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Burke LG, Burke RC, Duggan CE, Figueroa JF, Boltz M, Fick D, Orav EJ, Marcantonio ER. Trends in observation stays for Medicare beneficiaries with and without Alzheimer's disease and related dementias. J Am Geriatr Soc 2024; 72:1442-1452. [PMID: 38546202 PMCID: PMC11090746 DOI: 10.1111/jgs.18890] [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] [Received: 12/22/2023] [Revised: 02/19/2024] [Accepted: 02/24/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown. METHODS Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-). RESULTS Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7). CONCLUSIONS Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Marie Boltz
- The Pennsylvania State University College of Nursing, University Park, PA, USA
| | - Donna Fick
- The Pennsylvania State University College of Nursing, University Park, PA, USA
| | - E. John Orav
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
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Cressman AM, Purohit U, Shadowitz E, Etchells E, Weinerman A, Gerson D, Shojania KG, Stroud L, Wong BM, Shadowitz S. Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study. CMAJ Open 2023; 11:E201-E207. [PMID: 36854457 PMCID: PMC9981162 DOI: 10.9778/cmajo.20220020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors. METHODS We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more. RESULTS We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit. INTERPRETATION Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.
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Affiliation(s)
- Alex M Cressman
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont.
| | - Ushma Purohit
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Ellen Shadowitz
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Edward Etchells
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Adina Weinerman
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Darren Gerson
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Kaveh G Shojania
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Lynfa Stroud
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Brian M Wong
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Steve Shadowitz
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
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Chen AY, Blue L, Tilipman J, McCall N. Development of claims-based measures of unplanned acute care with superior power for assessing the effectiveness of interventions following acute care. Health Serv Res 2021; 56:550-557. [PMID: 33543477 DOI: 10.1111/1475-6773.13617] [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] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To develop outcome measures that are more sensitive than current measures for evaluating primary or transitional care after hospitalizations, emergency department (ED) visits, or observation stays. DATA SOURCES Medicare claims data from January 1, 2015, to October 31, 2017, for 1 261 707 Medicare fee-for-service beneficiaries served by (a) primary care practices participating in Track 1 of the Comprehensive Primary Care Plus (CPC+) initiative, and (b) their matched comparison practices. STUDY DESIGN Given the poor statistical power in many studies to detect effects on readmissions, we developed two novel claims-based measures of unplanned acute care (UAC) following an index acute care event. The first measure assesses the proportion of hospitalizations followed by an unplanned readmission, ED visit, or observation stay within 30 days of discharge; the second assesses the proportion of ED visits and observation stays followed by a hospitalization, ED visit, or observation stay within 30 days. We calculate minimum detectable effects (MDEs) for both measures and for a conventional measure of 30-day unplanned readmissions, using CPC+ data. PRINCIPAL FINDINGS Repeat UAC events are common among Medicare beneficiaries served by the CPC+ practices. In 2017, 22% of discharges and 21% of ED visits and observation stays had a UAC event within 30 days. Readmissions were the most common UAC event following discharge, whereas ED visits were most common following index ED visits or observation stays. MDEs are 25%-40% lower for the new measures than for the standard 30-day readmissions measure, indicating better statistical power to detect impacts of primary or transitional care interventions. CONCLUSIONS This study introduces two new claims-based measures to assess quality of care during a patient's vulnerable period following acute care. The new measures complement existing measures, covering a broader range of UAC events than the standard 30-day readmissions measure, and yielding greater statistical power.
