A randomized trial of a telephone care-management strategy.

BACKGROUND: Studies have shown that telephone interventions designed to promote patients' self-management skills and improve patient-physician communication can increase patients' satisfaction and their use of preventive services. The effect of such a strategy on health care costs remains controversial. METHODS: We conducted a stratified, randomized study of 174,120 subjects to assess the effect of a telephone-based care-management strategy on medical costs and resource utilization. Health coaches contacted subjects with selected medical conditions and predicted high health care costs to instruct them about shared decision making, self-care, and behavioral change. The subjects were randomly assigned to either a usual-support group or an enhanced-support group. Although the same telephone intervention was delivered to the two groups, a greater number of subjects in the enhanced-support group were made eligible for coaching through the lowering of cutoff points for predicted future costs and expansion of the number of qualifying health conditions. Primary outcome measures at 1 year were total medical costs and number of hospital admissions. RESULTS: At baseline, medical costs and resource utilization were similar in the two groups. After 12 months, 10.4% of the enhanced-support group and 3.7% of the usual-support group received the telephone intervention. The average monthly medical and pharmacy costs per person in the enhanced-support group were 3.6% ($7.96) lower than those in the usual-support group ($213.82 vs. $221.78, P=0.05); a 10.1% reduction in annual hospital admissions (P<0.001) accounted for the majority of savings. The cost of this intervention program was less than $2.00 per person per month. CONCLUSIONS: A targeted telephone care-management program was successful in reducing medical costs and hospitalizations in this population-based study. (Funded by Health Dialog Services; ClinicalTrials.gov number, NCT00793260.)

Spending differences associated with the Medicare Physician Group Practice Demonstration.

CONTEXT: The Centers for Medicare & Medicaid Services (CMS) recently launched accountable care organization (ACO) programs designed to improve quality and slow cost growth. The ACOs resemble an earlier pilot, the Medicare Physician Group Practice Demonstration (PGPD), in which participating physician groups received bonus payments if they achieved lower cost growth than local controls and met quality targets. Although evidence indicates the PGPD improved quality, uncertainty remains about its effect on costs. OBJECTIVE: To estimate cost savings associated with the PGPD overall and for beneficiaries dually eligible for Medicare and Medicaid. DESIGN: Quasi-experimental analyses comparing preintervention (2001-2004) and postintervention (2005-2009) trends in spending of PGPD participants to local control groups. We compared estimates using several alternative approaches to adjust for case mix. SETTING: Ten physician groups from across the United States. PATIENTS AND PARTICIPANTS: The intervention group was composed of fee-for-service Medicare beneficiaries (n = 990,177) receiving care primarily from the physicians in the participating medical groups. Controls were Medicare beneficiaries (n = 7,514,453) from the same regions who received care largely from non-PGPD physicians. Overall, 15% of beneficiaries were dually eligible for Medicare and Medicaid. MAIN OUTCOME MEASURE: Annual spending per Medicare fee-for-service beneficiary. RESULTS: Annual savings per beneficiary were modest overall (adjusted mean $114, 95% CI, $12-$216). Annual savings were significant in dually eligible beneficiaries (adjusted mean $532, 95% CI, $277-$786), but were not significant among nondually eligible beneficiaries (adjusted mean $59, 95% CI, $166 in savings to $47 in additional spending). The adjusted mean spending reductions were concentrated in acute care (overall, $118, 95% CI, $65-$170; dually eligible: $381, 95% CI, $247-$515; nondually eligible: $85, 95% CI, $32-$138). There was significant variation in savings across practice groups, ranging from an overall mean per-capita annual saving of $866 (95% CI, $815-$918) to an increase in expenditures of $749 (95% CI, $698-$799). Thirty-day medical readmissions decreased overall (-0.67%, 95% CI, -1.11% to -0.23%) and in the dually eligible (-1.07%, 95% CI, -1.73% to -0.41%), while surgical readmissions decreased only for the dually eligible (-2.21%, 95% CI, -3.07% to -1.34%). Estimates were sensitive to the risk-adjustment method. CONCLUSIONS: Substantial PGPD savings achieved by some participating institutions were offset by a lack of saving at other participating institutions. Most of the savings were concentrated among dually eligible beneficiaries.

Characteristics of new cardiac surgery programs in the United States: mitigating the learning curve.

