Correlation between hospital finances and quality and safety of patient care

Patient-reported experience is associated with higher future revenue and lower costs of hospitals

BACKGROUND

Despite the established positive association between patient experience and patient volume, the relationship between patient experience and the financial performance of hospitals has not been studied thoroughly.

METHODS

To investigate this relationship, we used longitudinal data from 132 Swiss acute-care hospitals from 2016 to 2019 to examine the associations between patient experience and the proportion of elective patients, revenue, costs, and profits of hospitals. To account for a potential time lag effect, we utilized annual patient experience data and employed multilevel mixed-effects regression modeling to investigate its association with the aforementioned financial performance indicators for the following year.

RESULTS

Data for private and public hospitals were analyzed both separately and in combination, to account for the different proportions of elective patients in these types of hospitals. The resulting mixed models, revealed that for each year studied, the previous year's patient experience was positively associated with the current year's proportion of elective patients (β = 0.09, p = 0.004, all hospitals) and revenue (β = 1789.83, p = 0.037, private hospitals only), and negatively associated with costs (β =  - 1191.13, p = 0.017, all hospitals); but not significantly associated with future profits (β = 629.12, p = 0.240, all hospitals).

CONCLUSIONS

This analysis showed that better patient experience is associated with a higher proportion of elective patients, greater revenue, and lower costs. Our findings may assist hospital managers and regulators in identifying strategies to increase revenue and reduce costs.

Assessing pharmacists' awareness of financial indicators in community pharmacy management: A cross-sectional study

Background

Community pharmacists play a vital role in the healthcare system, serving as accessible healthcare providers and entrepreneurs. To effectively manage community pharmacies, pharmacists must possess financial literacy and utilize appropriate financial indicators. However, studies addressing community pharmacists' awareness of financial indicator concepts are scarce. This study assesses the awareness of community pharmacists in Jordan regarding financial indicators.

Methods

Employing a cross-sectional study design, we utilized a structured and validated questionnaire to collect data from 353 community pharmacy owners across Jordan. The questionnaire assessed pharmacists' awareness and utilization of financial indicators in pharmacy management. Descriptive statistics summarized demographic data, while analytical statistics examined associations between demographic factors and financial indicator awareness.

Results

The study revealed varying levels of awareness among pharmacists regarding financial indicators, with younger pharmacists exhibiting higher awareness levels. Factors such as educational background and years of experience were found to influence awareness. Furthermore, pharmacists predominantly utilize profitability indicators to assess financial performance.

Conclusion

The findings underscore the importance of enhancing pharmacists' financial literacy and integrating financial management principles into pharmacy education. Continuous professional development programs are essential to improve financial competence among pharmacists. This study provides valuable insights into the awareness of financial indicators among community pharmacists in Jordan, emphasizing the need for collaborative efforts from policymakers, pharmacy faculties, and associations to enhance financial education and promote research in this critical area.

Temporal trends and correlates in multiple hospitalizations among older adults: findings from a nationally representative sample in China

OBJECTIVE

This study aims to examine the trends and correlates in multiple hospitalizations among older adults in China.

METHODS

The data were from the China Health and Retirement Longitudinal Study (CHARLS), and generalized ordered logit model (GOLM) was used to identify the correlates of multiple hospitalizations among older adults aged≥60 years old.

RESULTS

Between 2011 and 2018, the proportion of older adults having multiple hospitalizations in the past year showed an increasing trend in the total sample (p value for trend = 0.014). Being older, male, illiterate, living in the middle/western region, having higher annual per capita household expenditure, health insurance, multimorbidity, and being depressed were associated with increased odds of multiple hospitalizations.

CONCLUSIONS

Our findings indicated that older adults with multiple hospitalizations may expect an increasing burden on healthcare system. More efforts are needed to improve health insurance and primary healthcare to reduce avoidable hospitalizations.

Payment perception in the emergency department: The mediating role of perceived quality of healthcare and patient satisfaction

The aim of this research is to identify the main factors associated with patients' payment perception and the effects of these factors on payment perception. Patients admitted between January and December 2016 at an emergency department of a public hospital in Lisbon, Portugal, were included in this study, with a representative sample size of 382 patients. A 5% margin of error and a 95% confidence interval were used, and all the data were collected between May and November 2017. To test the mediation models, stepwise multiple linear regression analysis was used. The effect of doctors on payment perception through satisfaction and through perceived quality of healthcare (PQHC) is explained by 3% and 4% of the variation, respectively, with statistically significant results (P < .01). Moreover, the effect of privacy and meeting expectations on payment perception through PQHC is explained by 4% and 4% of the variation, with statistically significant results (P < .01). Doctors play a crucial role in understanding the patients' payment perception (with direct and indirect effects). Mediators, in turn, strengthen this effect, in which the contribution of PQHC is more significant than that of satisfaction.

The potential of artificial intelligence to revolutionize health care delivery, research, and education in cardiac electrophysiology

The field of electrophysiology (EP) has benefited from numerous seminal innovations and discoveries that have enabled clinicians to deliver therapies and interventions that save lives and promote quality of life. The rapid pace of innovation in EP may be hindered by several challenges including the aging population with increasing morbidity, the availability of multiple costly therapies that, in many instances, confer minor incremental benefit, the limitations of healthcare reimbursement, the lack of response to therapies by some patients, and the complications of the invasive procedures performed. To overcome these challenges and continue on a steadfast path of transformative innovation, the EP community must comprehensively explore how artificial intelligence (AI) can be applied to healthcare delivery, research, and education and consider all opportunities in which AI can catalyze innovation; create workflow, research, and education efficiencies; and improve patient outcomes at a lower cost. In this white paper, we define AI and discuss the potential of AI to revolutionize the EP field. We also address the requirements for implementing, maintaining, and enhancing quality when using AI and consider ethical, operational, and regulatory aspects of AI implementation. This manuscript will be followed by several perspective papers that will expand on some of these topics.

Improving resource allocation in the precision medicine Era: a simulation-based approach using R

The application of personalized medicine in developing countries is a major challenge, especially for those with poor economic status. A critical factor in improving the application of personalized medicine is the efficient allocation of resources. In healthcare systems, optimizing resource allocation without compromising patient care is paramount. This tutorial employs a simulation-based approach to evaluate the efficiency of bed allocation within a hospital setting. Utilizing a patient arrival model with an exponential distribution, we simulated patient trajectories to examine system bottlenecks, particularly focusing on waiting times. Initial simulations painted a scenario of an 'unstable' system, where waiting times and queue lengths surged due to the limited number of available beds. This research offers insights for hospital management on resource optimization leading to improved patient care.

Extremes of Emergency Department Boarding are Associated With Poorer Financial Performance Among Hospitals

GOAL

Boarding emergency department (ED) patients is associated with reductions in quality of care, patient safety and experience, and ED operational efficiency. However, ED boarding is ultimately reflective of inefficiencies in hospital capacity management. The ability of a hospital to accommodate variability in patient flow presumably affects its financial performance, but this relationship is not well studied. We investigated the relationship between ED boarding and hospital financial performance measures. Our objective was to see if there was an association between key financial measures of business performance and limitations in patient progression efficiency, as evidenced by ED boarding.

