Home Health Care Quality, Its Costs and Implications for Home Health Value-Based Purchasing.

The Home Health Value-based Purchasing (HHVBP) demonstration, incorporating a payment formula designed to incentivize both high-quality care and quality improvement, is expected to become a national program after 2022, when the demonstration ends. This study investigated the relationship between costs and several quality dimensions, to inform HHVBP policy. Using Medicare cost reports, OASIS and Home Health Compare data for 7,673 home health agencies nationally, we estimated cost functions with instrumental variables for quality. The estimated net marginal costs varied by composite quality measure, baseline quality, and agency size. For four of the five composite quality measures, the net marginal cost was negative for low-quality agencies, suggesting that quality improvement was cost saving for this agency type. As the magnitude of the net marginal cost is commensurate with the payment incentive planned for HHVBP, it should be considered when designing the incentives for HHVBP, to maximize their effectiveness.

PROMIS Global Health: Feasibility in home health.

PURPOSE: This feasibility study assessed if the Patient-Reported Outcomes Measurement Information System (PROMIS®) 10-item Global Health Survey (PROMIS-10) could be a reliable and valid patient-reported outcome measure (PROM) for a population of cognitively intact home health (HH) patients. METHODS: The Centers for Medicare and Medicaid Services (CMS) along with their measurement contractor, Abt Associates, held a field test (2016-2017) to test the feasibility of the PROMIS-10 in in the Outcome and Assessment Information Set (OASIS). Home Health clinician data collectors (registered nurses and physical therapists) were trained to complete the PROMIS-10 along with procedures to facilitate patient self-administration of PROMIS-10. These clinicians provided feedback about their experiences at a focus group at the end of data collection. RESULTS: 213 HH patients comprised the field test sample, 150 of whom completed PROMIS-10 surveys. Clinicians reported they found the PROMIS-10 relevant and acceptable for their HH patients, and noted the surveys provided insight into patients' views of their health. The PROMIS-10 measured the full range of patient-reported health and was sensitive to change between admission and discharge. CONCLUSIONS: The study confirmed that the PROMIS-10 can be implemented in the HH setting, opening the door for consideration for implementing the PROMIS-10 in post-acute care (PAC) settings. This study is a first step toward establishing an assessment that captures the patient's voice and could be reported by the CMS PAC quality reporting programs.

Adjusting Quality Measures For Social Risk Factors Can Promote Equity In Health Care.

Risk adjustment of quality measures using clinical risk factors is widely accepted; risk adjustment using social risk factors remains controversial. We argue here that social risk adjustment is appropriate and necessary in defined circumstances and that social risk adjustment should be the default option when there are valid empirical arguments for and against adjustment for a given measure. Social risk adjustment is an important way to avoid exacerbating inequity in the health care system.

Identifying Associations between Quality Initiatives and Quality Measures among Home Health Agencies: Findings from a National Study.

Home health performance gained visibility with the publication of Home Health Compare and the Home Health Value-Based Payment demonstration. Both provide incentives for home health agencies (HHA) to invest in quality improvements. The objective of this study is to identify the association between quality initiatives adopted by HHAs and improved performance. A 2018 national survey of 7459 HHAs, yielding a sample of 1192 eligible HHAs, provided information about 23 quality initiatives, which was linked to 5 composite Super Quality Measures (SQMs): ADL/pain, self-treatment, timely care, hospitalizations, and patient experience. Exclusions for missing data and outliers yielded a final analytical sample of 903 HHAs. Regression models estimated associations between quality initiatives and SQMs. The relationships between sixteen of the SQM/quality initiative pairs were positively associated with improvement and 7 were negatively associated. Web-based technologies for staff and care-givers improved performance but deteriorated patient experience. Web support-groups for staff and review of HHC rankings reduced hospitalization rates. While this study offers insights for quality improvement, a limitation may be a lack of sensitivity to the nuances of quality improvement implementation. Therefore, this study should be viewed as hypothesis-generating concerning initiatives likely to have the greatest potential meriting further investigation.

The NQF Scientific Methods Panel: Enhancing the Review and Endorsement Process for Performance Measures.

In the summer of 2017, the National Quality Forum (NQF) announced the formation of a Scientific Methods Panel (hereafter referred to as "the Panel") as part of a redesign of its endorsement process. NQF created the Panel in response to stakeholder request during a Kaizen improvement event held in May 2017. Given the Panel's role in the endorsement of performance measures used in national payment programs, the objective of this article is to describe the work of the Panel, and to describe its function in the larger context of the NQF measure endorsement process and in the measurement enterprise writ large. This article also serves as an introduction to a series of planned white papers being authored by the panel on specific technical issues in the area of health care performance measurement.

Certificate of need and the cost of competition in home healthcare markets.

