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The Value Proposition of Observation Medicine in Managing Acute Oncologic Pain. Curr Oncol Rep 2022; 24:595-602. [PMID: 35192121 DOI: 10.1007/s11912-022-01245-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Despite recommended best practice guidelines, pain remains an ongoing but undertreated symptom in patients with cancer, many of whom require emergency department evaluation for acute oncologic pain. A significant proportion of these patients are hospitalized for pain management, which increases healthcare costs and exposes patients to the risks of hospitalization. We reviewed the literature on observation medicine: an emerging mode of healthcare delivery which can offer patients with acute pain access to a hospital's pain management solutions and specialists without an inpatient hospitalization. Specifically, we appraised the role of observation medicine in acute pain management and its financial implications in order to consider its potential impact on the management of acute oncologic pain. RECENT FINDINGS Recent evidence shows that observation medicine has the potential to decrease short-stay hospitalizations in cancer patients presenting with various concerns, including pain. Observation medicine is reported to be successful in providing comprehensive and cost-effective care for non-cancer patients with acute pain, making it a promising alternative to short-stay hospitalizations for cancer patients with acute oncologic pain.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Johnston KJ, Wen H, Kotwal A, Joynt Maddox KE. Comparing Preventable Acute Care Use of Rural Versus Urban Americans: an Observational Study of National Rates During 2008-2017. J Gen Intern Med 2021; 36:3728-3736. [PMID: 33511571 PMCID: PMC8642477 DOI: 10.1007/s11606-020-06532-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Rural Americans have less access to care than urban Americans. Preventable acute care use is a marker of unmet ambulatory healthcare needs, but little is known about how such utilization has differed between rural and urban areas over time. OBJECTIVE Compare preventable emergency department (ED) visit and hospitalization rates among rural versus urban residents over the past decade. DESIGN Observational study using a validated algorithm to compute age-sex-adjusted rates per 100,000 individuals of preventable ED visits and hospitalizations. Differences in overall, annual, and condition-specific rates for rural versus urban residents were assessed and linear regression was used to assess 10-year trends. SETTING Nationwide Emergency Department Sample, National Inpatient Sample, and US Census, 2008-2017. PARTICIPANTS US adults, an annual average of 241.3 million individuals. MEASUREMENTS Preventable ED visits and hospitalizations. RESULTS Compared to urban residents, rural residents had 45% higher rates of preventable ED visits in 2008 (3003 vs. 2070 per 100,000, adjusted difference [AD]: 933; 95% CI: 928-938) and 44% higher rates of preventable ED visits in 2017 (3911 vs. 2708 per 100,000, AD: 1202; 95% CI: 1196-1208). Rural residents had 26% higher rates of preventable hospitalizations in 2008 (2104 vs. 1666 per 100,000, AD: 439; 95% CI: 434-443) and 13% higher rates in 2017 (1634 vs. 1440 per 100,000, AD: 194; 95% CI: 190-199). Preventable ED visits increased more in absolute terms in rural versus urban residents, but the percentage increase was similar (30% vs. 31%) because rural residents started at a higher baseline. Preventable hospitalizations decreased at a faster rate (22% vs. 14%) among rural versus urban residents. LIMITATIONS Observational study; unable to infer causality. CONCLUSIONS Rural disparities in acute care use are narrowing for preventable hospitalizations but have persisted for all preventable acute care use, suggesting unmet demand for high-quality ambulatory care in rural areas.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University , 3545 Lafayette Ave., Room 362, St. Louis, MO, 63104, USA.
| | - Hefei Wen
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute , 401 Park Drive, Suite 401 East, Boston, MA, 02215, USA
| | - Ameya Kotwal
- Department of Health Management and Policy, College for Public Health and Social Justice, Saint Louis University , 3545 Lafayette Ave, St. Louis, MO, 63104, USA
| | - Karen E Joynt Maddox
- Cardiovascular Division, Washington University School of Medicine , 660 S. Euclid Ave, CB 8086, St. Louis, MO, 63110, USA
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 319] [Impact Index Per Article: 106.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:2218-2261. [PMID: 34756652 DOI: 10.1016/j.jacc.2021.07.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 152] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709928 DOI: 10.1161/cir.0000000000001030] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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Tian Y, Hall M, Ingram MCE, Hu A, Raval MV. Trends and Variation in the Use of Observation Stays at Children's Hospitals. J Hosp Med 2021; 16:645-651. [PMID: 34328847 DOI: 10.12788/jhm.3622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/22/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Observation status could improve efficiency of healthcare resource use but also might shift financial burdens to patients and hospitals. Although the use of observation stays has increased for adult patient populations, the trends are unknown among hospitalized children. OBJECTIVE The goal of this study was to describe recent trends in observation stays for pediatric populations at children's hospitals. DESIGN, SETTING, AND PARTICIPANTS Both observation and inpatient stays for all conditions were retrospectively studied using the Pediatric Health Information System database (2010 to 2019). EXPOSURE, MAIN OUTCOMES, AND MEASURES Patient type was classified as inpatient or observation status. Main outcomes included annual percentage of observation stays, annual percentage of observation stays having prolonged length of stay (>2 days), and growth rates of observation stays for the 20 most common conditions. Risk adjusted hospital-level use of observation stays was estimated using generalized linear mixed-effects models. RESULTS The percentage of observation stays increased from 23.6% in 2010 to 34.3% in 2019 (P < .001), and the percentage of observation stays with prolonged length of stay rose from 1.1% to 4.6% (P < .001). Observation status was expanded among a diverse group of clinical conditions; diabetes mellitus and surgical procedures showed the highest growth rates. Adjusted hospital-level use ranged from 0% to 67% in 2019, indicating considerable variation among hospitals. CONCLUSION Based on the increase in observation stays, future studies should explore the appropriateness of observation care related to efficient use of healthcare resources and financial implications for hospitals and patients.