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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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5
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Bucholz EM, Schuster MA, Toomey SL. Trends in 30-Day Readmission for Medicaid and Privately Insured Pediatric Patients: 2010-2017. Pediatrics 2020; 146:peds.2020-0270. [PMID: 32611808 DOI: 10.1542/peds.2020-0270] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children insured by Medicaid have higher readmission rates than privately insured children. However, little is known about whether this disparity has changed over time. METHODS Data from the 2010 to 2017 Healthcare Cost and Utilization Project Nationwide Readmissions Database were used to compare trends in 30-day readmission rates for children insured by Medicaid and private insurers. Patient-level crude and risk-adjusted readmission rates were compared by using Poisson regression. Hospital-level risk-adjusted readmission rates were compared between Medicaid- and privately insured patients within a hospital by using linear regression. RESULTS Approximately 60% of pediatric admissions were covered by Medicaid. From 2010 to 2017, the percentage of children with a complex or chronic condition increased for both Medicaid- and privately insured patients. Readmission rates were consistently higher for Medicaid beneficiaries from 2010 to 2017. Readmission rates declined slightly for both Medicaid- and privately insured patients; however, they declined faster for privately insured patients (rate ratio: 0.988 [95% confidence interval: 0.986-0.989] vs 0.995 [95% confidence interval: 0.994-0.996], P for interaction <.001]). After adjustment, readmission rates for Medicaid- and privately insured patients declined at a similar rate (P for interaction = .87). Risk-adjusted hospital readmission rates were also consistently higher for Medicaid beneficiaries. The within-hospital difference in readmission rates for Medicaid versus privately insured patients remained stable over time (slope for difference: 0.015 [SE 0.011], P = .019). CONCLUSIONS Readmission rates for Medicaid- and privately insured pediatric patients declined slightly from 2010 to 2017 but remained substantially higher among Medicaid beneficiaries suggesting a persistence of the disparity by insurance status.
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Affiliation(s)
- Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; .,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Bernard J. Tyson School of Medicine, Kaiser Permanente, Pasadena, California
| | - Sara L Toomey
- Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and
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Nursing Home Residents' Functional Trajectories and Mortality After a Transfer to the Emergency Department. J Am Med Dir Assoc 2020; 22:393-398.e3. [PMID: 32660854 DOI: 10.1016/j.jamda.2020.05.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To describe nursing home residents' (NHRs) functional trajectories and mortality after a transfer to the emergency department (ED). DESIGN Case-control observational multicenter study. SETTING AND PARTICIPANTS In total, 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks in 2016. METHODS Finite mixture models were fitted to longitudinal data on activities of daily living (ADL) scores before transfer (time 1), during hospitalization (time 2), and within 1 week after discharge (time 3) to identify groups of NHRs following similar functional evolution. Factors associated with mortality were investigated by Cox regressions. RESULTS Trajectory modeling identified 4 distinct trajectories of ADL. The first showed a high and stable (across time 1, time 2, and time 3) functional capacity around 5.2/6 ADL points, with breathlessness as the main condition leading to transfer. The second displayed an initial 37.8% decrease in baseline ADL performance (between time 1 and time 2), followed by a 12.5% recovery of baseline ADL performance (time 2‒time 3), with fractures as the main condition. The third displayed a similar initial decrease, followed by a 6.7% recovery. The fourth displayed an initial 70.1% decrease, followed by an 8.5% recover, with more complex geriatric polypathology situations. Functional decline was more likely after being transferred for a cerebrovascular condition or for a fracture, after being discharged from ED to a surgery department, and with a heavier burden of distressing symptoms during transfer. Mortality after ED transfer was more likely in older NHRs, those in a more severe condition, those who were hospitalized more frequently in the past month, and those transferred for cerebrovascular conditions or breathlessness. CONCLUSIONS AND IMPLICATIONS Identified trajectories and factors associated with functional decline and mortality should help clinicians decide whether to transfer NHRs to ED. NHRs with high functional ability seem to benefit from ED transfers whereas on-site alternatives should be sought for those with poor functional ability.
