1
|
Lam K, Kleijwegt H, Bollens-Lund E, Nicholas LH, Covinsky KE, Ankuda CK. Long-term outcomes after rehabilitation in Medicare Advantage and fee-for-service beneficiaries. J Am Geriatr Soc 2024; 72:1697-1706. [PMID: 38597342 DOI: 10.1111/jgs.18917] [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: 12/19/2023] [Revised: 03/05/2024] [Accepted: 03/15/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Financial incentives in capitated Medicare Advantage (MA) plans may lead to inadequate rehabilitation. We therefore investigated if MA enrollees had worse long-term physical performance and functional outcomes after rehabilitation. METHODS We conducted a retrospective cohort study of Medicare beneficiaries in the nationally representative National Health and Aging Trends Study. We compared MA and fee-for-service (FFS) beneficiaries reporting rehabilitation between 2014 and 2017 by change in (1) Short Physical Performance Battery (SPPB) and (2) NHATS-derived Functional Independence Measure (FIM) from the previous year, using t-tests incorporating inverse-probability weighting and complex survey design. Secondary outcomes were self-reported: (1) improved function during rehabilitation, (2) worse function since rehabilitation ended, (3) meeting rehabilitation goals, and (4) meeting insurance limits. RESULTS Among 738 MA and 1488 FFS participants, weighted mean age was 76 years (SD 7.0), 59% were female, and 9% had probable dementia. MA beneficiaries were more likely to be Black (9% vs. 6%) or Hispanic/other race (15% vs. 10%), be on Medicaid (14% vs. 10%), have lower income (median $35,000 vs. $48,000), and receive <1 month of rehabilitation (30% vs. 23%). MA beneficiaries had a similar decline in SPPB (-0.46 [SD 1.8] vs. -0.21 [SD 2.7], p-value 0.069) and adapted FIM (-1.05 [SD 3.7] vs. -1.13 [SD 5.45], p-value 0.764) compared to FFS. MA beneficiaries were less likely to report improved function during rehabilitation (61% [95% CI 56-67] vs. 70% [95% CI 67-74], p-value 0.006). Other outcomes and analyses restricted to inpatient rehabilitation participants were non-significant. CONCLUSIONS AND RELEVANCE MA enrollment was associated with lower likelihood of self-reported functional improvement during rehabilitation but no clinically or statistically significant differences in annual changes of physical performance or function. As MA expands, future studies must monitor implications on rehabilitation coverage and older adults' independence.
Collapse
Affiliation(s)
- Kenneth Lam
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hannah Kleijwegt
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lauren H Nicholas
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Economics, University of Colorado Denver, Denver, Colorado, USA
| | - Kenneth E Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
2
|
Cogan AM, Roberts P, Mallinson T. Using Electronic Health Record Data for Occupational Therapy Health Services Research: Invited Commentary. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2024:15394492241246544. [PMID: 38622903 DOI: 10.1177/15394492241246544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Health services research (HSR) is a field of study that examines how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and health and well-being. HSR approaches can help build the occupational therapy evidence base, particularly in relation to population health. Data from electronic health record (EHR) systems provide a rich resource for applying HSR approaches to examine the value of occupational therapy services. Transparency about data preparation procedures is important for interpreting results. Based on our findings, we describe a six-step cleaning protocol for preparing EHR and billing data from an inpatient rehabilitation facility for research and provide recommendations for the field based on our experience. Using and reporting similar strategies across studies will improve efficiency and transparency, and facilitate comparability of results.
Collapse
Affiliation(s)
| | - Pamela Roberts
- University of Southern California, Los Angeles, USA
- Cedars-Sinai, Los Angeles, CA, USA
- California Rehabilitation Institute, Los Angeles, USA
| | | |
Collapse
|
3
|
Chen C, Miller G, Setoguchi S. Climate change and excess length of stay: A call to action for health equity and environmental sustainability. J Hosp Med 2024. [PMID: 38563357 DOI: 10.1002/jhm.13348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 03/09/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Catherine Chen
- Department of Medicine, Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | - Soko Setoguchi
- Department of Medicine, Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Institute for Health, Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| |
Collapse
|
4
|
Devaux E, Roditis T, Quily G, Karanfilovic C, Bouniol A, Nidegger D, Charpentier P, Ghulam S, Azouvi P. Predictors and indicators of prolonged hospital stay ("bed blocking") in rehabilitation: Data from the Paris region. Ann Phys Rehabil Med 2024; 67:101816. [PMID: 38479115 DOI: 10.1016/j.rehab.2023.101816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 04/13/2024]
Affiliation(s)
- Emmanuelle Devaux
- Agence Régionale de Santé Ile de France, 13 rue du Landy, Saint Denis 93200, France
| | - Thierry Roditis
- Groupe Clinalliance, 43 Rue de Verdun, Villiers-sur-Orge 91700, France
| | - Gaelle Quily
- Agence Régionale de Santé Ile de France, 13 rue du Landy, Saint Denis 93200, France
| | | | - Agnès Bouniol
- Hopital de Pédiatrie et de rééducation, Lieu-dit Hpr Longchêne, Bullion 78830, France
| | - Delphine Nidegger
- AP-HP, Hôpital Avicenne, 125, rue de Stalingrad, Bobigny 93000, France
| | | | - Sadia Ghulam
- Agence Régionale de Santé Ile de France, 13 rue du Landy, Saint Denis 93200, France
| | - Philippe Azouvi
- Agence Régionale de Santé Ile de France, 13 rue du Landy, Saint Denis 93200, France; AP-HP, GH Paris Saclay, Hôpital Raymond Poincaré, service de Médecine Physique et de Réadaptation 104, boulevard Raymond Poincaré, Garches 92380, France; Equipe INSERM DevPsy, CESP, UMR 1018, Université Paris-Saclay, UVSQ, France.
| |
Collapse
|
5
|
Downer B, Wickliff M, Malagaris I, Li CY, Lee MJ. Achieving Functional Goals During a Skilled Nursing Facility Stay: A National Study of Medicare Beneficiaries. Am J Phys Med Rehabil 2024; 103:333-339. [PMID: 38112630 PMCID: PMC10947948 DOI: 10.1097/phm.0000000000002382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
OBJECTIVES The aims of the study are to describe the frequency that functional goals are documented on the Minimum Data Set and to identify resident characteristics associated with meeting or exceeding discharge goals. METHODS We selected Medicare fee-for-service beneficiaries admitted to a skilled nursing facility within 3 days of hospital discharge from October 1, 2018, to December 31, 2019 ( N = 1,228,913). The admission Minimum Data Set was used to describe the discharge goal scores for seven self-care and 16 mobility items. We used the eight self-care and mobility items originally included in a publicly reported quality measure to calculate total scores for discharge goals, admission performance, and discharge performance ( n = 371,801). RESULTS For all self-care items, more than 70% of residents had a goal score of 1-6 points documented on the admission Minimum Data Set. Chair/bed-to-chair transfer had the highest percentage of residents with a score of 1-6 points (77.1%) and walking up/down 12 steps had the lowest (23.2%). Approximately 44% of residents had a discharge performance score that met or exceeded their goal score. Older age, urinary incontinence, and cognitive impairment had the lowest odds of meeting or exceeding discharge goals. CONCLUSIONS Assessing a resident's functional goals is important to providing patient-centered care. This information may help skilled nursing facilities determine whether a resident has made meaningful functional improvements.
Collapse
Affiliation(s)
- Brian Downer
- Department of Population Health and Health Disparities. School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
- Sealy Center on Aging. University of Texas Medical Branch, Galveston, TX
| | - Megan Wickliff
- Department of Population Health and Health Disparities. School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
| | - Ioannis Malagaris
- Office of Biostatistics. University of Texas Medical Branch, Galveston, TX
| | - Chih-Ying Li
- Department of Occupational Therapy. School of Health Professions, University of Texas Medical Branch, Galveston, TX
| | - Mi Jung Lee
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch at Galveston, TX
| |
Collapse
|
6
|
Merimee S, Ali A, Downes K, Mullins J, Sajid MI, Mir H. Lost in the Shuffle: Low Health Literacy in Geriatric Fracture Patients and Families Regarding Post-Acute Care-A Prospective Study. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00012. [PMID: 38569089 PMCID: PMC10994444 DOI: 10.5435/jaaosglobal-d-24-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION This study aims to evaluate health literacy (HL) in geriatric orthopaedic trauma patients and their families as it relates to their post-acute care (PAC) in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). METHODS This nonrandomized controlled clinical trial included patients aged 65 years and older treated for acute fracture at a Level 1 trauma center and discharged to either IRF or SNF. First 106 patients enrolled served as the control group and received standard discharge instructions. The second 101 patients were given a set of oral and written instructions regarding PAC detailing important questions to ask upon arrival to their facility. RESULTS The mean HL score for all patients/families was 2.4 out of 5. No significant difference was noted in HL scores (2.4 versus 2.3) or median LOS (22 versus 28 days) between the control and intervention groups. Family involvement (68%) slightly improved HL scores (2.6 versus 1.9, P < 0.001). Patients discharged to IRF had better HL scores (3.4 versus 2.3, P < 0.001), shorter LOS (median 15 vs 30 days, P < 0.001), and trended toward improved knowledge of discharge goals (48.1% versus 35.6%) than those in SNF. CONCLUSION System-wide solutions are necessary to improve geriatric HL and optimize outcomes in orthopaedic trauma.
Collapse
Affiliation(s)
- Stephanie Merimee
- From the Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, FL (Dr. Merimee and Dr. Ali), and the Florida Orthopaedic Institute, Tampa, FL (Dr. Downes, Dr. Mullins, Dr. Sajid, and Dr. Mir)
| | - Ashley Ali
- From the Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, FL (Dr. Merimee and Dr. Ali), and the Florida Orthopaedic Institute, Tampa, FL (Dr. Downes, Dr. Mullins, Dr. Sajid, and Dr. Mir)
| | - Katheryne Downes
- From the Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, FL (Dr. Merimee and Dr. Ali), and the Florida Orthopaedic Institute, Tampa, FL (Dr. Downes, Dr. Mullins, Dr. Sajid, and Dr. Mir)
| | - Joanna Mullins
- From the Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, FL (Dr. Merimee and Dr. Ali), and the Florida Orthopaedic Institute, Tampa, FL (Dr. Downes, Dr. Mullins, Dr. Sajid, and Dr. Mir)
| | - Mir Ibrahim Sajid
- From the Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, FL (Dr. Merimee and Dr. Ali), and the Florida Orthopaedic Institute, Tampa, FL (Dr. Downes, Dr. Mullins, Dr. Sajid, and Dr. Mir)
| | - Hassan Mir
- From the Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, FL (Dr. Merimee and Dr. Ali), and the Florida Orthopaedic Institute, Tampa, FL (Dr. Downes, Dr. Mullins, Dr. Sajid, and Dr. Mir)
| |
Collapse
|
7
|
Prusynski RA, D’Alonzo A, Johnson MP, Mroz TM, Leland NE. Differences in Home Health Services and Outcomes Between Traditional Medicare and Medicare Advantage. JAMA HEALTH FORUM 2024; 5:e235454. [PMID: 38427341 PMCID: PMC10907922 DOI: 10.1001/jamahealthforum.2023.5454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024] Open
Abstract
Importance Private Medicare Advantage (MA) plans recently surpassed traditional Medicare (TM) in enrollment. However, MA plans are facing scrutiny for burdensome prior authorization and potential rationing of care, including home health. MA beneficiaries are less likely to receive home health, but recent evidence on differences in service intensity and outcomes among home health patients is lacking. Objective To examine differences in home health service intensity and patient outcomes between MA and TM. Design, Setting, and Participants This cross-sectional study was conducted from January 2019 to December 2022 in 102 home health locations in 19 states and included 178 195 TM and 107 102 MA patients 65 years or older with 2 or fewer 60-day home health episodes. It included a secondary analysis of standardized assessment and visit data. Inverse probability of treatment weighting regression compared service intensity and patient outcomes between MA and TM episodes, accounting for differences in demographic characteristics, medical complexity, functional and cognitive impairments, social environment, caregiver support, and local community factors. Models included office location, year, and reimbursement policy fixed effects. Data were analyzed between September 2023 and July 2024. Exposure TM vs MA plan. Main Outcomes and Measures Home health length of stay and number of visits from nursing, physical, occupational, and speech therapy, social work, and home health aides. Patient outcomes included improvement in self-care and mobility function, discharge to the community, and transfer to an inpatient facility during home health. Results Of 285 297 total patients, 180 283 (63.2%) were female; 586 (0.2%) were American Indian/Alaska Native, 8957 (3.1%) Asian, 28 694 (10.1%) Black, 7406 (2.6%) Hispanic, 1959 (0.7%) Native Hawaiian/Pacific Islander, 237 017 (83.1%) non-Hispanic White, and 678 (0.2%) multiracial individuals. MA patients had shorter home health length of stay by 1.62 days (95% CI, -1.82 to 1.42) and received fewer visits from all disciplines except social work. There were no differences in inpatient transfers. MA patients had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively (mobility odds ratio [OR], 0.97; 95% CI, 0.94-0.99; self-care OR, 0.96; 95% CI, 0.92-0.99). MA patients were 5% more likely to discharge to the community compared with TM (OR, 1.05; 95% CI, 1.01-1.08). Conclusions and Relevance The results of this cross-sectional study suggest that MA patients receive shorter and less intensive home health care vs TM patients with similar needs. Differences may be due to the administrative burden and cost-limiting incentives of MA plans. MA patients experienced slightly worse functional outcomes but were more likely to discharge to the community, which may have negative implications for MA patients, including reduced functional independence or increased caregiver burden.