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Affiliation(s)
- Yao Tian
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois
| | - Andrew Hu
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois
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Perry M, Franks N, Pitts SR, Moran TP, Osborne A, Peterson D, Ross MA. The impact of emergency department observation units on a health system. Am J Emerg Med 2021; 48:231-237. [PMID: 33991972 DOI: 10.1016/j.ajem.2021.04.079] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Protocol driven ED observation units (EDOU) have been shown to improve outcomes for patients and payers, however their impact on an entire health system is unknown. Two thirds of US hospitals do not have such units. OBJECTIVE To determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization. METHODS A retrospective, observational, cross-sectional study of observation patients managed over 25 consecutive months in a four-hospital academic health system. Patients were identified using the "admit to observation" order and limited to adult, emergent / urgent, non-obstetric patients. Data was retrieved from a cost accounting database. The primary study exposure was the setting for observation care which was broken into three discrete groups: EDOUs (n = 3), hospital medicine observation units (HMSOU, n = 2), and a non-observation unit (NOU) bed located anywhere in the hospital. Outcomes included observation-to-inpatient admission rate, length of stay (LoS), total direct cost, and inpatient bed days saved. Unadjusted outcomes were compared, and outcomes were adjusted using multiple study variables. LoS and cost were compared using quantile regressions. Inpatient admit rate was compared using logistic regressions. RESULTS The sample consisted of 48,145 patients who were 57.4% female, 48% Black, 46% White, median age of 58, with some variation in most common diagnoses and payer groups. The median unadjusted outcomes favored EDOU over NOU settings for admission rate (13.1% vs 37.1%), LoS [17.9 vs 35.6 h), and cost ($1279 vs $2022). The adjusted outcomes favored EDOU over NOU settings for admission rates [12.3% (95% CI 9.7-15.3) vs 26.4% (CI 21.3-32.3)], LoS differences [11.1 h (CI 10.6-11.5 h)] and cost differences [$127.5 (CI $105.4 - $149.5)]. Adjusted differences were similar and favored EDOU over HMSOU settings. For the health system, the total adjusted annualized savings of the EDOUs was 10,399 bed days and $1,329,443 in total direct cost per year. CONCLUSION Within an academic medical center, EDOUs were associated with improved resource utilization and reduced cost. This represents a significant opportunity for hospitals to improve efficiency and contain costs.
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Affiliation(s)
- Michael Perry
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nicole Franks
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen R Pitts
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Anwar Osborne
- Department of Emergency Medicine, Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Michael A Ross
- Department of Emergency Medicine, Observation Medicine, Emory University School of Medicine, 531 Asbury Circle - Annex, Suite N340, Atlanta, Georgia.
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Johnson K, Lane BR, Weizer AZ, Herrel LA, Rogers CG, Qi J, Johnson AM, Seifman BD, Sarle RC. Partial nephrectomy should be classified as an inpatient procedure: Results from a statewide quality improvement collaborative. Urol Oncol 2021; 39:239.e9-239.e16. [PMID: 33485765 DOI: 10.1016/j.urolonc.2021.01.001] [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: 10/15/2020] [Revised: 12/15/2020] [Accepted: 01/03/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To examine length of stay (LOS) and readmission rates for all minimally-invasive partial nephrectomy (MIPN) and MI radical nephrectomy (MIRN) performed for localized renal masses ≤7 cm in size (cT1RM) within 12 Michigan urology practices. Both RN and PN are commonly performed in treating cT1RM. Although technically more complex and associated with higher complication rates, Centers for Medicare & Medicaid Services considers MIPN an outpatient procedure and MIRN is inpatient. METHODS We collected data for renal surgeries for cT1RM at MUSIC-KIDNEY practices between May 2017-February 2020. Data abstractors recorded clinical, radiographic, pathologic, surgical, and short-term follow-up data into the registry for cT1RM patients. RESULTS Within MUSIC-KIDNEY, 807 patients underwent MI renal surgery at 12 practices. Median LOS for cT1RM patients after MIPN (n = 531, 66%) was 2 days and after MIRN (n = 276, 34%) was also 2 days. Among patients undergoing laparoscopic or robotic PN, 171 (32%), 230 (43%), and 130 (24%) stayed ≤1, 2, ≥3 days. Among patients undergoing laparoscopic or robotic RN, 81 (29%), 112 (41%), and 83 (30%) stayed ≤1, 2, ≥3 days. No significant difference was observed between MIPN and MIRN on LOS commensurate with outpatient surgery (≤1-day, OR = 0.97, P = 0.87). CONCLUSIONS Less than one-third of patients had a LOS ≤1-day and LOS was comparable for MIPN and MIRN. Centers for Medicare & Medicaid Services should be advised that MIPN is a more complex surgery than MIRN, most patients receiving a MIPN will require a ≥2-day hospital stay and it would be more appropriate to classify MIPN an inpatient procedure with MIRN.
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Affiliation(s)
| | - Brian R Lane
- Michigan State University College of Human Medicine, Grand Rapids, MI; Spectrum Health Hospital System, Grand Rapids, MI.
| | | | | | | | - Ji Qi
- Michigan Medicine, Ann Arbor, MI
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Sheehy AM, Powell WR, Kaiksow FA, Buckingham WR, Bartels CM, Birstler J, Yu M, Bykovskyi AG, Shi F, Kind AJH. Thirty-Day Re-observation, Chronic Re-observation, and Neighborhood Disadvantage. Mayo Clin Proc 2020; 95:2644-2654. [PMID: 33276837 PMCID: PMC7720926 DOI: 10.1016/j.mayocp.2020.06.059] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/28/2020] [Accepted: 06/25/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine whether neighborhood socioeconomic disadvantage, as determined by the Area Deprivation Index, increases 30-day hospital re-observation risk. PARTICIPANTS AND METHODS This retrospective study of 20% Medicare fee-for-service beneficiary observation stays from January 1, 2014, to November 30, 2014, included 319,980 stays among 273,308 beneficiaries. We evaluated risk for a 30-day re-observation following an index observation stay for those living in the 15% most disadvantaged compared with the 85% least disadvantaged neighborhoods. RESULTS Overall, 4.5% (270,600 of 6,080,664) of beneficiaries had index observation stays, which varied by disadvantage (4.3% [232,568 of 5,398,311] in the least disadvantaged 85% compared with 5.6% [38,032 of 682,353] in the most disadvantaged 15%). Patients in the most disadvantaged neighborhoods had a higher 30-day re-observation rate (2857 of 41,975; 6.8%) compared with least disadvantaged neighborhoods (13,543 of 278,005; 4.9%); a 43% increased risk (unadjusted odds ratio [OR], 1.43; 95% CI, 1.31 to 1.55). After adjustment, this risk remained (adjusted OR, 1.13; 95% CI, 1.04 to 1.22). Discharge to a skilled nursing facility reduced 30-day re-observation risk (OR, 0.63; 95% CI, 0.57 to 0.69), whereas index observation length of stay of 4 or more days (3 midnights) conferred increased risk (OR, 1.29; 95% CI, 1.09 to 1.52); those living in disadvantaged neighborhoods were less likely to discharge to skilled nursing facilities and more likely to have long index stays. Beneficiaries with more than one 30-day re-observation (chronic re-observation) had progressively greater disadvantage by number of stays (adjusted incident rate ratio, 1.08; 95% CI, 1.02 to 1.14). Observation prevalence varied nationally. CONCLUSION Thirty-day re-observation, especially chronic re-observation, is highly associated with socioeconomic neighborhood disadvantage, even after accounting for factors such as race, disability, and Medicaid eligibility. Beneficiaries least able to pay are potentially most vulnerable to costs from serial re-observations and challenges of Medicare observation policy, which may discourage patients from seeking necessary care.