METHODS

Cross-sectional ED operational data were collected from the Emergency Department Benchmarking Alliance, a voluntarily self-reporting operational database that includes 54% of EDs in the United States. Freestanding EDs, pediatric EDs and EDs with missing boarding data were excluded. The key operational outcome variable was boarding time. We reviewed the financial information of these nonprofit institutions by accessing their Internal Revenue Service Form 990. We examined standard measures of financial performance, including return on equity, total margin, total asset turnover, and equity multiplier (EM). We studied these associations using quantile regressions of added ED volume, ED admission percentage, urban versus nonurban ED site location, trauma status, and percentage of the population receiving Medicare and Medicaid as covariates in the regression models.

PRINCIPAL FINDINGS

Operational data were available for 892 EDs from 31 states. Of those, 127 reported a Form 990 in the year corresponding to the ED boarding measures. Median boarding time across EDs was 148 min (interquartile range [IQR]: 100-216). A significant relationship exists between boarding and the EM, along with a negative association with the hospital's total profit margin in the highest-performing hospitals (by profit margin percentage). After adjusting for the covariates in the regression model, we found that for every 10 min above 90 min of boarding, the mean EM for the top quartile increased from 245.8% to 249.5% (p < .001). In hospitals in the top 90th percentile of total margin, every 10 min beyond the median ED boarding interval led to a decrease in total margin of 0.24%.

PRACTICAL APPLICATIONS

Using the largest available national registry of ED operational data and concordant nonprofit financial reports, higher boarding among the highest-profitability hospitals (i.e., top 10%) is associated with a drag on profit margin, while hospitals with the highest boarding are associated with the highest leverage (i.e., indicated by the EM). These relationships suggest an association between a key ED indicator of hospital capacity management and overall institutional financial performance.

Profits over care? An analysis of the relationship between corporate capitalism in the healthcare industry and cancer mortality in the United States

The characteristic features of 21st-century corporate capitalism - monopoly and financialization - are increasingly being recognized by public health scholars as undermining the foundations of human health. While the "vectors" through which this is occurring are well known - poverty, inequality, climate change among others - locating the root cause of this process in the nature and institutions of contemporary capitalism is relatively new. Researchers have been somewhat slow to study the relationship between contemporary capitalism and human health. In this paper, we focus on one of the leading causes of death in the United States; cancer, and empirically estimate the relationship between various measures of financialization and monopoly in the US healthcare system and cancer mortality. The measures we focus on are for the hospital industry, the health insurance industry, and the pharmaceutical industry. Using a fixed effects model with different specifications and control variables, our analysis is at the state level for the years 2012-2019. These variables include data on population demographic controls, social and economic factors, and health behavior and clinical care. We compare Medicaid expansion states with non-Medicaid expansion states to investigate variations in state-level funded health insurance coverage. The results show a statistically significant positive correlation between the HHI index in the individual healthcare market and cancer mortality and the opioid dispensing rate and cancer mortality.

Non-operating revenue is an important source of funding for rural hospitals, especially those that are government-owned

PURPOSE

Non-operating revenue (NOR), derived from investments, contributions, government appropriations, and medical space rentals, can contribute to financial stability of hospitals by offsetting operating losses and improving profitability. NOR might benefit rural hospitals that often face intense financial pressures. However, little is known about how much rural hospitals rely on NOR and if certain organizational characteristics are associated with differences in NOR.

METHODS

Healthcare Cost Report Information System data from 2011 to 2019 were used to analyze sources of revenue among Critical Access Hospitals (CAHs) and Rural Prospective Payment System (R-PPS) hospitals through descriptive statistics and regression models. Reliance on NOR was measured by the percentage of total revenue from non-operating sources.

FINDINGS

Results indicate that both CAHs and R-PPS hospitals rely on NOR; however, CAHs have a higher percentage of total revenue derived from non-operating sources (3.2%) as compared to R-PPS hospitals (1.9%) (p < 0.001). Government-owned hospitals have significantly higher reliance on NOR than other ownership types. System affiliation also influences reliance on NOR. Lastly, results suggest that NOR may play a role in improving overall profit margins.

CONCLUSIONS

As rural hospitals disproportionately face challenges related to declining profitability and the risk for closure, they may rely on NOR to continue to strengthen financial performance and provide health care to their communities. However, NOR is not guaranteed, and reliance on NOR further reiterates the value of stable, adequate reimbursement to guard against fluctuations in NOR.

Financial indicators utilization among community pharmacists: A comprehensive study for pharmacy management

BACKGROUND

The financial management of community pharmacies is a critical aspect of healthcare delivery, as pharmacists often operate as healthcare providers and business managers. Understanding pharmacists' awareness, perceptions, and practices related to financial indicators is essential for effective pharmacy management. There is a paucity of research addressing this issue regionally and locally.

OBJECTIVES

This study aimed to investigate the perceptions and utilization of financial indicators among community pharmacists in Jordan and identify demographic and contextual factors influencing their financial practices.

METHODS

A cross-sectional study was conducted, surveying 353 community pharmacists from various regions of Jordan. The developed and validated survey assessed demographic characteristics, utilizations of financial indicators, and perceptions of their significance. Pharmacists were queried about their financial practices, including the use of various financial indicators. Descriptive and analytical statistics were used to portray the study's findings.

RESULTS

The study included a diverse group of community pharmacists in terms of demographic characteristics. Most pharmacists exhibited awareness of financial indicators, with a higher awareness of profitability and liquidity indicators. Pharmacists generally had positive perceptions of the importance of these indicators in daily practice. High agreement was observed in financial practices, including following up on payables and receivables, monitoring changes in monthly revenue, and preparing income statements. There was significant variation in the utilization and perception of financial indicators based on factors such as pharmacy ownership, province, foundation age, and practical experience.

CONCLUSION

The findings indicate a positive correlation between utilization and perception, emphasizing the importance of raising awareness of financial indicators among pharmacists. The study also highlights the significance of tailored financial training programs for pharmacists at different stages of their careers and the importance of regional context in financial practices. Understanding these variations can lead to more effective financial management and improved healthcare services in community pharmacies.

Hospitals' financial performance across European countries: a scoping review protocol

INTRODUCTION

Hospitals remain the cornerstone of health systems in European countries. Therefore, the financial sustainability of hospitals constitutes an important determinant of healthcare provision security. The fragmentary data available indicate that hospitals in many European countries are continuously facing financial deficits and/or insolvency problems. Yet a comparative analysis of hospital financial performance across European countries has been lacking. The proposed review will, therefore, fill in an important research gap and build a knowledge base on the topic of assessing and monitoring the financial sustainability of hospitals in Europe. The general objective is to identify, synthetise and map existing evidence on hospital financial performance across European countries.