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7
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Martsolf GR, Nuckols TK, Fingar KR, Barrett ML, Stocks C, Owens PL. Nonspecific chest pain and hospital revisits within 7 days of care: variation across emergency department, observation and inpatient visits. BMC Health Serv Res 2020; 20:516. [PMID: 32513147 PMCID: PMC7278151 DOI: 10.1186/s12913-020-05200-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/08/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Grant R Martsolf
- University of Pittsburgh School of Nursing, 3500 Victoria St, 315B, Pittsburgh, PA, 15213, USA.,RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Teryl K Nuckols
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA.,Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Becker 113, Los Angeles, CA, 90048, USA
| | - Kathryn R Fingar
- IBM Watson Health, 5425 Hollister Ave, Suite 140, Santa Barbara, CA, 93111, USA
| | | | - Carol Stocks
- Affiliation during this investigation: Agency for Healthcare Research and Quality, Rockville, Maryland, USA.,Present address: West Virginia University, School of Public Health, 64 Medical Center Drive, PO Box 9190, Morgantown, WV, 26506-9190, USA
| | - Pamela L Owens
- Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD, 20857, 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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9
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Khera R, Wang Y, Bernheim SM, Lin Z, Krumholz HM. Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States. BMJ 2020; 368:l6831. [PMID: 31941686 PMCID: PMC7190056 DOI: 10.1136/bmj.l6831] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. DESIGN Retrospective cohort study. SETTING Medicare claims data for 2008-16 in the United States. PARTICIPANTS Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia-conditions included in the US Hospital Readmissions Reduction Program. MAIN OUTCOME MEASURES Post-discharge 30 day mortality according to patients' 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. RESULTS 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (-0.09% to -0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. CONCLUSIONS The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.
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Affiliation(s)
- Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX 75219, USA
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Susannah M Bernheim
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Quality Measurement Programs, Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Zhenqiu Lin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
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10
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Hastings SN, Stechuchak KM, Coffman CJ, Mahanna EP, Weinberger M, Van Houtven CH, Schmader KE, Hendrix CC, Kessler C, Hughes JM, Ramos K, Wieland GD, Weiner M, Robinson K, Oddone E. Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial. J Gen Intern Med 2020; 35:79-86. [PMID: 31489559 PMCID: PMC6957582 DOI: 10.1007/s11606-019-05319-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 06/10/2019] [Accepted: 08/08/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Little research has been done on primary care-based models to improve health care use after an emergency department (ED) visit. OBJECTIVE To examine the effectiveness of a primary care-based, nurse telephone support intervention for Veterans treated and released from the ED. DESIGN Randomized controlled trial with 1:1 assignment to telephone support intervention or usual care arms (ClinicalTrials.gov: NCT01717976). SETTING Department of Veterans Affairs Health Care System (VAHCS) in Durham, NC. PARTICIPANTS Five hundred thirteen Veterans who were at high risk for repeat ED visits. INTERVENTION The telephone support intervention consisted of two core calls in the week following an ED visit. Call content focused on improving the ED to primary care transition, enhancing chronic disease management, and educating Veterans and family members about VHA and community services. MAIN MEASURES The primary outcome was repeat ED use within 30 days. KEY RESULTS Observed rates of repeat ED use at 30 days in usual care and intervention groups were 23.1% and 24.9%, respectively (OR = 1.1; 95% CI = 0.7, 1.7; P = 0.6). The intervention group had a higher rate of having at least 1 primary care visit at 30 days (OR = 1.6, 95% CI = 1.1-2.3). At 180 days, the intervention group had a higher rate of usage of a weight management program (OR = 3.5, 95% CI = 1.6-7.5), diabetes/nutrition (OR = 1.8, 95% CI = 1.0-3.0), and home telehealth services (OR = 1.7, 95% CI = 1.0-2.9) compared with usual care. CONCLUSIONS A brief primary care-based nurse telephone support program after an ED visit did not reduce repeat ED visits within 30 days, despite intervention participants' increased engagement with primary care and some chronic disease management services. TRIALS REGISTRATION ClinicalTrials.gov NCT01717976.