BACKGROUND: New cardiac surgery programs continue to open across the United States, and it is not known how new programs deal with potentially low volumes during their start-up period. We compared patient, procedure, and physician characteristics and short-term mortality at established cardiac surgery programs, new programs in general hospitals, and new specialty cardiac hospitals. METHODS: We used Medicare Provider Analysis and Review, part B physician claims, and denominator files to evaluate established and new programs performing coronary artery bypass graft surgery (CABG) from 1994-2003. Short-term mortality was defined as death in-hospital or within 30 days. RESULTS: From 1994-2003, 257 new programs in general hospitals and 20 new specialty hospitals opened; and 884 established programs were in operation. New programs in general hospitals had much lower CABG volume than established programs and performed fewer concomitant valves and reoperations. New specialty hospitals had high CABG volume from inception, similar valve and reoperation rates to established programs, and conducted more elective procedures. Short-term mortality was significantly lower at new programs in general hospitals. CONCLUSIONS: Start-up strategies used by new specialty hospitals and new programs in general hospitals differed markedly. By choosing to conduct safer procedures on low-risk patients, new general programs may have offset potential concerns about operating at low volume. Neither type of new program exhibited an increased risk of short-term mortality. The high volume at specialty hospitals may reassure patients and policy makers, although the high proportion of elective procedures and the new program's effect on surrounding hospitals require further consideration.

Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001.

BACKGROUND: Rates of invasive testing and treatment for coronary artery disease have increased over time. Less is known about trends in the utilization of noninvasive cardiac testing for coronary artery disease. The objective of this study was 2-fold: to explore temporal trends in the utilization of noninvasive and invasive cardiac services in relation to changes in the prevalence of cardiac disease, and to examine whether temporal increases have been targeted to potentially underserved populations. METHODS AND RESULTS: We performed an annual cross-sectional population-based study of Medicare patients from 1993 to 2001. We identified stress testing, cardiac catheterization, and revascularization procedures, as well as hospitalizations for acute myocardial infarction, during each year and calculated population-based rates for each using the total fee-for-service Medicare population as the denominator and adjusting for age, gender, and race. We observed marked growth in the utilization rates of cardiac services over time, with relative rates nearly doubling for most services. Acute myocardial infarction hospitalization rates have remained stable over the study period. Although rates of all procedures except coronary artery bypass increased in all subgroups, differences in rates of cardiac testing and treatment between nonblack men and other subgroups persisted over time. CONCLUSIONS: Temporal increases in the use of noninvasive and invasive cardiac services are not explained by changes in disease prevalence and have not succeeded in narrowing preexisting treatment differences by gender and race. Such increases, although conferring benefit for some, may expose others to risk and cost without benefit.

Surgeon volume and operative mortality in the United States.

BACKGROUND: Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain. METHODS: Using information from the national Medicare claims data base for 1998 through 1999, we examined mortality among all 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections. Using nested regression models, we examined the relations between operative mortality and surgeon volume and hospital volume (each in terms of total procedures performed per year), with adjustment for characteristics of the patients and other characteristics of the providers. RESULTS: Surgeon volume was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The adjusted odds ratio for operative death (for patients with a low-volume surgeon vs. those with a high-volume surgeon) varied widely according to the procedure--from 1.24 for lung resection to 3.61 for pancreatic resection. Surgeon volume accounted for a large proportion of the apparent effect of the hospital volume, to an extent that varied according to the procedure: it accounted for 100 percent of the effect for aortic-valve replacement, 57 percent for elective repair of an abdominal aortic aneurysm, 55 percent for pancreatic resection, 49 percent for coronary-artery bypass grafting, 46 percent for esophagectomy, 39 percent for cystectomy, and 24 percent for lung resection. For most procedures, the mortality rate was higher among patients of low-volume surgeons than among those of high-volume surgeons, regardless of the surgical volume of the hospital in which they practiced. CONCLUSIONS: For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently.

Hospital volume and surgical mortality in the United States.