METHODS AND ANALYSIS

This scoping review will follow six stages: (1) defining the research question, (2) identifying relevant literature, (3) studies selection, (4) data extraction, (5) collating, summarising and reporting of results and (6) consultation process and involvement of knowledge users. The following databases will be searched:(1) Medline via PubMed, (2) Web of Science Core Collection, (3) Scopus and (4) ProQuest Central. In addition, a Google Engine search will also be performed. Furthermore, reference lists of relevant papers will be visually scanned to identify further studies of interest. The review will include both quantitative and qualitative empirical studies as well as theoretical papers and technical reports. The PRISMA extension for a Scoping Review checklist will be used for reporting.

ETHICS AND DISSEMINATION

Formal ethical approval is not required because no primary data will be collected in this study. Results will be published in a peer-reviewed journal. The findings will also be disseminated through conference presentations and summaries to key stakeholders.

Analysis of Centralized Efficiency Improvement Practices in Australian Public Health Systems

Aim

Analysis of centralized efficiency improvement practices in Australian public health systems.

Introduction

Public health systems seek to maximize outcomes generated for resources used through efficiency improvement (EI) in response to funding and demand pressures. Despite this focus, evidence for EI approaches at the whole-of-system level is lacking in the literature. There is an urgent need for evidence-based approaches to centralized EI to address these pressures. This study aims to address this gap by answering the research question "How is EI conceptualized and managed by central public health system management entities in Australia?".

Material and Methods

Document analysis was selected due to its suitability for systematically searching and appraising health system documentation, with this study following Altheide's approach focusing on whole-of-system strategic plan and management framework documents originating from Australian public health organizations.

Results

Conceptualization of efficiency varied substantially with no consistent definition identified, however common attributes included resource use, management, service and delivery. Forty-two of 43 documents contained approaches associated with improving efficiency at the whole of system level.

Discussion

While no comprehensive framework for centralized EI was evident, we identified nine core approaches which together characterize centralized EI. Together these approaches represent a comprehensive evidence-based approach to EI at the whole of system level.

Conclusion

The approaches to whole-of-system EI identified in this study are likely to be highly transferable across health systems internationally with approaches including strategic priority setting, incentivization, performance support, use of EI evidence, digital enablement and workforce capability development.

Early trends in ECMO mortality during the first quarters of 2019 and 2020: Could we have predicted the onset of the pandemic?

OBJECTIVE

To compare mortality trends in patients requiring Extracorporeal Membrane Oxygenation (ECMO) support between the first quarters of 2019 and 2020 and determine whether these trends might have predicted the severe acute respiratory syndrome coronavirus-2 (SARS)-Cov-2 pandemic in the United States.

METHODS

We analyzed 5% Medicare claims data at aggregate, state, hospital, and encounter levels using MS-DRG (Medicare Severity-Diagnosis Related Group) codes for ECMO, combining state-level data with national census data. Necessity and sufficiency relations associated with change in mortality between the 2 years were modeled using qualitative comparative analysis (QCA). Multilevel, generalized linear modeling was used to evaluate mortality trends.

RESULTS

Based on state-level data, there was a 3.36% increase in mortality between 2019 and 2020. Necessity and sufficiency evaluation of aggregate data at state and institutional levels did not identify any association or combinations of risk factors associated with this increase in mortality. However, multilevel and generalized linear models using disaggregated patient-level data to evaluate institution mortality and patient death, identified statistically significant differences between the first (p = .019) and second (p = .02) months of the 2 years, the first and second quarters (p < .001 and p = .042, respectively), and the first 6 months (p < .001) of 2019 and 2020.

CONCLUSION

Mortality in ECMO patients increased significantly during the first quarter of 2020 and may have served as an early warning of the SARS-Cov-2 pandemic. Granular data shared in real-time may be used to better predict public health threats.

Improving Patient Outcomes Through Effective Hospital Administration: A Comprehensive Review

This comprehensive review delves into the critical role of effective hospital administration in shaping patient outcomes within the healthcare ecosystem. Exploration of key components, strategies, measurement methodologies, and future trends elucidates the multifaceted nature of hospital administration. Key findings underscore the profound impact of administrative decisions and practices on patient safety, satisfaction, and overall well-being. The review highlights the importance of patient-centred care and interdisciplinary collaboration for enhancing patient outcomes. It emphasises the significance of data-driven measurement and benchmarking, which are instrumental in assessing hospital performance and fostering continuous improvement. Looking ahead, emerging technologies, evolving healthcare policies, and persistent challenges are drivers of change in healthcare administration. However, amidst these transformations, the overarching message remains consistent: effective hospital administration is integral to improving patient outcomes. The conclusion calls for a collective commitment from healthcare leaders and policymakers to prioritise the development of capable administrators, invest in technology, promote value-based care, and address healthcare disparities. This collaborative effort ensures that the pursuit of better patient outcomes remains at the forefront of healthcare administration, ultimately shaping the future of healthcare for generations to come.

How is return on investment from quality improvement programmes conceptualised by mental healthcare leaders and why: a qualitative study

BACKGROUND

Return on Investment (ROI), whereby the ratio of costs to benefits is assessed, is encouraged in-order to justify the value of Quality Improvement (QI) programmes. We previously performed a literature review to develop a ROI conceptual framework for QI programmes. We concluded that, QI-ROI is conceptualised as any monetary and non-monetary benefit. In the current study, we explored if this finding is shared by mental healthcare leaders. We also investigated the stability of this conceptualisation against influencing factors and potential for disinvestment.

METHODS

We performed qualitative interviews with leaders in an NHS mental health organisation. There were 16 participants: nine board members and seven senior leaders. The interviews were held online via Microsoft Teams and lasted an hour on average. We performed deductive-inductive analysis to seek data from our initial ROI framework and any new data.

RESULTS

We found that in mental healthcare, QI-ROI is also conceptualised as any valued monetary and non-monetary benefits. There was a strong emphasis on benefits to external partners and a de-emphasis of benefit monetisation. This conceptualisation was influenced by the 1) perceived mandates to improve quality and manage scarce resources, 2) expectations from QI, 3) health and social care values, 4) ambiguity over expectations, and 5) uncertainty over outcomes. Uncertainty, ambiguity, and potential for disinvestment posed a threat to the stability of this conceptualisation but did not ultimately change it. Health and social care values supported maintaining the QI-ROI as any benefit, with a focus on patients and staff outcomes. Socio-political desires to improve quality were strong drivers for QI investment.

CONCLUSION

Mental healthcare leaders primarily conceptualise QI-ROI as any valued benefit. The inclusion of externalised outcomes which are hard to attribute may be challenging. However, mental healthcare services do collaborate with external partners. The de-emphases of benefit monetisation may also be controversial due to the need for financial accountability. Mental healthcare leaders recognise the importance of efficiency savings. However, they raised concerns over the legitimacy and utility of traditional ROI as a tool for assessing QI value. Further research is needed to bring more clarity on these aspects of the QI-ROI concept.

The influence of elevated international normalized ratio on complications following total shoulder arthroplasty

Background

Identifying preoperative risk factors for complications following total shoulder arthroplasty (TSA) has both clinical and financial implications. The purpose of this study was to determine the influence of different degrees of preoperative INR elevation on complications following TSA.

