Effects of Medicare Medical Reviews on Ambiguous Short-Stay Hospital Admissions.
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ABSTRACT:
SUBMITTER: Silver BC
PROVIDER: S-EPMC6232404 | biostudies-literature | 2018 Dec
REPOSITORIES: biostudies-literature
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Effects of Medicare Medical Reviews on Ambiguous Short-Stay Hospital Admissions.
Silver Benjamin C BC Rahman Momotazur M Wright Brad B Besdine Richard R Gozalo Pedro P Mor Vincent V
Health services research 20180904 6
<h4>Objective</h4>To examine the effects of Medicare's Medical Review (MR) program on short-stay inpatient hospitalization.<h4>Data sources/study setting</h4>One Hundred percent of Medicare Part A and Part B claims and the Master Beneficiary Summary File (2007-2010).<h4>Study design</h4>Retrospective observational study using a difference-in-differences approach. We examined six primary intake diagnoses, we believed likely to be targeted by MR. We stratified by hospital profit structure, bed siz ...[more]
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Project description:BackgroundMany inpatient facilities in Scotland have opened short stay paediatric assessment units (SSPAU) which are clinical areas separate from the usual inpatient ward area and these are where most short stay (also called zero day) admissions are accommodated. Here we describe the effect of opening short stay paediatric assessment units (SSPAU) on the proportion of zero day admissions relative to all emergency admissions.MethodsDetails of all emergency medical paediatric admissions to Scottish hospitals between 2000 and 2013 were obtained, including the number of zero day admissions per month and health board (i.e. geographic region). The month and year that an SSPAU opened in each health board was provided by local clinicians.ResultsSSPAUs opened in 7 health boards, between 2004 and 2012. Health boards with an SSPAU had a slower rise in zero day admissions compared to those without SSPAU (0.6% per month [95% CI 0.04, 0.09]. Across all 7 health boards, opening an SSPAU was associated with a 13% [95% CI 10, 15] increase in the proportion of zero day admissions. When considered individually, zero day admissions rose in four health boards after their SSPAU opened, were unchanged in one and fell in two health boards. Independent of SSPAUs opening, there was an increase in the proportion of all admissions which were zero day admissions (0.1% per month), and this accelerated after SSPAUs opened.ConclusionOpening an SSPAU has heterogeneous outcomes on the proportion of zero day admissions in different settings. Zero day admissions could be reduced in some health boards by understanding differences in clinical referral pathways between health boards with contrasting trends in zero day admissions after their SSPAU opens.
| S-EPMC8164232 | biostudies-literature
Project description:BackgroundTimely care by general practitioners in the community keeps children out of hospital and provides better continuity of care. Yet in the UK, access to primary care has diminished since 2004 when changes in general practitioners' contracts enabled them to 'opt out' of providing out-of-hours care and since then unplanned pediatric hospital admission rates have escalated, particularly through emergency departments. We hypothesised that any increase in isolated short stay admissions for childhood illness might reflect failure to manage these cases in the community over a 10 year period spanning these changes.Methods and findingsWe conducted a population based time trends study of major causes of hospital admission in children <10 years using the Hospital Episode Statistics database, which records all admissions to all NHS hospitals in England using ICD10 codes. Outcomes measures were total and isolated short stay unplanned hospital admissions (lasting less than 2 days without readmission within 28 days) from 1997 to 2006. Over the period annual unplanned admission rates in children aged <10 years rose by 22% (from 73.6/1000 to 89.5/1000 child years) with larger increases of 41% in isolated short stay admissions (from 42.7/1000 to 60.2/1000 child years). There was a smaller fall of 12% in admissions with length of stay of >2 days. By 2006, 67.3% of all unplanned admissions were isolated short stays <2 days. The increases in admission rates were greater for common non-infectious than infectious causes of admissions.ConclusionsShort stay unplanned hospital admission rates in young children in England have increased substantially in recent years and are not accounted for by reductions in length of in-hospital stay. The majority are isolated short stay admissions for minor illness episodes that could be better managed by primary care in the community and may be evidence of a failure of primary care services.
