Dataset Information

Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment.

ABSTRACT:

Background

Despite numerous studies of geographic variation in healthcare cost and utilization at the local, regional, and state levels across the U.S., a comprehensive characterization of geographic variation in outcomes has not been published. Our objective was to quantify variation in US health outcomes in an all-payer population before and after risk-adjustment.

Methods and findings

We used information from 16 independent data sources, including 22 million all-payer inpatient admissions from the Healthcare Cost and Utilization Project (which covers regions where 50% of the U.S. population lives) to analyze 24 inpatient mortality, inpatient safety, and prevention outcomes. We compared outcome variation at state, hospital referral region, hospital service area, county, and hospital levels. Risk-adjusted outcomes were calculated after adjusting for population factors, co-morbidities, and health system factors. Even after risk-adjustment, there exists large geographical variation in outcomes. The variation in healthcare outcomes exceeds the well publicized variation in US healthcare costs. On average, we observed a 2.1-fold difference in risk-adjusted mortality outcomes between top- and bottom-decile hospitals. For example, we observed a 2.3-fold difference for risk-adjusted acute myocardial infarction inpatient mortality. On average a 10.2-fold difference in risk-adjusted patient safety outcomes exists between top and bottom-decile hospitals, including an 18.3-fold difference for risk-adjusted Central Venous Catheter Bloodstream Infection rates. A 3.0-fold difference in prevention outcomes exists between top- and bottom-decile counties on average; including a 2.2-fold difference for risk-adjusted congestive heart failure admission rates. The population, co-morbidity, and health system factors accounted for a range of R2 between 18-64% of variability in mortality outcomes, 3-39% of variability in patient safety outcomes, and 22-70% of variability in prevention outcomes.

Conclusion

The amount of variability in health outcomes in the U.S. is large even after accounting for differences in population, co-morbidities, and health system factors. These findings suggest that: 1) additional examination of regional and local variation in risk-adjusted outcomes should be a priority; 2) assumptions of uniform hospital quality that underpin rationale for policy choices (such as narrow insurance networks or antitrust enforcement) should be challenged; and 3) there exists substantial opportunity for outcomes improvement in the US healthcare system.

SUBMITTER: Rosenberg BL

PROVIDER: S-EPMC5156342 | biostudies-literature | 2016

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment.

Rosenberg Barry L BL Kellar Joshua A JA Labno Anna A Matheson David H M DH Ringel Michael M VonAchen Paige P Lesser Richard I RI Li Yue Y Dimick Justin B JB Gawande Atul A AA Larsson Stefan H SH Moses Hamilton H

PloS one 20161214 12

<h4>Background</h4>Despite numerous studies of geographic variation in healthcare cost and utilization at the local, regional, and state levels across the U.S., a comprehensive characterization of geographic variation in outcomes has not been published. Our objective was to quantify variation in US health outcomes in an all-payer population before and after risk-adjustment.<h4>Methods and findings</h4>We used information from 16 independent data sources, including 22 million all-payer inpatient ...[more]

PMID: 27973617

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Project description:ImportanceGeographic variation in Medicare spending is often used as a measure of wasteful spending. A 2013 Institute of Medicine report found that postacute care was a key contributor of geographic variation from 2007 to 2009. However, payment reforms and antifraud efforts implemented after the passage of the Affordable Care Act (ACA) may have reduced geographic variation in spending, especially postacute care spending.ObjectiveTo investigate how geographic variation in Medicare fee-for-service per-beneficiary spending changed from 2007 to 2018 before and after passage of the ACA.Design setting and participantsThis cross-sectional study included all fee-for-service Medicare enrollees 65 years or older from January 1, 2007, to December 31, 2018. The fee-for-service Medicare Geographic Variation Public Use File was used to group hospital referral regions (HRRs) in each year into deciles (10 equal groups) based on per-beneficiary total spending. The difference between the per-beneficiary monthly spending in each decile and the national mean, as well as the ratio of per-beneficiary total spending in the top deciles to that of the bottom decile, were reported. Data analysis occurred from July 22, 2019, to October 21, 2021.Main outcomes and measuresPer-beneficiary spending on hospital inpatient, hospital outpatient, physician, and postacute care (and type of postacute care).ResultsThere were 27.2 million fee-for-service beneficiaries in 2007 (58.0% women) and 28.3 million beneficiaries in 2018 (55.9% women). Per-beneficiary Medicare spending was $9691 in 2007 and $9847 in 2018 (using inflation-adjusted 2018 dollars). Geographic variation in Medicare spending was stable from 2007 to 2011 and then declined steadily from 2012 to 2018. The ratio of per-beneficiary total Medicare spending in the HRRs in the top decile to the bottom decile was 1.68 in 2007 ($415 monthly difference in spending) but only 1.56 ($361 monthly difference in spending) in 2018 (estimated change, -0.12 [95% CI, -0.21 to -0.02]; P = .01). Focusing on specific spending categories, the only statistically significant reductions in geographic variation were found for home health; the ratio of home health spending among HRRs in the top to bottom deciles of total Medicare spending fell from 5.14 in 2007 to 3.45 in 2018 (change, -1.69 [95% CI, -3.30 to -0.09]; P = .04).Conclusions and relevanceGeographic variation in total per-beneficiary Medicare spending fell from 2007 to 2018, with home health spending being a key factor associated with geographic variation. The ACA's value-based payment programs and enhanced integrity efforts in home health provide a possible explanation for the decrease.

Project description:BACKGROUND:Acute kidney injury (AKI) during pregnancy is a public health problem and is associated with maternal and fetal morbidity and mortality. Clinical outcomes and health care utilization in pregnancy-related AKI, especially in women with diabetes, are not well studied. METHODS:Using data from the 2006 to 2015 Nationwide Inpatient Sample, we identified 42,190,790 pregnancy-related hospitalizations in women aged 15-49 years. We determined factors associated with AKI, including race/ethnicity, and associations between AKI and inpatient mortality, and between AKI and cardiovascular (CV) events, during pregnancy-related hospitalizations. We calculated health care expenditures from pregnancy-related AKI hospitalizations. RESULTS:Overall, the rate of AKI during pregnancy-related hospitalizations was 0.08%. In the adjusted regression analysis, a higher likelihood of AKI during pregnancy-related hospitalizations was seen in 2015 (OR 2.20; 95% CI 1.89-2.55) than in 2006; in older women aged 36-40 years (OR 1.49; 95% CI 1.36-1.64) and 41-49 years (OR 2.12; 95% CI 1.84-2.45) than in women aged 20-25 years; in blacks (OR 1.52; 95% CI 1.40-1.65) and Native Americans (OR 1.45; 95% CI 1.10-1.91) than in whites, and in diabetic women (OR 4.43; 95% CI 4.04-4.86) than in those without diabetes. Pregnancy-related hospitalizations with AKI were associated with a higher likelihood of inpatient mortality (OR 13.50; 95% CI 10.47-17.42) and CV events (OR 9.74; 95% CI 9.08-10.46) than were hospitalizations with no AKI. The median cost was higher for a delivery hospitalization with AKI than without AKI (USD 18,072 vs. 4,447). CONCLUSION:The rates of pregnancy-related AKI hospitalizations have increased during the last decade. Factors associated with a higher likelihood of AKI during pregnancy included older age, black and Native American race/ethnicity, and diabetes. Hospitalizations with pregnancy-related AKI have an increased risk of inpatient mortality and CV events, and a higher health care utilization than do those without AKI.

Dataset Information

Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment.

Background

Methods and findings

Conclusion

Publications

Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment.

Similar Datasets

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