Collapse
Affiliation(s)
| | | | | | - Tracy M. Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Natalie E. Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
8
|
Huckfeldt PJ, Shier V, Escarce JJ, Rabideau B, Boese T, Parsons HM, Sood N. Postacute Care for Medicare Advantage Enrollees Who Switched to Traditional Medicare Compared With Those Who Remained in Medicare Advantage. JAMA HEALTH FORUM 2024; 5:e235325. [PMID: 38363561 PMCID: PMC10873769 DOI: 10.1001/jamahealthforum.2023.5325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/13/2023] [Indexed: 02/17/2024] Open
Abstract
Importance Medicare Advantage (MA) plans receive capitated per enrollee payments that create financial incentives to provide care more efficiently than traditional Medicare (TM); however, incentives could be associated with MA plans reducing use of beneficial services. Postacute care can improve functional status, but it is costly, and thus may be provided differently to Medicare beneficiaries by MA plans compared with TM. Objective To estimate the association of MA compared with TM enrollment with postacute care use and postdischarge outcomes. Design, Setting, and Participants This was a cohort study using Medicare data on 4613 hospitalizations among retired Ohio state employees and 2 comparison groups in 2015 and 2016. The study investigated the association of a policy change with use of postacute care and outcomes. The policy changed state retiree health benefits in Ohio from a mandatory MA plan to subsidies for either supplemental TM coverage or an MA plan. After policy implementation, approximately 75% of retired Ohio state employees switched to TM. Hospitalizations for 3 high-volume conditions that usually require postacute rehabilitation were assessed. Data from the Medicare Provider Analysis and Review files were used to identify all hospitalizations in short-term acute care hospitals. Difference-in-difference regressions were used to estimate changes for retired Ohio state employees compared with other 2015 MA enrollees in Ohio and with Kentucky public retirees who were continuously offered a mandatory MA plan. Data analyses were performed from September 1, 2019, to November 30, 2023. Exposures Enrollment in Ohio state retiree health benefits in 2015, after which most members shifted to TM. Main Outcomes and Measures Received care in an inpatient rehabilitation facility, skilled nursing facility, or home health, or any postacute care; the occurrence of any hospital readmission; the number of days in the community during the 30 days after hospital discharge; and mortality. Results The study sample included 2373 hospitalizations for Ohio public retirees, 1651 hospitalizations for other Humana MA enrollees in Ohio, and 589 hospitalizations for public retirees in Kentucky. After the 2016 policy implementation, the percentage of hospitalizations covered by MA decreased by 70.1 (95% CI, -74.2 to -65.9) percentage points (pp), inpatient rehabilitation facility admissions increased by 9.7 (95% CI, 4.7 to 14.7) pp, use of only home health or skilled nursing facility care fell by 8.6 (95% CI, -14.6 to -2.6) pp, and days in the community fell by 1.6 (95% CI, -2.9 to -0.3) days for Ohio public retirees compared with other Humana MA enrollees in Ohio. There was no change in 30-day mortality or hospital readmissions; similar results were found by comparisons using Kentucky public retirees as a control group. Conclusions and Relevance The findings of this cohort study indicate that after a change in retiree health benefits, most Ohio public retirees shifted from MA to TM and received more intensive postacute care with no significant change in measured short-term postdischarge outcomes. Future work should consider additional measures of postacute functional status over a longer follow-up period.
Collapse
Affiliation(s)
- Peter J. Huckfeldt
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Victoria Shier
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - José J. Escarce
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
| | - Brendan Rabideau
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Analysis Group, Inc, Los Angeles, California
| | - Tyler Boese
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Helen M. Parsons
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Neeraj Sood
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles
| |
Collapse
|
9
|
Boockvar KS. CORR Insights®: High Risk of Readmission After THA Regardless of Functional Status in Patients Discharged to Skilled Nursing Facility. Clin Orthop Relat Res 2024:00003086-990000000-01474. [PMID: 38259161 DOI: 10.1097/corr.0000000000002989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Affiliation(s)
- Kenneth S Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, Birmingham, AL, USA
| |
Collapse
|
10
|
Unnanuntana A, Kuptniratsaikul V, Srinonprasert V, Charatcharoenwitthaya N, Kulachote N, Papinwitchakul L, Wattanachanya L, Chotanaphuti T. A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review. Injury 2023; 54:111039. [PMID: 37757673 DOI: 10.1016/j.injury.2023.111039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 08/21/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand. METHODS A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel. RESULTS Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan. CONCLUSION We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.
Collapse
Affiliation(s)
- Aasis Unnanuntana
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand.
| | - Vilai Kuptniratsaikul
- Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Varalak Srinonprasert
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Natthinee Charatcharoenwitthaya
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Noratep Kulachote
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Lalita Wattanachanya
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University and Excellence Center for Diabetes, Hormone and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Thanainit Chotanaphuti
- Department of Orthopedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| |
Collapse
|
11
|
Prusynski RA, Rundell SD, Pradhan S, Mroz TM. Some But Not Too Much: Multiparticipant Therapy and Positive Patient Outcomes in Skilled Nursing Facilities. J Geriatr Phys Ther 2023; 46:185-195. [PMID: 36103147 PMCID: PMC10008750 DOI: 10.1519/jpt.0000000000000363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Physical and occupational therapy practices in skilled nursing facilities (SNFs) were greatly impacted by the 2019 Medicare Patient-Driven Payment Model (PDPM). Under the PDPM, the practice of multiparticipant therapy-treating more than one patient per therapy provider per session-increased in SNFs, but it is unknown how substituting multiparticipant therapy for individualized therapy may impact patient outcomes. This cross-sectional study establishes baseline relationships between multiparticipant therapy and patient outcomes using pre-PDPM data. METHODS We used Minimum Data Set assessments from all short-term Medicare fee-for-service SNF stays in 2018. Using generalized mixed-effects logistic regression adjusted for therapy volume and patient factors, we examined associations between the proportion of minutes of physical and occupational therapy that were received as multiparticipant sessions during the SNF stay and 2 outcomes: community discharge and functional improvement. Multiparticipant therapy minutes as a proportion of total therapy time were categorized as none, low (below the median of 5%), medium (median to <25%), and high (≥25%) to reflect the 25% multiparticipant therapy limit required by the PDPM. RESULTS AND DISCUSSION We included 901 544 patients with complete data for functional improvement and 912 996 for the discharge outcome. Compared with patients receiving no multiparticipant therapy, adjusted models found small positive associations between low and medium multiparticipant therapy levels and outcomes. Patients receiving low levels of multiparticipant therapy had 14% higher odds of improving in function (95% CI 1.09-1.19) and 10% higher odds of community discharge (95% CI 1.05-1.15). Patients receiving medium levels of multiparticipant therapy had 18% higher odds of functional improvement (95% CI 1.13-1.24) and 44% higher odds of community discharge (95% CI 1.34-1.55). However, associations disappeared with high levels of multiparticipant therapy. CONCLUSIONS Prior to the PDPM, providing up to 25% multiparticipant therapy was an efficient strategy for SNFs that may have also benefitted patients. As positive associations disappeared with high levels (≥25%) of multiparticipant therapy, it may be best to continue delivering the majority of therapy in SNFs as individualized treatment.
Collapse
Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | | | | |
Collapse
|
12
|
Achola EM, Stevenson DG, Keohane LM. Postacute Care Services Use and Outcomes Among Traditional Medicare and Medicare Advantage Beneficiaries. JAMA HEALTH FORUM 2023; 4:e232517. [PMID: 37594745 PMCID: PMC10439482 DOI: 10.1001/jamahealthforum.2023.2517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/13/2023] [Indexed: 08/19/2023] Open
Abstract
Importance Better evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes. Objective To compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees. Design, Setting, and Participants This cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design. Exposures Enrollment in MA and dual eligibility for Medicare and Medicaid. Main Outcomes and Measures Postacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services. Results Included in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility. Conclusions and relevance In this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.
Collapse
Affiliation(s)
- Emma M. Achola
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David G. Stevenson
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville
| | - Laura M. Keohane
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
13
|
Riester MR, Beaudoin FL, Joshi R, Hayes KN, Cupp MA, Berry SD, Zullo AR. Evaluation of post-acute care and one-year outcomes among Medicare beneficiaries with hip fractures: a retrospective cohort study. BMC Med 2023; 21:232. [PMID: 37400841 DOI: 10.1186/s12916-023-02958-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/22/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Post-acute care (PAC) services after hospitalization for hip fracture are typically provided in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or at home via home health care (HHC). Little is known about the clinical course following PAC for hip fracture. We examined the nationwide burden of adverse outcomes by PAC setting in the year following discharge from PAC for hip fracture. METHODS This retrospective cohort included Medicare Fee-for-Service beneficiaries > 65 years who received PAC services in U.S. SNFs, IRFs, or HHC following hip fracture hospitalization between 2012 and 2018. Individuals who had a fall-related injury (FRI) during PAC or received PAC services in multiple settings were excluded. Primary outcomes included FRIs, all-cause hospital readmissions, and death in the year following discharge from PAC. Cumulative incidences and incidence rates for adverse outcomes were reported by PAC setting. Exploratory analyses examined risk ratios and hazard ratios between settings before and after inverse-probability-of-treatment-weighting, which accounted for 43 covariates. RESULTS Among 624,631 participants (SNF, 67.78%; IRF, 16.08%; HHC, 16.15%), the mean (standard deviation) age was 82.70 (8.26) years, 74.96% were female, and 91.30% were non-Hispanic White. Crude incidence rates (95%CLs) per 1000 person-years were highest among individuals receiving SNF care for FRIs (SNF, 123 [121, 123]; IRF, 105 [102, 107]; HHC, 89 [87, 91]), hospital readmission (SNF, 623 [619, 626]; IRF, 538 [532, 544]; HHC, 418 [414, 423]), and death (SNF, 167 [165, 169]; IRF, 47 [46, 49]; HHC, 55 [53, 56]). Overall, rates of adverse outcomes generally remained higher among SNF care recipients after covariate adjustment. However, inferences about the group with greater adverse outcomes differed for FRIs and hospital readmissions based on risk ratio or hazard ratio estimates. CONCLUSIONS In this retrospective cohort study of individuals hospitalized for hip fracture, rates of adverse outcomes in the year following PAC were common, especially among SNF care recipients. Understanding risks and rates of adverse events can inform future efforts to improve outcomes for older adults receiving PAC for hip fracture. Future work should consider calculating risk and rate measures to assess the influence of differential time under observation across PAC groups.