| S-EPMC2758998 | biostudies-literature
Project description:It is important that actual outcomes of care and not surrogate markers, such as process measures, be used to evaluate the quality of inpatient care. Because of the heterogenous composition of patients, risk-adjustment is essential for the objective evaluation of outcomes following inpatient care. Comparative evaluation of risk-adjusted outcomes can be used to identify suboptimal performance and can provide direction for care improvement initiatives.We studied the risk-adjusted outcomes of 6 medical conditions during the inpatient and 90-day post-discharge period to identify the opportunities for care improvement. The Medicare Limited Dataset for 2012 to 2014 was used to identify acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pneumonia (PNEU), cerebrovascular accidents (CVA), and gastrointestinal hemorrhage (GIH). Stepwise logistic predictive models were developed for the adverse outcomes (AOs) of inpatient deaths, 3-sigma prolonged length-of-stay outliers, 90-day post-discharge deaths, and 90-day readmissions after unrelated events were excluded. Observed and predicted AOs were determined for each hospital with ?75 cases for each of the 6 medical conditions. Z-scores and risk-adjusted AO rates for each hospital permitted comparative analysis of outcomes after adjusting for covariance among the medical conditions.There were a total of 1,811,749 patients from 973 acute care hospitals with the 6 medical conditions. A total of 41% of all patients had ?1 AO events. One or more readmissions were identified in 29.8% of patients. A total of 64 hospitals (6.4%) were 2 standard deviations better than the mean for risk-adjusted outcomes, and 72 (7.4%) were 2 standard deviations poorer. The best performing decile of hospitals had mean AO rates of 35.1% (odds ratio?=?0.766; 95% confidence interval (CI) CI: 0.762-0.771) and the poorest performing decile a mean AO rate of 48.5% (odds ratio?=?1.357; 95% CI: 1.346-1.369). Volume of qualifying cases ranged from 670 to 9314; no association was identified for increased volume of patients (P?<?.40).Risk-adjusted AO rates demonstrated nearly a 14% opportunity for care improvement between top and suboptimal performing hospitals. Hospitals must be able to benchmark objective measurement of outcomes to inform quality initiatives.
| S-EPMC6156012 | biostudies-literature
Project description:ObjectiveTo inform interventions focused on safely reducing urgent paediatric short stay admissions (SSAs) for convulsions.MethodsRoutinely acquired administrative data from hospital admissions in Scotland between 2015-2017 investigated characteristics of unscheduled SSAs (an urgent admission where admission and discharge occur on the same day) for a diagnosis of febrile and/or afebrile convulsions. Semi-structured interviews to explore perspectives of health professionals (n = 19) making referral or admission decisions about convulsions were undertaken. Interpretation of mixed methods findings was complemented by interviews with four parents with experience of unscheduled SSAs of children with convulsion.ResultsMost SSAs for convulsions present initially at hospital emergency departments (ED). In a subset of 10,588 (11%) of all cause SSAs with linked general practice data available, 72 (37%) children with a convulsion contacted both the GP and ED pre-admission. Within 30 days of discharge, 10% (n = 141) of children admitted with afebrile convulsions had been readmitted to hospital with a further convulsion. Interview data suggest that panic and anxiety, through fear that the situation is life threatening, was a primary factor driving hospital attendance and admission. Lengthy waits to speak to appropriate professionals exacerbate parental anxiety and can trigger direct attendance at ED, whereas some children with complex needs had direct access to convulsion professionals.ConclusionsSSAs for convulsions are different to SSAs for other conditions and our findings could inform new efficient convulsion-specific pre and post hospital pathways designed to improve family experiences and reduce admissions and readmissions.
| S-EPMC10984513 | biostudies-literature
Project description:BACKGROUND:Patients with heart failure (HF) are admitted either under observation (OBS) or inpatient stays; however, there is little data on whether this designation reflects the clinical status of a patient, with significant logistical and financial implications. We sought to compare the outcomes of patients with HF admitted OBS versus inpatient stay (?2 days; INPT). METHODS AND RESULTS:From January 1, 2008 to September 30, 2015, our multisite health system saw 21 339 unique patients totaling 52 493 hospital admissions with a primary diagnosis of HF. Patients were excluded if they underwent cardiac surgery (n=611), heart transplantation (n=187), or left ventricular assist device insertion (n=198), or if they died during hospitalization (n=1839). Of the remaining 50 654 discharges, 2 groups were identified: INPT group and OBS group. Outcomes were HF readmission, all-cause readmission, and all-cause mortality within 1 year of discharge. Hazard ratios were computed using the Andersen-Gill method in the Cox proportional-hazards model. A total of 8709 admissions (17%) occurred in the INPT group and 2648 admissions (5%) occurred in the OBS group. HF readmission rate at 1 year was 55.3% in INPT versus 66.5% in OBS (hazard ratio, 0.75; 95% confidence interval, 0.71-0.80; P<0.01). All-cause readmission rate at 1 year was 70.7% in INPT versus 82.5% in OBS (hazard ratio, 0.74; 95% confidence interval, 0.70-0.78; P<0.01). All-cause mortality at 1 year occurred in 25.2% of INPT versus 24.2% of OBS (hazard ratio, 1.03; 95% confidence interval, 0.95-1.12; P=0.46). CONCLUSIONS:HF admissions designated INPTs were associated with lower readmission rates and equivalent mortality to those designated OBS.
