Did case-based payment influence surgical readmission rates in France? A retrospective study.
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ABSTRACT:
SUBMITTER: Vuagnat A
PROVIDER: S-EPMC5829593 | biostudies-literature | 2018 Feb
REPOSITORIES: biostudies-literature
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Did case-based payment influence surgical readmission rates in France? A retrospective study.
Vuagnat Albert A Yilmaz Engin E Roussot Adrien A Rodwin Victor V Gadreau Maryse M Bernard Alain A Creuzot-Garcher Catherine C Quantin Catherine C
BMJ open 20180201 2
<h4>Objectives</h4>To determine whether implementation of a case-based payment system changed all-cause readmission rates in the 30 days following discharge after surgery, we analysed all surgical procedures performed in all hospitals in France before (2002-2004), during (2005-2008) and after (2009-2012) its implementation.<h4>Setting</h4>Our study is based on claims data for all surgical procedures performed in all acute care hospitals with >300 surgical admissions per year (740 hospitals) in F ...[more]
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Project description:ObjectiveTo examine the association of hospital volume (a marker of quality of care) with hospital readmission rates.DesignRetrospective cross-sectional study.Setting4651 US acute care hospitals.Study data6,916,644 adult discharges, excluding patients receiving psychiatric or medical cancer treatment.Main outcome measuresWe used Medicare fee-for-service data from 1 July 2011 to 30 June 2012 to calculate observed-to-expected, unplanned, 30 day, standardized readmission rates for hospitals and for specialty cohorts medicine, surgery/gynecology, cardiorespiratory, cardiovascular, and neurology. We assessed the association of hospital volume by quintiles with 30 day, standardized readmission rates, with and without adjustment for hospital characteristics (safety net status, teaching status, geographic region, urban/rural status, nurse to bed ratio, ownership, and cardiac procedure capability. We also examined associations with the composite outcome of 30 day, standardized readmission or mortality rates.ResultsMean 30 day, standardized readmission rate among the fifth of hospitals with the lowest volume was 14.7 (standard deviation 5.3) compared with 15.9 (1.7) among the fifth of hospitals with the highest volume (P<0.001). We observed the same pattern of lower readmission rates in the lowest versus highest volume hospitals in the specialty cohorts for medicine (16.6 v 17.4, P<0.001), cardiorespiratory (18.5 v 20.5, P<0.001), and neurology (13.2 v 14.0, p=0.01) cohorts; the cardiovascular cohort, however, had an inverse association (14.6 v 13.7, P<0.001). These associations remained after adjustment for hospital characteristics except in the cardiovascular cohort, which became non-significant, and the surgery/gynecology cohort, in which the lowest volume fifth of hospitals had significantly higher standardized readmission rates than the highest volume fifth (difference 0.63 percentage points (95% confidence interval 0.10 to 1.17), P=0.02). Mean 30 day, standardized mortality or readmission rate was not significantly different between highest and lowest volume fifths (20.4 v 20.2, P=0.19) and was highest in the middle fifth of hospitals (range 20.6-20.8).ConclusionsStandardized readmission rates are lowest in the lowest volume hospitals-opposite from the typical association of greater hospital volume with better outcomes. This association was independent of hospital characteristics and was only partially attenuated by examining mortality and readmission together. Our findings suggest that readmissions are associated with different aspects of care than mortality or complications.
| S-EPMC4353286 | biostudies-literature
Project description:BackgroundMedicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries.ObjectiveTo compare readmission rates between Medicare Advantage and traditional Medicare.DesignRetrospective cohort study linking the Medicare Provider Analysis and Review (MedPAR) file with the Healthcare Effectiveness Data and Information Set (HEDIS).Setting4748 U.S. acute care hospitals.PatientsPatients aged 65 years or older hospitalized for acute myocardial infarction (AMI) (n = 841 613), congestive heart failure (CHF) (n = 1 458 652), or pneumonia (n = 2 020 365) between 2011 and 2014.Measurements30-day readmissions.ResultsAmong admissions for AMI, CHF, and pneumonia identified in MedPAR, 29.2%, 38.0%, and 37.2%, respectively, did not have a corresponding record in HEDIS. Of these, 18.9% for AMI, 23.7% for CHF, and 18.3% for pneumonia resulted in a readmission that was identified in MedPAR. However, among index admissions appearing in HEDIS, 14.4% for AMI, 18.4% for CHF, and 13.9% for pneumonia resulted in a readmission. Patients in Medicare Advantage had lower unadjusted readmission rates than those in traditional Medicare for all 3 conditions (16.6% vs. 17.1% for AMI, 21.4% vs. 21.7% for CHF, and 16.3% vs. 16.4% for pneumonia). However, after standardization, patients in Medicare Advantage had higher readmission rates than patients in traditional Medicare for AMI (17.2% vs. 16.9%; difference, 0.3 percentage point [95% CI, 0.1 to 0.5 percentage point]), CHF (21.7% vs. 21.4%; difference, 0.3 percentage point [CI, 0.2 to 0.5 percentage point]), and pneumonia (16.5% vs. 16.0%; difference, 0.5 percentage point [95% CI, 0.4 to 0.6 percentage point]). Rate differences increased between 2011 and 2014.LimitationPotential unobserved differences between populations.ConclusionThe HEDIS data underreported hospital admissions for 3 common medical conditions, and readmission rates were higher among patients with underreported admissions. Medicare Advantage beneficiaries had higher risk-adjusted 30-day readmission rates than traditional Medicare beneficiaries.Primary funding sourceNational Institute on Aging.