Methods

Patients undergoing primary TSA from 2007 to 2018 were identified in a national database. Patients were stratified into 4 cohorts: INR of <1.0, INR of >1.0 to 1.25, INR of >1.25 to 1.5, and INR of >1.5. Postoperative complications were assessed. Multivariate logistic regressions were performed to adjust for differences in demographics and comorbidities among the INR groups.

Results

Following adjustment and relative to patients with an INR of <1.0, those with INR of >1.0-1.25, >1.25-1.5, and >1.5 had 1.6-times, 2.4-times, and 2.8-times higher odds of having postoperative bleeding requiring transfusion, respectively (p < 0.05 for all). Relative to patients with INR <1.0, those with INR of > 1.25-1.5 and INR of >1.5 had 7.8-times and 7.0-times higher odds of having pulmonary complications, respectively (p < 0.05 for both).

Discussion

With increasing INR levels, there is an independent and step-wise increase in odd ratios for postoperative complications. Current guidelines for preoperative INR thresholds may need to be adjusted for more predictive risk-stratification for TSA.

Level of Evidence

III.

Early Financial Impact of the COVID-19 Pandemic on U.S. Hospitals

GOAL

The COVID-19 pandemic has left a significant impact on hospitals' operations, expenses, and revenues. However, little is known about the pandemic's financial impact on rural and urban hospitals. Our main objective was to analyze how hospital profitability changed during the first year of the pandemic. We specifically studied the association between COVID-19 infections and hospitalizations and county-level variables with operating margins (OMs) and total margins (TMs).

METHODS

We obtained data from Medicare Cost Reports, the American Hospital Association Annual Survey Database, and the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry (CDC/ATSDR) for 2012-2020. Our final dataset consisted of an unbalanced panel with 17,510 observations for urban hospitals and 17,876 observations for rural hospitals. We estimated separate hospital fixed-effects models for urban and rural hospitals' OMs and TMs. The fixed-effects models controlled for time-invariant differences across hospitals.

PRINCIPAL FINDINGS

In our review of the early impact of the COVID-19 pandemic on rural and urban hospitals' profits as well as trends in OMs and TMs from 2012 to 2020, we found that OMs were inversely related to the duration of hospitals' exposure to infections in urban and rural locations. In contrast, TMs and hospitals' exposures had a positive relationship. Government relief funds, a source of nonoperating revenue, apparently allowed most hospitals to avoid financial distress from the pandemic. We also found a positive relationship between the magnitude of weekly adult hospitalizations and OMs in urban and rural hospitals. Size, participation in group purchasing organizations (GPOs), and occupancy rates were positively related to OMs, with size and participation in GPOs relating to scale economies and occupancy rates reflecting capital efficiencies.

PRACTICAL APPLICATIONS

Hospitals' OMs have been declining since 2014. The pandemic made this decline worse, especially for rural hospitals. Federal relief funds, along with investment income, helped hospitals remain financially solvent during the pandemic. However, investment income and temporary federal aid are insufficient to sustain financial well-being. Executives need to explore cost-saving opportunities such as joining a GPO. Small rural hospitals with low occupancy and low community COVID-19 hospitalization rates have been particularly vulnerable to the financial impact of the pandemic. Although federal relief funds have limited hospital financial distress induced by the pandemic, we maintain that the funds should have been more effectively targeted, as the mean TM increased to its highest level in a decade. The disparate results of our analysis of OMs and TMs illustrate the utility of using multiple measures of profitability.

"Attempting to protect self and patient:" A grounded theory study of error recovery by intensive care nurses

AIM

The aim of this study was to explore the process of error recovery (ER) by nurses in intensive care unit (ICU).

DESIGN

This qualitative study was conducted in 2018-2020 using the grounded theory methodology.

METHODS

Participants were 20 staff nurses, head nurses and nursing managers recruited from the ICUs. Sampling was started purposively and continued theoretically. Data were collected using semi-structured interviews and were analysed using the approach proposed by Corbin and Strauss.

RESULTS

The findings indicated that nurses' primary concern was for the patient and their own personal/professional identity. Five strategies were found including evaluating situation, identifying error, analysing error and situation, determining the agent for error correction, and reducing error effects. Contextual factors were also highlighted as being important in the error recovery. Attempting to protect self and patient" was the core category of the study. Nurses' concern about protecting patient life and their own personal/professional identity make them use unprofessional approaches for ER.

Temporal trends in the rate of complications and prolonged length of stay relative to body mass index in patients undergoing total knee arthroplasty from 2012 to 2020

BACKGROUND

Elevated body mass index (BMI) is a risk factor for complications following total knee arthroplasty (TKA). Thus, we believe it is important to constantly re-evaluate the relationship between BMI and complication risk following TKA.

METHOD

Patients undergoing primary TKA were identified in a national database from 2012-2020. Rates of major complications, minor complications, and length of stay (LOS) greater than 2 days were calculated. The prevalence of postoperative outcomes were calculated per unit of BMI and then multiplied by a factor of 10^{^2} or 10^{^3} in order to create adjusted-BMI (aBMI). To isolate the effect of aBMI on postoperative outcomes, changes over time were analyzed using linear regression analysis controlling for age, sex, American Society of Anesthesiology (ASA) classification and smoking status.

RESULTS

365,333 patients were included. Mean BMI 33 ± 6.8. 10,616 (2.9%) of patients had a major postoperative complication, 9,345 (2.6%) minor complications, 3,277 (0.9%) had a deep or superficial surgical site infection (SSI). 133,563 (37%) of patients had LOS > 2 days. From 2012-2020, the ratio of major complications to aBMI decreased significantly by an average of -2.7% per year. The ratio of patients with LOS > 2 days to aBMI decreased significantly by -27% per year. The ratio of SSI to aBMI increased significantly by 10.8% per year.

CONCLUSIONS

From 2012 to 2020, the ratio of major complications and extended LOS following TKA as a function of BMI has decreased significantly, while the ratio of SSI as a function of BMI has doubled.

The impact of Medicare shared savings program participation on hospital financial performance: An event-study analysis

OBJECTIVE

To evaluate the impact of hospitals' participation in the Medicare Shared Savings Program (MSSP) on their financial performance.

DATA SOURCES

Centers for Medicare & Medicaid Services Hospital Cost Reports and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2011 to 2018.

STUDY DESIGN

We used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate.

DATA COLLECTION/EXTRACTION METHODS

Secondary data linked at the hospital level.

PRINCIPAL FINDINGS

Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p < 0.001), $3.20 million (p < 0.01), and $4.20 million (p < 0.01) in the second, third, and fourth year and beyond after joining MSSP, respectively. Medicare revenue differentially increased by $1.50 million (p < 0.05), $2.24 million (p < 0.05), and $4.47 million (p < 0.05) in the first, second, and fourth year and beyond. Inpatient revenue share differentially increased by 0.29% (p < 0.05) in the second year and 0.44% (p < 0.05) in the fourth year and beyond. Medicare revenue share differentially increased by 0.17% (p < 0.01), 0.25% (p < 0.01), 0.32% (p < 0.01), and 0.41% (p < 0.01) in consecutive years following MSSP participation. MSSP participation was associated with 0.33% (p < 0.05) and 0.39% (p < 0.05) differential reduction in allowance and discount rate in the second and third years.