BACKGROUND: Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is disputed. METHODS: Using information from the national Medicare claims data base and the Nationwide Inpatient Sample, we examined the mortality associated with six different types of cardiovascular procedures and eight types of major cancer resections between 1994 and 1999 (total number of procedures, 2.5 million). Regression techniques were used to describe relations between hospital volume (total number of procedures performed per year) and mortality (in-hospital or within 30 days), with adjustment for characteristics of the patients. RESULTS: Mortality decreased as volume increased for all 14 types of procedures, but the relative importance of volume varied markedly according to the type of procedure. Absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals ranged from over 12 percent (for pancreatic resection, 16.3 percent vs. 3.8 percent) to only 0.2 percent (for carotid endarterectomy, 1.7 percent vs. 1.5 percent). The absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals were greater than 5 percent for esophagectomy and pneumonectomy, 2 to 5 percent for gastrectomy, cystectomy, repair of a nonruptured abdominal aneurysm, and replacement of an aortic or mitral valve, and less than 2 percent for coronary-artery bypass grafting, lower-extremity bypass, colectomy, lobectomy, and nephrectomy. CONCLUSIONS: In the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.

Differences in cardiac stress testing by sex and race among Medicare beneficiaries.

BACKGROUND: Although there is a wide literature demonstrating sex and race differences in the receipt of invasive cardiac tests and treatments, much less is known about the influence of such characteristics on receipt of a stress test, the first event in the diagnostic/treatment cascade for many patients. We explored the influence of patient characteristics on receipt of a stress test, with special attention to sex and race. METHODS: We performed a nested case-control study of Medicare beneficiaries who were aged 66 years and older during 1999-2001 and were free of cardiac diagnoses and procedures for at least 1 year. Cases were recipients of a stress test. RESULTS: Cases were younger, less likely to be female or black, but more likely to live in high-income, highly educated, and urban areas than controls. Nonblack men were more likely to receive a stress test than women and black men, controlling for age, area characteristics, and clinical characteristics (odds ratio for nonblack men compared with black women 1.71). These results were not explained by physician visit frequency. CONCLUSIONS: Efforts at minimizing disparities in cardiac care must attend to what is, for many patients, the entry into the cardiac care system: the stress test. Our findings suggest that simple "access," as measured by physician visit frequency, is not a rate-limiting factor.

Analysis of observational studies in the presence of treatment selection bias: effects of invasive cardiac management on AMI survival using propensity score and instrumental variable methods.

CONTEXT: Comparisons of outcomes between patients treated and untreated in observational studies may be biased due to differences in patient prognosis between groups, often because of unobserved treatment selection biases. OBJECTIVE: To compare 4 analytic methods for removing the effects of selection bias in observational studies: multivariable model risk adjustment, propensity score risk adjustment, propensity-based matching, and instrumental variable analysis. DESIGN, SETTING, AND PATIENTS: A national cohort of 122,124 patients who were elderly (aged 65-84 years), receiving Medicare, and hospitalized with acute myocardial infarction (AMI) in 1994-1995, and who were eligible for cardiac catheterization. Baseline chart reviews were taken from the Cooperative Cardiovascular Project and linked to Medicare health administrative data to provide a rich set of prognostic variables. Patients were followed up for 7 years through December 31, 2001, to assess the association between long-term survival and cardiac catheterization within 30 days of hospital admission. MAIN OUTCOME MEASURE: Risk-adjusted relative mortality rate using each of the analytic methods. RESULTS: Patients who received cardiac catheterization (n = 73 238) were younger and had lower AMI severity than those who did not. After adjustment for prognostic factors by using standard statistical risk-adjustment methods, cardiac catheterization was associated with a 50% relative decrease in mortality (for multivariable model risk adjustment: adjusted relative risk [RR], 0.51; 95% confidence interval [CI], 0.50-0.52; for propensity score risk adjustment: adjusted RR, 0.54; 95% CI, 0.53-0.55; and for propensity-based matching: adjusted RR, 0.54; 95% CI, 0.52-0.56). Using regional catheterization rate as an instrument, instrumental variable analysis showed a 16% relative decrease in mortality (adjusted RR, 0.84; 95% CI, 0.79-0.90). The survival benefits of routine invasive care from randomized clinical trials are between 8% and 21%. CONCLUSIONS: Estimates of the observational association of cardiac catheterization with long-term AMI mortality are highly sensitive to analytic method. All standard risk-adjustment methods have the same limitations regarding removal of unmeasured treatment selection biases. Compared with standard modeling, instrumental variable analysis may produce less biased estimates of treatment effects, but is more suited to answering policy questions than specific clinical questions.

Gender-related changes in the practice and outcomes of percutaneous coronary interventions in Northern New England from 1994 to 1999.