| S-EPMC6736728 | biostudies-literature
Project description:BackgroundIn the past decade, the rate of cesarean delivery increased dramatically in rural China under the fee-for-service (FFS) system. In September 2011, the New Cooperative Medical Scheme (NCMS) agency in Yong'an county in Fujian province of China adopted a policy of reforming payment for childbirth by transforming the FFS payment into episode-based bundled payment (EBP), which made the cesarean deliveries less profitable. Thus, this study was conducted to determine the effect of EBP policy on reducing cesarean use and controlling delivery costs for rural patients in the NCMS.MethodsData from the inpatient information database of the NCMS agency from January 2010 to March 2013 was collected, in which Yong'an county was employed as a reform county and 2 other counties as controls. We investigated the effects of EBP on cesarean delivery rate, costs of childbirth and readmission for rural patients in the NCMS using a natural experiment design and difference in differences (DID) analysis method.ResultsThe EBP reform was associated with 33.97% (p<0.01) decrease in the probability of cesarean delivery. The EBP reform, on average, reduced the total spending per admission, government reimbursement expenses per admission, and out-of-pocket (OOP) payments per admission by ¥ 649.61, ¥ 575.01, and ¥ 74.59, respectively. The OOP payments had a net decrease of 14.24% (p<0.01); whereas the OOP payments as a share of total spending had a net increase of 8.72% (p<0.01). There was no evidence of increase in readmission rates.ConclusionsThese results indicate that the EBP policy has achieved at least a short-term success in lowering the increase of cesarean delivery rate and costs of childbirth. Considering both the cesarean rate and the OOP payments as a share of total spending after the reform were still high, China still has a long way to go to achieve the ideal level of cesarean rate and improve the benefits of deliveries for rural population.
| S-EPMC6515611 | biostudies-literature
Project description:BackgroundAlthough spinal meningiomas respond favorably to surgical excision, their surgical management is impacted by several factors. This study utilized a surgery-based grading system to discuss the optimal surgical strategy.MethodsTwenty-three consecutive patients who underwent surgery for spinal meningiomas were included in this retrospective study. The patients' neurological condition was assessed using the modified McCormick functional schema (mMFS) and sensory pain scale (SPS), and tumor removal was assessed using Simpson grade. Major factors contributing to surgical difficulty included; tumor size, extent/severity of cord compression, location of tumor attachment, spinal level, and anatomical relationships plus tumor extending in a dumbbell shape and local postoperative recurrence.ResultsFifteen cases were classified as ventral attachment (65.2%). There were two dumbbell-shaped tumors and three local recurrences at the primary site. Simpson grade 1 or 2 resections were performed in 18 of 20 cases (90%) with preoperative surgical grades 0 to 3. Simpson grade 4 resections were achieved in all three cases with preoperative surgical grades 4 to 5. Overall neurological assessment after surgery revealed the satisfactory or acceptable recovery on mMFS and SPS analysis.ConclusionsLower preoperative grade yielded better results, while the higher the preoperative grade, the more likely tumor was insufficiently removed. A preoperative surgical grading system appeared to be helpful when considering the surgical strategy. Ventral meningiomas could be safely resected via the posterolateral or lateral approach using technical modifications. Recurrent tumors, especially with ventral attachment, were hard to resolve, and primary surgery appears to be important.