CONCLUSIONS

MSSP participation was associated with differential increases in net patient revenue, Medicare revenue, inpatient revenue share, and Medicare revenue share, and a differential reduction in allowance and discount rate.

The Association Between Hospital Financial Performance and the Quality of Care - A Scoping Literature Review

BACKGROUND

Improving the quality of hospital care is an important policy objective. Hospitals operate under pressure to contain costs and might face challenges related to financial deficits. The objective of this paper was to identify and map the available evidence on the association between hospital financial performance (FP) and quality of care (Q).

METHODS

A scoping review was performed. Searches were conducted in 7 databases: Medline via PubMed, EMBASE, Web of Science, Scopus, EconLit, ABI/INFORM, and Business Source Complete. The search strategy combined multiple terms from 3 topics: hospital AND FP AND Q. The collected data were analysed using both quantitative and qualitative methods.

RESULTS

10 503 records were screened and 151 full text papers analysed. A total of 69 papers were included (60 empirical, 2 theoretical, 5 literature reviews, and 2 dissertations). The majority of identified studies were published within the last decade (2010-2021). Most empirical studies had been conducted in the United States (55/60), used cross-sectional approaches (32/60) and applied diverse regression models with FP measures as dependent variables, thus measuring the impact of Q on hospitals FP (34/60). The comparability of the studies' results is limited due to differences in applied methods and settings. Yet, the general overview shows that in almost half of the cases the association between hospital FP and Q was positive, while no study showed a clear negative association.

CONCLUSION

This scoping review provides an overview of the available literature on the association between hospital FP and Q. The results highlight numerous research gaps: (1) systematic reviews and meta-analyses of existing studies with similar measures of FP and Q are unavailable, (2) further methodological/conceptual work is needed on the metrics measuring hospital FP and Q, and (3) more empirical studies should analyse the association between FP and Q in non-US healthcare settings.

Status of patient safety in selected Ghanaian hospitals: a national cross-sectional study

BACKGROUND

Safety is one of the dimensions of healthcare quality and is core to achieving universal health coverage and healthcare delivery worldwide. In Ghana, the status of patient safety in the last 7 years has remained unknown. Therefore, this study aims to assess the patient safety status in selected hospitals in Ghana.

METHODS

Using the WHO Patient Safety Long Form, a mixed methodology was used to assess the patient safety status in 27 hospitals in Ghana. Data were analysed using descriptive statistics and axial codes for thematic analysis.

RESULTS

The average national patient safety score was high (85%). However, there were variations in the performance of the hospitals across the WHO patient safety action areas. Knowledge and learning in patient safety (97%) was the highest-rated patient safety action area. Patient safety surveillance, patient safety funding, patient safety partnerships and national patient safety policy had mean scores lower than the national average score (85%). Less than half (42%) of the hospitals had a dedicated budget for patient safety activities. The means of continuous education for health professionals include clinical sessions, and in-service training, while the system of clinical audits in the hospitals were maternal mortality, perinatal mortality, stillbirth and general mortality audits. The hospitals use posters, leaflets, public address systems and health education sessions to inform patients about their rights. Patient safety issues are reported through suggestion boxes, designated desks and the use of contacts of core management staff.

CONCLUSION

The current patient safety status in the hospitals was generally good, with the highest score in the knowledge and learning in the patient safety domain. Patient safety surveillance was identified as the weakest action area. The findings of this study will form the scientific basis for initiating the development of a national patient safety policy in Ghana. This is crucial for ensuring resilient and sustainable health systems that guarantee safer care to all patients in Ghana.

Driving Efficiency Improvement (EI): Exploratory Analysis of a Centralised Model in New South Wales

Introduction

Public healthcare systems face rising demand coupled with reducing funding growth rates, necessitating ongoing approaches to efficiency improvement (EI). Centrally coordinated EI approaches l may support EI leaders, yet few such approaches exist internationally. This study provides evidence to inform system-wide EI by harnessing understanding of the perceptions, role demands and support requirements of key EI stakeholders in the centralised EI model implemented in New South Wales.

Methods

A purposive sample of key informants within NSW Health with responsibility for EI in their organisation were invited to participate. Semi-structured interviews were conducted, recorded and transcribed. A thematic analysis was undertaken using a theoretical deductive approach.

Results

Seventeen respondents participated who occupied EI leadership roles in metro (8) and rural (6) health services as well as non-clinical support (3) services. Four primary themes emerged on the perceptions and experiences of participants in 1. holding a unique skillset which enables them to undertake EI; 2. inheriting EI accountabilities as additional duties rather than holding dedicated EI roles; 3. the importance of senior support for EI success; and 4. feelings of isolation in undertaking EI. An additional underpinning theme that EI is not well conceptualized in public health systems also emerged, whereby EI planners felt that frontline staff generally do not consider efficiency as a component of their duties.

Conclusion

EI leaders provide points of authority, experience and influence across organisations within public health systems. This study finds that EI planners possess a unique skillset, can feel isolated both within their health organisation and within the broader public health system and believe that EI is poorly conceptualized amongst health staff. Centralised support for EI stakeholders across a public health system can promote knowledge sharing and capability development. Addressing the role and support requirements of key EI stakeholders is essential.

Patient safety indicators from a spine surgery perspective: the importance of a specialty specific clinician working with the documentation team and the impact to your hospital

BACKGROUND CONTEXT

The Hospital Acquired Conditions (HAC) Reduction Program supports the Centers for Medicare and Medicaid Services (CMS) effort to prevent harm to patients by providing a financial incentive to reduce HACs. HAC scores are impacted by Patient Safety Indicators (PSIs), potentially preventable hospital-related events associated with harmful patient outcomes. PSIs are identified using International Classification of Diseases (ICD) coding; however, ICD coding does not always reflect the patient's true medical course.

PURPOSE

To evaluate the efficacy of and costs savings associated with a clinical documentation review process in tandem with clinician collaboration in identifying incorrectly generated PSIs.

STUDY DESIGN

Retrospective chart review.

PATIENT SAMPLE

All patients undergoing spine surgery at a single multi-surgeon tertiary spine center.

OUTCOME MEASURES

Occurrence of PSI.

METHODS

Over two 11-month periods, all PSIs attributable to spine surgery were determined. The number and type of spine related PSIs were compared before (Control) and after the implementation of a specialty specific clinical review (Intervention) to identify incorrectly generated PSIs. The financial impact of this intervention was calculated in the form of an annual cost savings to our hospital system.