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Affiliation(s)
- Ann M Sheehy
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI.
| | - W Ryan Powell
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Farah A Kaiksow
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - William R Buckingham
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Applied Population Laboratory, University of Wisconsin, Madison, WI
| | - Christie M Bartels
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jen Birstler
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI
| | - Menggang Yu
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI
| | - Andrea Gilmore Bykovskyi
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; School of Nursing, University of Wisconsin, Madison, WI
| | - Fangfang Shi
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Amy J H Kind
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, WI
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12
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Cichowitz C, Loevinsohn G, Klein EY, Colantuoni E, Galiatsatos P, Rennert J, Irvin NA. Racial and ethnic disparities in hospital observation in Maryland. Am J Emerg Med 2020; 46:532-538. [PMID: 33243537 DOI: 10.1016/j.ajem.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/27/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES Hospital observation is a key disposition option from the emergency department (ED) and encompasses up to one third of patients requiring post-ED care. Observation has been associated with higher incidence of catastrophic financial costs and has downstream effects on post-discharge clinical services. Yet little is known about the non-clinical determinants of observation assignment. We sought to evaluate the impact of patient-level demographic factors on observation designation among Maryland patients. METHODS We conducted a retrospective analysis of all ED encounters in Maryland between July 2012 and January 2017 for four priority diagnoses (heart failure, chronic obstructive pulmonary disease [COPD], pneumonia, and acute chest pain) using multilevel logistic models allowing for heterogeneity of the effects across hospitals. The primary exposure was self-reported race and ethnicity. The primary outcome was the initial status assignment from the ED: hospital observation versus inpatient admission. RESULTS Across 46 Maryland hospitals, 259,788 patient encounters resulted in a disposition of inpatient admission (65%) or observation designation (35%). Black (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 1.16-1.23) and Hispanic (aOR: 1.11; 95% CI: 1.01-1.21) patients were significantly more likely to be placed in observation than white, non-Hispanic patients. These differences were consistent across the majority of acute-care hospitals in Maryland (27/46). CONCLUSION Black and Hispanic patients in Maryland are more likely to be treated under the observation designation than white, non-Hispanic patients independent of clinical presentation. Race agnostic, time-based status assignments may be key in eliminating these disparities.
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Affiliation(s)
- Cody Cichowitz
- Massachussetts General Hospital, Department of Medicine, Center for Global Health, Boston, MA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gideon Loevinsohn
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - Eili Y Klein
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA; Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Elizabeth Colantuoni
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Panagis Galiatsatos
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Baltimore, MD, USA
| | - Jodi Rennert
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA
| | - Nathan A Irvin
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA.
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Powell WR, Kaiksow FA, Kind AJH, Sheehy AM. What Is an Observation Stay? Evaluating the Use of Hospital Observation Stays in Medicare. J Am Geriatr Soc 2020; 68:1568-1572. [PMID: 32270480 DOI: 10.1111/jgs.16441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Observation stays are increasingly common for older adults, yet little is known about the extent to which they are being used as the Centers for Medicare and Medicaid Services (CMS) originally intended for unscheduled or acute problems and whether different types of services are reflected in current billing practices. DESIGN Observational cohort study. SETTING/PARTICIPANTS A total of 867,165 qualifying observation stays identified from 451,408 patients using Medicare fee-for-service claims data from a nationally representative 20% beneficiary sample between January 1, 2014, and November 30, 2014. MEASUREMENTS Using descriptive and multivariable logistic model analytic approaches, we evaluated the patient, stay, and hospital characteristics associated with the most common billing practice for observation stays (charge revenue center 0761 exclusively) vs all other practices. RESULTS Sixty-three percent of observation stays were billed exclusively under the 0761 revenue center and were more likely to be for preplanned chronic conditions consisting of short-term treatments (eg, chemotherapy, radiation therapy, wound care, paracentesis, epidural spinal injection). These stays appeared to be used for recurrent single-day visits, given their strong association with prior visits and a high rate of reobservation (41.4%), with frequent return stays appearing in a 7-day pattern. CONCLUSION Nearly two-thirds of observation stays are billed using only the 0761 revenue code and appear to be for prescheduled, repeated treatments-differing substantially from CMS' explicitly stated purpose as a form of care used while a healthcare provider determines whether a patient presenting for unscheduled or acute conditions requires inpatient hospital admission or can be safely discharged. Guidance is needed from CMS to clarify the appropriate role of observation stays, with discussion as to whether episodic single-day, planned treatment for chronic conditions not originating in the emergency department should be billed as observation stays or placed under another mechanism. Subsequent research is needed to understand how the current use of observation stays impact patient out-of-pocket costs. J Am Geriatr Soc 68:1568-1572, 2020.
