The Revival of US Hospital Care, 2004-2019.

BACKGROUND: Between 2004 and 2019, the US hospital industry reversed the 21-year decline in its share of national health spending. OBJECTIVE: To measure and explain changes in hospital utilization, cost, charges, and inpatient case mix. DATA SOURCES: Principal sources were the American Hospital Association annual survey, the National Inpatient Sample, and the Healthcare Cost Reporting Information System. The study included all US community hospitals (n=5141 in 2019). ANALYTIC APPROACH: We used factor decomposition to separate the impacts of population, utilization, unit cost, and charge markups on the growth in cost and charges for inpatient and outpatient care nationwide and for each state. For unit cost, we separated the impacts of input price inflation and treatment intensity. To measure the inpatient case mix, we applied an all-patient diagnosis-related groups algorithm. RESULTS: Between 2004 and 2019, charges more than tripled to $4.11 trillion. The cost more than doubled to $911 billion. For inpatient care, discharges fell 5%, discharges per person fell 15%, cost per discharge increased 88%, and charge markups rose 43%. For outpatient care, visits rose 36%, visits per person rose 21%, cost per visit rose 119%, and charge markups rose 52%. Treatment intensity increased by 33% per discharge and 55% per visit. Nationwide, the inpatient case mix increased by 34%, reflecting sicker patients and better clinical documentation. CONCLUSIONS: We quantified 3 important trends: rapid growth in outpatient visits, increased treatment intensity, and sustained increases in markups. Increased treatment intensity was the largest factor behind $491 billion in hospital cost growth between 2004 and 2019.

The effects of framed messages for engaging adolescents with online smoking prevention interventions.

Messages emphasizing the harms of smoking (loss-framed) or the benefits of not smoking (gain-framed) may be effective for engaging adolescents with tobacco prevention resources. This novel approach could help to close a gap in tobacco prevention intervention delivery in the pediatric primary care setting. To examine the effects of framed messages for engaging adolescents with an evidence-based smoking prevention website, adolescents ages 12 to 17 presenting for primary care well-visits were recruited for a three-arm experiment. Participants completed baseline measures including demographics, smoking behavior, and smoking susceptibility and were randomized to view 1 of 3 messages introducing an evidence-based smoking prevention website: (1) gain-framed communicating the benefits of avoiding smoking, (2) loss-framed communicating the harms of smoking, or (3) neutral. Self-reported website engagement was assessed at 1-month follow-up. Participants (279) (87% of those enrolled) completed a follow-up (M age 14.9 years, 66% female, 32% non-white race, 47% non-susceptible never smokers, 53% susceptible never smokers/ever smokers). Overall, 26% of participants reported website engagement. After adjusting for baseline intentions to visit the website, engagement was significantly greater in response to the loss-framed message than the gain-framed (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.51, 6.15) and neutral (OR 2.31, 95% CI 1.15, 4.63) messages. The message framing effects did not differ by baseline smoking risk. Loss-framed messages emphasizing the harms of smoking may be effective for engaging adolescents with smoking prevention resources.

Patient reported outcomes for diabetic peripheral neuropathy.

OBJECTIVE: Multiple patient-reported outcomes (PROs) have been used to assess symptoms among patients with Diabetic Peripheral Neuropathy (DPN). However, there is little consistent application of measures in clinical or research settings. Our goal was to identify and compare patient reported outcome measures (PROs) specifically evaluated in neuropathy populations. METHODS: Literature search, summary, and qualitative comparison of PROs validated in neuropathy populations. RESULTS: We identified 12 studies of PROs evaluated in neuropathy populations that included DPN patients. Two assessed sleep quality, 5 assessed painful symptoms, and 5 assessed quality of life. The number of items per measure ranged from one to 97, and the number of domains ranged from one to 18. All had adequate internal consistency (Chronbach's Alpha>0.70). There was mild to moderate standardization of domains across measures and only a few instruments used common comparators. The spectrum of DPN symptoms addressed included: sensory symptoms, autonomic symptoms, and function, beliefs, role participation, sleep quality, and perceptions of illness. CONCLUSIONS: There remains a need for a gold standard for DPN symptom assessment. Few existing instruments are adequately validated and the domains assessed are inconsistent. Current instrument selection should depend on the clinical and social context of the assessment.

Training providers: beyond the basics of electronic health records.