RESULTS

During the Control phase, 61 PSIs were reported in 3368 spine cases, representing a total of 3.6 PSIs/month. During Intervention phase, 26 PSIs in 4,482 spine cases, resulting in a statistically significant decrease of 1.5 PSIs per month. The percentage of PSIs across all surgical cases attributable to spine surgery had a statistically significant decrease during the Intervention period compared to the Control period (16% vs. 10%, p=.034), resulting in the avoidance of a 1% CMS cost reduction, an annual cost saving of approximately $3-4 million dollars per year.

CONCLUSIONS

The implementation of a clinical documentation review process with clinician collaboration to ensure ICD-10 coding accurately reflects the patient's medical course leads to more accurate PSI reporting, with the potential for substantial cost-savings for hospitals from CMS reimbursement.

Association of Measured Quality and Future Financial Performance Among Hospitals Performing Cardiac Surgery

GOAL

For decades, hospitals performing cardiac surgery have carried the cost of implementing quality improvement activities and reporting quality outcomes. However, the financial return of such investments is unclear, which weakens the incentive for hospitals to invest in quality improvement activities. This study explored the relationship between a hospital's measured quality and its financial performance.

METHODS

Using data from the American Hospital Association and Hospital Compare from 2014 to 2018, we performed an observational study of hospitals performing cardiac surgery. We used mixed-effects regression models with fixed-year effects and random intercepts to explore associations between measured quality and hospital financial performance. Our dependent variables were margins (profit divided by revenue) and financial distress; our independent variables included Patient Safety Indicator 90 (PSI-90) and hospital characteristics.

PRINCIPAL FINDINGS

Our sample included 4,927 hospital-years from 1,209 unique hospitals. Hospitals in the worst-performing PSI-90 score quartile experienced a lower operating margin (-1.26%, 95% CI [-2.10 to -0.41], p = .004), a lower total margin (-0.92%, 95% CI [-1.66 to -0.17], p = .016), and an increased odds of financial distress in the next year (OR: 2.12, 95% CI [1.36-3.30], p = .001) when compared with the best-performing hospitals.

PRACTICAL APPLICATIONS

Our exploration into financial distress provides managers with a better understanding of the relationship between a hospital's measured quality and its financial position. In reflecting on our findings, hospital leaders may consider viewing patient safety as a modifiable factor that can improve their organization's overall financial health. Our findings suggest that excellent safety performance may be both financially and clinically beneficial to hospitals.

Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States

Importance

Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant.

Objective

To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities.

Design, Setting, and Participants

This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022.

Main Outcomes and Measures

Hospitals' likelihood of adopting stroke care certification.

Results

A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51).

Conclusions and Relevance

In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Is the Hospital Value-Based Purchasing Program Associated with Reduced Hospital Readmissions?

Introduction

Hospital readmissions have been associated with adverse outcomes and elevated financial costs to patients, families, and hospitals across the United States. Historically, nearly 20% of all Medicare discharges had a readmission within 30 days. In an effort to address this issue, the Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012 to positively influence readmissions associated with acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and total hip and/or knee arthroplasty. However, as recently as 2018, there were still 3.8 million 30-day all-cause adult hospital readmissions, with a 14% readmission rate and an average readmission cost of $15,200. The ACA also produced the Hospital Value-Based Purchasing (HVBP) program with the stated intent to (1) reduce mortality and complications, (2) reduce healthcare-associated infections, (3) increase patient safety, (4) improve the patient experience, and (5) increase efficiency and reduce costs. Given the costs and quality implications of an average readmission, it is logical to believe that HVBP eligible hospitals are simultaneously seeking to meet the goals of both programs. However, to date, no studies have examined if that is the case. Thus, in this study, we seek to determine if HVBP eligible hospitals are associated with a reduction in the core set of HRRP readmission rates better than the facilities that are not eligible for the HVBP program.

Methods

Hospital-level data from calendar year 2019 for 3,276 short-term acute care hospitals in the United States were evaluated using multivariate regression analysis to examine the readmission rate performance between 2,719 HVBP eligible hospitals and 557 ineligible hospitals.

Results

Our six separate multivariable linear regressions revealed a statistically significant and positive association between HVBP participation and readmission rates after controlling for numerous organizational, clinical complexity, and environmental factors. In each case, the magnitude of the positive directional association is moderate, ranging from and increase of +0.19% (pneumonia readmissions) to as high as +0.37% (all cause readmissions) for HVBP eligible hospitals. When considered in the context of the average number of discharges in our data set (x- = 9570), a third of a percent increase from the average 15.56% all cause readmissions to 16.08% in HVBP eligible hospitals equates to 50 additional readmissions annually (9570 × 15.56% = 1,489 vs 9570 × 16.08% = 1,539). At an average cost of $15,200 per readmission, which equates to an average additional cost to the average HVBP eligible hospital in excess of $760,000.

Discussion

The fact that there is a positive association between HVBP participating hospitals and readmissions at all, and that the same effect appears to be persistent across all dependent measures is concerning. One would logically expect hospitals that are focused on quality-based care to thoroughly care for individuals in order for them to not be readmitted to the hospital. The results provided do not necessarily prove that either program is not working. But they also do not confirm that the HVBP and HRRP programs are working together and accomplishing what they were originally designed to do: improve patient care and lower health-care costs.

Association of measured quality with financial health among U.S. hospitals

BACKGROUND

High-quality care is a clear objective for hospital leaders, but hospitals must balance investing in quality with financial stability. Poor hospital financial health can precipitate closure, limiting patients' access to care. Whether hospital quality is associated with financial health remains poorly understood. The objective of this study was to compare financial performance at high-quality and low-quality hospitals.

METHODS

We performed a retrospective observational cohort study of U.S. hospitals using the American Hospital Association and Hospital Compare datasets for years 2013 to 2018. We used multilevel mixed-effects linear and logistic regression models with fixed year effects and random intercepts for hospitals to identify associations between hospitals' measured quality outcomes-30-day hospital-wide readmission rate and the patient safety indicator-90 (PSI-90)-and their financial margins and risk of financial distress in the same year and the subsequent year. Our sample included 20,919 observations from 4,331 unique hospitals.

RESULTS

In 2018, the median 30-day readmission rate was 15.2 (interquartile range [IQR] 14.8-15.6), the median PSI-90 score was 0.96 (IQR 0.89-1.07), the median operating margin was -1.8 (IQR -9.7-5.9), and 750 (22.7%) hospitals experienced financial distress. Hospitals in the best quintile of readmission rates experienced higher operating margins (+0.95%, 95% CI [0.51-1.39], p < .001) and lower odds of distress (odds ratio [OR] 0.56, 95% CI [0.45-0.70], p < .001) in the same year as compared to hospitals in the worst quintile. Hospitals in the best quintile of PSI-90 had higher operating margins (+0.62%, 95% CI [0.17-1.08], p = .007) and lower odds of financial distress (OR 0.70, 95% CI [0.55-0.89], p = .003) as compared to hospitals in the worst quintile. The results were qualitatively similar for the same-year and lag-year analyses.

CONCLUSION

Hospitals that deliver high-quality outcomes may experience superior financial performance compared to hospitals with poor-quality outcomes.