Collapse
Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA.
| | - Francesca L Beaudoin
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Richa Joshi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
| | - Kaleen N Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
- Graduate Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto Leslie Dan, Toronto, ON, Canada
| | - Meghan A Cupp
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| |
Collapse
|
14
|
Cupp MA, Beaudoin FL, Hayes KN, Riester MR, Berry SD, Joshi R, Zullo AR. Post-Acute Care Setting After Hip Fracture Hospitalization and Subsequent Opioid Use in Older Adults. J Am Med Dir Assoc 2023; 24:971-977.e4. [PMID: 37080246 PMCID: PMC10293035 DOI: 10.1016/j.jamda.2023.03.012] [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: 12/21/2022] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE Pain management in post-acute care (PAC) requires careful balance, with both opioid use and inadequate pain treatment linked to poor outcomes. We describe opioid use among older adults following discharge from PAC for hip fracture in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). DESIGN Retrospective cohort. SETTING AND PARTICIPANTS Medicare beneficiaries with Medicare Provider Analysis (MedPAR) claims, aged 66 years and older with a hip fracture hospitalization between 2012 and 2018 followed by PAC in SNFs or IRFs and then discharge to the community. METHODS Individuals were followed from PAC discharge for up to 1 year to assess opioid use. Covariate-standardized risk ratios (RR) and risk differences (RD) for opioid use within 7 days of PAC discharge were estimated via parametric g-formula with modified Poisson regression, and hazard ratios (HRs) for any post-PAC opioid use and long-term opioid use via Fine-Gray sub-distribution hazards regression. RESULTS Of 101,021 individuals, 80% (n = 80,495) were discharged from SNFs and 20% (n = 20,526) from IRFs. Opioids were dispensed to 50,433 patients (50%) overall and the 1-year cumulative incidence was notably higher in IRF (68%) than SNF (46%) patients. The adjusted risk of discharge from PAC with an opioid was 41% lower after SNFs versus IRFs [RR: 0.59; 95% confidence limits (CLs): 0.57-0.61; and RD: -0.16; 95% CLs: -0.17 to -0.15]. The adjusted rate of any opioid use in the year after PAC discharge was 44% lower (HR: 0.56; 95% CLs: 0.54-0.57) and of long-term opioid use was 17% lower (HR: 0.83; 95% CLs: 0.80-0.87) after SNFs versus IRFs. CONCLUSIONS AND IMPLICATIONS Opioid use is highly prevalent upon discharge from PAC after hip fracture, with lower use after SNF versus IRF care. Future research should assess the benefits and harms of post-PAC opioid prescribing and whether care practices during PAC can be improved to optimize long-term opioid use.
Collapse
Affiliation(s)
- Meghan A Cupp
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Francesca L Beaudoin
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kaleen N Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Richa Joshi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; Department of Pharmacy, Rhode Island Hospital, Providence, RI, USA
| |
Collapse
|
15
|
Geng F, Lake D, Meyers DJ, Resnik LJ, Teno JM, Gozalo P, Grabowski DC. Increased Medicare Advantage Penetration Is Associated With Lower Postacute Care Use For Traditional Medicare Patients. Health Aff (Millwood) 2023; 42:488-497. [PMID: 37011319 DOI: 10.1377/hlthaff.2022.00994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Medicare Advantage (MA) plans, which accounted for 45 percent of total Medicare enrollment in 2022, are incentivized to minimize spending on low-value services. Prior research indicates that MA plan enrollment is associated with reduced postacute care use without adverse impacts on patient outcomes. However, it is unclear whether a rising MA enrollment level is associated with a change in postacute care use in traditional Medicare, especially given growing participation in traditional Medicare Alternative Payment Models that have been found to be associated with lower postacute care spending. We hypothesize that market-level MA expansion is associated with reduced postacute care use among traditional Medicare beneficiaries-a "spillover" effect of providers modifying their practice patterns in response to MA plans' incentives. We found increased MA market penetration associated with reduced postacute care use among traditional Medicare beneficiaries, without a corresponding increase in hospital readmissions. This association was generally stronger in markets with a greater share of traditional Medicare beneficiaries attributed to accountable care organizations, suggesting that policy makers should account for MA penetration when evaluating potential savings in Alternative Payment Models within traditional Medicare.
Collapse
Affiliation(s)
- Fangli Geng
- Fangli Geng , Harvard University, Cambridge, Massachusetts
| | - Derek Lake
- Derek Lake, Brown University, Providence, Rhode Island
| | | | | | | | - Pedro Gozalo
- Pedro Gozalo, Brown University and Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | | |
Collapse
|
16
|
Kumar A, Roy I, Falvey J, Rudolph JL, Rivera-Hernandez M, Shaibi S, Sood P, Childers C, Karmarkar A. Effect of Variation in Early Rehabilitation on Hospital Readmission After Hip Fracture. Phys Ther 2023; 103:pzac170. [PMID: 37172126 PMCID: PMC10071584 DOI: 10.1093/ptj/pzac170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 08/18/2022] [Accepted: 10/16/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Provision of early rehabilitation services during acute hospitalization after a hip fracture is vital for improving patient outcomes. The purpose of this study was to examine the association between the amount of rehabilitation services received during the acute care stay and hospital readmission in older patients after a hip fracture. METHODS Medicare claims data (2016-2017) for older adults admitted to acute hospitals for a hip fracture (n = 131,127) were used. Hospital-based rehabilitation (physical therapy, occupational therapy, or both) was categorized into tertiles by minutes per day as low (median = 17.5), middle (median = 30.0), and high (median = 48.8). The study outcome was risk-adjusted 7-day and 30-day all-cause hospital readmission. RESULTS The median hospital stay was 5 days (interquartile range [IQR] = 4-6 days). The median rehabilitation minutes per day was 30 (IQR = 21-42.5 minutes), with 17 (IQR = 12.6-20.6 minutes) in the low tertile, 30 (IQR = 12.6-20.6 minutes) in the middle tertile, and 48.8 (IQR = 42.8-60.0 minutes) in the high tertile. Compared with high therapy minutes groups, those in the low and middle tertiles had higher odds of a 30-day readmission (low tertile: odds ratio [OR] = 1.11, 95% CI = 1.06-1.17; middle tertile: OR = 1.07, 95% CI = 1.02-1.12). In addition, patients who received low rehabilitation volume had higher odds of a 7-day readmission (OR = 1.20; 95% CI = 1.10-1.30) compared with high volume. CONCLUSION Elderly patients with hip fractures who received less rehabilitation were at higher risk of readmission within 7 and 30 days. IMPACT These findings confirm the need to update clinical guidelines in the provision of early rehabilitation services to improve patient outcomes during acute hospital stays for individuals with hip fracture. LAY SUMMARY There is significant individual- and hospital-level variation in the amount of hospital-based rehabilitation delivered to older adults during hip fracture hospitalization. Higher intensity of hospital-based rehabilitation care was associated with a lower risk of hospital readmission within 7 and 30 days.
Collapse
Affiliation(s)
- Amit Kumar
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
- Department of Health Sciences, Northern Arizona University, Flagstaff, Arizona, USA
| | - Jason Falvey
- University of Maryland School of Medicine, Department of Physical Therapy and Rehabilitation Science Baltimore, Maryland, USA
- University of Maryland School of Medicine, Department of Epidemiology and Public Health Baltimore, Maryland, USA
| | - James L Rudolph
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Stefany Shaibi
- Creighton University Health Sciences Campus, Phoenix, Arizona, USA
| | - Pallavi Sood
- Center for Optimal Aging, Marymount University, Arlington, Virginia, USA
| | - Christine Childers
- Physical Therapy Program, University of Arizona Health Sciences, Tucson, Arizona, USA
| | - Amol Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
- Sheltering Arms Institute, Richmond, Virginia, USA
| |
Collapse
|
17
|
Reistetter TA, Dean JM, Haas AM, Prochaska JD, Jupiter DC, Eschbach K, Kuo YF. Development and Evaluation of Rehabilitation Service Areas for the United States. BMC Health Serv Res 2023; 23:204. [PMID: 36859285 PMCID: PMC9976368 DOI: 10.1186/s12913-023-09184-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/15/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Geographic areas have been developed for many healthcare sectors including acute and primary care. These areas aid in understanding health care supply, use, and outcomes. However, little attention has been given to developing similar geographic tools for understanding rehabilitation in post-acute care. The purpose of this study was to develop and characterize post-acute care Rehabilitation Service Areas (RSAs) in the United States (US) that reflect rehabilitation use by Medicare beneficiaries. METHODS A patient origin study was conducted to cluster beneficiary ZIP (Zone Improvement Plan) code tabulation areas (ZCTAs) with providers who service those areas using Ward's clustering method. We used US national Medicare claims data for 2013 to 2015 for beneficiaries discharged from an acute care hospital to an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term care hospital (LTCH), or home health agency (HHA). Medicare is a US health insurance program primarily for older adults. The study population included patient records across all diagnostic groups. We used IRF, SNF, LTCH and HHA services to create the RSAs. We used 2013 and 2014 data (n = 2,730,366) to develop the RSAs and 2015 data (n = 1,118,936) to evaluate stability. We described the RSAs by provider type availability, population, and traveling patterns among beneficiaries. RESULTS The method resulted in 1,711 discrete RSAs. 38.7% of these RSAs had IRFs, 16.1% had LTCHs, and 99.7% had SNFs. The number of RSAs varied across states; some had fewer than 10 while others had greater than 70. Overall, 21.9% of beneficiaries traveled from the RSA where they resided to another RSA for care. CONCLUSIONS Rehabilitation Service Areas are a new tool for the measurement and understanding of post-acute care utilization, resources, quality, and outcomes. These areas provide policy makers, researchers, and administrators with small-area boundaries to assess access, supply, demand, and understanding of financing to improve practice and policy for post-acute care in the US.
Collapse
Affiliation(s)
- Timothy A Reistetter
- University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, 78229, USA.
| | - Julianna M Dean
- University of Houston-Clear Lake, 2700 Bay Area Blvd, Houston, TX, 77058, USA
| | - Allen M Haas
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - John D Prochaska
- The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Daniel C Jupiter
- The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Karl Eschbach
- The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Yong-Fang Kuo
- The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| |
Collapse
|
18
|
Grabowski DC, Chen A, Saliba D. Paying for Nursing Home Quality: An Elusive But Important Goal. J Am Geriatr Soc 2023; 71:342-348. [PMID: 36795634 PMCID: PMC10030098 DOI: 10.1111/jgs.18260] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/23/2023] [Indexed: 02/17/2023]
Affiliation(s)
- David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Amanda Chen
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Debra Saliba
- Borun Center for Gerontological Research, University of California Los Angeles, Los Angeles, California, USA
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
- RAND Health, Santa Monica, California, USA
| |
Collapse
|
19
|
Uddin T, Ahmed B, Shoma FK. Relations between indoor rehabilitation and basic health services in a developing country. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1001084. [PMID: 36761089 PMCID: PMC9905241 DOI: 10.3389/fresc.2023.1001084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/02/2023] [Indexed: 01/26/2023]
Abstract
Background and Introduction: Physical rehabilitation is vital for patients to regain maximum function. Approximately 80% of people with a disability live in developing countries, where they face multiple challenges in rehabilitation. The goal of the study was to conduct an analysis of indoor rehabilitation programs based on the demographics and medical conditions of the admitted patients and to relate to the available basic health and rehabilitation facilities. Methods This was a mixed method study conducted in an inpatient rehabilitation ward of a tertiary level academic university hospital in a developing country. All admitted patients who stayed for a period of minimum two weeks were included in the study. Demographic and clinical data were obtained by means of a retrospective medical record review utilizing a standardized data extraction form. The study was further strengthened by an online literature search for the available documents for analysis, relation, and discussion. Results Among the 1,309 admitted patients was male- female ratio was 10:7, with the majority (31.4%) cases falling between the ages of 46 and 60yrs. Rehabilitation outpatient department was the principal mode of admission (78%), and musculoskeletal and neurological conditions represented the maximum number (79.8%). Majority of patients (60.8%) were discharged home on completion of the rehabilitation program with a large number of patients who were absconded. Poor health budget allocation and lack of prioritization of the rehabilitation sector face multiple challenges, including the rehabilitation team functioning resources, space crisis for expansion which was further impacted by the COVID-19 pandemic. Conclusions The country's current health-related rehabilitation process and socio-demographic variables have a negative relationship. There was a large number of missing data in the medical records and many patients were lost prematurely from the indoor rehabilitation program. Musculoskeletal disorders were common, and the majority of patients were discharged home once the program was completed.
Collapse
|
20
|
Landon BE, Anderson TS, Curto VE, Cram P, Fu C, Weinreb G, Zaslavsky AM, Ayanian JZ. Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction. JAMA 2022; 328:2126-2135. [PMID: 36472594 PMCID: PMC9856265 DOI: 10.1001/jama.2022.20982] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Medicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown. OBJECTIVE To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non-ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019). EXPOSURES Enrollment in Medicare Advantage vs traditional Medicare. MAIN OUTCOMES AND MEASURES The primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions). RESULTS The study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, -1.5 percentage points [95% CI, -2.2 to -0.7] and 12.0% vs 12.5% for NSTEMI; difference, -0.5 percentage points [95% CI, -0.9% to -0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, -0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, -0.2 percentage points [95% CI, -0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, -0.9 percentage points [95% CI, -1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, -1.3 percentage points [95% CI, -2.0 to -0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, -1.5 to 0.0]). CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.
