Based on key measures, care quality for Medicare enrollees at safety-net and non-safety-net hospitals was almost equal.
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SUBMITTER: Ross JS
PROVIDER: S-EPMC3527010 | biostudies-literature | 2012 Aug
REPOSITORIES: biostudies-literature
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Based on key measures, care quality for Medicare enrollees at safety-net and non-safety-net hospitals was almost equal.
Ross Joseph S JS Bernheim Susannah M SM Lin Zhenqiu Z Drye Elizabeth E EE Chen Jersey J Normand Sharon-Lise T SL Krumholz Harlan M HM
Health affairs (Project Hope) 20120801 8
Safety-net hospitals, which include urban hospitals serving large numbers of low-income, uninsured, and otherwise vulnerable populations, have historically faced greater financial strains than hospitals that serve more affluent populations. These strains can affect hospitals' quality of care, perhaps resulting in worse outcomes that are commonly used as indicators of care quality-mortality and readmission rates. We compared risk-standardized rates of both of these clinical outcomes among fee-for ...[more]
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Project description:Background:Although safety-net hospitals (SNH) provide a valuable role serving vulnerable patients, the quality of gynecologic oncology care at these hospitals remains inadequately documented. We examined the quality of care at SNH for women with gynecologic cancers. Methods:We used the National Cancer Database to identify hospitals that treated patients with uterine, ovarian, or cervical cancer from 2004 to 2015. Hospitals with the greatest proportion of uninsured patients or Medicaid beneficiaries were defined as SNH. Quality metrics were derived from evidence-based recommendations. Thirty-day mortality, readmission rates, and 5-year survival were calculated. Multivariable models were developed to determine the association between treatment at SNH and outcomes. Results:Overall, 594?750 patients diagnosed with gynecologic cancer were treated at 1340 hospitals. Compared with non-SNH, patients at SNH were younger, more frequently racial minorities, low income, and had more aggressive histologies and advanced-stage tumors. SNH had lower rates of minimally invasive surgery for uterine cancer (62.3% vs 75.9%, P?<?.0001), debulking for ovarian cancer (83.6% vs 86.9%, P?<?.05), and lymph node assessment for all three cancer types (P?<?.05). Rates of chemotherapy for uterine and ovarian cancer was greater whereas concurrent chemoradiation for cervical cancer was lower (P?<?.05 for all). Thirty-day mortality and readmission rates were equivalent. Mortality was moderately worse for patients with stage IV ovarian cancer and stage II-III cervical cancer (P?<?.05) but were otherwise equivalent. Conclusions:After adjusting for patient and tumor characteristics, women with gynecologic cancers treated at SNH receive lower-quality surgical care and equivalent medical care and a subset of these patients has modest decreases in survival.
| S-EPMC6735612 | biostudies-literature
Project description:OBJECTIVE:To examine relationships between penalties assessed by Medicare's Hospital Readmission Reduction Program and Value-Based Purchasing Program and hospital financial condition. DATA SOURCES/STUDY SETTING:Centers for Medicare and Medicaid Services, American Hospital Association, and Area Health Resource File data for 4,824 hospital-year observations. STUDY DESIGN:Bivariate and multivariate analysis of pooled cross-sectional data. PRINCIPAL FINDINGS:Safety net hospitals have significantly higher HRRP/VBP penalties, but, unlike nonsafety net hospitals, increases in their penalty rate did not significantly affect their total margins. CONCLUSIONS:Safety net hospitals appear to rely on nonpatient care revenues to offset higher penalties for the years studied. While reassuring, these funding streams are volatile and may not be able to compensate for cumulative losses over time.
| S-EPMC6153176 | biostudies-literature
Project description:BackgroundQuality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition's Quality Measurement Enhancement Project sought to collect data from primary care providers' (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs' perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare.MethodsQualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes.ResultsThree themes with sub-themes emerged. Theme #1: Minnesota's current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity.ConclusionAligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs' perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them.