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Affiliation(s)
- W Ryan Powell
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Farah A Kaiksow
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, Wisconsin.,Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, Wisconsin.,Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, Wisconsin
| | - Ann M Sheehy
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, Wisconsin.,Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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14
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Cram P. Hospital Length of Stay … A Measure of What, Exactly? Med Care 2019; 57:751-752. [PMID: 31415346 PMCID: PMC6742542 DOI: 10.1097/mlr.0000000000001198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Peter Cram
- Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, ON Canada
- Faculty of Medicine, University of Toronto, Toronto, ON Canada
- North American Observatory on Health Systems and Policies, Institute for Health Policy, Management, and Evaluation, University of Toronto
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15
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Albritton J, Belnap TW, Savitz LA. The Effect Of The Hospital Readmissions Reduction Program On Readmission And Observation Stay Rates For Heart Failure. Health Aff (Millwood) 2019; 37:1632-1639. [PMID: 30273024 DOI: 10.1377/hlthaff.2018.0064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The Hospital Readmissions Reduction Program reduces Medicare prospective payments for hospitals with excess readmissions for selected diagnoses. By comparing data for patients who were readmitted or placed on observation status immediately before and immediately after the thirty-day cutoff for penalties, we sought to determine whether hospitals have responded to the program by shifting readmissions for heart failure to observation status. We used regression discontinuity, taking advantage of the cutoff to generate unbiased estimates of treatment effects. Overall, we found no evidence that the program has affected the use of observation stays. However, for nonpenalized hospitals, the use of observation status was 5.4 percent higher for patients returning to the hospital immediately before the thirty-day cutoff than for patients returning immediately after the cutoff, which suggests that some hospitals may have used observation status to help avoid penalties. Because differences in the cost-sharing rules may lead to higher out-of-pocket expenses for Medicare patients placed on observation status, the program could have an inequitable financial impact.
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Affiliation(s)
- Jordan Albritton
- Jordan Albritton ( ) is a senior statistical data analyst in the Telehealth Services Department, Intermountain Healthcare, in Midvale, Utah
| | - Thomas W Belnap
- Thomas W. Belnap is a consultant statistical data analyst in the Institute for Health Care Delivery Research, Intermountain Healthcare, in Salt Lake City, Utah
| | - Lucy A Savitz
- Lucy A. Savitz is vice president for health research at Kaiser Permanente Northwest, in Portland, Oregon
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16
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Abstract
Observation stays are increasingly common, yet no standard method to identify observation stays in Medicare claims is available, including events with status change. To determine the claims patterns of Medicare observation stays, define comprehensive claims-based methodology for future Medicare observation research and data reporting, and identify policy implications of such definition, we identified potential observation events in a 2014 20% random sample of Medicare beneficiaries with both Part A and B claims and at least 1 acute care stay (1,667,660 events). Observation revenue center (ORC) and Healthcare Common Procedure Coding System codes occurring within 30 days of an inpatient hospitalization were recorded. A total of 125,920 (7.6%) events had an ORC code, and 75,502 (4.5%) were in the outpatient revenue center. Claims patterns varied tremendously, and almost half (47.3%, 59,529) of the ORC codes were associated with an inpatient claim, indicating status change and demonstrating a need for clarity in observation policy. The proposed University of Wisconsin method identified 72,858 of 75,502 (96.5%) events with ORC codes as observation stays, and provides a comprehensive, reproducible methodology.
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Affiliation(s)
- Ann M Sheehy
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA.
| | - Fangfang Shi
- Department of Medicine, Division of Geriatrics, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA
| | - Amy J H Kind
- Department of Medicine, Division of Geriatrics, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA
- VA Geriatric Research Education and Clinical Center, William S Middleton VA Hospital, Madison, Wisconsin, USA
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17
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Glover M, Gottumukkala RV, Sanchez Y, Yun BJ, Benzer TI, White BA, Prabhakar AM, Raja AS. Appropriateness of Extremity Magnetic Resonance Imaging Examinations in an Academic Emergency Department Observation Unit. West J Emerg Med 2018; 19:467-473. [PMID: 29760842 PMCID: PMC5942010 DOI: 10.5811/westjem.2018.3.35463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/26/2017] [Accepted: 03/09/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction Emergency departments (ED) and hospitals face increasing challenges related to capacity, throughput, and stewardship of limited resources while maintaining high quality. Appropriate utilization of extremity magnetic resonance imaging (MRI) examinations within the emergency setting is not well known. Therefore, this study aimed to determine indications for and appropriateness of MRI of the extremities for musculoskeletal conditions in the ED observation unit (EDOU). Methods We conducted this institutional review board-approved, retrospective study in a large, quaternary care academic center and Level I trauma center. An institutional database was queried retrospectively to identify all adult patients undergoing an extremity MRI while in the EDOU during the two-year study period from October 2013 through September 2015. We compared clinical history with the American College of Radiology (ACR) Appropriateness Criteria® for musculoskeletal indications. The primary outcome was appropriateness of musculoskeletal MRI exams of the extremities; examinations with an ACR Criteria score of seven or higher were deemed appropriate. Secondary measures included MRI utilization and imaging findings. Results During the study period, 22,713 patients were evaluated in the EDOU. Of those patients, 4,409 had at least one MRI performed, and 88 MRIs met inclusion criteria as musculoskeletal extremity examinations (2% of all patients undergoing an MRI exam in the EDOU during the study period). The most common exams were foot (27, 31%); knee (26, 30%); leg/femur (10, 11%); and shoulder (10, 11%). The most common indications were suspected infection (42, 48%) and acute trauma (23, 26%). Fifty-six percent of exams were performed with intravenous contrast; and 83% (73) of all MRIs were deemed appropriate based on ACR Criteria. The most common reason for inappropriate imaging was lack of performance of radiographs prior to MRI. Conclusion The majority of musculoskeletal extremity MRI examinations performed in the EDOU were appropriate based on ACR Appropriateness Criteria. However, the optimal timing and most-appropriate site for performance of many clinically appropriate musculoskeletal extremity MRIs performed in the EDOU remains unclear. Potential deferral to the outpatient setting may be a preferred population health management strategy.