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Affiliation(s)
- Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA. .,Department of Medicine, Duke University School of Medicine, Durham, NC, USA. .,Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA. .,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA. .,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Elizabeth P Mahanna
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA
| | - Morris Weinberger
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kenneth E Schmader
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA.,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - Cristina C Hendrix
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA.,Duke University School of Nursing, Durham, NC, USA
| | - Chad Kessler
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jaime M Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Katherine Ramos
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA.,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA.,Department of Psychiatry, Duke University School of Medicine, Durham, NC, USA
| | - G Darryl Wieland
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA.,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - Madeline Weiner
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Katina Robinson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA
| | - Eugene Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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11
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Figueroa JF, Burke LG, Zheng J, Orav EJ, Jha AK. Trends in Hospitalization vs Observation Stay for Ambulatory Care-Sensitive Conditions. JAMA Intern Med 2019; 179:1714-1716. [PMID: 31449290 PMCID: PMC6714003 DOI: 10.1001/jamainternmed.2019.3177] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study of Medicare-defined avoidable hospital stays for conditions such as urinary tract infection and complications of diabetes uses Medicare Fee-for-Service Inpatient and Outpatient Claim Files to investigate whether a decrease in inpatient admissions from 2011 to 2015 represented real gains in ambulatory care.
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Affiliation(s)
- Jose F Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Laura G Burke
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - E John Orav
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Harvard Global Health Institute, Harvard University, Cambridge, Massachusetts
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12
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Wadhera RK, Joynt Maddox KE, Kazi DS, Shen C, Yeh RW. Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis. BMJ 2019; 366:l4563. [PMID: 31405902 PMCID: PMC6689820 DOI: 10.1136/bmj.l4563] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine any changes in total hospital revisits within 30 days of discharge after a hospital stay for medical conditions targeted by the Hospital Readmissions Reduction Program (HRRP). DESIGN Retrospective cohort study. SETTING Hospital stays among Medicare patients for heart failure, acute myocardial infarction, or pneumonia between 1 January 2012 and 1 October 2015. PARTICIPANTS Medicare fee-for-service patients aged 65 or over. MAIN OUTCOMES Total hospital revisits within 30 days of discharge after hospital stays for medical conditions targeted by the HRRP, and by type of revisit: treat-and-discharge visit to an emergency department, observation stay (not leading to inpatient readmission), and inpatient readmission. Patient subgroups (age, sex, race) were also evaluated for each type of revisit. RESULTS Our study cohort included 3 038 740 total index hospital stays from January 2012 to September 2015: 1 357 620 for heart failure, 634 795 for acute myocardial infarction, and 1 046 325 for pneumonia. Counting all revisits after discharge, the total number of hospital revisits per 100 patient discharges for target conditions increased across the study period (monthly increase 0.023 visits per 100 patient discharges (95% confidence interval 0.010 to 0.035)). This change was due to monthly increases in treat-and-discharge visits to an emergency department (0.023 (0.015 to 0.032) and observation stays (0.022 (0.020 to 0.025)), which were only partly offset by declines in readmissions (-0.023 (-0.035 to -0.012)). Increases in observation stay use were more pronounced among non-white patients than white patients. No significant change was seen in mortality within 30 days of discharge for target conditions (-0.0034 (-0.012 to 0.0054)). CONCLUSIONS In the United States, total hospital revisits within 30 days of discharge for conditions targeted by the HRRP increased across the study period. This increase was due to a rise in post-discharge emergency department visits and observation stays, which exceeded the decline in readmissions. Although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, our findings suggest that these declines could instead be because hospitals and clinicians have intensified efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.