Supporting efficiency improvement in public health systems: a rapid evidence synthesis

Background

Public health systems internationally are under pressure to meet increasing demand for healthcare in the context of increasing financial resource constraint. There is therefore a need to maximise health outcomes achieved with public healthcare expenditure. This paper aims to establish and synthesize the contemporary evidence base for approaches taken at a system management level to improve efficiency.

Methods

Rapid Evidence Assessment (REA) methodology was employed. A search strategy was developed and applied (PUBMED, MEDLINE) returning 5,377 unique titles. 172 full-text articles were screened to determine relevance with 82 publications included in the final review. Data regarding country, study design, key findings and approaches to efficiency improvement were extracted and a narrative synthesis produced. Publications covering health systems from developed countries were included.

Results

Identified study designs included policy reviews, qualitative reviews, mixed methods reviews, systematic reviews, literature reviews, retrospective analyses, scoping reviews, narrative papers, regression analyses and opinion papers. While findings revealed no comprehensive frameworks for system-wide efficiency improvement, a range of specific centrally led improvement approaches were identified. Elements associated with success in current approaches included dedicated central functions to drive system-wide efficiency improvement, managing efficiency in tandem with quality and value, and inclusive stakeholder engagement.

Conclusions

The requirement for public health systems to improve efficiency is likely to continue to increase. Reactive cost-cutting measures and short-term initiatives aimed only at reducing expenditure are unlikely to deliver sustainable efficiency improvement. By providing dedicated central system-wide efficiency improvement support, public health system management entities can deliver improved financial, health service and stakeholder outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07694-z.

First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance

BACKGROUND

The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions.

OBJECTIVE

The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP.

RESEARCH DESIGN

We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis.

RESULTS

The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312.

CONCLUSIONS

SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.

Racial and Ethnic Disparities in Cancer Associated Thrombosis

Active malignancy increases the risk of developing venous thromboembolism (VTE) by four- to seven-fold. The risk of VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE), in patients with cancer varies based on several clinical factors, such as cancer stage and age. However, race and ethnicity are also associated with increased VTE risk. Black (African American) patients with cancer have a higher risk of developing VTE than White patients, while Asian/Pacific Islanders have a lower risk. Studies on cancer associated thrombosis (CAT) demonstrate a need to advance our understanding of both the biologic and sociologic underpinnings of the observed differences according to race. Addressing the causes of these disparities can better health outcomes for historically underserved patient populations.

The association between hospital financial performance and the quality of care-a scoping review protocol

BACKGROUND

Hospitals operate under constant pressure to contain costs and improve the quality of care. The literature suggests that there is an association between health care providers' financial performance and the quality of care. On the one hand, providers that are financially more stable might have better capacity to maintain reliable systems and resources for quality improvement. On the other hand, providing better quality of care might lead to financial gains in the form of increased revenues or achieved savings and, in consequence, a higher profitability. The general objective of this scoping review is to identify and map the available evidence on the association between hospital financial performance and the quality of care. It aims to (1) provide a broad overview of the topic and (2) indicate a more precise research question for a future systematic review.

METHODS

This scoping review will follow five stages: (1) defining the research question; (2) identifying relevant literature; (3) study selection; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) the consultation process and engagement of knowledge users. The following databases will be searched: MEDLINE via PubMed, (2) EMBASE, (3) Web of Science, (4) Scopus, (5) EconLit, (6) ABI/INFORM, and (7) Business Source Premier. The reference lists of relevant papers will be visually scanned with the aim of identifying further studies of interest. Also, a gray literature search will be conducted by screening the websites of diverse organizations dealing with hospital performance and/or quality of care. The review will not apply a publication date limit and will include both quantitative and qualitative empirical studies as well as theoretical papers, technical reports, books/chapters, and thesis. The reporting will utilize the PRISMA extension for a Scoping Review checklist.

DISCUSSION

This scoping review will provide an overview of the existing literature on the association between hospital financial performance and the quality of care. The review process will apply a rigorous methodological approach while broad inclusion criteria should assure comprehensive coverage of the available literature. The main limitation of the review is related to the general limitation of scoping reviews, i.e., the lack of a systematic quality and risk of bias assessment of included studies. In addition, the review will include only publications in English.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework osf.io/z25ag.

The Effect of RN Circulator-Scrub Person Dyad Consistency on Total OR Time and Turnover Time

Operating room efficiency is an important consideration for perioperative nurse leaders because it can affect their facilities' revenue and provider and patient satisfaction. Using consistent perioperative teams, including the same RN circulator and scrub person, for consecutive procedures may improve OR efficiency. This retrospective cross-sectional cohort study assessed the effects of a consistent team in the form of RN circulator-scrub person dyads on the total OR and turnover times for 310 surgical procedures using electronic OR records data from the National Surgical Quality Improvement Program that was collected in 2008. Controlling for relevant variables (eg, procedure type consistency, number of staff members present, procedure complexity), the association between RN circulator-scrub person dyads and total OR time and turnover time was not significant.

Associations between Hospital Quality Outcomes and Medicare Spending per Beneficiary in the USA

The cost of healthcare in the United States has increased over time. However, patient health outcomes have not trended with spending. There is a need to better comprehend the association between healthcare costs in the United States and hospital quality outcomes. Medicare spending per beneficiary (MSPB), a homogeneous metric across providers, can be used to evaluate the association between episodic Medicare spending and quality of care. Fifteen inpatient outcome measures were selected from Hospital Compare data among all (n = 4758) facilities and transformed to quintiles to ensure comparability across measures and to reduce the influence of outliers on the analysis. Both univariate and multiresponse multinomial ordered probit regression models were utilized across outcome domains to quantify associations between outcomes and spending. We found that MSPB was not associated with quality of care in most cases, adding evidence of a lack of outcome accountability among Medicare-funded facilities. Furthermore, worse outcomes were found to be associated with increased spending for some metrics. Policies are needed to align quality of care outcomes with the increasing costs of U.S. healthcare.

Black-White disparities in maternal in-hospital mortality according to teaching and Black-serving hospital status

BACKGROUND

Maternal mortality is higher among Black than White people in the United States. Whether Black-White disparities in maternal in-hospital mortality during the delivery hospitalization vary across hospital types (Black-serving vs nonBlack-serving and teaching vs nonteaching) and whether overall maternal mortality differs across hospital types is not known.

OBJECTIVE

The aims of this study were to determine whether risk-adjusted Black-White disparities in maternal mortality during the delivery hospitalization vary by hospital types (this is analysis of disparities in mortality within hospital types) and compare risk-adjusted in-hospital maternal mortality among Black-serving and nonBlack-serving teaching and nonteaching hospitals regardless of race (this is an analysis of overall mortality across hospital types).