We used 2010-16 Medicare Cost Reports for 10,737 freestanding home health agencies (HHAs) to examine the impact of home health (HH) and nursing home (NH) certificate-of-need (CON) laws on HHA caseload, total and per-patient variable costs. After adjusting for other HHA characteristics, total costs were higher in states with only HH CON laws ($2,975,698), only NH CON laws ($1,768,097), and both types of laws ($3,511,277), compared with no CON laws ($1,538,536). Higher costs were driven by caseloads, as CON reduced per-patient costs. Additional research is needed to distinguish whether this is due to skimping on quality vs. economies of scale.

Predicting Hospital Readmissions from Home Healthcare in Medicare Beneficiaries.

OBJECTIVE: To use patient-level clinical variables to develop and validate a parsimonious model to predict hospital readmissions from home healthcare (HHC) in Medicare fee-for-service beneficiaries. DESIGN: Retrospective analysis using multivariable logistic regression and gradient boosting machine (GBM) learning to develop and validate a predictive model. SETTING/PARTICIPANTS/MEAUREMENTS: A 5% national sample of patients, aged 65 years or older, with Medicare fee-for-service who received skilled HHC services within 5 days of hospital discharge in 2012 (n = 43 407). Multiple data sets were merged, including Medicare Outcome and Assessment Information Set, Home Health Claims, Medicare Provider Analysis and Review, and Master Beneficiary Summary Files, to extract patient-level variables from the first HHC visit after discharge and measure 30-day readmission outcomes. RESULTS: Among 43 407 patients with inpatient hospitalizations followed by HHC, 14.7% were readmitted within 30 days. Of the 53 candidate variables, seven remained in the final model as individually predictive of outcome: Elixhauser comorbidity index, index hospital length of stay, urinary catheter presence, patient status (ie, fragile health with high risk of complications or serious progressive condition), two or more hospitalizations in prior year, pressure injury risk or presence, and surgical wound presence. Of interest, surgical wounds, either from a total hip or total knee arthroplasty procedure or another surgical procedure, were associated with fewer readmissions. The optimism-corrected c-statistics for the full model and parsimonious model were 0.67 and 0.66, respectively, indicating fair discrimination. The Brier score for both models was 0.120, indicating good calibration. The GBM model identified similar predictive variables. CONCLUSION: Variables available to HHC clinicians at the first postdischarge HHC visit can predict readmission risk and inform care plans in HHC. Future analyses incorporating measures of social determinants of health, such as housing instability or social support, have the potential to enhance prediction of this outcome. J Am Geriatr Soc 67:2505-2510, 2019.

Home-Health-Care Physical Therapy Improves Early Functional Recovery of Medicare Beneficiaries After Total Knee Arthroplasty.

BACKGROUND: Home-health-care utilization after total knee arthroplasty (TKA) is increasing. Recent publications have suggested that supervised rehabilitation is not needed to optimize functional recovery after TKA; however, few studies have evaluated patients in home-health-care settings. The objectives of this study were to (1) determine whether physical therapy (PT) utilization is associated with functional improvements for patients in home-health-care settings after TKA and (2) determine which factors are related to utilization of PT. METHODS: This study was an analysis of Medicare home-health-care claims data for patients treated with a TKA in 2012 who received home-health-care services for postoperative rehabilitation. Multivariable linear regression models were used to evaluate relationships between PT utilization and recovery in activities of daily living (ADLs). Negative binomial regression models were used to determine factors associated with PT utilization. RESULTS: Records from 5,967 Medicare beneficiaries were evaluated. Low home-health-care PT utilization (≤5 visits) was associated with less improvement in ADLs compared with 6 to 9 visits, 10 to 13 visits, or ≥14 visits. Compared with low home-health-care utilization, utilization of 6 to 9 visits was associated with a 25% greater improvement in ADLs over the home-health-care episode (p < 0.0001); 10 to 13 visits, with a 40% greater improvement (p < 0.0001); and ≥14 visits, with a 50% greater improvement (p < 0.0001). The findings remained robust following adjustments for medical complexity, baseline functional status, and home-health-care episode duration. After adjustment, lower PT utilization was observed for patients receiving home health care from rural agencies (10.7% fewer visits, 95% confidence interval [CI] = 7.9% to 13.7%), those with depressive symptoms (4.8% fewer visits, 95% CI = 1.3% to 8.3%), and those with any baseline dyspnea (5.3% fewer visits, 95% CI = 3.1% to 7.5%). CONCLUSIONS: Low home-health-care PT utilization was significantly associated with worse recovery in ADLs after TKA for Medicare beneficiaries, after controlling for medical complexity, baseline function, and home-health-care episode duration. Patients who are served by rural agencies or who have higher medical complexity receive fewer PT visits after TKA and may need closer monitoring to ensure optimal functional recovery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association of Uric Acid With Vascular Stiffness in the Framingham Heart Study.