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Affiliation(s)
- McKinley Glover
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Massachusetts General Physicians Organization, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Ravi V Gottumukkala
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Yadiel Sanchez
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Brian J Yun
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Theodore I Benzer
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Benjamin A White
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Anand M Prabhakar
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Division of Emergency Imaging, Boston, Massachusetts
| | - Ali S Raja
- Massachusetts General Hospital, Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Wright B, Zhang X, Rahman M, Kocher K. Informing Medicare's Two-Midnight Rule Policy With an Analysis of Hospital-Based Long Observation Stays. Ann Emerg Med 2018. [PMID: 29530652 DOI: 10.1016/j.annemergmed.2018.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Outpatient observation stays are increasingly substituting for standard inpatient hospitalizations. In 2013, the Centers for Medicare & Medicaid Services adopted the controversial Two-Midnight Rule policy to curb long observation stays and better define the use of hospital-based observation services versus inpatient hospitalizations. We seek to determine the extent to which Medicare beneficiaries exposed to long observation stays (>48 hours) are clinically similar to those with short observation stays (≤48 hours) because this has relevance to the Two-Midnight Rule. METHODS Using 100% Medicare claims data from 2008 to 2010, we identified all patients with long observation stays (>48 hours) who were admitted through the emergency department (ED). We report beneficiary characteristics, as well as crude and risk-adjusted 30-day rates of mortality, readmissions, and return ED visits stratified by observation stay length. RESULTS Seven percent of 2.8 million observation stays were greater than 48 hours. Beneficiaries with long observation stays tended to be older, women, nonwhite, and urban residents, with a greater number of comorbid conditions. Crude rates increased with observation stay length for all 3 outcomes. However, after directly standardizing the rates, we observed the reverse trend because all adjusted rates decreased stepwise with observation stay length greater than 48 hours in a dose-response pattern. CONCLUSION Patients with observation stays lasting longer than 48 hours are a clinically distinct population. Our findings support the conceptual underpinnings of the Two-Midnight Rule, but suggest that observation versus inpatient determinations should be based on actual length of stay rather than prospective prediction to reduce the administrative ambiguity this policy has created.
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Affiliation(s)
- Brad Wright
- Department of Health Management and Policy, and the Public Policy Center, University of Iowa, Iowa City, IA.
| | - Xuan Zhang
- Department of Economics, Brown University, Providence, RI
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
| | - Keith Kocher
- Department of Emergency Medicine, School of Medicine, the Institute for Healthcare Policy and Innovation, and the Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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19
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Goldstein JN, Zhang Z, Schwartz JS, Hicks LS. Observation Status, Poverty, and High Financial Liability Among Medicare Beneficiaries. Am J Med 2018; 131:101.e9-101.e15. [PMID: 28774801 PMCID: PMC5725232 DOI: 10.1016/j.amjmed.2017.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries. METHODS We performed a retrospective, observational analysis of Medicare Part B claims and US Census Bureau data from 2013. Medicare beneficiaries with Part A and B coverage for the full calendar year, with 1 or more observation stay(s), were included in the study. Beneficiaries were divided into quartiles representing poverty level. The associations between poverty quartile and high use of observation care and between poverty quartile and high financial liability for observation care were evaluated. RESULTS After multivariate adjustment, the risk of high use was higher for beneficiaries in the poor (Quartile 3) and poorest (Quartile 4) quartiles compared with those in the wealthiest quartile (Quartile 1) (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.13-1.31; AOR, 1.24; 95% CI, 1.16-1.33). The risk of high financial liability was higher in every poverty quartile compared with the wealthiest and peaked in Quartile 3, which represented the poor but not the poorest beneficiaries (AOR, 1.17; 95% CI, 1.10-1.24). CONCLUSIONS Poverty predicts high use of observation care. The poor or near poor may be at highest risk for high liability.
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Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine, Christiana Care Health System, Newark Del; The Value Institute, Christiana Care Health System, Newark, Del.
| | - Zugui Zhang
- The Value Institute, Christiana Care Health System, Newark, Del
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - LeRoi S Hicks
- Department of Medicine, Christiana Care Health System, Newark Del; The Value Institute, Christiana Care Health System, Newark, Del
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20
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The Effect of the Hospital Readmission Reduction Program on the Duration of Observation Stays: Using Regression Discontinuity to Estimate Causal Effects. EGEMS 2017; 5:6. [PMID: 29930970 PMCID: PMC5994952 DOI: 10.5334/egems.197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Research Objective: Determine whether hospitals are increasing the duration of observation stays following index admission for heart failure to avoid potential payment penalties from the Hospital Readmission Reduction Program. Study Design: The Hospital Readmission Reduction Program applies a 30-day cutoff after which readmissions are no longer penalized. Given this seemingly arbitrary cutoff, we use regression discontinuity design, a quasi-experimental research design that can be used to make causal inferences. Population Studied: The High Value Healthcare Collaborative includes member healthcare systems covering 57% of the nation’s hospital referral regions. We used Medicare claims data including all patients residing within these regions. The study included patients with index admissions for heart failure from January 1, 2012 to June 30, 2015 and a subsequent observation stay within 60 days. We excluded hospitals with fewer than 25 heart failure readmissions in a year or fewer than 5 observation stays in a year and patients with subsequent observation stays at a different hospital. Principal Findings: Overall, there was no discontinuity at the 30-day cutoff in the duration of observation stays, the percent of observation stays over 12 hours, or the percent of observation stays over 24 hours. In the sub-analysis, the discontinuity was significant for non-penalized. Conclusion: The findings reveal evidence that the HRRP has resulted in an increase in the duration of observation stays for some non-penalized hospitals.
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21
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Ross MA, Granovsky M. History, Principles, and Policies of Observation Medicine. Emerg Med Clin North Am 2017; 35:503-518. [DOI: 10.1016/j.emc.2017.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Sánchez Y, Yun BJ, Prabhakar AM, Glover M, White BA, Benzer TI, Raja AS. Magnetic Resonance Imaging Utilization in an Emergency Department Observation Unit. West J Emerg Med 2017; 18:780-784. [PMID: 28874928 PMCID: PMC5576612 DOI: 10.5811/westjem.2017.6.33992] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 02/17/2017] [Accepted: 06/22/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Emergency department observation units (EDOUs) are a valuable alternative to inpatient admissions for ED patients needing extended care. However, while the use of advanced imaging is becoming more common in the ED, there are no studies characterizing the use of magnetic resonance imaging (MRI) examinations in the EDOU. Methods This institutional review board-approved, retrospective study was performed at a 999-bed quaternary care academic Level I adult and pediatric trauma center, with approximately 114,000 ED visits annually and a 32-bed adult EDOU. We retrospectively reviewed the EDOU patient database for all MRI examinations done from October 1, 2013, to September 30, 2015. We sought to describe the most frequent uses for MRI during EDOU admissions and reviewed EDOU length of stay (LOS) to determine whether the use of MRI was associated with any change in LOS. Results A total of 22,840 EDOU admissions were recorded during the two-year study period, and 4,437 (19%) of these patients had a least one MRI examination during their stay; 2,730 (62%) of these studies were of the brain, head, or neck, and an additional 1,392 (31%) were of the spine. There was no significant difference between the median LOS of admissions in which an MRI study was performed (17.5 hours) and the median LOS (17.7 hours) of admissions in which an MRI study was not performed [p=0.33]. Conclusion Neuroimaging makes up the clear majority of MRI examinations from our EDOU, and the use of MRI does not appear to prolong EDOU LOS. Future work should focus on the appropriateness of these MRI examinations to determine potential resource and cost savings.