Collapse
Affiliation(s)
- Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Timothy S. Anderson
- Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Vilsa E. Curto
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Peter Cram
- Department of Medicine, University of Texas Medical Branch, Galveston
| | - Christina Fu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Gabe Weinreb
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - John Z. Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor
| |
Collapse
|
21
|
Gozalo PL, Inrator O, Phibbs CS, Kinosian B, Allen SM. Successful Discharge of Short Stay Veterans from VA Community Living Centers. J Aging Soc Policy 2022; 34:690-706. [PMID: 35959862 DOI: 10.1080/08959420.2022.2111169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007-2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed the patient and facility rates of successful discharge to the community (SDC) of these short-stay Veterans. We found large variation in inter- as well as intra- facility SDC rates across the rehabilitation and skilled nursing short-stay cohorts. We discuss how our results can help guide VHA policy directed at delivering high-quality short-stay CLC care for Veterans.
Collapse
Affiliation(s)
- Pedro L Gozalo
- Research Health Scientist, U.S. Department of Veterans Affairs Medical Center, Center of Innovation in Long-Term Services and Supports, Providence, Rhode Island, USA.,Professor, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Orna Inrator
- Professor, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Research Health Scientist, Geriatrics & Extended Care Data & Analysis Center (GEC DAC), Canandaigua VA Medical Center, Canandaigua, New York, USA
| | - Ciaran S Phibbs
- Research Health Scientist, Health Economics Resource Center, Palo Alto VA Health Care System, Palo Alto, California, USA.,Associate Professor, Center for Innovation to Implementation, Stanford University School of Medicine, Palo Alto, California, USA.,Research Health Scientist, Geriatrics and Extended Care Data and Analysis Center, Palo Alto VA Health Care System, Palo Alto, California, USA
| | - Bruce Kinosian
- Associate Professor, Division of Geriatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Research Health Scientist, Geriatrics & Extended Care Data & Analysis Center (GEC DAC), Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Susan M Allen
- Research Health Scientist, U.S. Department of Veterans Affairs Medical Center, Center of Innovation in Long-Term Services and Supports, Providence, Rhode Island, USA.,Professor, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
22
|
Parikh RB, Emanuel EJ, Brensinger CM, Boyle CW, Price-Haywood EG, Burton JH, Heltz SB, Navathe AS. Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program. JAMA Netw Open 2022; 5:e2228529. [PMID: 35997977 PMCID: PMC9399862 DOI: 10.1001/jamanetworkopen.2022.28529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE The 2 primary efforts of Medicare to advance value-based care are Medicare Advantage (MA) and the fee-for-service-based Medicare Shared Savings Program (MSSP). It is unknown how spending differs between the 2 programs after accounting for differences in patient clinical risk. OBJECTIVE To examine how spending and utilization differ between MA and MSSP beneficiaries after accounting for differences in clinical risk using data from administrative claims and electronic health records. DESIGN, SETTING, AND PARTICIPANTS This retrospective economic evaluation used data from 15 763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022. EXPOSURES Enrollment in MA or attribution to an accountable care organization in the MSSP program. MAIN OUTCOMES AND MEASURES Per-beneficiary annual total spending and subcomponents, including inpatient hospital, outpatient hospital, skilled nursing facility, emergency department, primary care, and specialist spending. RESULTS The sample of 15 763 participants included 12 720 (81%) MA and 3043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). The mean unadjusted per-member per-year spending difference between MSSP and MA disease-specific subcohorts was $2159 in diabetes, $4074 in CHF, $2560 in CKD, and $2330 in hypertension. After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2454; 95% CI, $1431-$3574), CHF ($3699; 95% CI, $1235-$6523), CKD ($2478; 95% CI, $1172-$3920), and hypertension ($2258; 95% CI, $1616-2,939). Higher MSSP spending among matched beneficiaries was consistent over time. In the matched cohort in 2018, MSSP total spending ranged from 23% (CHF) to 30% (CKD) higher than MA. Adjusting for differential trends in coding intensity did not affect these results. Higher outpatient hospital spending among MSSP beneficiaries contributed most to spending differences between MSSP and MA, representing 49% to 62% of spending differences across disease cohorts. CONCLUSIONS AND RELEVANCE In this study, utilization and spending were consistently higher for MSSP than MA beneficiaries within the same health system even after adjusting for granular metrics of clinical risk. Nonclinical factors likely contribute to the large differences in MA vs MSSP spending, which may create challenges for health systems participating in MSSP relative to their participation in MA.
Collapse
Affiliation(s)
- Ravi B. Parikh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Ezekiel J. Emanuel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | | | - Connor W. Boyle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | | | - Amol S. Navathe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| |
Collapse
|
23
|
Wang X, Xu X, Oates M, Hill T, Wade RL. Medical management patterns in a US commercial claims database following a nontraumatic fracture in postmenopausal women. Arch Osteoporos 2022; 17:92. [PMID: 35834032 PMCID: PMC9283183 DOI: 10.1007/s11657-022-01135-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/22/2022] [Indexed: 02/03/2023]
Abstract
Among women ≥ 50 years with fracture, 76% had not received osteoporosis diagnosis or treatment at 6 months and only 14% underwent a DXA scan. Nearly half of all and 90% of hip fracture patients required surgery. Fractures cause substantial clinical burden and are not linked to osteoporosis diagnosis or treatment. PURPOSE Osteoporosis (OP) and OP-related fractures are a major public health concern, associated with significant economic burden. This study describes management patterns following a nontraumatic fracture for commercially insured patients. METHODS This retrospective cohort study identified women aged ≥ 50 years having their first nontraumatic index fracture (IF) between January 1, 2015 and June 30, 2019, from IQVIA's PharMetrics® Plus claims database. Medical management patterns at month 6 and medication use patterns at months 6, 12, and 24 following the IF were described. RESULTS Among 48,939 women (mean (SD) age: 62.7 (9.5) years), the most common fracture types were vertebral (30.6%), radius/ulna (24.9%), and hip (HF; 12.1%). By month 6, 76% of patients had not received an OP diagnosis or treatment, 13.6% underwent a DXA scan, and 11.2% received any OP treatment. Surgery was required in 43.1% of all patients and 90.0% of HF patients on or within 6 months of the fracture date. Among HF patients, 41.4% were admitted to a skilled nursing facility, 96.7% were hospitalized an average of 5.5 days, and 38.1% required durable medical equipment use. The 30-day all-cause readmission rate was 14.3% among those hospitalized for the IF. Overall, 7.4%, 9.9%, and 13.2% had a subsequent fracture at months 6, 12, and 24, respectively. CONCLUSION Our findings provide an overview of post-fracture management patterns using real-world data. OP was remarkably underdiagnosed and undertreated following the initial fracture. Nontraumatic fracture, particularly HF, resulted in substantial ongoing clinical burden.
Collapse
Affiliation(s)
- Xin Wang
- IQVIA, Plymouth Meeting, PA, USA.
| | | | | | | | | |
Collapse
|
24
|
Rahman M, White EM, McGarry BE, Santostefano C, Shewmaker P, Resnik L, Grabowski DC. Association Between the Patient Driven Payment Model and Therapy Utilization and Patient Outcomes in US Skilled Nursing Facilities. JAMA HEALTH FORUM 2022; 3:e214366. [PMID: 35977232 PMCID: PMC8903117 DOI: 10.1001/jamahealthforum.2021.4366] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
Question Was the Patient Driven Payment Model (PDPM), implemented in October 2019, associated with rehabilitation therapy utilization and health outcomes of patients admitted to skilled nursing facilities (SNFs)? Findings In this cross-sectional study of 201 084 patients admitted to an SNF after hip fracture between January 2018 and March 2020, those admitted post-PDPM received about 13% fewer therapy minutes than those admitted pre-PDPM, but the likelihood of rehospitalization and functional scores at discharge remained unchanged. Meaning Implementation of PDPM was associated with a reduction in the volume of therapy use without changes in subsequent hospitalization risk or discharge functional scores. Importance In October 2019, Medicare changed its skilled nursing facility (SNF) reimbursement model to the Patient Driven Payment Model (PDPM), which has modified financial incentives for SNFs that may relate to therapy use and health outcomes. Objective To assess whether implementation of the PDPM was associated with changes in therapy utilization or health outcomes. Design, Setting, and Participants This cross-sectional study used a regression discontinuity (RD) approach among Medicare fee-for-service postacute-care patients admitted to a Medicare-certified SNF following hip fracture between January 2018 and March 2020. Exposures Skilled nursing facility admission after PDPM implementation. Main Outcomes and Measures Main outcomes were individual and nonindividual (concurrent and group) therapy minutes per day, hospitalization within 40 days of SNF admission, SNF length of stay longer than 40 days, and discharge activities of daily living score. Results The study cohort included 201 084 postacute-care patients (mean [SD] age, 83.8 [8.3] years; 143 830 women [71.5%]; 185 854 White patients [92.4%]); 147 711 were admitted pre-PDPM, and 53 373 were admitted post-PDPM. A decrease in individual therapy (RD estimate: −15.9 minutes per day; 95% CI, −16.9 to −14.6) and an increase in nonindividual therapy (RD estimate: 3.6 minutes per day; 95% CI, 3.4 to 3.8) were observed. Total therapy use in the first week following admission was about 12 minutes per day (95% CI, −13.3 to −11.3) (approximately 13%) lower for residents admitted post-PDPM vs pre-PDPM. No consistent and statistically significant discontinuity in hospital readmission (0.31 percentage point increase; 95% CI, −1.46 to 2.09), SNF length of stay (2.7 percentage point decrease in likelihood of staying longer than 40 days; 95% CI, −4.83 to −0.54), or functional score at discharge (0.04 point increase in activities of daily living score; 95% CI, −0.19 to 0.26) was observed. Nonindividual therapy minutes were reduced to nearly zero in late March 2020, likely owing to COVID-19–related restrictions on communal activities in SNFs. Conclusions and Relevance In this cross-sectional study of SNF admission after PDPM implementation, a reduction of total therapy minutes was observed following the implementation of PDPM, even though PDPM was designed to be budget neutral. No significant changes in postacute outcomes were observed. Further study is needed to understand whether the PDPM is associated with successful discharge outcomes.
Collapse
Affiliation(s)
- Momotazur Rahman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Elizabeth M. White
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Brian E. McGarry
- Department of Medicine, University of Rochester, Rochester, New York
| | - Christopher Santostefano
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Peter Shewmaker
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Linda Resnik
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
25
|
Casebeer AW, Ronning D, Schwartz R, Long C, Bhattacharya R, Uribe C, Brown CR, Cameron J, Painter P, Sharma A, Spitale S, Powers B, Stemple C, Shrank W. A Comparison of Home Health Utilization, Outcomes, and Cost Between Medicare Advantage and Traditional Medicare. Med Care 2022; 60:66-74. [PMID: 34739413 DOI: 10.1097/mlr.0000000000001661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Home health use is rising rapidly in the United States as the population ages, the prevalence of chronic disease increases, and older Americans express their desire to age at home. Enrollment in Medicare Advantage (MA) plans rather than Traditional Medicare (TM) has grown as well, from 13% of total Medicare enrollment in 2004 to 39% in 2020. Despite these shifts, little is known about outcomes and costs following home health in MA as compared with TM. OBJECTIVE The objective of this study was to measure the association of MA enrollment with outcomes and costs for patients using home health. DESIGN This was a retrospective cohort study. PARTICIPANTS Patients enrolled in plans offered by 1 large, national MA organization and patients enrolled in TM, with at least 1 home health visit between January 1, 2017, and June 30, 2018. EXPOSURE MA enrollment. MAIN MEASURES We compared the intensity of home health services and types of care delivered. The main outcome measures were hospitalization, the proportion of days in the home, and total allowed costs during the 180-day period following the first qualifying home health visit during the study period. KEY RESULTS Among patients who used home health, our models demonstrated enrollment in MA was associated with 14%, and 6% decreased odds of 60- and 180-day hospitalization, respectively, a 12.8% and 14.7% decrease in medical costs exclusive and inclusive of home health costs, respectively, and a 0.27% increase in the proportion of days at home during the 180-day follow-up, equivalent to an additional half-day at home. There were few differences in home health care delivered for MA and TM [mean number of visits in the first episode of care (17.1 vs. 17.3) and mean visits per week (3.2 vs. 3.3)]. The mean number of visits by visit type and percent of patients with each type was similar between MA and TM as well. CONCLUSIONS Compared with enrollment in TM, enrollment in MA was associated with improved patient-centered outcomes and lower cost and utilization, despite few differences in the way home health was delivered. These findings might be explained by structural components of MA that encourage better care management, but further investigation is needed to clarify the mechanisms by which MA enrollment may lead to higher value home health care.