BACKGROUND: Training is a critical part of health information technology implementations, but little emphasis is placed on post-implementation training to support day-to-day activities. The goal of this study was to evaluate the impact of post-implementation training on key electronic health record activities. METHODS: Based on feedback from providers and requests for technical support, we developed two classes designed to improve providers' effectiveness with the electronic health record. Training took place at Kaiser Permanente, Mid-Atlantic States. The classes focused on managing patient-level information using problem lists and medication lists, as well as efficient documentation and chart review. Both classes used the blended learning method, integrating concrete scenarios, hands-on exercises and take-home materials to reinforce class concepts. To evaluate training effectiveness, we used a case-control study with a 1:4 match on pre-training performance. We measured the usage rate of two key electronic health record functions (problem list and medication list management) for six months before and after training. Change scores were compared using the Wilcoxon sign rank test. RESULTS: 36 participants and 144 non-participants were included in the training evaluation. Training participants were more likely to manage both medication lists and problem lists after training. Class material is now being incorporated into an enterprise-wide multi-modal training program available to all providers at Kaiser Permanente in the Mid-Atlantic States. CONCLUSIONS: Ongoing information technology training is well-received by healthcare providers, who expressed a clear preference for additional training. Training improved use of two important electronic health record features that are included as part of the Meaningful Use criteria.

Managing personal health information in distributed research network environments.

BACKGROUND: Studying rare outcomes, new interventions and diverse populations often requires collaborations across multiple health research partners. However, transferring healthcare research data from one institution to another can increase the risk of data privacy and security breaches. METHODS: A working group of multi-site research programmers evaluated the need for tools to support data security and data privacy. The group determined that data privacy support tools should: 1) allow for a range of allowable Protected Health Information (PHI); 2) clearly identify what type of data should be protected under the Health Insurance Portability and Accountability Act (HIPAA); and 3) help analysts identify which protected health information data elements are allowable in a given project and how they should be protected during data transfer. Based on these requirements we developed two performance support tools to support data programmers and site analysts in exchanging research data. RESULTS: The first tool, a workplan template, guides the lead programmer through effectively communicating the details of multi-site programming, including how to run the program, what output the program will create, and whether the output is expected to contain protected health information. The second performance support tool is a checklist that site analysts can use to ensure that multi-site program output conforms to expectations and does not contain protected health information beyond what is allowed under the multi-site research agreements. CONCLUSIONS: Together the two tools create a formal multi-site programming workflow designed to reduce the chance of accidental PHI disclosure.

Managing protected health information in distributed research network environments: automated review to facilitate collaboration.

BACKGROUND: Multi-site health sciences research is becoming more common, as it enables investigation of rare outcomes and diseases and new healthcare innovations. Multi-site research usually involves the transfer of large amounts of research data between collaborators, which increases the potential for accidental disclosures of protected health information (PHI). Standard protocols for preventing release of PHI are extremely vulnerable to human error, particularly when the shared data sets are large. METHODS: To address this problem, we developed an automated program (SAS macro) to identify possible PHI in research data before it is transferred between research sites. The macro reviews all data in a designated directory to identify suspicious variable names and data patterns. The macro looks for variables that may contain personal identifiers such as medical record numbers and social security numbers. In addition, the macro identifies dates and numbers that may identify people who belong to small groups, who may be identifiable even in the absences of traditional identifiers. RESULTS: Evaluation of the macro on 100 sample research data sets indicated a recall of 0.98 and precision of 0.81. CONCLUSIONS: When implemented consistently, the macro has the potential to streamline the PHI review process and significantly reduce accidental PHI disclosures.

Neonatal outcomes after antenatal influenza immunization during the 2009 H1N1 influenza pandemic: impact on preterm birth, birth weight, and small for gestational age birth.

BACKGROUND: Influenza infection during pregnancy is associated with adverse fetal outcomes such as preterm birth and small for gestational age (SGA). Maternal influenza immunization may prevent these adverse infant outcomes during periods of influenza circulation. METHODS: We conducted a retrospective cohort study of live births within Kaiser Permanente (KP) Georgia and Mid-Atlantic States (n = 3327) during the period of 2009 influenza A (H1N1) virus circulation. Primary outcomes were third-trimester preterm birth (27-36 weeks), birth weight, low birth weight (LBW, <2500 g), and SGA. RESULTS: There were 327 (9.8%) preterm, 236 (7.4%) LBW, and 267 (8.4%) SGA births. Among H1N1-vaccinated mothers (n = 1125), there were 86 (7.6%) preterm, 68 (6.4%) LBW, and 99 (9.3%) SGA births, and the mean birth weight was 3308.5 g (95% confidence interval [CI], 3276.6-3340.4). Among unvaccinated mothers (n = 1581), there were 191 (12.1%) preterm, 132 (8.8%) LBW, and 123 (8.2%) SGA births, and the mean birth weight was 3245.3 g (95% CI, 3216.5-3274.2). Infants of H1N1-vaccinated mothers had 37% lower odds of being born preterm than infants of unvaccinated mothers (adjusted odds ratio, 0.63 [95% CI, .47-.84]). The mean birth weight difference between infants of H1N1-vaccinated mothers and infants of unvaccinated mothers was 45.1 g (95% CI, 1.8-88.3). There was no significant association between maternal H1N1 influenza immunization and LBW or SGA. CONCLUSIONS: Pregnant women who received H1N1 influenza vaccine were less likely to give birth preterm, and gave birth to heavier infants. The findings support US vaccine policy choices to prioritize pregnant women during the 2009 influenza A (H1N1) pandemic.