| S-EPMC6222992 | biostudies-literature
Project description:ImportanceIn the US, federal value-based incentive programs are more likely to penalize safety-net institutions than non-safety-net institutions. Whether these programs differentially change the rates of targeted health care-associated infections in safety-net vs non-safety-net hospitals is unknown.ObjectiveTo assess the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care-associated infections and disparities in rates among safety-net and non-safety-net hospitals.Design, setting, and participantsThis interrupted time series included all US acute care hospitals enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study that participated in mandatory reporting to the National Healthcare Safety Network from January 1, 2013, through June 30, 2018. Hospital characteristics were obtained from the 2015 American Hospital Association annual survey. Penalty statuses for 2015 to 2018 were obtained from Hospital Compare. Data were analyzed between July 9, 2018, and October 1, 2019.ExposuresHACRP and HVBP implementation in fiscal year 2015 or 2016.Main outcomes and measuresThe primary outcomes were rates of 4 health care-associated infections: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) after colon surgical procedures, and SSI after abdominal hysterectomy procedures. Regression models were fit using generalized estimating equations to assess the association of HACRP and HVBP implementation with health care-associated infection rates and disparities in infection rates.ResultsOf the 618 acute care hospitals included in this study, 473 (76.5%) were non-safety net and 145 (23.5%) were considered safety net. In these hospitals, HACRP and HVBP implementation was not associated with improvements in level or trend for any health care-associated infection examined (eg, CAUTI in safety-net hospitals: incidence rate ratio [IRR] for level change, 0.98 [95% CI, 0.79-1.23; P = .89]; IRR for change in slope, 1.00 [95% CI, 0.97-1.03; P = .80]). Before program implementation, infection rates were statistically significantly higher for safety-net than for non-safety-net hospitals for CLABSI (IRR, 1.23; 95% CI, 1.07-1.42; P = .004), CAUTI (IRR, 1.38; 95% CI, 1.16-1.64; P < .001), and SSI after colon surgical procedure (odds ratio [OR], 1.26; 95% CI, 1.06-1.50; P = .009). The disparity persisted over time when comparing the last year of the study with the first year (CLABSI: ratio of ratios [ROR], 0.93 [95% CI, 0.77-1.13; P = .48]; CAUTI: ROR, 0.90 [95% CI, 0.73-1.10; P = .31]; SSI after colon surgical procedures: ROR, 0.96 [95% CI, 0.78-1.20; P = .75]). Rates of SSI after abdominal hysterectomy procedure were similar in safety-net and non-safety-net hospitals before implementation (OR, 1.13; 95% CI, 0.91-1.40; P = .27) but higher after implementation (OR, 1.43; 95% CI, 1.11-1.83; P = .006), although this change was not significant (ROR, 1.20; 95% CI, 0.91-1.59; P = .20).Conclusions and relevanceThis study found that HACRP and HVBP implementation was not associated with any improvements in targeted health care-associated infections among safety-net or non-safety-net hospitals or with changes in disparities in infection rates. Given the persistent health care-associated infection rate disparities, these programs appear to function as a disproportionate penalty system for safety-net hospitals that offer no measurable benefits for patients.