Collapse
|
26
|
Sood N, Yang Z, Huckfeldt P, Escarce J, Popescu I, Nuckols T. Geographic Variation in Medicare Fee-for-Service Health Care Expenditures Before and After the Passage of the Affordable Care Act. JAMA HEALTH FORUM 2021; 2:e214122. [PMID: 35977300 PMCID: PMC8796890 DOI: 10.1001/jamahealthforum.2021.4122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/18/2021] [Indexed: 12/01/2022] Open
Abstract
Question Which categories of spending were associated with reductions in geographic variation of Medicare per-beneficiary spending across the US after the passage of the Affordable Care Act? Findings In this cross-sectional study of Medicare enrollees aged 65 years or older, geographic variation in Medicare fee-for-service spending per beneficiary was stable from 2007 to 2011 and then declined steadily from 2012 to 2018. A key factor associated with reduced geographic variation in spending was reduced variation in postacute care spending, specifically home health spending. Meaning These findings suggest that antifraud enforcement efforts and payment reforms that were instituted as part of the Affordable Care Act may have reduced geographic variation in Medicare fee-for-service per-beneficiary spending, although significant geographic variation remains. Importance Geographic variation in Medicare spending is often used as a measure of wasteful spending. A 2013 Institute of Medicine report found that postacute care was a key contributor of geographic variation from 2007 to 2009. However, payment reforms and antifraud efforts implemented after the passage of the Affordable Care Act (ACA) may have reduced geographic variation in spending, especially postacute care spending. Objective To investigate how geographic variation in Medicare fee-for-service per-beneficiary spending changed from 2007 to 2018 before and after passage of the ACA. Design, Setting, and Participants This cross-sectional study included all fee-for-service Medicare enrollees 65 years or older from January 1, 2007, to December 31, 2018. The fee-for-service Medicare Geographic Variation Public Use File was used to group hospital referral regions (HRRs) in each year into deciles (10 equal groups) based on per-beneficiary total spending. The difference between the per-beneficiary monthly spending in each decile and the national mean, as well as the ratio of per-beneficiary total spending in the top deciles to that of the bottom decile, were reported. Data analysis occurred from July 22, 2019, to October 21, 2021. Main Outcomes and Measures Per-beneficiary spending on hospital inpatient, hospital outpatient, physician, and postacute care (and type of postacute care). Results There were 27.2 million fee-for-service beneficiaries in 2007 (58.0% women) and 28.3 million beneficiaries in 2018 (55.9% women). Per-beneficiary Medicare spending was $9691 in 2007 and $9847 in 2018 (using inflation-adjusted 2018 dollars). Geographic variation in Medicare spending was stable from 2007 to 2011 and then declined steadily from 2012 to 2018. The ratio of per-beneficiary total Medicare spending in the HRRs in the top decile to the bottom decile was 1.68 in 2007 ($415 monthly difference in spending) but only 1.56 ($361 monthly difference in spending) in 2018 (estimated change, −0.12 [95% CI, −0.21 to −0.02]; P = .01). Focusing on specific spending categories, the only statistically significant reductions in geographic variation were found for home health; the ratio of home health spending among HRRs in the top to bottom deciles of total Medicare spending fell from 5.14 in 2007 to 3.45 in 2018 (change, −1.69 [95% CI, −3.30 to −0.09]; P = .04). Conclusions and Relevance Geographic variation in total per-beneficiary Medicare spending fell from 2007 to 2018, with home health spending being a key factor associated with geographic variation. The ACA’s value-based payment programs and enhanced integrity efforts in home health provide a possible explanation for the decrease.
Collapse
Affiliation(s)
- Neeraj Sood
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Zhiyou Yang
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston
| | - Peter Huckfeldt
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - José Escarce
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA (University of California, Los Angeles)
- Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Ioana Popescu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA (University of California, Los Angeles)
| | - Teryl Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| |
Collapse
|
27
|
Lee C, McConnell ES, Wei S, Xue TM, Tsumura H, Pan W. Effect of Race/ethnicity, Insurance Status, and Area Deprivation on Hip Fracture Outcomes Among Older Adults in the United States. Clin Nurs Res 2021; 31:541-552. [PMID: 34814771 DOI: 10.1177/10547738211061216] [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: 11/17/2022]
Abstract
This retrospective cohort study used electronic health records to explore the effect of race/ethnicity, insurance status, and area deprivation on post-discharge outcomes in older patients undergoing hip fracture surgery between 2015 and 2018 (N = 1,150). Inverse probability of treatment weight-adjusted regression analysis was used to identify the effects of the predictors on outcomes. White patients had higher 90- and 365-day readmission risks than Black patients and higher all-period readmissions than the Other racial/ethnic (Hispanic, Asian, American Indian, and Multicultural) group (p < .000). Black patients had a higher risk of 30- and 90-day readmission than the Other racial/ethnic group (p < .000). Readmission risk across 1-year follow-up was generally higher among patients from less deprived areas than more deprived areas (p < .05). The 90- and 365-day mortality risk was lower for patients from less deprived areas (vs. more deprived areas) and patients with Medicare Advantage (vs. Medicare), respectively (p < .05). Our findings can guide efforts to identify patients for additional post-discharge support. Nevertheless, the findings regarding readmission risks contrast with previous knowledge and thus require more validation studies.
Collapse
Affiliation(s)
| | - Eleanor Schildwachter McConnell
- Duke University, Durham, NC, USA.,Duke Center for the Study of Aging and Human Development, Durham, NC, USA.,Durham Veterans Affairs Healthcare System, NC, USA
| | | | | | | | - Wei Pan
- Duke University, Durham, NC, USA
| |
Collapse
|
28
|
Shorter acute hospital length of stay in hip fracture patients after surgery predicted by early surgery and mobilization. Arch Osteoporos 2021; 16:162. [PMID: 34718871 DOI: 10.1007/s11657-021-01027-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/18/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Time to surgery, early mobilization, fracture type, and ASA grades independently affect acute hospital length of stay after hip fracture surgery. Modifiable factors can be audited to reduce length of stay, and non-modifiable factors can be used for consideration of a tiered bundled payment reimbursement model. INTRODUCTION As hip fracture incidence rises with our ageing global population, there will be an increase in consumption of healthcare resources. We hypothesized that hospital management and patient factors can affect healthcare burden load. Using length of stay (LOS) as a surrogate for consumption, the aim of this study is to elucidate the effect of hospital management and patient-related factors on length of stay (LOS) for patients after hip fracture surgery. We studied modifiable and non-modifiable factors influencing LOS, and identification of these modifiable factors accords opportunities for mitigating these factors. METHODS This retrospective study examines hip fracture data from a large tertiary hospital in Singapore over the period of 2017 to 2020. Data collected on the electronic medical record included age, gender, race, marital status, payer type, ASA score, TTS, type of surgery, fracture type, POD1 mobilization, discharge position, and presence of pressure sores, and they were correlated with LOS using binary logistic regression on SAS. RESULTS A total of 1045 patients were included in this study with 704 females and 341 males. The mean age was 79.5 ± 8.57 years (range 60-105) with an average LOS 13.64 ± 10.0 days (range 2-114). On binary logistic regression, ASA and trochanteric fracture remains a significant non-modifiable factor for LOS with OR = 1.486 (95% CI 1.106, 1.996, p = 0.0086) and OR 1.522 (95% CI 1.149, 2.015, p = 0.0034) respectively. Significant modifiable factors were TTS > 48 h (OR = 1.819, 95% CI 1.205, 2.746, p = 0.0044) and POD1 mobilization (OR = 0.441, 95% CI 0.257, 0.756, p = 0.0029). CONCLUSIONS Our analysis showed TTS and POD1 are significant modifiable factors for LOS, and resources can be diverted towards them for the management of hip fracture patients and pre-empting the increasing load on our healthcare system.
Collapse
|
29
|
Jordan N, Deutsch A. Why and How to Demonstrate the Value of Rehabilitation Services. Arch Phys Med Rehabil 2021; 103:S172-S177. [PMID: 34407445 DOI: 10.1016/j.apmr.2021.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/29/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022]
Abstract
The health care delivery landscape in the United States is changing as payment models consider both costs and health outcomes, which are key components of value in health care. Without evidence about the effectiveness and costs of rehabilitation interventions, it is difficult to judge the value of rehabilitation interventions. Understanding the short- and long-term costs associated with implementing a rehabilitation intervention and the intervention's cost-effectiveness compared with other alternatives is critical to supporting decision-making by policymakers, health care administrators, and other decision makers. This article describes the policy context for considering the costs and outcomes of postacute care and rehabilitation interventions, introduces methods for assessing the value of rehabilitation interventions, and summarizes the challenges and opportunities associated with applying value measurement to rehabilitation services. Assessing the value of rehabilitation interventions is critical as we continue to identify, implement, and sustain evidence-based interventions that promote the health and function of people with disabilities.
Collapse
Affiliation(s)
- Neil Jordan
- Northwestern University Feinberg School of Medicine, Chicago, IL; Edward J Hines Jr Hospital VA, Hines, IL.
| | - Anne Deutsch
- Northwestern University Feinberg School of Medicine, Chicago, IL; Shirley Ryan AbilityLab, Chicago, IL; RTI International, Chicago, IL
| |
Collapse
|
30
|
Comparing Receipt of Prescribed Post-acute Home Health Care Between Medicare Advantage and Traditional Medicare Beneficiaries: an Observational Study. J Gen Intern Med 2021; 36:2323-2331. [PMID: 33051838 PMCID: PMC8342740 DOI: 10.1007/s11606-020-06282-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Medicare Advantage (MA) covers more than 1/3rd of all Medicare beneficiaries. MA plans are required to provide the same benefits as Traditional Medicare (TM), but can impose utilization management tools to control costs. OBJECTIVE To assess differences between TM and MA enrollees in the probability of receiving prescribed post-acute home health (HH) care and to describe MA plan characteristics associated with HH receipt. DESIGN Retrospective cross-sectional analysis of claims data, HH patient assessment data, and MA plan data from 2011 to 2017. PARTICIPANTS Medicare beneficiaries aged 66 and older with an incident hospitalization for joint replacement, pneumonia, chronic obstructive pulmonary disease, stroke, urinary tract infection, septicemia, acute renal failure, or congestive heart failure. MAIN MEASURES Receipt of prescribed HH as indicated by a HH discharge code and corresponding HH patient assessment within 14 days of hospital discharge. KEY RESULTS There were 2,723,245 beneficiaries prescribed HH at discharge (68% TM, 32% MA). About 75% of TM enrollees and 62% of MA enrollees received prescribed post-acute HH. In adjusted analyses, MA enrollees had an -11.7 percentage point (pp) (95% confidence interval (CI): -16.8, -6.5) lower probability of receiving HH compared with TM enrollees. In adjusted analyses, HMO enrollees in plans with cost sharing (- 8.4 pp; 95% CI: - 14.3, - 2.5), referrals (- 3.7 pp; 95% CI: - 6.1, - 1.2), and pre-authorization (- 5.1 pp; 95% CI: - 8.3, - 2.0) were less likely to receive prescribed HH. In adjusted analyses, PPO enrollees in plans with cost sharing were -7.0 pp (95% CI: - 12.7, - 1.4) less likely to receive HH, but there was no difference for those with referrals (1.1 pp; 95% CI, - 1.5, 3.7) or pre-authorization (1.6 pp; 95% CI: - 0.6, - 3.9). CONCLUSIONS Among Medicare beneficiaries, MA enrollees were less likely to receive prescribed post-acute HH compared with TM. As enrollment in MA continues to grow, it is important to examine how differences in utilization relate to outcomes.
Collapse
|
31
|
Agarwal R, Connolly J, Gupta S, Navathe AS. Comparing Medicare Advantage And Traditional Medicare: A Systematic Review. Health Aff (Millwood) 2021; 40:937-944. [PMID: 34097516 DOI: 10.1377/hlthaff.2020.02149] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare Advantage enrollment has almost doubled since 2010 and now accounts for more than a third of all Medicare beneficiaries. We performed a systematic review to compare Medicare Advantage and traditional Medicare on key metrics. Evidence from forty-eight studies showed that in most or all comparisons, Medicare Advantage was associated with more preventive care visits, fewer hospital admissions and emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending. Medicare Advantage outperformed traditional Medicare in most studies comparing quality-of-care metrics. However, the evidence on patient experience, readmission rates, mortality, and racial/ethnic disparities did not show a trend of better performance in Medicare Advantage. Evidence to date might not fully account for selection bias, unobserved differences in social determinants of health, or risk adjustment challenges, in part because of differences in data quality that limit the comparability of outcomes between Medicare Advantage and traditional Medicare. With Medicare Advantage plans expected to grow in popularity, policy makers should support policies to improve data completeness and comparability, and health plans should focus on improving patient experience.