OBJECTIVES: We sought to determine whether the changing practice of interventional cardiology has been associated with improved outcomes for women, and how these outcomes compare with those for men. BACKGROUND: Previous work from the early 1990s suggested women are at a higher risk than men for adverse outcomes after percutaneous coronary interventions (PCIs). From 1994 to 1999 data were collected on 33,666 consecutive hospital admissions for a PCI in Northern New England. Multivariate models were used to adjust for differences in case-mix across year of procedure when comparing outcomes. Direct standardization was used to calculate adjusted rates. RESULTS: From 1994 to 1999, the case-mix worsened for both women and men, although women had more co-morbidities than did men throughout the period. Stent use increased over time (>75% in 1999). Concomitantly, the need for emergency coronary artery bypass graft surgery (CABG) decreased significantly (p(trend) < or = 0.001; in 1999: 0.06% for women, 0.05% for men). Although the emergency CABG rates were higher for women at the beginning of the study, by the end, they were comparable (adjusted odds ratio 1.34, 95% confidence interval 0.76 to 2.38, p = 0.315). The myocardial infarction (MI) rates decreased over time for both women (by 29.7%, p(trend) = 0.378) and men (by 37.6%, p(trend) = 0.009) and did not differ by gender. The mortality rates did not decrease significantly over time and were not significantly different between the genders (mean 1.21% for women, 1.06% for men; p = 0.096). CONCLUSIONS: Concurrent with the changing practice of PCI, and despite treating sicker patients, there have been important improvements in post-PCI CABG and MI rates for women, as well as for men. Unlike in earlier years, there are no longer significant differences in outcomes by gender.

The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care.

BACKGROUND: The health implications of regional differences in Medicare spending are unknown. OBJECTIVE: To determine whether regions with higher Medicare spending provide better care. DESIGN: Cohort study. SETTING: National study of Medicare beneficiaries. PATIENTS: Patients hospitalized between 1993 and 1995 for hip fracture (n = 614,503), colorectal cancer (n = 195,429), or acute myocardial infarction (n = 159,393) and a representative sample (n = 18,190) drawn from the Medicare Current Beneficiary Survey (1992-1995). EXPOSURE MEASUREMENT: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306). OUTCOME MEASUREMENTS: Content of care (for example, frequency and type of services received), quality of care (for example, use of aspirin after acute myocardial infarction, influenza immunization), and access to care (for example, having a usual source of care). RESULTS: Average baseline health status of cohort members was similar across regions of differing spending levels, but patients in higher-spending regions received approximately 60% more care. The increased utilization was explained by more frequent physician visits, especially in the inpatient setting (rate ratios in the highest vs. the lowest quintile of hospital referral regions were 2.13 [95% CI, 2.12 to 2.14] for inpatient visits and 2.36 [CI, 2.33 to 2.39] for new inpatient consultations), more frequent tests and minor (but not major) procedures, and increased use of specialists and hospitals (rate ratio in the highest vs. the lowest quintile was 1.52 [CI, 1.50 to 1.54] for inpatient days and 1.55 [CI, 1.50 to 1.60] for intensive care unit days). Quality of care in higher-spending regions was no better on most measures and was worse for several preventive care measures. Access to care in higher-spending regions was also no better or worse. CONCLUSIONS: Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist-oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions.

The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care.

BACKGROUND: The health implications of regional differences in Medicare spending are unknown. OBJECTIVE: To determine whether regions with higher Medicare spending achieve better survival, functional status, or satisfaction with care. DESIGN: Cohort study. SETTING: National study of Medicare beneficiaries. PATIENTS: Patients hospitalized between 1993 and 1995 for hip fracture (n = 614,503), colorectal cancer (n = 195,429), or acute myocardial infarction (n = 159,393) and a representative sample (n = 18,190) drawn from the Medicare Current Beneficiary Survey (MCBS) (1992-1995). EXPOSURE MEASUREMENT: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306). OUTCOME MEASUREMENTS: 5-year mortality rate (all four cohorts), change in functional status (MCBS cohort), and satisfaction (MCBS cohort). RESULTS: Cohort members were similar in baseline health status, but those in regions with higher end-of-life spending received 60% more care. Each 10% increase in regional end-of-life spending was associated with the following relative risks for death: hip fracture cohort, 1.003 (95% CI, 0.999 to 1.006); colorectal cancer cohort, 1.012 (CI, 1.004 to 1.019); acute myocardial infarction cohort, 1.007 (CI, 1.001 to 1.014); and MCBS cohort, 1.01 (CI, 0.99 to 1.03). There were no differences in the rate of decline in functional status across spending levels and no consistent differences in satisfaction. CONCLUSIONS: Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions but do not have better health outcomes or satisfaction with care. Efforts to reduce spending should proceed with caution, but policies to better manage further spending growth are warranted.