| S-EPMC5850263 | biostudies-literature
Project description:BackgroundNumbers of urgent short stay admissions (SSAs) of children to UK hospitals are rising rapidly. This paper reports on experiences of SSAs from the perspective of parents accessing urgent care for their acutely unwell child and of health professionals referring, caring for, or admitting children.MethodsA qualitative interview study was conducted by a multi-disciplinary team with patient and public involvement (PPI) to explore contextual factors relating to SSAs and better understand pre-hospital urgent care pathways. Purposive sampling of Health Board areas in Scotland, health professionals with experience of paediatric urgent care pathways and parents with experience of a SSA for their acutely unwell child was undertaken to ensure maximal variation in characteristics such as deprivation, urban-rural and hospital structure. Interviews took place between Dec 2019 and Mar 2021 and thematic framework analysis was applied.ResultsTwenty-one parents and forty-eight health professionals were interviewed. In the context of an urgent SSA, the themes were centred around shared outcomes of care that matter. The main outcome which was common to both parents and health professionals was the importance of preserving the child's safety. Additional shared outcomes by parents and health professionals were a desire to reduce worries and uncertainty about the illness trajectory, and provide reassurance with sufficient time, space and personnel to undertake a period of skilled observation to assess and manage the acutely unwell child. Parents wanted easy access to urgent care and, preferably, with input from paediatric-trained staff. Healthcare professionals considered that it was important to reduce the number of children admitted to hospital where safe and appropriate to do so.ConclusionsThe shared outcomes of care between parents and health professionals emphasises the potential merit of adopting a partnership approach in identifying, developing and testing interventions to improve the acceptability, safety, efficiency, and cost-effectiveness of urgent care pathways between home and hospital.
| S-EPMC9757586 | biostudies-literature
Project description:Background and objectiveHigh concentrations of air pollutants have been linked to increased incidence of stroke in North America and Europe but not yet assessed in mainland China. The aim of this study is to evaluate the association between stroke hospitalization and short-term elevation of air pollutants in Wuhan, China.MethodsDaily mean NO2, SO2 and PM10 levels, temperature and humidity were obtained from 2006 through 2008. Data on stroke hospitalizations (ICD 10: I60-I69) at four hospitals in Wuhan were obtained for the same period. A time-stratified case-crossover design was performed by season (April-September and October-March) to assess effects of pollutants on stroke hospital admissions.ResultsPollution levels were higher in October-March with averages of 136.1 µg/m(3) for PM10, 63.6 µg/m(3) for NO2 and 71.0 µg/m(3) for SO2 than in April-September when averages were 102.0 µg/m(3), 41.7 µg/m(3) and 41.7 µg/m(3), respectively (p<.001). During the cold season, every 10 µg/m(3) increase in NO2 was associated with a 2.9% (95%C.I. 1.2%-4.6%) increase in stroke admissions on the same day. Every 10 ug/m(3) increase in PM10 daily concentration was significantly associated with an approximate 1% (95% C.I. 0.1%-1.4%) increase in stroke hospitalization. A two-pollutant model indicated that NO2 was associated with stroke admissions when controlling for PM10. During the warm season, no significant associations were noted for any of the pollutants.ConclusionsExposure to NO2 is significantly associated with stroke hospitalizations during the cold season in Wuhan, China when pollution levels are 50% greater than in the warm season. Larger and multi-center studies in Chinese cities are warranted to validate our findings.
| S-EPMC3625157 | biostudies-literature
Project description:ImportanceSkilled nursing facility (SNF) changes in ownership are receiving attention in the national conversation regarding health care quality and oversight. SNF ownership changes have been cited as possible ways for SNFs to obscure financial arrangements and shift funds away from patient care; however, it is unclear whether ownership changes are associated with quality outcomes, especially for short-stay patients.ObjectiveTo determine which SNF characteristics are associated with changes in ownership and whether ownership changes were associated with differences in short-stay patient outcomes.Design, setting, and participantsThis cohort study was a secondary analysis of 2016 to 2019 Medicare administrative data including SNFs in the United States with complete data. Data were analyzed from January 2016 through December 2019.ExposureSNF change in ownership.Main outcomes and measuresOutcomes of interest were facility-level risk-adjusted rates of hospital readmissions, emergency department visits, and community discharge for short-stay patients after admission to an SNF. Analyses were conducted using multivariable logistic regression and controlled interrupted time series.ResultsOf 11 004 SNFs, 1459 (13.26%) changed ownership between 2016 and 2019. Compared with for-profit SNFs, nonprofit and government SNFs had lower odds of changing ownership (nonprofit: odds ratio [OR], 0.40; 95% CI, 0.32-0.49; government: OR, 0.26; 95% CI, 0.17-0.41). Chain SNFs had higher odds of changing ownership than nonchain SNFs (OR, 1.38; 95% CI, 1.21-1.59). Urban SNFs with lower occupancy rates (OR per 10-percentage-point decrease, 1.19; 95% CI, 1.14-1.25), larger Medicaid populations (OR per 10-percentage-point increase, 1.17; 95% CI, 1.13-1.22), and lower staffing ratings (OR per 1-star increase on staffing rating, 1.18; 95% CI, 1.14-1.25) had higher odds of changing ownership. Descriptively, all 3 quality outcomes were worse throughout the study in SNFs undergoing ownership change compared with controls that did not change ownership. However, results of interrupted time series models found no associations between an ownership change and hospital readmissions or community discharge rates. Ownership change was associated with a short-term increase of 0.32 (95% CI, 0.03 to 0.62) percentage points in emergency department visits.Conclusions and relevanceIn this cohort study of 11 004 SNFs in the US between 2016 and 2019, SNF characteristics historically associated with lower quality were more likely to change ownership; however, ownership changes were only associated with short-term increases in ED visits. These results suggest that SNF ownership changes may be a symptom, not a cause, of lower quality.