Collapse
Affiliation(s)
- Rajender Agarwal
- Rajender Agarwal is director of the Center for Health Reform, in Southlake, Texas
| | - John Connolly
- John Connolly is a medical student in the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, in Philadelphia, Pennsylvania
| | - Shweta Gupta
- Shweta Gupta is the fellowship director of the Oncology Program, Department of Medicine, John H. Stroger Jr. Hospital of Cook County, in Chicago, Illinois
| | - Amol S Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center; an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine; and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, all in Philadelphia
| |
Collapse
|
32
|
Gustavson AM, LeDoux CV, Stutzbach JA, Miller MJ, Seidler KJ, Stevens-Lapsley JE. Mixed-Methods Approach to Understanding Determinants of Practice Change in Skilled Nursing Facility Rehabilitation: Adapting to and Sustaining Value With Postacute Reform. J Geriatr Phys Ther 2021; 44:108-118. [PMID: 33534337 PMCID: PMC8869848 DOI: 10.1519/jpt.0000000000000288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Postacute care reform is driving physical and occupational therapists in skilled nursing facilities (SNFs) to change how they deliver care to produce better outcomes in less time. However, gaps exist in understanding determinants of practice change, which limits translation of evidence into practice. This study explored what determinants impacted change in care delivery at 2 SNFs that implemented a high-intensity resistance training intervention. METHODS We used a mixed-methods, sequential explanatory design to explain quantitative findings using qualitative methods with a multiple-case study approach. Quantitative data were collected on therapists' attitudes toward evidence-based practice and aspects of intervention implementation. We conducted focus groups with therapists (N = 15) at 2 SNFs, classified as either high- (SNF-H) or low-performing (SNF-L) based on implementation fidelity and sustainability. RESULTS AND DISCUSSION Determinants of SNF rehabilitation practice change included the organizational system, team dynamics, patient and therapist self-efficacy, perceptions of intervention effectiveness, and ability to overcome preconceived notions. A patient-centered system, positive team dynamics, and ability to overcome preconceived notions fostered practice change at SNF-H. While self-efficacy and perception of effectiveness positively impacted change in practice at both SNFs, these determinants were not enough to overcome challenges at SNF-L. To adapt to changes and sustain rehabilitation value, further research must identify the combination of determinants that promote application of evidence-based practice. CONCLUSIONS This study is the first step in understanding what drives change in SNF rehabilitation practice. As SNF rehabilitation continues to face changes in health care delivery and reimbursement, therapists will need to adapt, by changing practice patterns and adopting evidence-based approaches, to demonstrate value in postacute care.
Collapse
Affiliation(s)
- Allison M Gustavson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Cherie V LeDoux
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora
| | - Julie A Stutzbach
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora
| | - Matthew J Miller
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco
- Division of Geriatrics, University of California, San Francisco
| | - Katie J Seidler
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora
| |
Collapse
|
33
|
Adrados M, Wang K, Deng Y, Bozzo J, Messina T, Stevens A, Moore A, Morris J, O'Connor MI. A Simple Physical Therapy Algorithm Is Successful in Decreasing Skilled Nursing Facility Length of Stay and Increasing Cost Savings After Hip Fracture With No Increase in Adverse Events. Geriatr Orthop Surg Rehabil 2021; 12:2151459321998615. [PMID: 33815865 PMCID: PMC7995299 DOI: 10.1177/2151459321998615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction: Shorter length of stays (LOS) at a Skilled Nursing Facility (SNF) after hip fracture surgery would be expected to lead to costs savings for the healthcare system. Evidence also suggests that shorter SNF stays also leads to improved 30-day outcomes, thus compounding this value proposition. Our Integrated Fragility Hip Fracture Program created a simple algorithm at discharge to provide each post-operative hip fracture patient with an expected SNF LOS. We studied whether this intervention produced a shorter SNF LOS and other observable short-term outcomes. Methods: We retrospectively reviewed all original Medicare hip fracture patients treated with operative fixation who were admitted to our hospital in 2015, 2017 and 2018. We selected patients who were discharged to a single SNF following hospitalization, and excluded patients with incomplete records. The algorithm for the expected LOS recommendation was based on the degree of assistance the patient needed for ambulation: 7 days (“0-person assist”), 14 days (“1-person assist”), or 21 days (“2-person assist”). We compare the SNF LOS of our hip fracture patient population between those discharged to a program participant, those SNF that agreed to this algorithm, and those discharged to a non-program participant SNF. Results: We identified 246 patients meeting our selection criteria. 69 were discharged to a program participant SNF. Patients discharged to a participant SNF had similar baseline demographics and ASA distributions to those discharged to a non-participant provider. There was a statistically significant difference in length of stay between the groups, with program participant patients spending an average of 23 days at the SNF while the control group spent an average of 31 days. (p < 0.001). Program participant discharges were also associated with additional cost savings. There was no significant difference in ED visits within 90 days of discharge. Discussion: SNF LOS for geriatric hip fractures can be decreased with implementation of a simple physical therapy driven algorithm based on the patient’s ambulatory independence at hospital discharge. Conclusion: This is a simple, yet completely unique program that seems to have increased the value of healthcare provided.
Collapse
Affiliation(s)
- Murillo Adrados
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Kaicheng Wang
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Janis Bozzo
- ITS Analytic Strategy, Yale New Haven Health System, New Haven, CT, USA
| | | | - Amie Stevens
- Grimes Center, Yale New Haven Health System, New Haven, CT, USA
| | - Anne Moore
- Yale New Haven Hospital, New Haven, CT, USA
| | - Jensa Morris
- Hospitalist Service, Yale New Haven Hospital, New Haven, CT, USA
| | - Mary I O'Connor
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
34
|
Keeney T, Kumar A, Erler KS, Karmarkar AM. Making the Case for Patient-Reported Outcome Measures in Big-Data Rehabilitation Research: Implications for Optimizing Patient-Centered Care. Arch Phys Med Rehabil 2021; 103:S140-S145. [PMID: 33548207 DOI: 10.1016/j.apmr.2020.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 11/02/2022]
Abstract
Advances in data science and timely access to health informatics provide a pathway to integrate patient-reported outcome measures (PROMs) into clinical workflows and optimize rehabilitation service delivery. With the shift toward value-based care in the United States health care system, as highlighted by the recent Centers for Medicare and Medicaid Services incentive and penalty programs, it is critical for rehabilitation providers to systematically collect and effectively use PROMs to facilitate evaluation of quality and outcomes within and across health systems. This editorial discusses the potential of PROMs to transform clinical practice, provides examples of health systems using PROMs to guide care, and identifies barriers to aggregating data from PROMs to conduct health services research. The article proposes 2 priority areas to help advance rehabilitation health services research: (1) standardization of collecting PROMs data in electronic health records to facilitate comparing health system performance and quality and (2) increased partnerships between rehabilitation providers, researchers, and payors to accelerate health system learning. As health care reform continues to emphasize value-based payment strategies, it is essential for the field of physical medicine and rehabilitation to be at the forefront of demonstrating its value in the care continuum.
Collapse
Affiliation(s)
- Tamra Keeney
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI; Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA.
| | - Amit Kumar
- Department of Physical Therapy, Northern Arizona University, Flagstaff, AZ
| | - Kimberly S Erler
- Department of Occupation Therapy, MGH Institute of Health Professions, Boston, MA
| | - Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA; Sheltering Arms Institute, Richmond, VA
| |
Collapse
|
35
|
Meyers DJ, Trivedi AN, Wilson IB, Mor V, Rahman M. Higher Medicare Advantage Star Ratings Are Associated With Improvements In Patient Outcomes. Health Aff (Millwood) 2021; 40:243-250. [PMID: 33523734 PMCID: PMC7899034 DOI: 10.1377/hlthaff.2020.00845] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Little is known about how well the Centers for Medicare and Medicaid Services' five-star rating system for the overall quality of Medicare Advantage (MA) contracts captures quality of care. Leveraging contract consolidation as a natural experiment to study the association between outcomes and insurer-initiated enrollee shifts to plans with higher-rated contracts, we found that enrollees experiencing a one-star MA rating increase were 20.8 percent less likely to voluntarily leave their plan to enroll in another plan or traditional Medicare. When hospitalized, they were 3.4 percent more likely to use a higher-quality hospital and 2.6 percent less likely to be readmitted within ninety days. Our findings suggest that MA star ratings may capture key domains of an MA plan's quality; however, the differences in outcomes that they capture might not all be clinically meaningful.
Collapse
Affiliation(s)
- David J Meyers
- David J. Meyers is an assistant professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Amal N Trivedi
- Amal N. Trivedi is a professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health and a research health scientist at the Providence Veterans Affairs (VA) Medical Center, both in Providence
| | - Ira B Wilson
- Ira B. Wilson is a professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health
| | - Vincent Mor
- Vincent Mor is a professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health and a research health scientist at the Providence VA Medical Center
| | - Momotazur Rahman
- Momotazur Rahman is an associate professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
| |
Collapse
|
36
|
Figueroa JF, Wadhera RK, Frakt AB, Fonarow GC, Heidenreich PA, Xu H, Lytle B, DeVore AD, Matsouaka R, Yancy CW, Bhatt DL, Joynt Maddox KE. Quality of Care and Outcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized With Heart Failure. JAMA Cardiol 2020; 5:1349-1357. [PMID: 32876650 DOI: 10.1001/jamacardio.2020.3638] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance Medicare Advantage (MA), a private insurance plan option, now covers one-third of all Medicare beneficiaries. Although patients with cardiovascular disease enrolled in MA have been reported to receive higher quality of care in the ambulatory setting than patients enrolled in fee-for-service (FFS) Medicare, it is unclear whether MA is associated with higher quality in patients hospitalized with heart failure, or alternatively, if incentives to reduce utilization under MA plans may be associated with worse care. Objective To determine whether there are differences in quality of care received and in-hospital outcomes among patients enrolled in MA vs FFS Medicare. Design, Setting, and Participants Observational, retrospective cohort study of patients hospitalized with heart failure in hospitals participating in the Get With the Guidelines-Heart Failure registry. Exposures Medicare Advantage enrollment. Main Outcomes and Measures In-hospital mortality, discharge disposition, length of stay, and 4 heart failure achievement measures. Results Of 262 626 patients hospitalized with heart failure, 93 549 (35.6%) were enrolled in MA and 169 077 (64.4%) in FFS Medicare. The median (interquartile range) age was 78 (70-85) years for patients enrolled in MA and 78 (69-86) years for patients enrolled in FFS Medicare. Standard mean differences in age, sex, prevalence of comorbidities, or objective measures on admission, including vital signs and laboratory values, were less than 10%. After adjustment, there were no statistically significant differences in receipt of evidence-based β-blockers when indicated; angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, or angiotensin receptor-neprilysin inhibitors at discharge; measurement of left ventricular function; and postdischarge appointments by Medicare insurance type. Patients enrolled in MA, however, had higher odds of being discharged directly home (adjusted odds ratio [AOR], 1.16; 95% CI, 1.13-1.19; P < .001) relative to patients enrolled in FFS Medicare and lower odds of being discharged within 4 days (AOR, 0.97; 95% CI, 0.93-1.00; P = .04). There was no significant difference in in-hospital mortality between patients with MA and patients with FFS Medicare (AOR, 0.98; 95% CI, 0.92-1.03; P = .42). Conclusions and Relevance Among patients hospitalized with heart failure, no observable benefit was noted in quality of care or in-hospital mortality between those enrolled in MA vs FFS Medicare, except lower use of post-acute care facilities. As MA continues to grow, it will be important to ensure that participating private plans provide an added value to the patients they cover to justify the higher administrative costs compared with traditional FFS Medicare.
