Changes in Hospital-acquired Conditions and Mortality Associated With the Hospital-acquired Condition Reduction Program.

IMPORTANCE: To improve patient safety, the Centers for Medicare and Medicaid Services announced the Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The program reduces Medicare payments by 1% for hospitals in the lowest performance quartile related to hospital-acquired conditions. Performance measures are focused on perioperative care. OBJECTIVE: To evaluate changes in HACs and 30-day mortality after the announcement of the HACRP. DESIGN: Interrupted time-series design using Medicare Provider and Analysis Review (MEDPAR) claims data. We estimated models with linear splines to test for changes in HACs and 30-day mortality before the Affordable Care Act (ACA), after the ACA, and after the HACRP. SETTING: Fee-for-service Medicare 2009-2015. PARTICIPANTS: Medicare beneficiaries undergoing surgery and discharged from an acute care hospital between January 2009 and August 2015 (N = 8,857,877). MAIN OUTCOME AND MEASURE: Changes in HACs and 30-day mortality after the announcement of the HACRP. RESULTS: Patients experienced HACs at a rate of 13.39 per 1000 discharges [95% confidence interval (CI), 13.10 to 13.68] in the pre-ACA period. This declined after the ACA was passed and declined further after the HACRP announcement [adjusted difference in annual slope, -1.34 (95% CI, -1.64 to -1.04)]. Adjusted 30-day mortality was 3.69 (95% CI, 3.64 to 3.74) in the pre-ACA period among patients receiving surgery. Thirty-day mortality continued to decline after the ACA [adjusted annual slope -0.04 (95% CI, -0.05 to -0.02)] but was flat after the HACRP [adjusted annual slope -0.01 (95% CI, -0.04 to 0.02)]. CONCLUSIONS AND RELEVANCE: Although hospital-acquired conditions targeted under the HACRP declined at a greater rate after the program was announced, 30-day mortality was unchanged.

Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions.

OBJECTIVE: To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons. SUMMARY OF BACKGROUND DATA: Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes. METHODS: This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative. Surgeons were categorized as coach, participant, or nonparticipant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends, and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program. RESULTS: The coaching program was viewed favorably by most surgeons and many participants described numerous technical and nontechnical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants, and nonparticipants of 0.99 (0.62-1.37), 0.91 (0.64-1.17), and 1.15 (0.83-1.47), respectively. Operative times did improve for participants, but not coaches or nonparticipants, with risk differences of -14.0 (-22.3, -5.7), -1.0 (-4.5, 2.4), and -2.6 (-6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review. CONCLUSIONS: This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.

Coaching as a Mechanism to Challenge Surgical Professional Identities.

BACKGROUND: The "surgical personality" is a mostly negative academic and cultural image of the surgeon as egotistical, paternalistic, and inflexible. Because of this image, surgeons have been viewed as resistant to change and some behaviors, vulnerability, for example, are viewed as "suspect" because they seemingly threaten professional competency. We report on exit interviews of surgeons who participated in a coaching program and demonstrate how their narratives challenge the surgical "personality" and forge an evolving and more open professional surgical identity. METHODS: We interviewed n = 34 bariatric surgeons at the end of a 2-year surgical coaching program. Transcribed interviews were analyzed in NVivo, computer-assisted qualitative data analysis software. Coding of transcripts was approached through iterative steps. We utilized an exploratory method; each member of our team independently examined 3 transcripts to evaluate emergent themes early in the investigation. The team met to discuss our independent themes and develop the codebook collectively. We created a descriptive framework for our first round of coding based on emerging themes and employed an interpretive framework to arrive at our themes. RESULTS: Three major themes emerged from our data. Participants in this study discussed the ways that participation in the coaching program initially conflicted with their identity as a competent professional. Surgeons were acutely aware of how participation might have destabilized their surgical identity because they might be viewed as vulnerable. Despite these concerns about image, surgeons found impetus for improvement because of poor outcome scores or because they desired early career affirmation. Finally, surgeons report that the safe spaces of intentional coaching contributed to their ideas about how surgeons, and ultimately surgery, can change. CONCLUSIONS: Participation in a coaching program challenged how surgeons thought of themselves in relationship to social and peer expectations. Our results indicate that surgeons do feel peer and social pressures related to identity but are much more complex and nuanced than has been previously discussed. The safe space of intentional coaching allowed participants to practice vulnerability without the pressures of sometimes caustic professional norms. Participants in this study viewed coaching as the way to improve the culture of surgery.

Evaluation of US Hospital Episode Spending for Acute Inpatient Conditions After the Patient Protection and Affordable Care Act.

