similar program, the Hospital Readmissions Reduction Program, stratifies hospitals into 5 peer groups for evaluation based on the proportion of their patients dually enrolled in Medicare and Medicaid, but the effect of stratification on the HACRP is unknown. Objective To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification. Design, Setting, and Participants This economic evaluation used publicly available data on HACRP performance and penalties merged with hospital characteristics and cost reports. A total of 3102 hospitals participating in the HACRP in fiscal year 2020 (covering data from July 1, 2016, to December 31, 2018) were studied. Exposures Hospitals were divided into 5 groups based on the proportion of patients dually enrolled, and penalties were assigned to the lowest-performing quartile of hospitals in each group rather than the lowest-performing quartile overall. Main Outcomes and Measures Penalties in the prestratification vs poststratification schemes. Results The study identified 3102 hospitals evaluated by the HACRP. Safety-net hospitals received $111 333 384 in penalties before stratification compared with an estimated $79 087 744 after stratification-a savings of $32 245 640. Hospitals less likely to receive penalties after stratification included safety-net hospitals (33.6% penalized before stratification vs 24.8% after stratification, Δ = -8.8 percentage points [pp], P < .001), public hospitals (34.1% vs 30.5%, Δ = -3.6 pp, P = .003), hospitals in the West (26.8% vs 23.2%, Δ = -3.6 pp, P < .001), hospitals in Medicaid expansion states (27.3% vs 25.6%, Δ = -1.7 pp, P = .003), and hospitals caring for the most patients with disabilities (32.2% vs 28.3%, Δ = -3.9 pp, P < .001) and from racial/ethnic minority backgrounds (35.1% vs 31.5%, Δ = -3.6 pp, P < .001). In multivariate analyses, safety-net status and treating patients with highly medically complex conditions were associated with higher odds of moving from penalized to nonpenalized status. Conclusions and Relevance This economic evaluation suggests that stratification of hospitals would be associated with a narrowing of disparities in penalties and a marked reduction in penalties for safety-net hospitals. Policy makers should consider adopting stratification for the HACRP.
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Affiliation(s)
- Sukruth A. Shashikumar
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - R. J. Waken
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alina A. Luke
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
- Behavioral, Social, and Health Education Sciences Division, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - David R. Nerenz
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
- Center for Health Economics and Policy, Institute for Public Health at Washington University in St Louis, St Louis, Missouri
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29
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Hirji S, Kaneko T. Integrated Cardiac Surgery Systems of Care and Care Fragmentation - A Continuum Beyond Discharge. Ann Thorac Surg 2021; 112:1379-1380. [PMID: 33524342 DOI: 10.1016/j.athoracsur.2021.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/10/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, 15Francis Street Boston, MA 02115
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, 15Francis Street Boston, MA 02115.
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30
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Perpetuation of Inequity: Disproportionate Penalties to Minority-serving and Safety-net Hospitals Under Another Medicare Value-based Payment Model. Ann Surg 2020; 271:994-995. [DOI: 10.1097/sla.0000000000003911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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