Collapse
Affiliation(s)
- Jose F Figueroa
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Austin B Frakt
- VA Boston Healthcare System, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center.,Section Editor, JAMA Cardiology
| | | | - Haolin Xu
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Barbara Lytle
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Adam D DeVore
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Roland Matsouaka
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Clyde W Yancy
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Deputy Editor, JAMA Cardiology
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.,Center for Health Economics and Policy, Washington University Institute for Public Health, St Louis, Missouri
| |
Collapse
|
37
|
Whitney DG. Nontrauma fracture increases risk for respiratory disease among adults with cerebral palsy. J Orthop Res 2020; 38:2551-2558. [PMID: 32233002 DOI: 10.1002/jor.24675] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 03/25/2020] [Indexed: 02/04/2023]
Abstract
Individuals with cerebral palsy (CP) manifest skeletal fragility problems early in life and are vulnerable to nontrauma fracture (NTFx), which may exacerbate the risk of respiratory disease (RD)- the main cause of premature mortality for this population. The purpose of this study was to determine if adults with CP had a greater 12-month risk of RD post-NTFx compared to adults without CP. Data from 2011 to 2017 were leveraged from Optum Clinformatics Data Mart; a claims database from a single private payer in the United States diagnostic codes were used to identify adults (≥18 years) with and without CP, NTFx, incident RD, and pre-NTFx cardiometabolic diseases. Cox proportional hazards regression models were used to compare 12-month RD incidence following NTFx with adjustment for sociodemographics and cardiometabolic diseases. Mean age (SD) at baseline was 57.5 (18.4) for adults with CP (n = 646) and 61.8 (19.7) for adults without CP (n = 321,482). During the follow-up, 172 adults with CP (26.6%) and 73 937 adults without CP (23.0%) developed RD. Adults with CP had higher 12-month post-NTFx RD incidence compared to adults without CP (hazard ratio [HR] = 1.20; 95% confidence interval [CI] = 1.03-1.37). When stratified by the RD subtype, adults with CP had a higher incidence of pneumonia (HR = 2.15; 95% CI = 1.56-2.95), interstitial/pleura disease (HR = 2.13; 95% CI = 1.53-2.96), and other RD (eg, respiratory failure; HR = 2.33; 95% CI = 1.82-2.98), but not acute respiratory infection (HR = 0.93; 95% CI = 0.75-1.15) or chronic obstructive pulmonary disease (HR = 1.15; 95% CI = 0.86-1.53). Among privately insured adults with CP, NTFx is associated with greater risk of RD among adults with vs without CP.
Collapse
Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
38
|
Park S, Larson EB, Fishman P, White L, Coe NB. Differences in Health Care Utilization, Process of Diabetes Care, Care Satisfaction, and Health Status in Patients With Diabetes in Medicare Advantage Versus Traditional Medicare. Med Care 2020; 58:1004-1012. [PMID: 32925471 PMCID: PMC7572707 DOI: 10.1097/mlr.0000000000001390] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective of this study was to determine differences in health care utilization, process of diabetes care, care satisfaction, and health status for Medicare Advantage (MA) and traditional Medicare (TM) beneficiaries with and without diabetes. METHODS Using the 2010-2016 Medicare Current Beneficiary Survey, we identified MA and TM beneficiaries with and without diabetes. To address the endogenous plan choice between MA and TM, we used an instrumental variable approach. Using marginal effects, we estimated differences in the outcomes between MA and TM beneficiaries with and without diabetes. RESULTS Our instrumental variable analysis showed that compared with TM beneficiaries with diabetes, MA beneficiaries with diabetes had less annual health care utilization, including -22.4 medical provider visits [95% confidence interval (CI): -23.6 to -21.1] and -3.4 outpatient hospital visits (95% CI: -3.8 to -3.0). A significant difference between MA and TM beneficiaries without diabetes was only observed in medical provider visits and the difference was greater among beneficiaries with diabetes than beneficiaries without diabetes (-12.5 medical provider visits; 95% CI: -15.9 to -9.2). While we did not detect significant differences in 5 measures of the process of diabetes care between MA and TM beneficiaries with diabetes, there were inconsistent results in the other 3 measures. There were no or marginal differences in care satisfaction and health status between MA and TM beneficiaries with and without diabetes. CONCLUSIONS MA enrollment was associated with lower health care utilization without compromising care satisfaction and health status, particularly for beneficiaries with diabetes. MA may have a more efficient care delivery system for beneficiaries with diabetes.
Collapse
Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington
| | | | - Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
39
|
Whitney DG, Bell S, Hurvitz EA, Peterson MD, Caird MS, Jepsen KJ. The mortality burden of non-trauma fracture for adults with cerebral palsy. Bone Rep 2020; 13:100725. [PMID: 33088868 PMCID: PMC7560646 DOI: 10.1016/j.bonr.2020.100725] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/14/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022] Open
Abstract
Background Individuals with cerebral palsy (CP) manifest skeletal fragility problems early in life, are vulnerable to non-trauma fracture (NTFx), and have a high burden of premature mortality. No studies have examined the contribution of NTFx to mortality among adults with CP. The purpose of this study was to determine if NTFx is a risk factor for mortality among adults with CP and if NTFx exacerbates mortality risk compared to adults without CP. Methods Data from 2011 to 2016 Optum Clinformatics® Data Mart and a random 20% sample Medicare fee-for-service were used for this retrospective cohort study. Diagnosis codes were used to identify adults (18+ years) with and without CP, NTFx, and pre-NTFx comorbidities. Crude mortality rates per 100 person years were estimated. Cox regression estimated hazard ratios (HR and 95% confidence interval [CI]) for mortality, comparing: (1) CP and NTFx (CP + NTFx; n = 1777); (2) CP without NTFx (CP w/o NTFx; n = 12,933); (3) without CP and with NTFx (w/o CP + NTFx; n = 433,560); and (4) without CP and without NTFx (w/o CP w/o NTFx; n = 6.8 M) after adjusting for demographics and pre-NTFx comorbidities. Results The 3-, 6-, and 12-month crude mortality rates were highest among CP + NTFx (12-month mortality rate = 6.80), followed by w/o CP + NTFx (12-month mortality rate = 4.91), CP w/o NTFx (12-month mortality rate = 2.15), and w/o CP w/o NTFx (12-month mortality rate = 0.49). After adjustments, the mortality rate was elevated for CP + NTFx for all time points compared to CP w/o NTFx (e.g., 12-month HR = 1.61; 95%CI = 1.29–2.01), w/o CP + NTFx (e.g., 12-month HR = 1.49; 95%CI = 1.24–1.80), and w/o CP w/o NTFx (e.g., 12-month HR = 5.33; 95%CI = 4.42–6.44). There were site-specific effects (vertebral column, lower extremities) on 12-month mortality. Conclusions NTFx is associated with an increase of 12-month mortality risk among adults with CP and compared to adults without CP. Findings suggest that NTFx may be a robust risk factor for mortality among adults with CP.
Collapse
Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E. Eisenhower, Ann Arbor, MI 48108, United States of America.,Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Rd., Ann Arbor, MI 48109, United States of America
| | - Sarah Bell
- Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E. Eisenhower, Ann Arbor, MI 48108, United States of America
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E. Eisenhower, Ann Arbor, MI 48108, United States of America
| | - Mark D Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E. Eisenhower, Ann Arbor, MI 48108, United States of America.,Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Rd., Ann Arbor, MI 48109, United States of America
| | - Michelle S Caird
- Department of Orthopaedic Surgery, University of Michigan, 1540 E Hospital Dr., Ann Arbor, MI 48109, United States of America
| | - Karl J Jepsen
- Department of Orthopaedic Surgery, University of Michigan, 1540 E Hospital Dr., Ann Arbor, MI 48109, United States of America
| |
Collapse
|
40
|
Risk for respiratory and cardiovascular disease and mortality after non-trauma fracture and the mediating effects of respiratory and cardiovascular disease on mortality risk among adults with epilepsy. Epilepsy Res 2020; 166:106411. [DOI: 10.1016/j.eplepsyres.2020.106411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 12/29/2022]
|
41
|
Temkin-Greener H, Wang S, Caprio T, Mukamel DB, Cai S. Obesity among Nursing Home Residents: Association with Potentially Avoidable Hospitalizations. J Am Med Dir Assoc 2020; 21:1331-1335.e1. [PMID: 32631800 PMCID: PMC7483884 DOI: 10.1016/j.jamda.2020.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES Studies show that in nursing homes (NHs), the prevalence of moderate-to-severe obesity has doubled in the last decade and continues to increase. Obese residents are often complex and costly, and this increase in prevalence has come at a time when NHs struggle to decrease hospitalizations, particularly those that are potentially avoidable. This study examined the association between obesity and hospitalizations. DESIGN We linked 2011-2014 national data using Medicare NH assessments, hospital claims, and the NH Compare. SETTING AND PARTICIPANTS Individuals aged ≥65 years, newly admitted to NHs, who became long-term residents between July 1, 2011 and March 26, 2014. The analytical sample included 490,086 residents. METHODS NH-originating hospitalization was the outcome; a categorical variable defined as no hospitalization, potentially avoidable hospitalization (PAH), and other hospitalization (non-PAH). The main independent variable was body mass index (BMI) defined as normal weight (30 >BMI ≥18.5 kg/m2), mildly obese (35 >BMI ≥30 kg/m2), or moderately-to-severely obese (BMI ≥35 kg/m2). Covariates included individual and NH characteristics. Multinomial models with NH random effects and state dummies were estimated. RESULTS After adjusting for individual level covariates, the risk of non-PAH for the mildly and moderate/severely obese was not different from normal weight residents. But the risk of PAH remained significantly higher for the moderate/severely obese (relative risk ratio = 1.055; 95% confidence interval 1.018, 1.094). Several NH-level factors also influenced hospitalization risk. CONCLUSIONS AND IMPLICATIONS Obese residents are more likely to experience PAH but not non-PAH. Efforts to improve care for these residents may need to broadly consider the ability of NHs to commit additional resources to fully integrate care for this growing segment of the population.
Collapse
Affiliation(s)
- Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry. Rochester, NY.
| | - Sijiu Wang
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry. Rochester, NY
| | - Thomas Caprio
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Dana B Mukamel
- Department of Medicine, Director, iTEQC Research Program, University of California at Irvine, Irvine, CA
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry. Rochester, NY
| |
Collapse
|
42
|
Berry SD, Daiello LA, Lee Y, Zullo AR, Wright NC, Curtis JR, Kiel DP. Secular Trends in the Incidence of Hip Fracture Among Nursing Home Residents. J Bone Miner Res 2020; 35:1668-1675. [PMID: 32302028 PMCID: PMC7486242 DOI: 10.1002/jbmr.4032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 03/28/2020] [Accepted: 04/13/2020] [Indexed: 12/30/2022]
Abstract
A recent study suggested a decline in the incidence of hip fracture among US women between 2002 and 2012, followed by a leveling in the incidence rate from 2013 to 2015. Newly admitted nursing home residents are particularly vulnerable to hip fracture, and it is unclear whether that trend is observed in this high risk group. The purpose of our study was to describe trends in hip fracture rates and postfracture mortality among 2.6 million newly admitted US nursing home residents from 2007 to 2015, and to examine whether these trends could be explained by differences in resident characteristics. Medicare claims data were linked with the Minimum Data Set (MDS), a clinical assessment performed quarterly on all nursing home residents. In each year (2007-2015), we identified newly admitted long-stay (ie, 100 days in the same facility) nursing home residents. Hip fracture was defined using Medicare Part A diagnostic codes. Follow-up time was calculated from the index date until the first event of hospitalized hip fracture, Medicare disenrollment, death, or until 1 year. Poisson regression was used to adjust rates of hip fracture for age and sex. The number of newly admitted nursing home residents ranged from 324,508 in 2007 to 257,350 in 2015. Although mean age remained similar (83 years), residents were more functionally dependent over time. There was a small absolute decrease in the incidence rate of hip fracture between 2007 (3.32/100 person-years) and 2013 (2.82/100 person-years), with an increase again in 2015 (3.03/100 person-years). Adjusting for patient characteristics somewhat attenuated these trends. One-year mortality was high following fracture in all years (42.6% in 2007, 42.1% in 2014). In summary, we observed a recent slight rise in the incidence rates of hip fracture among nursing home residents that was at least partially explained by differences in resident characteristics over time. © 2020 American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| | - Lori A Daiello
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Nicole C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey R Curtis
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Douglas P Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| |
Collapse
|
43
|
Einav L, Finkelstein A, Ji Y, Mahoney N. Randomized trial shows healthcare payment reform has equal-sized spillover effects on patients not targeted by reform. Proc Natl Acad Sci U S A 2020; 117:18939-18947. [PMID: 32719129 PMCID: PMC7431052 DOI: 10.1073/pnas.2004759117] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Changes in the way health insurers pay healthcare providers may not only directly affect the insurer's patients but may also affect patients covered by other insurers. We provide evidence of such spillovers in the context of a nationwide Medicare bundled payment reform that was implemented in some areas of the country but not in others, via random assignment. We estimate that the payment reform-which targeted traditional Medicare patients-had effects of similar magnitude on the healthcare experience of nontargeted, privately insured Medicare Advantage patients. We discuss the implications of these findings for estimates of the impact of healthcare payment reforms and more generally for the design of healthcare policy.