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Affiliation(s)
- Rishi K Wadhera
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
| | - Karen E Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
| | - Dhruv S Kazi
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
| | - Changyu Shen
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
| | - Robert W Yeh
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
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13
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Vadlamani A, Perry JA, McCunn M, Stein DM, Albrecht JS. Racial Differences in Discharge Location After a Traumatic Brain Injury Among Older Adults. Arch Phys Med Rehabil 2019; 100:1622-1628. [PMID: 30954440 DOI: 10.1016/j.apmr.2019.03.008] [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] [Received: 07/25/2018] [Revised: 12/05/2018] [Accepted: 03/05/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine if there were racial differences in discharge location among older adults treated for traumatic brain injury (TBI) at a level 1 trauma center. DESIGN Retrospective cohort study. SETTING R Adams Cowley Shock Trauma Center. PARTICIPANTS Black and white adults aged ≥65 years treated for TBI between 1998 and 2012 and discharged to home without services or inpatient rehabilitation (N=2902). MAIN OUTCOME MEASURES We assessed the association between race and discharge location via logistic regression. Covariates included age, sex, Abbreviated Injury Scale-Head score, insurance type, Glasgow Coma Scale score, and comorbidities. RESULTS There were 2487 (86%) whites and 415 blacks (14%) in the sample. A total of 1513 (52%) were discharged to inpatient rehabilitation and 1389 (48%) were discharged home without services. In adjusted logistic regression, blacks were more likely to be discharged to inpatient rehabilitation than to home without services compared to whites (odds ratio 1.34, 95% confidence interval, 1.06-1.70). CONCLUSIONS In this group of Medicare-eligible older adults, blacks were more likely to be discharged to inpatient rehabilitation compared to whites.
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Affiliation(s)
- Aparna Vadlamani
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD.
| | - Justin A Perry
- Department of Care Management, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD
| | - Maureen McCunn
- Department of Anesthesiology, Divisions of Trauma Anesthesiology and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Deborah M Stein
- Department of Surgery, Division of Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
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14
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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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15
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Bucholz EM, Toomey SL, Schuster MA. Trends in Pediatric Hospitalizations and Readmissions: 2010-2016. Pediatrics 2019; 143:peds.2018-1958. [PMID: 30696756 PMCID: PMC6764425 DOI: 10.1542/peds.2018-1958] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Health reform and policy initiatives over the last 2 decades have led to significant changes in pediatric clinical practice. However, little is known about recent trends in pediatric hospitalizations and readmissions at a national level. METHODS Data from the 2010-2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database and National Inpatient Sample were analyzed to characterize patient-level and hospital-level trends in annual pediatric (ages 1-17 years) admissions and 30-day readmissions. Poisson regression was used to evaluate trends in pediatric readmissions over time. RESULTS From 2010 to 2016, the total number of index admissions decreased by 21.3%, but the percentage of admissions for children with complex chronic conditions increased by 5.7%. Unadjusted pediatric 30-day readmission rates increased over time from 6.26% in 2010 to 7.02% in 2016 with a corresponding increase in numbers of admissions for patients with complex chronic conditions. When stratified by complex or chronic conditions, readmission rates declined or remained stable across patient subgroups. Mean risk-adjusted hospital readmission rates increased over time overall (6.46% in 2010 to 7.14% in 2016) and in most hospital subgroups but decreased over time in metropolitan teaching hospitals. CONCLUSIONS Pediatric admissions declined from 2010 to 2016 as 30-day readmission rates increased. The increase in readmission rates was associated with greater numbers of admissions for children with chronic conditions. Hospitals serving pediatric patients need to account for the rising complexity of pediatric admissions and develop strategies for reducing readmissions in this high-risk population.