Importance: Under the Patient Protection and Affordable Care Act (ACA), US hospitals were exposed to a number of reforms intended to reduce spending, many of which, beginning in 2012, targeted acute care hospitals and often focused on specific diagnoses (eg, acute myocardial infarction, heart failure, and pneumonia) for Medicare patients. Other provisions enacted in the ACA and under budget sequestration (beginning in 2013) mandated Medicare fee cuts. Objective: To evaluate the association between the enactment of ACA reforms and 30-day price-standardized hospital episode spending. Design, Setting, and Participants: This policy evaluation included index discharges between January 1, 2008, and August 31, 2015, from a national random 20% sample of Medicare beneficiaries. Data analysis was performed from February 1, 2019 to July 8, 2020. Exposure: Payment reforms after passage of the ACA. Main Outcomes and Measures: 30-day price-standardized episode payments. Three alternative estimation approaches were used to evaluate the association between reforms following the ACA and episode spending: (1) a difference-in-difference (DID) analysis among acute care hospitals, comparing spending for diagnoses commonly targeted by ACA programs with nontargeted diagnoses; (2) a DID analysis comparing acute care hospitals and critical access hospitals (not exposed to reforms); and (3) a generalized synthetic control analysis, comparing acute care and critical access hospitals. Supplemental analysis examined the degree to which Medicare fee cuts contributed to spending reductions. Results: A total of 7 634 242 index discharges (4 525 630 [59.2%] female patients; mean [SD] age, 79.31 [8.02] years) were included. All 3 approaches found that reforms following the ACA were associated with a significant reduction in episode spending. The DID estimate comparing targeted and untargeted diagnoses suggested that reforms following the ACA were associated with a -$431 (95% CI, -$492 to -$369; -2.87%) change in total spending, while the generalized synthetic control analysis suggested that reforms were associated with a -$1232 (95% CI, -$1488 to -$965; -10.12%) change in total episode spending, amounting in a total annual savings of $5.68 billion. Cuts to Medicare fees accounted for most of these savings. Conclusions and Relevance: In this policy evaluation, the ACA was associated with large reductions in US hospital episode spending.

Is social capital protective against hospital readmissions?

BACKGROUND: To evaluate the association between social capital and 30-day readmission to the hospital among Medicare beneficiaries overall, beneficiaries with dementia and related memory disorders, and beneficiaries with dual eligibility for Medicaid. METHODS: Using Health and Retirement Study (HRS) data linked with 2008-2015 Medicare claims from traditional Medicare beneficiaries hospitalized during the study period (1246 unique respondents, 2212 total responses), we examined whether dementia and related memory disorders and dual eligibility were associated with social capital. We then estimated a multiple regression model to test whether social capital was associated with a reduced likelihood of readmission. RESULTS: Dementia was associated with an - 0.241 standard deviation (sd) change in social capital (95% CI: - 0.378, - 0.103), dual eligibility with a - 0.461 sd change (95% CI: - 0.611, - 0.310), and the occurrence of both was associated with an additional - 0.236 sd change (95% CI: - 0.525, - 0.053). 30-day readmission rates were 14.47% over the study period. In both adjusted and unadjusted models, social capital was associated with small and nonsignificant differences in 30-day readmissions. These effects did not vary across dementia status and socioeconomic status. CONCLUSIONS: Dementia and dual eligibility were associated with lower social capital, but social capital was not associated with the risk of readmission for any population.

Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study.

OBJECTIVE: To evaluate the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and subsequent changes in clinical outcomes. DESIGN: Regression discontinuity design applied to a retrospective cohort from inpatient Medicare claims. SETTING: 3238 acute care hospitals in the United States. PARTICIPANTS: Medicare fee-for-service beneficiaries discharged from acute care hospitals between 23 July 2014 and 30 November 2016 and eligible for at least one targeted hospital acquired condition (n=15 470 334). INTERVENTION: Hospital receipt of a penalty in the first year of the HACRP. MAIN OUTCOME MEASURES: Episode level count of targeted hospital acquired conditions per 1000 episodes, 30 day readmissions, and 30 day mortality. RESULTS: Of 724 hospitals penalized under the HACRP in fiscal year 2015, 708 were represented in the study. Mean counts of hospital acquired conditions were 2.72 per 1000 episodes for penalized hospitals and 2.06 per 1000 episodes for non-penalized hospitals; 30 day readmissions were 14.4% and 14.0%, respectively, and 30 day mortality was 9.0% for both hospital groups. Penalized hospitals were more likely to be large, teaching institutions, and have a greater share of patients with low socioeconomic status than non-penalized hospitals. HACRP penalties were associated with a non-significant change of -0.16 hospital acquired conditions per 1000 episodes (95% confidence interval -0.53 to 0.20), -0.36 percentage points in 30 day readmission (-1.06 to 0.33), and -0.04 percentage points in 30 day mortality (-0.59 to 0.52). No clear patterns of clinical improvement were observed across hospital characteristics. CONCLUSIONS: Penalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements. By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care.

Sprint to work: A novel model for team science collaboration in academic medicine.

Collaborative research in academic medicine is often inefficient and ineffective. It often fails to leverage the expertise of interdisciplinary team members, does not seek or incorporate team input at opportune times, and creates workload inequities. Adapting approaches developed in venture capital, we created the 'sprint model' for writing academic papers based on the analysis of secondary data. The 'sprint model' minimizes common barriers that undermine collaboration in academic medicine. This model for team science collaboration begins with team members convening for a highly focused, guided session. In this session, a facilitator moves the group through a structured process to create the study plan. This includes refining the research questions, developing the study design, and prototyping the presentation of results. After adopting this model, our team has drastically reduced time from idea inception to final product submission through increased efficiencies and reduced redundancies. From December 2016 to April 2018, our team has initiated 15 paper sprints. The median time from sprint to submission for paper sprints has been 1.7 months (minimum: 0.5; maximum: 9). Although our current 'sprint' approach has already demonstrated a substantial improvement in our ability to rapidly produce high-quality research, we believe the 'pre-sprint' preparation and 'post-sprint' processes can be further refined. Finally, we discuss the limitations of this model and our efforts to adapt the process to meet the evolving needs of research teams.