STUDY DESIGN

We performed a population-based, retrospective cohort study of 5,679,044 deliveries among Black (14.2%) and White patients (85.8%) in 3 states (California, Missouri, and Pennsylvania) from 1995 to 2009. A hospital discharge disposition of "death" defined maternal in-hospital mortality. Black-serving hospitals had at least 7% Black obstetrical patients (top quartile). We performed risk adjustment by calculating expected death rates using predictions from logistic regression models incorporating sociodemographics, rurality, comorbidities, multiple gestations, gestational age at delivery, year, state, and mode of delivery. We calculated risk-adjusted risk ratios of mortality by comparing observed-to-expected ratios among Black and White patients within hospital types and then examined mortality across hospital types, regardless of patient race. We quantified the proportion of Black-White disparities in mortality attributable to delivering in Black-serving hospitals using causal mediation analysis.

RESULTS

There were 330 maternal deaths among 5,679,044 patients (5.8 per 100,000). Black patients died more often (11.5 per 100,000) than White patients (4.8 per 100,000) (relative risk, 2.38; 95% confidence interval, 1.89-2.98). Examination of Black-White disparities revealed that after risk adjustment, Black patients had significantly greater risk of death (adjusted relative risk, 1.44; 95% confidence interval, 1.17-1.79) and that the disparity was similar within each of the hospital types. Comparison of mortality, regardless of race, across hospital types revealed that among teaching hospitals, mortality was similar in Black-serving and nonBlack-serving hospitals. However, among nonteaching hospitals, mortality was significantly higher in Black-serving vs nonBlack-serving hospitals (adjusted relative risk, 1.47; 95% confidence interval, 1.15-1.87). Notably, 53% of Black patients delivered in nonteaching, Black-serving hospitals compared with just 19% of White patients. Among nonteaching hospitals, 47% of Black-White disparities in maternal in-hospital mortality were attributable to delivering at Black-serving hospitals.

CONCLUSION

Maternal in-hospital mortality during the delivery hospitalization among Black patients is more than double that of White patients. Our data suggest this disparity is caused by excess mortality among Black patients within each hospital type, in addition to excess mortality in nonteaching, Black-serving hospitals where most Black patients deliver. Addressing downstream effects of racism to achieve equity in maternal in-hospital mortality will require transparent reporting of quality metrics by race to reduce differential care and outcomes within hospital types, improvements in care delivery at Black-serving hospitals, overcoming barriers to accessing high-quality care among Black patients, and eventually desegregation of healthcare.

Association of Medicaid Expansion With Quality in Safety-Net Hospitals

IMPORTANCE

Safety-net hospitals (SNHs) operate under limited financial resources and have had challenges providing high-quality care. Medicaid expansion under the Affordable Care Act led to improvements in hospital finances, but whether this was associated with better hospital quality, particularly among SNHs given their baseline financial constraints, remains unknown.

OBJECTIVE

To compare changes in quality from 2012 to 2018 between SNHs in states that expanded Medicaid vs those in states that did not.

DESIGN, SETTING, AND PARTICIPANTS

Using a difference-in-differences analysis in a cohort study, performance on quality measures was compared between SNHs, defined as those in the highest quartile of uncompensated care in the pre-Medicaid expansion period, in expansion vs nonexpansion states, before and after the implementation of Medicaid expansion. A total of 811 SNHs were included in the analysis, with 316 in nonexpansion states and 495 in expansion states. The study was conducted from January to November 2020.

EXPOSURES

Time-varying indicators for Medicaid expansion status.

MAIN OUTCOMES AND MEASURES

The primary outcome was hospital quality measured by patient-reported experience (Hospital Consumer Assessment of Healthcare Providers and Systems Survey), health care-associated infections (central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical site infections following colon surgery) and patient outcomes (30-day mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia). Secondary outcomes included hospital financial measures (uncompensated care and operating margins), adoption of electronic health records, provision of safety-net services (enabling, linguistic/translation, and transportation services), or safety-net service lines (trauma, burn, obstetrics, neonatal intensive, and psychiatric care).

RESULTS

In this difference-in-differences analysis of a cohort of 811 SNHs, no differential changes in patient-reported experience, health care-associated infections, readmissions, or mortality were noted, regardless of Medicaid expansion status after the Affordable Care Act. There were modest differential increases between 2012 and 2016 in the adoption of electronic health records (mean [SD]: nonexpansion states, 99.4 [7.4] vs 99.9 [3.8]; expansion states, 94.6 [22.6] vs 100.0 [2.2]; 1.7 percentage points; P = .02) and between 2012 and 2018 in the number of inpatient psychiatric beds (mean [SD]: nonexpansion states, 24.7 [36.0] vs 23.6 [39.0]; expansion states: 29.3 [42.8] vs 31.4 [44.3]; 1.4 beds; P = .02) among SNHs in expansion states, although they were not statistically significant at a threshold adjusted for multiple comparisons. In subgroup analyses comparing SNHs with higher vs lower baseline operating margins, an isolated differential improvement was noted in heart failure readmissions among SNHs with lower baseline operating margins in expansion states (mean [SD], 22.8 [2.1]; -0.53 percentage points; P = .001).

CONCLUSIONS AND RELEVANCE

This difference-in-differences cohort study found that despite reductions in uncompensated care and improvements in operating margins, there appears to be little evidence of quality improvement among SNHs in states that expanded Medicaid compared with those in states that did not.

Social determinants of health affect unplanned readmissions following acute myocardial infarction

Background: Low socioeconomic status predicts inferior clinical outcomes in many patient populations. The effects of patient insurance status and hospital safety-net status on readmission rates following acute myocardial infarction are unclear. Materials & methods: A retrospective review of State Inpatient Databases for New York, California, Florida and Maryland, 2007-2014. Results: A total of 1,055,162 patients were included. Medicaid status was associated with 37.7 and 44.0% increases in risk-adjusted readmission odds at 30 and 90 days (p < 0.0001). Uninsured status was associated with reduced odds of readmission at both time points. High-burden safety-net status was associated with 9.6 and 9.5% increased odds of readmission at 30 and 90 days (p < 0.0003). Conclusion: Insurance status and hospital safety-net burden affect readmission odds following acute myocardial infarction.

Financial Performance of Public Hospitals: A Cross-Sectional Study among Polish Providers

There is growing evidence of a positive association between health care providers’ financial standing and the quality of care. In Poland, the instable financial situation and growing debt of public hospitals has been a source of concern for more than two decades now. The objectives of this paper were to compare the financial performance of public hospitals in Poland, depending on the ownership and organizational form; and analyze whether there is an association between financial performance and the chosen variables. We conducted a cross sectional study covering the whole population of public hospitals operating in 2018. The total number of included units was 805. The hospitals’ financial outcomes were measured by several variables; Spearman’s rank correlation was calculated, and a multivariable logistic regression model was performed. In 2018, the majority of public hospitals in Poland (52%) generated a gross loss, while 40% hospitals had overdue liabilities. There were statistically significant differences between hospital groups, with university hospitals and those owned by counties (local hospitals) being in the most disadvantageous situation. Additionally, corporatized public hospitals performed worse than those functioning in the classic legal form of independent health care units. Urgent actions are needed to measure and monitor the potential impact of financial performance on the quality of care.