| S-EPMC4173305 | biostudies-literature
Project description:BackgroundUnplanned hospital readmission is a complex process, particularly if the patient is readmitted to an acute care institution other than the original hospital. This study tested the hypothesis that readmission to an alternative hospital is associated with increased mortality compared with readmission to the original hospital.MethodsWe performed a population-based retrospective cohort analysis set between 1995 and 2010 for all 21 acute care adult general hospitals in the Greater Toronto and Hamilton Area. Participants were consecutive adults (age ≥ 18 yr) readmitted through the emergency department within 30 days after hospital discharge. The primary outcome measure was all-cause mortality within 30 days after readmission.ResultsOf the 198 149 patients included in the study, 38 134 (19.2%) died within 30 days after readmission. Patients readmitted to an alternative hospital were more likely than those readmitted to the original hospital to be older, reside in a chronic-care facility and arrive by ambulance. Alternative-hospital readmission was associated with a higher risk of death within 30 days (22.3% v. 18.6%, p < 0.001; odds ratio [OR] 1.26, 95% confidence interval [CI] 1.23-1.30). The increased risk was substantially less after adjustment for patient- and hospital-level covariables (adjusted OR 1.06, 95% CI 1.02-1.10). Unadjusted Kaplan-Meier survival curves separated early and the absolute difference in mortality continued throughout the entire 1-year follow-up period, but no difference between groups was observed based on adjusted survival analyses.InterpretationAmong patients readmitted within 30 days after discharge, readmission to an alternative hospital was associated with a higher risk of death than readmission to the original hospital. Whether this adverse prognosis reflects a true causal relation or residual confounding is unknown.
| S-EPMC4084742 | biostudies-literature
Project description:OBJECTIVES:To identify modifiable factors leading to unplanned readmission and characterize differences in adjusted unplanned readmission rates across hospitals. DESIGN:Retrospective cohort study using prospectively collected clinical registry data SETTING:: Pediatric Cardiac Critical Care Consortium clinical registry. PATIENTS:Patients admitted to a pediatric cardiac ICU at Pediatric Cardiac Critical Care Consortium hospitals. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:We examined pediatric cardiac ICU encounters in the Pediatric Cardiac Critical Care Consortium registry from October 2013 to March 2016. The primary outcomes were early (< 48?hr from pediatric cardiac ICU transfer) and late (2-7 d) unplanned readmission. Generalized logit models identified independent predictors of unplanned readmission. We then calculated observed-to-expected ratios of unplanned readmission and identified higher-than or lower-than-expected unplanned readmission rates for those with an observed-to-expected ratios greater than or less than 1, respectively, and a 95% CI that did not cross 1. Of 11,301 pediatric cardiac ICU encounters (16 hospitals), 62% were surgical, and 18% were neonates. There were 175 (1.6%) early unplanned readmission, and 300 (2.7%) late unplanned readmission, most commonly for respiratory (31%), or cardiac (28%) indications. In multivariable analysis, unique modifiable factors were associated with unplanned readmission. Although shorter time between discontinuation of vasoactive infusions and pediatric cardiac ICU transfer was associated with early unplanned readmission, nighttime discharge was independently associated with a greater likelihood of late unplanned readmission. Two hospitals had lower-than-expected unplanned readmission in both the early and late categories, whereas two other hospitals were higher-than-expected in both. CONCLUSIONS:This analysis demonstrated time from discontinuation of critical care therapies to pediatric cardiac ICU transfer as a significant, modifiable predictor of unplanned readmission. We identified two hospitals with lower-than-expected adjusted rates of both early and late unplanned readmission, suggesting that their systems are well designed to prevent unplanned readmission. This offers the possibility of disseminating best practices to other hospitals through collaborative learning.
| S-EPMC6239958 | biostudies-literature
Project description:ImportanceThirty-day readmission rates have been suggested as a marker for quality of care. By investigating the factors associated with readmissions in all otolaryngology subspecialties we provide data relevant for the development of risk stratification systems to improve outcomes.ObjectiveTo establish the association of surgical and hospital volume and patient characteristics with 30-day readmission rates to guide the development of otolaryngology-specific risk stratification models.Design, setting, and participantsA retrospective cohort study including adult patients who underwent inpatient otolaryngology surgery in New York State between 1995 and 2015 was conducted using the Statewide Planning and Research Cooperative System (SPARCS). Regression techniques were used to describe relationships of patient-level factors, hospital, and surgeon volume to 30-day readmission rates in New York State.Main outcomes and measuresThe main outcome measures were patient-, surgeon-, and hospital-level risk factors for readmission. Secondary outcome measures were rate of readmissions by subspecialty procedure and by diagnosis on readmission.ResultsWe identified 254 257 cases of otolaryngology surgery (147 065 women [58%], mean [SD] age 50 [17] years). The 30-day readmission rate was 6%. In a multivariable model, odds ratios (ORs) identified Medicaid insurance (OR, 1.46; 99% CI, 1.36-1.57), Medicare insurance (OR, 1.32; 99% CI, 1.24-1.42), bottom quartile income (OR, 1.08; 99% CI, 1.01-1.15), patient comorbidities measured by the Charlson Comorbidity Index (CCI) (CCI >1; OR, 2.31; 99% CI, 2.16-2.47), length of stay (LOS) (LOS >10 days; OR, 2.29; 99% CI, 2.00-2.45), rhinology (OR, 1.37; 99% CI, 1.24-1.51), laryngology (OR, 1.98; 99% CI, 1.62-2.43), and head and neck cancer (OR, 1.27; 99% CI, 1.17-1.37) procedures as readmission predictors. High-volume surgeons were protective of 30-day readmission (OR, 0.67; 99% CI, 0.635-0.708) relative to low volume. Hospital volume was not significantly associated to readmissions. The most common causes of readmission included wound- (2682 patients, 18%), respiratory- (1776 patients, 12%), cardiovascular- (1210 patients, 8%), and volume- (1089 patients, 7%) related disorders.Conclusions and relevanceThis study evaluated the combined effects of patient-, surgeon-, and hospital-level factors on 30-day readmission after otolaryngology surgery. Socioeconomic factors, patient comorbidities, surgeon volumes, and procedure were significantly associated with 30-day readmission. Though the cause of 30-day readmission is multifactorial, a large portion is driven by socioeconomic factors. Addressing these disparities at the system level is necessary to address the described readmission disparities. The development of risk-stratification models based on patient-, procedure-, and surgeon-level factors may help facilitate resource distribution.