| S-EPMC10509722 | biostudies-literature
Project description:ObjectivesTo determine whether high performing hospitals with low 30 day risk standardized readmission rates have a lower proportion of readmissions from specific diagnoses and time periods after admission or instead have a similar distribution of readmission diagnoses and timing to lower performing institutions.DesignRetrospective cohort study.SettingMedicare beneficiaries in the United States.ParticipantsPatients aged 65 and older who were readmitted within 30 days after hospital admission for heart failure, acute myocardial infarction, or pneumonia in 2007-09.Main outcome measuresReadmission diagnoses were classified with a modified version of the Centers for Medicare and Medicaid Services' condition categories, and readmission timing was classified by day (0-30) after hospital discharge. Hospital 30 day risk standardized readmission rates over the three years of study were calculated with public reporting methods of the US federal government, and hospitals were categorized with bootstrap analysis as having high, average, or low readmission performance for each index condition. High and low performing hospitals had ≥ 95% probability of having an interval estimate respectively less than or greater than the national 30 day readmission rate over the three year period of study. All remaining hospitals were considered average performers.ResultsFor readmissions in the 30 days after the index admission, there were 320,003 after 1,291,211 admissions for heart failure (4041 hospitals), 102,536 after 517,827 admissions for acute myocardial infarction (2378 hospitals), and 208,438 after 1,135,932 admissions for pneumonia (4283 hospitals). The distribution of readmissions by diagnosis was similar across categories of hospital performance for all three conditions. High performing hospitals had fewer readmissions for all common diagnoses. Median time to readmission was similar by hospital performance for heart failure and acute myocardial infarction, though was 1.4 days longer among high versus low performing hospitals for pneumonia (P<0.001). Findings were unchanged after adjustment for other hospital characteristics potentially associated with readmission patterns.ConclusionsHigh performing hospitals have proportionately fewer 30 day readmissions without differences in readmission diagnoses and timing, suggesting the possible benefit of strategies that lower risk of readmission globally rather than for specific diagnoses or time periods after hospital stay.
| S-EPMC3898430 | biostudies-literature
Project description:Background/objectivesObservation stays are increasingly common for older adults, yet little is known about the extent to which they are being used as the Centers for Medicare and Medicaid Services (CMS) originally intended for unscheduled or acute problems and whether different types of services are reflected in current billing practices.DesignObservational cohort study.Setting/participantsA total of 867,165 qualifying observation stays identified from 451,408 patients using Medicare fee-for-service claims data from a nationally representative 20% beneficiary sample between January 1, 2014, and November 30, 2014.MeasurementsUsing descriptive and multivariable logistic model analytic approaches, we evaluated the patient, stay, and hospital characteristics associated with the most common billing practice for observation stays (charge revenue center 0761 exclusively) vs all other practices.ResultsSixty-three percent of observation stays were billed exclusively under the 0761 revenue center and were more likely to be for preplanned chronic conditions consisting of short-term treatments (eg, chemotherapy, radiation therapy, wound care, paracentesis, epidural spinal injection). These stays appeared to be used for recurrent single-day visits, given their strong association with prior visits and a high rate of reobservation (41.4%), with frequent return stays appearing in a 7-day pattern.ConclusionNearly two-thirds of observation stays are billed using only the 0761 revenue code and appear to be for prescheduled, repeated treatments-differing substantially from CMS' explicitly stated purpose as a form of care used while a healthcare provider determines whether a patient presenting for unscheduled or acute conditions requires inpatient hospital admission or can be safely discharged. Guidance is needed from CMS to clarify the appropriate role of observation stays, with discussion as to whether episodic single-day, planned treatment for chronic conditions not originating in the emergency department should be billed as observation stays or placed under another mechanism. Subsequent research is needed to understand how the current use of observation stays impact patient out-of-pocket costs. J Am Geriatr Soc 68:1568-1572, 2020.
| S-EPMC7363536 | biostudies-literature