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Affiliation(s)
- Emily M. Bucholz
- Department of Cardiology Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sara L. Toomey
- Harvard Medical School, Harvard University, Boston, Massachusetts,Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Mark A. Schuster
- Harvard Medical School, Harvard University, Boston, Massachusetts,Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts,Kaiser Permanente School of Medicine, Pasadena, California
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16
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Sabbatini AK, Wright B, Kocher K, Hall MK, Basu A. Postdischarge Unplanned Care Events Among Commercially Insured Patients With an Observation Stay Versus Short Inpatient Admission. Ann Emerg Med 2018; 74:334-344. [PMID: 30470517 DOI: 10.1016/j.annemergmed.2018.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/22/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE Observation stays are composing an increasing proportion of unscheduled hospitalizations in the United States, with unclear consequences for the quality of care. This study used a nationally representative data set of commercially insured patients hospitalized from the emergency department (ED) to compare 30-day postdischarge unplanned care events after an observation stay versus a short inpatient admission. METHODS This was a retrospective analysis of ED hospitalizations using the 2015 Truven MarketScan Commercial Claims and Encounters data set. Adult observation stays and short inpatient hospitalizations of 2 days or less were identified and followed for 30 days from hospital discharge to identify unplanned care events, defined as a subsequent inpatient admission, observation stay, or return ED visit. A propensity score analysis was used to compare rates of unplanned events after each type of index hospitalization. RESULTS Among the propensity-weighted cohorts, patients with an index observation stay were 28% more likely to experience any unplanned care event within 30 days of discharge compared with those with a short inpatient admission (20.4% versus 15.9%; risk ratio 1.28; 95% confidence interval [CI] 1.21 to 1.34). Specifically, patients in the observation stay group had substantially higher rates of postdischarge observation stays (4.8% versus 1.9%; odds ratio 2.60; 95% CI 2.15 to 3.16) and ED revisits with discharge (11.1% versus 8.8%; odds ratio 1.26; 95% CI 1.21 to 1.44) compared with those in the inpatient group, but were less likely to be readmitted as inpatients (6.4% versus 7.2%; odds ratio 0.90; 95% CI 0.83 to 0.96). CONCLUSION Commercially insured patients with an observation stay from the ED have a higher risk of postdischarge acute care events compared with similar patients with a short inpatient admission. Additional research is necessary to determine the extent to which quality of care, including care transitions, may differ between these 2 groups.
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Affiliation(s)
- Amber K Sabbatini
- Department of Emergency Medicine, University of Washington, Seattle, WA.
| | - Brad Wright
- Department of Health Management and Policy, University of Iowa, Iowa City, IA
| | - Keith Kocher
- Department of Emergency Medicine and Institute for Health Policy and Innovation, University of Michigan
| | - M Kennedy Hall
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Anirban Basu
- Departments of Health Services and Center for Comparative Health Outcomes, Policy, and Economics, University of Washington, Seattle, WA
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17
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Systems-Based Practice to Improve Care Within and Beyond the Emergency Department. Clin Geriatr Med 2018; 34:399-413. [DOI: 10.1016/j.cger.2018.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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18
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Wright B, Zhang X, Rahman M, Abir M, Ayyagari P, Kocher KE. Evidence of Racial and Geographic Disparities in the Use of Medicare Observation Stays and Subsequent Patient Outcomes Relative to Short-Stay Hospitalizations. Health Equity 2018; 2:45-54. [PMID: 30272046 PMCID: PMC6071902 DOI: 10.1089/heq.2017.0055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: To examine racial and geographic disparities in the use of—and outcomes associated with—Medicare observation stays versus short-stay hospitalizations. Methods: We used 2007–2010 fee-for-service Medicare claims, including 3,555,994 observation and short-stay hospitalizations for individuals over age 65. We estimated linear probability models with hospital fixed effects to identify within-facility disparities in observation stay use, estimated in-hospital mortality, 30- and 90-day postdischarge mortality, return emergency department (ED) visits, and hospital readmissions as a function of placement in observation using linear probability models, propensity-score matching, and interaction terms. Results: We identified racial and geographic disparities in the likelihood of observation stay use within hospitals (blacks 3.9% points more likely than whites, rural 5.4% points less likely than urban). Observation is associated with an increased likelihood of returning to the ED within 30 or 90 days and a decreased likelihood of readmission or mortality, but there are racial and geographic disparities in these outcomes. Conclusion: While observation generally results in improved outcomes, disparities in these outcomes and the use of observation stays within hospitals are concerning and may be driven by clinical and nonclinical factors.
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Affiliation(s)
- Brad Wright
- Department of Health Management and Policy, University of Iowa; Iowa City, IA.,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, Brown University; Providence, RI
| | - Mahshid Abir
- Department of Emergency Medicine, University of Michigan; Ann Arbor, MI.,RAND Corporation, Santa Monica, CA.,Institute for Healthcare Policy and Innovation, University of Michigan; Ann Arbor, MI
| | - Padmaja Ayyagari
- Department of Health Management and Policy, University of Iowa; Iowa City, IA
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan; Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan; Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, University of Michigan; Ann Arbor, MI
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