| S-EPMC6481432 | biostudies-literature
Project description:ObjectiveTo measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation.Data sources/study settingMedicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files.Study designWe measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time.Data collection/extraction methodsData downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas.Principal findingsIn 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time.ConclusionsAdjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.
| S-EPMC5346495 | biostudies-literature
Project description:BACKGROUND:Higher income population tend to prefer brand-name to generic drugs, which may cause disparity in access to brand-name drugs among income groups. A potential policy that can resolve such disparity is imposing a greater co-payment rate on high-income enrollees. However, the effects of such policy are unknown. We examined how patients' choice between brand-name and generic drugs are affected by the unique income-based co-payment rates in Japan; 10% for general enrollees and 30% for those with high income among the elderly aged 75 and over. METHODS:We drew on cross-sectional price variation among commonly prescribed 311 drugs using health insurance claims data from a large prefecture in Japan between October 2013 and September 2014 to identify between-income-group differences in responses to differentiated payments. RESULTS:Running 311 multivariate logistic regression models controlling individual demographics, the median estimate indicated that high-income group was 3% (odds ratio?=?0.97) less likely to choose a generic drug than the general-income group and the interquartile estimates ranged 0.92-1.02. The multivariate feasible generalized least squares model indicated high-income group's higher likelihood to choose brand-name drugs than the general-income group without co-payment rate differentiation (p?<?0.001). Such gap in the likelihood was attenuated by 0.4% (p?=?0.027) with an US$1 increase in the difference in additional payment/month for brand-name drugs between income groups - no gap with US$10 additional payment/month. This attenuation was observed in drugs for chronic diseases only, not for acute diseases. CONCLUSIONS:Income-based co-payment rates appeared to reduce disparity in access to brand-name drugs across income groups, in addition to reducing total medical expenditure among high-income group who shifted from brand-name drugs to generic ones due to larger drug price differences.
| S-EPMC6824135 | biostudies-literature
Project description:Background Proximal humerus fractures (PHFs) are generally surgically treated with open reduction internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). Diverse fracture patterns and a high prevalence in the elderly population make it difficult to establish objective guidelines for the decision to undergo surgical treatment. The purpose of this study was to investigate risk factors associated with readmission, reoperation, and nonhome discharge following ORIF, HA, and TSA for PHFs. Methods Data on all patients who underwent ORIF, TSA, or HA for treatment of closed PHF between 2015 and 2017 were obtained by querying the American College of Surgeons National Surgical Quality Improvement database. Rates of postoperative readmission, nonhome discharge, and reoperation within 30 days were collected. Multivariate logistic regression was employed to identify predictors of readmission, nonhome discharge, and reoperation. Results A total of 2825 patients were included in this study: 1829 underwent ORIF, 707 underwent TSA, and 289 underwent HA. The significant predictors for readmission were having an American Society of Anesthesiologists class ≥ 3 (odds ratio [OR] 1.95, P = .003) and being of dependent functional status (OR 3.15, P < .001). The significant predictors for reoperation were male sex (OR 2.41, P < .001) and dependent functional status (OR 2.92, P = .006). The significant predictors for nonhome discharge were age 66-80 years (OR 7.00, P < .001), age ≥ 81 years (OR 16.31, P < .001), American Society of Anesthesiologists ≥3 (OR 2.34, P < .001), dependent functional status (OR 2.48, P < .001), and inpatient status (OR 3.32, P < .001). TSA showed slightly higher rates of nonhome discharge than HA and ORIF. Conclusion Significant risk factors for readmission, reoperation, and nonhome discharge within 30 days following surgical treatment for PHF were identified. Additionally, TSA was significantly associated with nonhome discharge compared with HA and ORIF.
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