| S-EPMC7344380 | biostudies-literature
Project description:Geographic, racial, and ethnic variations in quality of care and outcomes have been well documented among the Medicare population. Few data exist on beneficiaries living in Puerto Rico, three-quarters of whom enroll in Medicare Advantage (MA).To determine the quality of care provided to white and Hispanic MA enrollees in the United States and Puerto Rico.A cross-sectional study of MA enrollees in 2011 was conducted, including white enrollees in the United States (n?=?6?289?374), Hispanic enrollees in the United States (n?=?795?039), and Hispanic enrollees in Puerto Rico (n?=?267?016). The study was conducted from January 1, 2011, to December 31, 2011; data analysis took place from January 19, 2015, to January 2, 2016.Seventeen performance measures related to diabetes mellitus (including hemoglobin A1c control, retinal eye examination, low-density lipoprotein cholesterol control, nephropathy screening, and blood pressure control), cardiovascular disease (including low-density lipoprotein cholesterol control, blood pressure control, and use of a ?-blocker after myocardial infarction), cancer screening (colorectal and breast), and appropriate medications (including systemic corticosteroids and bronchodilators for chronic obstructive pulmonary disease [COPD] and disease-modifying antirheumatic drugs).Of the 7.35 million MA enrollees in the United States and Puerto Rico in our study, 1.06 million (14.4%) were Hispanic. Approximately 25.1% of all Hispanic MA enrollees resided in Puerto Rico, which was more than those residing in any state. For 15 of the 17 measures assessed, Hispanic MA enrollees in Puerto Rico received worse care compared with Hispanics in the United States, with absolute differences in performance rates ranging from 2.2 percentage points for blood pressure control in diabetes mellitus (P?=?.03) to 31.3 percentage points for use of disease-modifying antirheumatic drug therapy (P?<?.01). Adjusted performance differences between Hispanic MA enrollees in Puerto Rico and Hispanic MA enrollees in the United States exceeded 20 percentage points for 3 measures: use of disease-modifying antirheumatic drug therapy (-23.8 percentage points [95% CI, -30.9 to -16.8]), use of systemic corticosteroid in COPD exacerbation (-21.3 percentage points [95% CI, -27.5 to -15.1]), and use of bronchodilator therapy in COPD exacerbation (-22.7 percentage points [95% CI, -27.7 to -17.6]).We found modest differences in care between white and Hispanic MA enrollees in the United States but substantially worse care for enrollees in Puerto Rico compared with their US counterparts. Major efforts are needed to improve care delivery on the island to a level equivalent to the United States.
| S-EPMC4934661 | biostudies-literature
Project description:Purpose:Newly enacted policies at the state and federal level in the United States require acute care hospitals to engage in sepsis quality improvement. However, responding to these policies requires considerable resources and may disproportionately burden safety-net hospitals. To better understand this issue, we analyzed the relationship between hospital safety-net status and performance on Medicare's SEP-1 quality measure.Materials and methods:We linked multiple publicly-available datasets with information on SEP-1 performance, structural hospital characteristics, hospital financial case mix, and health system affiliation. We analyzed the relationship between hospital safety-net status and SEP-1 performance, as well as whether hospital characteristics moderated that relationship.Results:We analyzed data from 2827 hospitals, defining safety-net hospitals using financial case mix data. The 703 safety-net hospitals performed worse on Medicare's SEP-1 quality measure (adjusted difference 2.3% compliance, 95% CI -4.0%--0.6%). This association was most evident in hospitals not affiliated with health systems, in which the difference between safety-net and non-safety-net hospitals was 6.8% compliance (95% CI -10.4%--3.3%).Conclusions:Existing sepsis policies may harm safety-net hospitals and widen health disparities. Our findings suggest that strategies to promote collaboration among hospitals may be an avenue for sepsis performance improvement in safety-net hospitals.