Collapse
Affiliation(s)
- Liran Einav
- Department of Economics, Stanford University, Stanford, CA 94305
- National Bureau of Economic Research, Cambridge, MA 02138
| | - Amy Finkelstein
- National Bureau of Economic Research, Cambridge, MA 02138;
- Department of Economics, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Yunan Ji
- Graduate School of Arts and Sciences, Harvard University, Cambridge, MA 02138
| | - Neale Mahoney
- Department of Economics, Stanford University, Stanford, CA 94305
- National Bureau of Economic Research, Cambridge, MA 02138
| |
Collapse
|
44
|
Zhu Y, Wang Z, Zhou Y, Onoda K, Maruyama H, Hu C, Liu Z. Summary of respiratory rehabilitation and physical therapy guidelines for patients with COVID-19 based on recommendations of World Confederation for Physical Therapy and National Association of Physical Therapy. J Phys Ther Sci 2020; 32:545-549. [PMID: 32884178 PMCID: PMC7443542 DOI: 10.1589/jpts.32.545] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/05/2020] [Indexed: 01/10/2023] Open
Abstract
[Purpose] To summarize the existing official guidelines issued by the World Confederation for Physical Therapy and Associations of Physical Therapy in various countries and to clarify the recommended methods of respiratory rehabilitation and physiotherapy for patients in different stages of the coronavirus disease of 2019 (COVID-19). [Methods] An introductory literature search was conducted using the keywords “COVID-19”, “respiratory rehabilitation”, “physical therapy”, and others in the database of the Association of Physical Therapy. [Results] Using 12 coronavirus disease-2019 rehabilitation-related articles, we summarized data on physical therapy (PT) evaluation; treatment; indications; contraindications; and termination indicators for patients in acute, stable, and post-discharge stages. [Conclusion] PT for COVID-19 patients with coronavirus disease 2019 should be formulated according to the stage of the disease and condition of the patients.
Collapse
Affiliation(s)
- Yuetong Zhu
- Graduate School of Health and Welfare Sciences, International University of Health and Welfare: 2600-1 Kitakanemaru, Ohtawara-shi, Tochigi 324-8501, Japan
| | - Zimin Wang
- Graduate School of Health and Welfare Sciences, International University of Health and Welfare: 2600-1 Kitakanemaru, Ohtawara-shi, Tochigi 324-8501, Japan
| | - Yue Zhou
- School of Rehabilitation Medicine, Capital Medical University, China
| | - Ko Onoda
- Graduate School of Health and Welfare Sciences, International University of Health and Welfare: 2600-1 Kitakanemaru, Ohtawara-shi, Tochigi 324-8501, Japan
| | - Hitoshi Maruyama
- Graduate School of Health and Welfare Sciences, International University of Health and Welfare: 2600-1 Kitakanemaru, Ohtawara-shi, Tochigi 324-8501, Japan
| | - Chunying Hu
- School of Rehabilitation Medicine, Capital Medical University, China
| | - Zun Liu
- CangZhou Medical College, China
| |
Collapse
|
45
|
Gustavson AM, Malone DJ, Boxer RS, Forster JE, Stevens-Lapsley JE. Application of High-Intensity Functional Resistance Training in a Skilled Nursing Facility: An Implementation Study. Phys Ther 2020; 100:1746-1758. [PMID: 32750132 PMCID: PMC7530575 DOI: 10.1093/ptj/pzaa126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 08/20/2019] [Accepted: 04/24/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Rehabilitation in skilled nursing facilities (SNFs) is under scrutiny to deliver high-quality care and superior outcomes in less time. High-intensity resistance training demonstrates functional improvements in community-dwelling and long-term care populations but has not been generalized to the SNF population. The purpose of this study was to evaluate implementation issues including safety and feasibility and to provide preliminary information on effectiveness of rehabilitation focused on high-intensity functional resistance training in an SNF. METHODS The implementation study design consisted of 2 nonrandomized independent groups (usual care and high intensity) that were staged within a single SNF. The i-STRONGER program (IntenSive Therapeutic Rehabilitation for Older Skilled NursinG HomE Residents) integrates principles of physiologic tissue overload into rehabilitation. Physical therapists administered the Short Physical Performance Battery and gait speed at evaluation and discharge. Reach, Effectiveness, Adoption, Implementation, and Maintenance was used to evaluate the implementation process. An observational checklist and documentation audits were used to assess treatment fidelity. Regression analyses evaluated the response of functional change by group. RESULTS No treatment-specific adverse events were reported. Treatment fidelity was high at >99%, whereas documentation varied from 21% to 50%. Patient satisfaction was greater in i-STRONGER, and patient refusals to participate in therapy sessions trended downward in i-STRONGER. Patients in i-STRONGER exhibited a 0.13 m/s greater change in gait speed than in the usual care group. Although not significant, i-STRONGER resulted in a 0.64-point greater change in the Short Physical Performance Battery than usual care, and average SNF length of stay was 3.5 days shorter for i-STRONGER patients. CONCLUSION The findings from this study indicate that implementation of a high-intensity resistance training framework in SNFs is safe and feasible. Furthermore, results support a signal effectiveness of improving function and satisfaction, although the heterogeneity of the population necessitates a larger implementation study to confirm. IMPACT STATEMENT This pragmatic study demonstrates that high-intensity resistance training in medically complex older adults is safe and favorable in SNFs. This work supports the need to fundamentally change the intensity of rehabilitation provided to this population to promote greater value within post-acute care. Furthermore, this study supports the application of implementation science to rehabilitation for rapid and effective translation of evidence into practice.
Collapse
Affiliation(s)
- Allison M Gustavson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado
| | - Daniel J Malone
- CCS, Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, and Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado
| | - Jeri E Forster
- Rocky Mountain Regional Veterans Affairs Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora; Department of Physical Medicine and Rehabilitation, University of Colorado; and Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | | |
Collapse
|
46
|
Chang CH, Mainor A, Colla C, Bynum J. Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations. J Am Med Dir Assoc 2020; 22:406-412. [PMID: 32693998 DOI: 10.1016/j.jamda.2020.05.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Nursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use. DESIGN Observational propensity-matched study. SETTING AND PARTICIPANTS Medicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration. METHODS ACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending. RESULTS Nearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents' attribution status switched (14.6%), either into or out of an ACO. CONCLUSIONS AND IMPLICATIONS ACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.
Collapse
Affiliation(s)
- Chiang-Hua Chang
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
| | - Alexander Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Carrie Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Julie Bynum
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| |
Collapse
|
47
|
Reyes BJ, Mendelson DA, Mujahid N, Mears SC, Gleason L, Mangione KK, Nana A, Mijares M, Ouslander JG. Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society. Geriatr Orthop Surg Rehabil 2020; 11:2151459320935100. [PMID: 32728485 PMCID: PMC7366407 DOI: 10.1177/2151459320935100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities. METHODOLOGY A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS. RESULTS/CONCLUSION A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.
Collapse
Affiliation(s)
- Bernardo J. Reyes
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | | | - Nadia Mujahid
- Warren Alpert School of Brown University, Rhode Island, USA
| | | | - Lauren Gleason
- The University of Chicago Medical and Biological Science, IL,
USA
| | | | - Arvind Nana
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | - Maria Mijares
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | | |
Collapse
|
48
|
Jung DH, DuGoff E, Smith M, Palta M, Gilmore-Bykovskyi A, Mullahy J. Likelihood of hospital readmission in Medicare Advantage and Fee-For-Service within same hospital. Health Serv Res 2020; 55:587-595. [PMID: 32608522 DOI: 10.1111/1475-6773.13315] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the extent to which all-cause 30-day readmission rate varies by Medicare program within the same hospitals. STUDY DESIGN We used conditional logistic regression clustered by hospital and generalized estimating equations to compare the odds of unplanned all-cause 30-day readmission between Medicare Fee-for-Service (FFS) and Medicare Advantage (MA). DATA COLLECTION Wisconsin Health Information Organization collects claims data from various payers including private insurance, Medicare, and Medicaid, twice a year. PRINCIPAL FINDINGS For 62 of 66 hospitals, hospital-level readmission rates for MA were lower than those for Medicare FFS. The odds of 30-day readmission in MA were 0.92 times lower than Medicare FFS within the same hospital (odds ratio, 0.93; 95 percent confidence interval, 0.89-0.98). The adjusted overall readmission rates of Medicare FFS and MA were 14.9 percent and 11.9 percent, respectively. CONCLUSION These findings provide additional evidence of potential variations in readmission risk by payer and support the need for improved monitoring systems in hospitals that incorporate payer-specific data. Further research is needed to delineate specific care delivery factors that contribute to differential readmission risk by payer source.
Collapse
Affiliation(s)
- Daniel H Jung
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | - Eva DuGoff
- Health Services Administration, University of Maryland at College Park, College Park, MD
| | - Maureen Smith
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.,Health Innovation Program, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.,Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Mari Palta
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Andrea Gilmore-Bykovskyi
- School of Nursing, University of Wisconsin-Madison, Madison, WI.,William S Middleton Memorial Veterans Hospital, Geriatric Research Education and Clinical Center (GRECC), Madison, WI.,Division of Geriatrics, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - John Mullahy
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| |
Collapse
|
49
|
Artificial Neural Network and Cox Regression Models for Predicting Mortality after Hip Fracture Surgery: A Population-Based Comparison. ACTA ACUST UNITED AC 2020; 56:medicina56050243. [PMID: 32438724 PMCID: PMC7279348 DOI: 10.3390/medicina56050243] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 01/31/2023]
Abstract
This study purposed to validate the accuracy of an artificial neural network (ANN) model for predicting the mortality after hip fracture surgery during the study period, and to compare performance indices between the ANN model and a Cox regression model. A total of 10,534 hip fracture surgery patients during 1996–2010 were recruited in the study. Three datasets were used: a training dataset (n = 7374) was used for model development, a testing dataset (n = 1580) was used for internal validation, and a validation dataset (1580) was used for external validation. Global sensitivity analysis also was performed to evaluate the relative importances of input predictors in the ANN model. Mortality after hip fracture surgery was significantly associated with referral system, age, gender, urbanization of residence area, socioeconomic status, Charlson comorbidity index (CCI) score, intracapsular fracture, hospital volume, and surgeon volume (p < 0.05). For predicting mortality after hip fracture surgery, the ANN model had higher prediction accuracy and overall performance indices compared to the Cox model. Global sensitivity analysis of the ANN model showed that the referral to lower-level medical institutions was the most important variable affecting mortality, followed by surgeon volume, hospital volume, and CCI score. Compared with the Cox regression model, the ANN model was more accurate in predicting postoperative mortality after a hip fracture. The forecasting predictors associated with postoperative mortality identified in this study can also bae used to educate candidates for hip fracture surgery with respect to the course of recovery and health outcomes.
Collapse
|
50
|
Meyers DJ, Mor V, Rahman M. Provider Integrated Medicare Advantage Plans Are Associated With Differences In Patterns Of Inpatient Care. Health Aff (Millwood) 2020; 39:843-851. [PMID: 32364859 DOI: 10.1377/hlthaff.2019.00678] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health systems have increasingly developed integrated Medicare Advantage (MA) plans to align financial incentives and improve coordination of care and services across payer and provider. However, little is known about integrated MA plans' effects on patient outcomes and care processes. We used 2015 MA hospitalization data to assess whether these new models are associated with differences in the processes that take place during hospitalizations and to differences in patient outcomes. We found that enrollees who received care in a fully integrated context were less likely to disenroll from Medicare Advantage or switch MA plans and had marginally lower adjusted mortality rates, compared to enrollees hospitalized in less integrated settings-with no differences in readmissions between the two groups. The fully integrated enrollees also acquired more diagnoses but were less often admitted to the ICU compared to other patients admitted to the same hospitals. As the number of these arrangements continues to grow, the potential advantages of coordination may need to be balanced against the increased cost to Medicare associated with apparently more diagnostic complexity.
Collapse
Affiliation(s)
- David J Meyers
- David J. Meyers ( david_meyers@brown. edu ) is a doctoral candidate in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Vincent Mor
- Vincent Mor is a professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
| | - Momotazur Rahman
- Momotazur Rahman is an associate professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health
| |
Collapse
|