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Affiliation(s)
- Yadiel Sánchez
- Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Brian J Yun
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Anand M Prabhakar
- Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Division of Emergency Imaging, Boston, Massachusetts
| | - McKinley Glover
- Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Benjamin A White
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Theodore I Benzer
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Ali S Raja
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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23
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Hospital Use of Observation Stays: Cross-sectional Study of the Impact on Readmission Rates. Med Care 2017; 54:1070-1077. [PMID: 27579906 DOI: 10.1097/mlr.0000000000000601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services publicly reports hospital risk-standardized readmission rates (RSRRs) as a measure of quality and performance; mischaracterizations may occur because observation stays are not captured by current measures. OBJECTIVES To describe variation in hospital use of observation stays, the relationship between hospitals observation stay use and RSRRs. MATERIALS AND METHODS Cross-sectional analysis of Medicare fee-for-service beneficiaries discharged after acute myocardial infarction (AMI), heart failure, or pneumonia between July 2011 and June 2012. We calculated 3 hospital-specific 30-day outcomes: (1) observation rate, the proportion of all discharges followed by an observation stay without a readmission; (2) observation proportion, the proportion of observation stays among all patients with an observation stay or readmission; and (3) RSRR. RESULTS For all 3 conditions, hospitals' observation rates were <2.5% and observation proportions were <12%, although there was variation across hospitals, including 28% of hospital with no observation stay use for AMI, 31% for heart failure, and 43% for pneumonia. There were statistically significant, but minimal, correlations between hospital observation rates and RSRRs: AMI (r=-0.02), heart failure (r=-0.11), and pneumonia (r=-0.02) (P<0.001). There were modest inverse correlations between hospital observation proportion and RSRR: AMI (r=-0.34), heart failure (r=-0.26), and pneumonia (r=-0.21) (P<0.001). If observation stays were included in readmission measures, <4% of top performing hospitals would be recategorized as having average performance. CONCLUSIONS Hospitals' observation stay use in the postdischarge period is low, but varies widely. Despite modest correlation between the observation proportion and RSRR, counting observation stays in readmission measures would minimally impact public reporting of performance.
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Goldstein JN, Schwartz JS, McGraw P, Banks TL, Hicks LS. The Unmet Need for Postacute Rehabilitation Among Medicare Observation Patients: A Single-Center Study. J Hosp Med 2017; 12:168-172. [PMID: 28272593 PMCID: PMC6467081 DOI: 10.12788/jhm.2700] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Medicare beneficiaries admitted under observation status must pay for postacute inpatient rehabilitation (PAIR) services, out of pocket, at potentially prohibitive costs. OBJECTIVE To determine if there is an unmet need for PAIR among Medicare observation patients and if this care is associated with longer hospital stay and increased rehospitalization. DESIGN/SETTING Observational study using electronic medical record and administrative data from a regional health system. PATIENTS 1323 community-dwelling Medicare patients admitted under observation status. MEASUREMENTS Summary statistics were calculated for demographic and administrative variables. Physical therapy (PT) and case management recommendations for a representative sample of 386 medical records were reviewed regarding need for PAIR services. Linear regression was used to measure the association between PT recommendation and hospital length of stay, adjusting for ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis, age, sex, and provider. Chi-square test was used to determine the association between PT recommendation and 30-day hospital revisit. RESULTS Of the 1323 study patients, 11 (0.83%) were discharged to PAIR facilities. However, 17 (4.4%) of the 386 patients whose charts were reviewed received a recommendation for this care. Adjusted mean hospital stay was longer (P ⟨ 0.001) for patients recommended for rehabilitation (75.9 h) than for patients with no PT needs (46.8 h). In addition, the 30-day hospital revisit rate was higher (P = 0.037) for the patients who had been recommended for rehabilitation (52.9%, 9/17) than for those who had not (25.4%, 30/118). CONCLUSIONS Medicare observation patients' potential need for PAIR services is 5- to 6-fold higher than their use of these services. Observation patients recommended for this care may have worse outcomes. Journal of Hospital Medicine 2017;12:168-172.
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Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine, Christiana Care Health System, Newark, DE, USA
- Value Institute, Christiana Care Health System, Newark, DE, USA
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patricia McGraw
- Department of Medicine, Christiana Care Health System, Newark, DE, USA
| | - Tobias L Banks
- Department of Medicine, Christiana Care Health System, Newark, DE, USA
| | - LeRoi S Hicks
- Department of Medicine, Christiana Care Health System, Newark, DE, USA
- Value Institute, Christiana Care Health System, Newark, DE, USA
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25
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Sattler SR, Baugh CW. Venous thromboembolism prophylaxis in ED observation units—Is it time? Am J Emerg Med 2016; 34:2238-2240. [DOI: 10.1016/j.ajem.2016.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 08/17/2016] [Indexed: 11/25/2022] Open
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Short HL, Sarda S, Heiss KF, Chern JJ, Raval MV. Return to the System Within 30 Days of Discharge after Pediatric Appendectomy. Am Surg 2016; 82:626-631. [PMID: 27457862 DOI: 10.1177/000313481608200729] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Postprocedural revisits, readmissions, and reoperations are commonly tracked quality metrics and have reimbursement and hospital-level comparison implications. Our purpose was to document these rates after pediatric appendectomy and to identify patient factors related to these metrics. This study included 3756 appendectomies performed at a single institution from 2009 to 2013. Data were prospectively collected and clinical events within 30 days of discharge were analyzed. Regression models identified factors associated with each metric. There were 328 returns to the emergency department (8.7%), 128 readmissions (3.4%), and 41 reoperations (1.0%). The main source of readmission was the emergency department (n = 118, 92%). Nearly two-thirds of readmissions were nonoperative (n = 87, 68%) and 12.5 per cent of readmissions were not related to the index appendectomy. Factors associated with readmission include procedure length >70 minutes [odds ratio (OR) 1.89, P = 0.043] and failed nonoperative management of perforated appendicitis (OR 2.97, P = 0.041). The most common indication for reoperation was intra-abdominal abscess (n = 20, 49%), 55 per cent of which were managed with image-guided drainage. In conclusion, although 30-day revisit, readmission, and reoperation rates after appendectomy are low, there are opportunities for improvement. Furthermore, many 30-day readmissions are not related to the index procedure and must be clearly identified to avoid inaccuracies with reimbursement and quality rankings.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