A large, population-based study of 2009 pandemic Influenza A virus subtype H1N1 infection diagnosis during pregnancy and outcomes for mothers and neonates.

BACKGROUND: Pregnant women were at increased risk for serious outcomes of 2009 pandemic influenza A virus subtype H1N1 (influenza A[H1N1]pdm09) infection, but little is known about the overall impact of the pandemic on neonatal and maternal outcomes. METHODS: We identified live births that occurred from 1 July 2008 through 31 May 2010 in 5 Kaiser Permanente regions. Pregnant women were considered to have influenza if they had a positive result of a laboratory test for influenza virus or if they received a diagnosis of influenza during a period in which seasonal influenza virus or A(H1N1)pdm09 was the predominant circulating virus. RESULTS: There were 111 158 births from 109 015 pregnancies involving 107 889 mothers; 368 pregnant women (0.3%) received a diagnosis of influenza due to seasonal virus, and 959 (0.9%) received a diagnosis of influenza due to A(H1N1)pdm09; 107 688 did not receive an influenza diagnosis. Pregnant women with influenza due to A(H1N1)pdm09 were more likely than women with seasonal influenza infection to be hospitalized within 30 days of the diagnosis (27% vs 12%; odds ratio [OR], 2.84 [95% confidence interval {CI}, 2.01-4.02]). Pregnant women with A(H1N1)pdm09 who started antiviral treatment ≥2 days after the diagnosis were significantly more likely to be hospitalized than those who started antiviral treatment <2 days after diagnosis (OR, 3.43 [95% CI, 1.55-7.56]). Mothers with seasonal influenza virus infection had an increased risk for having a small-for-gestational-age infant (OR, 1.59 [95% CI, 1.15-2.20]). CONCLUSIONS: In this large, geographically diverse population, A(H1N1)pdm09 infection increased the risk for hospitalization during pregnancy. Late initiation of antiviral treatment was also associated with an increased risk for hospitalization.

Effects of between visit physician-patient communication on Diabetes Recognition Program scores.

OBJECTIVE: To determine whether physicians who interact with their patients between office visits using secure messaging and phone provide better care for patients with diabetes when controlling for physician, patient and care center characteristics. DESIGN: Retrospective study. SETTING: Kaiser Permanente Mid-Atlantic States. PARTICIPANTS: 174 Primary Care Physicians. INTERVENTION: We modeled the relationship between communication via secure messaging or phone communication and Diabetes Recognition Program (DRP) scores with a Generalized Estimating Equations model. Covariates included physician age and panel size, patient age, race, income and number of comorbidities, and the population density around the care center. MAIN OUTCOME MEASURE: DRP scores. RESULTS: Physicians whose patients were predominantly white or mixed race were more likely than other physicians to use secure messaging and phone with their patients between visits, but there was no significant association between such contacts and DRP scores (P> 0.1). In contrast, physicians with predominantly black or Hispanic patients had significantly higher DRP scores associated with the use of secure messaging (P< 0.01) and higher, though not statistically significant, DRP scores associated with the use of phone (P< 0.1). These associations were strongest for outcome measures such as HbA1c and lipid levels, and were weaker or nonexistent for process measures such as annual foot and eye exams. CONCLUSIONS: The use of secure messaging, and, to a lesser extent, phone, appears to be associated with higher quality diabetes care, particularly among at-risk populations.

A simple account of cyclopean edge responses in macaque v2.

It has been shown recently that neurons in V2 respond selectively to the edges of figures defined only by disparity (cyclopean edges). These responses are orientation selective, often preferring similar orientations for cyclopean and luminance contours, suggesting that they may support a cue-invariant representation of contours. Here, we investigate the extent to which processing of purely local visual information (in the vicinity of the receptive field) might explain such results, using the most impoverished stimulus possible containing a cyclopean edge (a circular patch of random dots divided into two regions by a single edge). Many V2 cells responded better to the cyclopean edge than to uniform disparities, and most of these were at least broadly selective for the orientation of the cyclopean edge. Two characteristics argue against a cue-invariant contour representation: (1) the cyclopean edge response was frequently abolished by small changes to the component disparities; and (2) although V2 cells frequently responded to both signs of a cyclopean edge (defined by which side of the edge is in front), they did so at different edge locations. These characteristics are consistent with a simple feedforward scheme in which V2 neurons receive inputs from several V1 subunits with different disparity selectivity. We also found a correlation between the preferred orientations for cyclopean edges and contrast stimuli, suggesting that this feedforward wiring is not random. These characteristics suggest that V2 responses to cyclopean edges may be useful in supporting a cue-invariant contour representation higher in the visual pathway.