Long-term outcomes of regional variations in intensity of invasive vs medical management of Medicare Patients with acute myocardial infarction.

CONTEXT: The health and policy implications of the marked regional variations in intensity of invasive compared with medical management of patients with acute myocardial infarction (AMI) are unknown. OBJECTIVES: To evaluate patient clinical characteristics associated with receiving more intensive treatment; and to assess whether AMI patients residing in regions with more intensive invasive treatment and management strategies have better long-term survival than those residing in regions with more intensive medical management strategies. DESIGN, SETTING, AND PATIENTS: National cohort study of 158,831 elderly Medicare patients hospitalized with first episode of confirmed AMI in 1994-1995, followed up for 7 years (mean, 3.6 years), according to the intensity of invasive management (performance of cardiac catheterization within 30 days) and medical management (prescription of beta-blockers to appropriate patients at discharge) in their region of residence. Baseline chart reviews were drawn from the Cooperative Cardiovascular Project and linked to Medicare health administrative data. MAIN OUTCOME MEASURE: Long-term survival over 7 years of follow-up. RESULTS: Patient baseline AMI severity was similar across regions. In all regions, younger and healthier patients were more likely than older high-risk patients to receive invasive treatment and medical therapy. Regions with more invasive treatment practice styles had more cardiac catheterization laboratory capacity; patients in these regions were more likely to receive interventional treatment, regardless of age, clinical indication, or risk profile. The absolute unadjusted difference in 7-year survival between regions providing the highest rates of both invasive and medical management strategies and those providing the lowest rates of both was 6.2%. For both ST- and non-ST-segment elevation AMI patients, survival improved with regional intensity of both invasive and medical management. In areas with higher rates of medical management, there appeared to be little or no improvement in survival associated with increased invasive treatment. CONCLUSIONS: In elderly Medicare patients with AMI, more intensive medical treatment provides population survival benefits. However, routine use of more costly and invasive treatment strategies may not be associated with an overall population benefit beyond that seen with excellent medical management. Efforts should focus on directing invasive clinical resources to patients with the greatest expected benefit.

Trends in the diabetes quality improvement project measures in Maine from 1994 to 1999.

OBJECTIVE: To examine changes in the management of patients with diabetes from 1994 to 1999 using the claims-based Diabetes Quality Improvement Project (DQIP) accountability measures. RESEARCH DESIGN AND METHODS: Administrative claims from an employer-based health insurance cohort in Maine were used to describe the prevalence of claims-based DQIP accountability measures-HbA(1c) testing, dilated eye examination, lipid profile, and monitoring for diabetic nephropathy-from 1994 (n = 1151) to 1999 (n = 2221) in a 100% sample of adults (18-64 years of age) with diabetes. The Mantel-Haenszel chi(2) test for trend was performed on each measure. Prevalence estimates were also stratified by three insurance products: health maintenance organization (HMO), point of service, and indemnity. RESULTS: There was a positive trend for all outcome measures (P < 0.001). The baseline and final frequencies (percent increase) for lipid testing, HbA(1c), dilated eye examination, and screening for diabetic nephropathy were as follows: 13-50% (257%), 37-69% (92%), 30-46% (53%), and 37-50% (36%), respectively. Individuals with diabetes and indemnity insurance were much less likely to receive these measures than individuals with other types of insurance, whereas people in HMOs were more likely to receive HbA(1c) testing and lipid profiles. CONCLUSIONS: The proportion of patients with diabetes receiving DQIP accountability measures significantly increased from 1994 to 1999. There is large variation in prevalence among these measures and insurance products. It is urgent to identify effective mechanisms for delivering consistent preventive care that are congruent with defined standards of benefit.

Predicting vascular complications in percutaneous coronary interventions.