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27
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Kangovi S, Cafardi SG, Smith RA, Kulkarni R, Grande D. Patient financial responsibility for observation care. J Hosp Med 2015; 10:718-23. [PMID: 26292192 DOI: 10.1002/jhm.2436] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 06/16/2015] [Accepted: 06/22/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND As observation care grows, Medicare beneficiaries are increasingly likely to revisit observation care instead of being readmitted. This trend has potential financial implications for Medicare beneficiaries because observation care-although typically hospital based-is classified as an outpatient service. Beneficiaries who are readmitted pay the inpatient deductible only once per benefit period. In contrast, beneficiaries who have multiple care episodes under observations status are subject to coinsurance at every stay and could accrue higher cumulative costs. OBJECTIVES We were interested in answering the question: Do Medicare beneficiaries who revisit observation care pay more than they would have had they been readmitted? DESIGN We used a 20% sample of the Medicare Outpatient Standard Analytic File (2010-2012) to determine the total cumulative financial liability for Medicare beneficiaries who revisit observation care multiple times within a 60-day period. PARTICIPANTS Participants were fee-for-service Medicare beneficiaries who had Part A and Part B coverage for a full calendar year (or until death) during the study period. MEASUREMENTS Our primary measure was beneficiary financial responsibility for facilities fees. RESULTS On average, beneficiaries with multiple observation stays in a 60-day period had a cumulative financial liability of $947.40 (803.62), which is significantly lower than the $1100 inpatient deductible (P < 0.01). However, 26.6% of these beneficiaries had a cumulative financial liability that exceeded the inpatient deductible. CONCLUSIONS More than a quarter of Medicare beneficiaries with multiple observation stays in a 60-day time period have a higher financial liability than they would have had under Part A benefits.
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Affiliation(s)
- Shreya Kangovi
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Center for Community Health Workers, Philadelphia, Pennsylvania
| | | | - Robyn A Smith
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Penn Center for Community Health Workers, Philadelphia, Pennsylvania
| | - Raina Kulkarni
- Penn Center for Community Health Workers, Philadelphia, Pennsylvania
| | - David Grande
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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Cafardi SG, Pines JM, Deb P, Powers CA, Shrank WH. Increased observation services in Medicare beneficiaries with chest pain. Am J Emerg Med 2015; 34:16-9. [PMID: 26490388 DOI: 10.1016/j.ajem.2015.08.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION We examined trends in the use of observation services and the relationship between index service type (observation services, emergency department [ED] visits, inpatient stays) and both clinical outcomes and Medicare payments. METHODS We created a yearly cohort panel of Medicare beneficiaries with chest pain. We evaluate the relationships between index service type and 30-day clinical outcomes using a multinomial logit model and between index service type and Medicare payments using generalized linear models. RESULTS In 2009, 24% of patients with chest pain received observation services; this rose to 29% in 2011. Conversely, 20% were treated as hospital inpatients in 2009; this fell to 16% in 2011. In the adjusted analysis, the risk of 30-day return to the hospital was 7% less (95% confidence interval, 5%-8%) for those receiving observation services as compared with inpatients. Average Medicare payments ranged from $3032 for beneficiaries initially treated in the ED to $3885 for those initially treated in observation to $6545 for those initially treated as inpatients. DISCUSSION Patients treated in observation are less likely than those treated in the ED or as inpatients to have an adverse event within 30 days. Adjusted Medicare payments, including the index stay and the subsequent 30 days, were substantially less for those treated in observation as compared with those treated as inpatients, but more than for those treated and released from the ED. Higher rates of observation service use do not appear to be negatively affecting patient outcomes and may lower costs relative to inpatient treatment.
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Affiliation(s)
- Susannah G Cafardi
- Research and Rapid-Cycle Evaluation Group, Centers for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, MD.
| | - Jesse M Pines
- Department of Emergency Medicine, The George Washington University, Washington, DC; Department of Health Policy, The George Washington University, Washington, DC
| | - Partha Deb
- Department of Economics, Hunter College, New York, NY; Centers for Medicare & Medicaid Services, Center for Medicare & Medicaid Innovation, Baltimore, MD
| | - Christopher A Powers
- Office of Information Products and Data Analytics, Center for Medicare & Medicaid Services, Baltimore, MD
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Andrews RM. Statewide Hospital Discharge Data: Collection, Use, Limitations, and Improvements. Health Serv Res 2015; 50 Suppl 1:1273-99. [PMID: 26150118 PMCID: PMC4545332 DOI: 10.1111/1475-6773.12343] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To provide an overview of statewide hospital discharge databases (HDD), including their uses in health services research and limitations, and to describe Agency for Healthcare Research and Quality (AHRQ) Enhanced State Data grants to address clinical and race-ethnicity data limitations. PRINCIPAL FINDINGS Almost all states have statewide HDD collected by public or private data organizations. Statewide HDD, based on the hospital claim with state variations, contain useful core variables and require minimal collection burden. AHRQ's Healthcare Cost and Utilization Project builds uniform state and national research files using statewide HDD. States, hospitals, and researchers use statewide HDD for many purposes. Illustrating researchers' use, during 2012-2014, HSR published 26 HDD-based articles on health policy, access, quality, clinical aspects of care, race-ethnicity and insurance impacts, economics, financing, and research methods. HDD have limitations affecting their use. Five AHRQ grants focused on enhancing clinical data and three grants aimed at improving race-ethnicity data. CONCLUSION ICD-10 implementation will significantly affect the HDD. The AHRQ grants, information technology advances, payment policy changes, and the need for outpatient information may stimulate other statewide HDD changes. To remain a mainstay of health services research, statewide HDD need to keep pace with changing user needs while minimizing collection burdens.