| S-EPMC6901718 | biostudies-literature
Project description:BackgroundThe Pharmacy Quality Alliance (PQA) recently developed 3 quality measures for prescribing opioids: high dosages, multiple providers and pharmacies, and concurrent use of opioids and benzodiazepines.ObjectiveTo examine the prevalence of the PQA measures and identify the patient demographic and health characteristics associated with the measures.MethodsWe conducted a cross-sectional analysis using Pennsylvania Medicaid data (2013-2015). We limited our analyses to noncancer patients who were aged 18-64 years and not dual-eligible for Medicare/Medicaid. Per PQA specifications, patients were required to possess ≥ 2 opioid prescriptions for ≥ 15 days annual supply each year. Outcome measures included (a) high dosages, defined as > 120 morphine milligram equivalents for ≥ 90 consecutive days; (b) multiple providers/pharmacies, defined as receiving opioid prescriptions from ≥ 4 providers and ≥ 4 pharmacies; and (c) concurrent use of opioids and benzodiazepines, defined as ≥ 30 cumulative days of overlapping opioids and benzodiazepines among individuals having ≥ 2 opioid and ≥ 2 benzodiazepine fills. Patient characteristics assessed included demographics; other medication use; and physical, mental, and behavioral health comorbidities. We present descriptive and multivariable statistical analyses of the data to describe trends in quality measure prevalence and associations with enrollee health characteristics.ResultsNumbers of enrollees meeting inclusion criteria ranged from 73,082 in 2013 to 85,710 in 2015. From 2013 to 2015, high dosage prevalence increased from 5.1% to 5.5%; the use of multiple providers/pharmacies decreased from 7.1% to 5.0%; and concurrent use of opioids and benzodiazepines decreased from 29.1% to 28.4% (all P < 0.05). A substantial portion of patients with > 1 PQA measure from 2013 to 2015 was eligible for Medicaid because of disability (41.8%-81.9%). Enrollees with opioid use disorder were more likely to have high dosages (adjusted odds ratio [AOR] = 2.01, 95% CI = 1.83-2.21). Enrollees with anxiety and mood disorders were more likely to have multiple providers/pharmacies (anxiety: AOR = 1.54, 95% CI = 1.43-1.65; mood: AOR = 1.15, 95% CI = 1.06-1.25) and concurrent use of opioids and benzodiazepines (anxiety: AOR = 3.50, 95% CI = 3.38-3.63; mood: AOR = 1.42, 95% CI = 1.36-1.48).ConclusionsGiven high levels of eligibility based on disability and the prevalence of mood, anxiety, and opioid use disorders among those identified by the quality measures, providers may require additional support to care for this patient population.DisclosuresThis project was supported by a grant from the Centers for Disease Control and Prevention and was also supported by an intergovernmental agreement between the Pennsylvania Department of Human Services and the University of Pittsburgh. Lo-Ciganic was supported by the University of Arizona Health Sciences Career Development Award. The other authors have nothing to disclose. The conclusions, findings, and opinions expressed by authors contributing to this article do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the Commonwealth of Pennsylvania. A portion of these results was presented at the Association for Medical Education and Research in Substance Abuse 41st National Conference; November 2-4, 2017; Washington, DC.
| S-EPMC6418411 | biostudies-literature
Project description:ObjectivesEvidence suggests that homeless patients experience worse quality of care and poorer health outcomes across a range of medical conditions. It remains unclear, however, whether differences in care delivery at safety-net versus non-safety-net hospitals explain these disparities. We aimed to investigate whether homeless versus non-homeless adults hospitalised for cardiovascular conditions (acute myocardial infarction (AMI) and stroke) experience differences in care delivery and health outcomes at safety-net versus non-safety-net hospitals.DesignCross-sectional study.SettingData including all hospital admissions in four states (Florida, Massachusetts, Maryland, and New York) in 2014.ParticipantsWe analysed 167 105 adults aged 18 years or older hospitalised for cardiovascular conditions (age mean=64.5 years; 75 361 (45.1%) women; 2123 (1.3%) homeless hospitalisations) discharged from 348 hospitals.Outcome measuresRisk-adjusted diagnostic and therapeutic procedure and in-hospital mortality, after adjusting for patient characteristics and state and quarter fixed effects.ResultsAt safety-net hospitals, homeless adults hospitalised for AMI were less likely to receive coronary angiogram (adjusted OR (aOR), 0.42; 95% CI, 0.36 to 0.50; p<0.001), percutaneous coronary intervention (aOR, 0.52; 95% CI, 0.44 to 0.62; p<0.001) and coronary artery bypass graft (aOR, 0.43; 95% CI, 0.26 to 0.71; p<0.01) compared with non-homeless adults. Homeless patients treated for strokes at safety-net hospitals were less likely to receive cerebral arteriography (aOR, 0.23; 95% CI, 0.16 to 0.34; p<0.001), but were as likely to receive thrombolysis therapy. At non-safety-net hospitals, we found no evidence that the probability of receiving these procedures differed between homeless and non-homeless adults hospitalised for AMI or stroke. Finally, there were no differences in in-hospital mortality rates for homeless versus non-homeless patients at either safety-net or non-safety-net hospitals.ConclusionDisparities in receipt of diagnostic and therapeutic procedures for homeless patients with cardiovascular conditions were observed only at safety-net hospitals. However, we found no evidence that these differences influenced in-hospital mortality markedly.