OBJECTIVES: Using a large, current, regional registry of percutaneous coronary interventions (PCI), we identified risk factors for postprocedure vascular complications and developed a scoring system to estimate individual patient risk. BACKGROUND: A vascular complication (access-site injury requiring treatment or bleeding requiring transfusion) is a potentially avoidable outcome of PCI. METHODS: Data were collected on 18,137 consecutive patients undergoing PCI in northern New England from January 1997 to December 1999. Multivariate regression was used to identify characteristics associated with vascular complications and to develop a scoring system to predict risk. RESULTS: The rate of vascular complication was 2.98% (541 cases). Variables associated with increased risk in the multivariate analysis included age >or=70, odds ratio (OR) 2.7, female sex (OR 2.4), body surface area <1.6 m(2) (OR 1.9), history of congestive heart failure (OR 1.4), chronic obstructive pulmonary disease (OR 1.5), renal failure (OR 1.9), lower extremity vascular disease (OR 1.4), bleeding disorder (OR 1.68), emergent priority (OR 2.3), myocardial infarction (OR 1.7), shock (1.86), >or=1 type B2 (OR 1.32) or type C (OR 1.7) lesions, 3-vessel PCI (OR 1.5), use of thienopyridines (OR 1.4) or use of glycoprotein IIb/IIIa receptor inhibitors (OR 1.9). The model performed well in tests for significance, discrimination, and calibration. The scoring system captured 75% of actual vascular complications in its highest quintiles of predicted risk. CONCLUSION: Predicting the risk of post-PCI vascular complications is feasible. This information may be useful for clinical decision-making and institutional efforts at quality improvement.

Epidemiology and short-term outcomes of injured medicare patients.

OBJECTIVES: To describe characteristics and short-term outcomes of Medicare patients hospitalized after injuries in 1999. DESIGN: Analysis of national population-based case series. SETTING: Hospitalized Medicare patients. PARTICIPANTS: All fee-for-service Medicare patients aged 65 and older admitted for the first time in 1999 with principal injury diagnoses (International Classification of Diseases, Ninth Revision, codes 800-904, 910-929, 940-957, 959). MEASUREMENTS: Incidence rates, stratified by anatomic location (hip, other extremity, spine, head, chest, other), sex, and age group (65-74, 75-84, >or=85). For each category, Charlson comorbidity scores, Abbreviated Injury Scores, hospital length of stay, discharge disposition, hospital mortality, 30-day mortality, and readmissions within 30 days of discharge. RESULTS: A total of 439,605 persons were admitted at least once (crude rate 1,654/100,000). Rates of hospitalization increased with age and were generally higher in women (except head injuries). Comorbidities were more common in men. Hip fractures constituted 46.6% of cases and other extremity injuries another 30.7%. Hospital mortality (3.7% overall) increased with age, was greater in men, and was highest in patients with head injuries. The proportion discharged to skilled nursing facilities (43.8% overall, range 10.0-61.9% by age/sex/anatomic category) also increased with age, was higher in women, and was highest in patients with hip fractures. Slightly more than one-tenth (12.3%) of patients were readmitted within 30 days. Thirty-day mortality was 2.0 times hospital mortality (range 1.2-3.4 by category). CONCLUSION: Most injuries resulting in hospitalization for the Medicare population involve the extremities, but other injuries have higher mortality. Many injured patients are not discharged home but receive additional institutional care. Thirty-day survival is much lower than observed hospital survival. Further studies of injuries using Medicare data are warranted.

Adjusting surgical mortality rates for patient comorbidities: more harm than good?