BACKGROUND: Uric acid is associated with increased risk of cardiovascular disease and arterial stiffness in patients with hypertension or stroke. It remains unknown if uric acid is associated with arterial stiffness in the general population. METHODS: We analyzed the association between serum uric acid levels and measures of arterial stiffness such as carotid-femoral pulse wave velocity (CF PWV), carotid-radial pulse wave velocity (CR PWV) and augmentation index (AI) in 4,140 participants from the Generation 3 Framingham cohort using linear regression. RESULTS: Mean (SD) age was 40.0 (8.8) years and mean (SD) serum uric acid levels were 5.3 (1.5) mg/dl. Mean (SD) CF PWV was 7.0 (1.4) m/s. Individuals in the highest quartile of uric acid were more likely to be male, have a higher prevalence of hypertension, higher BMI, fasting glucose and insulin, and lower estimated glomerular filtration rate (eGFR). Multivariate adjusted means of CF PWV were 6.90, 6.94, 7.06, and 7.15 m/s for uric acid quartile 1, 2, 3, and 4 respectively. In unadjusted analysis each 1mg/dl increase in uric acid was associated with higher CF-PWV (ß = 0.27; 95% CI = 0.25, 0.29; P < 0.0001). This was attenuated but remained significant after adjusting for age, sex, smoking, hypertension, BMI, fasting glucose, insulin, animal protein intake, and eGFR (ß= 0.06; 95% CI = 0.02, 0.09; P < 0.0007). There was no association between serum uric acid levels and AI upon adjustment for cardiovascular risk factors. CONCLUSIONS: Serum uric acid levels are significantly associated with CF PWV and CR PWV in a younger Caucasian population.

Kidney disease and maternal and fetal outcomes in pregnancy.

BACKGROUND: Pregnancy in kidney disease is considered high risk, but the degree of this risk is unclear. We tested the hypothesis that kidney disease in pregnancy is associated with adverse maternal and fetal outcomes. STUDY DESIGN: Retrospective study comparing pregnant women with and without kidney disease. SETTING & PARTICIPANTS: Using data from an integrated health care delivery system from 2000 through 2013, a total of 778 women met the criteria for kidney disease. Using a pool of 74,105 women without kidney disease, we selected 778 women to use for matches for the women with kidney disease. These women were matched 1:1 by age, race, and history of diabetes, chronic hypertension, liver disease, and connective tissue disease. PREDICTOR: Kidney disease was defined using the NKF-KDOQI definition for chronic kidney disease or International Classification of Diseases, Ninth Revision codes prior to pregnancy or serum creatinine level > 1.2mg/dL and/or proteinuria in the first trimester. OUTCOMES & MEASUREMENTS: Maternal outcomes included preterm delivery, delivery by cesarean section, preeclampsia/eclampsia, length of stay at hospital (>3 days), and maternal death. Fetal outcomes included low birth weight (weight < 2,500g), small for gestational age, number of admissions to neonatal intensive care unit, and infant death. RESULTS: Compared with women without kidney disease, those with kidney disease had 52% increased odds of preterm delivery (OR, 1.52; 95% CI, 1.16-1.99) and 33% increased odds of delivery by cesarean section (OR, 1.33; 95% CI, 1.06-1.66). Infants born to women with kidney disease had 71% increased odds of admission to the neonatal intensive care unit or infant death compared with infants born to women without kidney disease (OR, 1.71; 95% CI, 1.17-2.51). Kidney disease also was associated with 2-fold increased odds of low birth weight (OR, 2.38; 95% CI, 1.64-3.44). Kidney disease was not associated with increased risk of maternal death. LIMITATIONS: Data for level of kidney function and cause of death not available. CONCLUSIONS: Kidney disease in pregnancy is associated independently with adverse maternal and fetal outcomes when other comorbid conditions are controlled by matching.

Primary Care Providers Perceptions of Racial/Ethnic and Socioeconomic Disparities in Hypertension Control.

OBJECTIVE: To evaluate the attitudes and perceptions of primary care providers (PCPs) regarding the presence and underlying sources of racial/ethnic and socioeconomic disparities in hypertension control. METHODS: We conducted a survey of 115 PCPs from 2 large academic centers in Colorado. We included physicians, nurse practitioners, and physician assistants. The survey assessed provider recognition and perceived contributors of disparities in hypertension control. RESULTS: Respondents were primarily female (66%), non-Hispanic White (84%), and physicians (80%). Among respondents, 67% and 73% supported the collection of data on the patients' race/ethnicity and socioeconomic status (SES), respectively. Eighty-six percent and 89% agreed that disparities in race/ethnicity and SES existed in hypertension care within the US health system. However, only 33% and 44% thought racial/ethnic and socioeconomic disparities existed in the care of their own patients. Providers were more likely to perceive patient factors rather than provider or health system factors as mediators of disparities. However, most supported interventions such as improving provider communication skills (87%) and cultural competency training (89%) to reduce disparities in hypertension control. CONCLUSIONS: Most providers acknowledged that racial/ethnic and socioeconomic disparities in hypertension control exist in the US health system, but only a minority reported disparities in care among patients they personally treat. Our study highlights the need for testing an intervention aimed at increasing provider awareness of disparities within the local health setting to improve hypertension control for minority patients.