| S-EPMC8039275 | biostudies-literature
Project description:BackgroundPrevious research addressed the development of a classification scheme for quality improvement systems in European hospitals. In this study we explore associations between the 'maturity' of the hospitals' quality improvement system and clinical outcomes.MethodsThe maturity classification scheme was developed based on survey results from 389 hospitals in eight European countries. We matched the hospitals from the Spanish sample (113 hospitals) with those hospitals participating in a nation-wide, voluntary hospital performance initiative. We then compared sample distributions and explored associations between the 'maturity' of the hospitals' quality improvement system and a range of composite outcomes measures, such as adjusted hospital-wide mortality, -readmission, -complication and -length of stay indices. Statistical analysis includes bivariate correlations for parametrically and non-parametrically distributed data, multiple robust regression models and bootstrapping techniques to obtain confidence-intervals for the correlation and regression estimates.ResultsOverall, 43 hospitals were included. Compared to the original sample of 113, this sample was characterized by a higher representation of university hospitals. Maturity of the quality improvement system was similar, although the matched sample showed less variability. Analysis of associations between the quality improvement system and hospital-wide outcomes suggests significant correlations for the indicator adjusted hospital complications, borderline significance for adjusted hospital readmissions and non-significance for the adjusted hospital mortality and length of stay indicators. These results are confirmed by the bootstrap estimates of the robust regression model after adjusting for hospital characteristics.ConclusionsWe assessed associations between hospitals' quality improvement systems and clinical outcomes. From this data it seems that having a more developed quality improvement system is associated with lower rates of adjusted hospital complications. A number of methodological and logistic hurdles remain to link hospital quality improvement systems to outcomes. Further research should aim at identifying the latent dimensions of quality improvement systems that predict quality and safety outcomes. Such research would add pertinent knowledge regarding the implementation of organizational strategies related with quality of care outcomes.
| S-EPMC3267703 | biostudies-literature
Project description:ObjectiveTo compare trends in readmission rates among safety net and non-safety net hospitals under the US Hospital Readmission Reduction Program (HRRP).DesignA retrospective time series analysis using Medicare administrative claims data from January 2008 to June 2015.SettingWe examined 3254 US hospitals eligible for penalties under the HRRP, categorised as safety net or non-safety net hospitals based on the hospital's proportion of patients with low socioeconomic status.ParticipantsAdmissions for Medicare fee-for-service patients, age ?65 years, discharged alive, who had a valid five-digit zip code and did not have a principal discharge diagnosis of cancer or psychiatric illness were included, for a total of 52 516 213 index admissions.Primary and secondary outcome measuresMean hospital-level, all-condition, 30-day risk-adjusted standardised unplanned readmission rate, measured quarterly, along with quarterly rate of change, and an interrupted time series examining: April-June 2010, after HRRP was passed, and October-December 2012, after HRRP penalties were implemented.Results58.0% (SD 15.3) of safety net hospitals and 17.1% (SD 10.4) of non-safety net hospitals' patients were in the lowest quartile of socioeconomic status. The mean safety net hospital standardised readmission rate declined from 17.0% (SD 3.7) to 13.6% (SD 3.6), whereas the mean non-safety net hospital declined from 15.4% (SD 3.0) to 12.7% (SD 2.5). The absolute difference in rates between safety net and non-safety net hospitals declined from 1.6% (95% CI 1.3 to 1.9) to 0.9% (0.7 to 1.2). The quarterly decline in standardised readmission rates was 0.03 percentage points (95%?CI 0.03 to 0.02, p<0.001) greater among safety net hospitals over the entire study period, and no differential change among safety net and non-safety net hospitals was found after either HRRP was passed or penalties enacted.ConclusionsSince HRRP was passed and penalties implemented, readmission rates for safety net hospitals have decreased more rapidly than those for non-safety net hospitals.
| S-EPMC5541519 | biostudies-literature