Background. Studies of medical admissions have questioned the validity of using claims data to adjust for preexisting medical conditions (comorbidities), but the impact of using comorbidities from claims data to risk-adjust mortality rates for high-risk surgery is not well characterized. The purpose of this study was to evaluate the relationship between comorbidities and mortality in administrative data in surgical populations and identify better risk-adjustment methods. Methods. Using the national Medicare database (1994-1997), we identified admissions for elective abdominal aortic aneurysm repair (140,577) and pancreaticoduodenectomy (10,530). We calculated the relative risk of mortality (adjusted for age, sex, race, and admission acuity) for 5 chronic conditions that are known (from clinical series) to increase the risk of postoperative mortality and are commonly used in claims-based risk-adjustment models. To explore the potential value of alternative risk-adjustment strategies, we examined relationships between surgical mortality and comorbidities using diagnosis codes identified from previous admissions. Results. Overall, in-hospital mortality for elective abdominal aortic aneurysm (AAA) repair and pancreaticoduodenectomy were 5.1% and 10.4%, respectively. For both procedures, 3 of the 5 comorbidities were associated with decreased risk of mortality: prior myocardial infarction (MI) [RR = 0.38; 95% confidence interval (CI), 0.33-0.43 for AAA; RR = 0.38; 95% CI, 0.21-0.69 for pancreaticoduodenectomy), malignancy (RR = 0.67; 95% CI, 0.59-0.76 for AAA; RR = 0.74; 95% CI, 0.45-1.21 for pancreaticoduodenectomy], and diabetes (RR = 0.76; 95% CI, 0.64-0.84 for AAA; RR = 0.59; 95% CI, 0.49-0.69 for pancreaticoduodenectomy). Using comorbidities identified from prior admissions increased the mortality risk estimates for prior MI (RR = 1.22; 95% CI, 1.08-1.38 for AAA; RR = 0.80; 95% CI, 0.49-1.30 for pancreaticoduodenectomy) and diabetes (RR = 1.41; 95% CI, 1.25-1.59 for AAA; RR = 0.94; 95% CI, 0.78-1.14 for pancreaticoduodenectomy). Conclusions. Because comorbidities coded on the index admission appear protective, incorporating them in risk-adjustment models for studies comparing surgical performance may penalize providers for taking care of sicker patients. When available, comorbidity information from prior hospitalizations may be more useful for risk adjustment.

Do hospitals with low mortality rates in coronary artery bypass also perform well in valve replacement?

BACKGROUND: While hospital performance in coronary artery bypass graft (CABG) surgery is reported widely, patients may find it difficult to learn about their hospital's performance in heart valve replacement. We sought to determine if a hospital's performance in CABG is correlated to its performance in heart valve replacement. METHODS: We studied operative mortality after CABG, aortic valve replacement (AVR), and mitral valve replacement (MVR) using the 1994 to 1999 national Medicare database. After excluding any hospital that did not perform at least 50 CABGs and 20 valve replacements per year we examined the correlation between hospital mortality in CABG and hospital mortality in AVR and MVR using least-squares simple linear regression models. Operative mortality was adjusted for patient characteristics using logistic regression models. RESULTS: A total of 684 hospitals performed 817,606 isolated CABGs, 142,488 AVRs (54% with concomitant CABG), and 61,252 MVRs (45% with concomitant CABG). Hospital mortality rates with AVR ranged from 6.0% to 13.0% between hospitals in the lowest and highest, respectively, 10th percentile of CABG performance. Similarly hospital mortality rates with MVR ranged from 10.1% to 20.5% in the lowest and highest respectively, 10th percentile of CABG performance. Adjusted mortality rates for both AVR and MVR were closely correlated with isolated CABG mortality rates (correlation coefficients 0.592 and 0.538, respectively; p = 0.001 for both correlations). In stratified analyses these correlations persisted regardless of whether valve replacement was performed with or without concomitant CABG or whether valve replacement was performed in a high- or low-volume hospital. CONCLUSIONS: Hospital mortality rates with CABG are closely correlated with mortality rates with valve replacement. These findings suggest that shared processes and systems of care are important determinants of performance in cardiac surgery.

Addressing variations: is there hope for the future?

The papers by Robert Berenson and by Steven Lieberman and colleagues show that variations remain a true challenge for those trying to improve the delivery of health care. Recent clarifications in the understanding of unwarranted variations allow us to address variations in a more logical and manageable fashion. In this Perspective we describe key challenges in addressing variations in the context of these recent clarifications. The Centers for Medicare and Medicaid Services (CMS) needs to move forward on information-sharing interventions and use demonstrations to pursue innovative strategies to improve the delivery of care through its purchasing power.

Will volume-based referral strategies reduce costs or just save lives?

Although recent policy initiatives aimed at concentrating selected surgical procedures in high-volume hospitals may reduce mortality, their economic implications have not been considered fully. From the hospital perspective, the primary effect of these policies will be to redistribute surgical profits to bigger centers. From the payer perspective, prices paid for procedures will likely increase in some geographic areas. From the societal perspective, how these policies will affect the true cost of providing surgical care is uncertain, but use of discretionary procedures will likely increase. For these reasons, the primary argument for volume-based referral strategies should be improving quality, not reducing costs.