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Affiliation(s)
- Roxanne M Andrews
- Center for Delivery, Organization, and Markets, Agency for Healthcare Research and QualityRockville, MD
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30
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Locke C, Sheehy AM, Deutschendorf A, Mackowiak S, Flansbaum BE, Petty B. Changes to inpatient versus outpatient hospitalization: Medicare's 2-midnight rule. J Hosp Med 2015; 10:194-201. [PMID: 25557865 DOI: 10.1002/jhm.2312] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 11/26/2014] [Accepted: 12/07/2014] [Indexed: 11/12/2022]
Abstract
Outpatient versus inpatient status determinations for hospitalized patients impact how hospitals bill Medicare for hospital services. Medicare policies related to status determinations and the Recovery Audit Contractor (RAC) program charged with postpayment review of such determinations are of increasing concern to hospitals and physicians. We present an overview and discussion of these policies, including the recent 2-midnight rule, the effect on status determinations by the RAC program, and other recent and pertinent legislative and regulatory activity. Finally, we discuss the future direction of Medicare status determination policies and the RAC program, so that physicians and other healthcare providers caring for hospitalized Medicare beneficiaries may better understand these important and dynamic topics.
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Affiliation(s)
- Charles Locke
- Utilization/Clinical Resource Management, Johns Hopkins Hospital, Baltimore, Maryland; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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31
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Galarraga JE, Mutter R, Pines JM. Costs associated with ambulatory care sensitive conditions across hospital-based settings. Acad Emerg Med 2015; 22:172-81. [PMID: 25639774 DOI: 10.1111/acem.12579] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 07/02/2014] [Accepted: 09/02/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Ambulatory care sensitive conditions (ACSCs) are acute care diagnoses that could potentially be prevented through improved primary care. This study investigated how payments and charges for these ACSC visits differ by three hospital-based settings (outpatient, emergency department [ED], and inpatient) and examined differences in payments and charges by their physician and facility components. METHODS This was a secondary analysis of data (2005 through 2010) from the Medical Expenditure Panel Survey. Multiple linear regression models were used to assess differences in the mean-adjusted payments and charges for ACSC visits by clinical setting and further divided payments and charges into physician and facility components. RESULTS Of all ACSC visits from 2005 through 2010, 41% were outpatient visits, 36% were ED visits, and 23% were hospital admissions. After adjusting for patient demographics and comorbid conditions, charges for an inpatient ACSC visit were four times higher ($11,414 vs. $2,563) and payments were five times higher ($4,325 vs. $859) when compared to an ED visit. By comparison, charges for an ACSC ED visit were two times higher ($2,563 vs. $1,084) and payments 2.5 times higher ($859 vs. $341) relative to an ACSC visit managed in an outpatient hospital-based clinic. Across all clinical settings, hospital facility fees account for 77% to 94% of the charge differences and 81% to 93% of the payment differences. CONCLUSIONS For hospital-based ACSC visits, inpatient hospitalizations are by far the most expensive. Finding ways to expand outpatient resources and improve the health management of the chronically ill may avoid conditions that lead to more expensive hospital-based encounters. Across all hospital-based settings, facility fees are the major contributor of expense.
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Affiliation(s)
| | - Ryan Mutter
- Agency for Healthcare Research and Quality; Rockville MD
| | - Jesse M. Pines
- Department of Emergency Medicine; George Washington University; Washington DC
- Department of Health Policy; George Washington University; Washington DC
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Using Healthcare Cost and Utilization Project (HCUP) Data for Emergency Medicine Research. Ann Emerg Med 2014; 64:458-60. [DOI: 10.1016/j.annemergmed.2014.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/16/2014] [Accepted: 09/17/2014] [Indexed: 11/20/2022]
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Kalanithi L, Tai W, Conley J, Platchek T, Zulman D, Milstein A. Better Health, Less Spending. Stroke 2014; 45:3105-11. [DOI: 10.1161/strokeaha.114.006236] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lucy Kalanithi
- From the Clinical Excellence Research Center (L.K., W.T., J.C., T.P., D.Z., A.M.), Stanford Stroke Center, Department of Neurology and Neurological Sciences (W.T.), Lucile Packard Children’s Hospital (T.P.), and Division of General Medical Disciplines, Department of Internal Medicine (D.Z.), Stanford University, CA; Case Western Reserve University School of Medicine, Cleveland, OH (J.C.); and Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA (D.Z.)
| | - Waimei Tai
- From the Clinical Excellence Research Center (L.K., W.T., J.C., T.P., D.Z., A.M.), Stanford Stroke Center, Department of Neurology and Neurological Sciences (W.T.), Lucile Packard Children’s Hospital (T.P.), and Division of General Medical Disciplines, Department of Internal Medicine (D.Z.), Stanford University, CA; Case Western Reserve University School of Medicine, Cleveland, OH (J.C.); and Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA (D.Z.)
| | - Jared Conley
- From the Clinical Excellence Research Center (L.K., W.T., J.C., T.P., D.Z., A.M.), Stanford Stroke Center, Department of Neurology and Neurological Sciences (W.T.), Lucile Packard Children’s Hospital (T.P.), and Division of General Medical Disciplines, Department of Internal Medicine (D.Z.), Stanford University, CA; Case Western Reserve University School of Medicine, Cleveland, OH (J.C.); and Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA (D.Z.)
| | - Terry Platchek
- From the Clinical Excellence Research Center (L.K., W.T., J.C., T.P., D.Z., A.M.), Stanford Stroke Center, Department of Neurology and Neurological Sciences (W.T.), Lucile Packard Children’s Hospital (T.P.), and Division of General Medical Disciplines, Department of Internal Medicine (D.Z.), Stanford University, CA; Case Western Reserve University School of Medicine, Cleveland, OH (J.C.); and Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA (D.Z.)
| | - Donna Zulman
- From the Clinical Excellence Research Center (L.K., W.T., J.C., T.P., D.Z., A.M.), Stanford Stroke Center, Department of Neurology and Neurological Sciences (W.T.), Lucile Packard Children’s Hospital (T.P.), and Division of General Medical Disciplines, Department of Internal Medicine (D.Z.), Stanford University, CA; Case Western Reserve University School of Medicine, Cleveland, OH (J.C.); and Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA (D.Z.)
| | - Arnold Milstein
- From the Clinical Excellence Research Center (L.K., W.T., J.C., T.P., D.Z., A.M.), Stanford Stroke Center, Department of Neurology and Neurological Sciences (W.T.), Lucile Packard Children’s Hospital (T.P.), and Division of General Medical Disciplines, Department of Internal Medicine (D.Z.), Stanford University, CA; Case Western Reserve University School of Medicine, Cleveland, OH (J.C.); and Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA (D.Z.)
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