Interventions to Reduce Hospital and Emergency Department Utilization Among People With Alcohol and Substance Use Disorders: A Scoping Review.

BACKGROUND: Substance use disorders (SUDs), prevalent worldwide, are associated with significant morbidity and health care utilization. OBJECTIVES: To identify interventions addressing hospital and emergency department utilization among people with substance use, to summarize findings for those seeking to implement such interventions, and to articulate gaps that can be addressed by future research. RESEARCH DESIGN: A scoping review of the literature. We searched PubMed, PsycInfo, and Google Scholar for any articles published from January 2010 to June 2020. The main search terms included the target population of adults with substance use or SUDs, the outcomes of hospital and emergency department utilization, and interventions aimed at improving these outcomes in the target population. SUBJECTS: Adults with substance use or SUDs, including alcohol use. MEASURES: Hospital and emergency department utilization. RESULTS: Our initial search identified 1807 titles, from which 44 articles were included in the review. Most interventions were implemented in the United States (n=35). Half focused on people using any substance (n=22) and a quarter on opioids (n=12). The tested approaches varied and included postdischarge services, medications, legislation, and counseling, among others. The majority of study designs were retrospective cohort studies (n=31). CONCLUSIONS: Overall, we found few studies assessing interventions to reduce health care utilization among people with SUDs. The studies that we did identify differed across multiple domains and included few randomized trials. Study heterogeneity limits our ability to compare interventions or to recommend one specific approach to reducing health care utilization among this high-risk population.

Consolidation in the Electronic Health Record Market, 2009-2017.

BACKGROUND: To quantify changes to the electronic health record (EHR) market in Rhode Island and to assess the degree of EHR market consolidation between 2009 and 2017. METHODS: The EHR market in Rhode Island is represented by three measures: the proportion of physicians who have adopted an EHR, the number of EHR vendors in use, and EHR market competitiveness, captured by the Herfindahl-Hirschman Index (HHI). RESULTS: The EHR market became more consolidated overall between 2009 and 2017. Among outpatient physicians, the market has remained competitive, despite ongoing consolidation. In contrast, the EHR market among inpatient physicians crossed into the "highly concentrated" zone in 2015. DISCUSSION: While consolidation in the EHR market may facilitate the exchange of data across health systems, potentially reducing duplicative testing and facilitating timely diagnosis, limiting competition may affect vendors' responsiveness to calls for improved usability and innovation.

Reducing Hospital Readmissions Through a Skilled Nursing Facility Discharge Intervention: A Pragmatic Trial.

OBJECTIVE: To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents admitted to the SNF following an index hospitalization. DESIGN: A pragmatic trial. SETTING AND PARTICIPANTS: SNFs in southeastern Massachusetts, and residents discharged to the community. METHODS: We compared SNFs that deployed an adapted RED intervention to a matched control group from the same region. The primary outcome was hospital readmission within 30 days after SNF discharge, among residents who had been admitted to the SNF following an index hospitalization and then discharged home. January 2016 through March 2017 was the baseline period; April 2017 through June 2018 was the follow-up period (after implementation of the intervention). We used a difference-in-differences analysis to compare the intervention SNFs to the control group, using generalized estimating equation regression and controlling for facility characteristics. RESULTS: After implementation of RED, readmission rates were lower across all 4 measures in the intervention group; control facilities' readmission rates remained stable or increased. The relative decrease was 0.9% for the primary outcome of hospital readmission within 30 days after SNF discharge and 1.7% for readmission within 30 days of the index hospitalization discharge date (P ≤ .001 for both comparisons). CONCLUSIONS AND IMPLICATIONS: We found that a systematic discharge process developed for the hospital can be adapted to the SNF environment and can reduce readmissions back to the hospital, perhaps through improved self-management skills and better engagement with community services. This work is particularly timely because of Medicare's new Value-Based Purchasing Program, in which nursing homes can receive incentive payments if their hospital readmission rates are low relative to their peers. To verify its scalability and broad potential, RED should be validated across a broader diversity of SNFs nationally.

Use of Chronic Care Management Codes for Medicare Beneficiaries: a Missed Opportunity?

BACKGROUND: Physicians spend significant time outside of regular office visits caring for complex patients, and this work is often uncompensated. In 2015, the Centers for Medicare & Medicaid Services (CMS) introduced a billing code for care coordination between office visits for beneficiaries with multiple chronic conditions. OBJECTIVE: Characterize use of the Chronic Care Management (CCM) code in New England in 2015. DESIGN: Retrospective observational analysis. PARTICIPANTS: All Medicare fee-for-service beneficiaries in New England continuously enrolled in Parts A and B in 2015. INTERVENTION: None. MAIN MEASURES: The primary outcome was the number of beneficiaries with a CCM claim per 1000 eligible beneficiaries. Secondary outcomes included the total number of CCM claims, total reimbursement, mean number of claims per beneficiary, and beneficiary characteristics independently associated with receiving CCM services. KEY RESULTS: Of the more than two million Medicare fee-for-service beneficiaries in New England, almost 1.7 million were potentially eligible for CCM services. Among eligible beneficiaries, 10,951 (0.65%) had a CCM claim in 2015. Massachusetts had the highest penetration of CCM use (9.40 claims per 1000 eligible beneficiaries); Vermont had the lowest (0.54 claims per 1000 eligible beneficiaries). Mean reimbursement per physician was $1745.98. Age, race/ethnicity, dual-eligible status, income, number of chronic conditions, and state of residence were associated with receiving CCM services in an adjusted model. CONCLUSIONS: The CCM code is likely underutilized in New England; the program may therefore not be achieving its intended goal of encouraging consistent, team-based chronic care management for Medicare's most complex beneficiaries. Or practices may be foregoing reimbursement for care coordination that they are already providing. Recently implemented revisions may improve uptake of CCM services; it will be important to compare our results with future utilization.

An analysis of diagnoses that drive readmission: What can we learn from the hospitals in Southern New England with the highest and lowest readmission performance?

Background: The Hospital Readmission Reduction Program was instituted by the Centers for Medicare & Medicaid Services in 2012 to incentivize hospitals to reduce readmissions. OBJECTIVE: To examine the most common diagnoses driving readmissions among fee-for-service Medicare beneficiaries in the hospitals with the highest and lowest readmission performance in Southern New England from 2014 to 2016. METHODS: This is a retrospective observational study using publicly available Hospital Compare data and Medicare Part A claims data. Hospitals were ranked based on risk-adjusted excess readmission ratios. Patient demographic and hospital characteristics were compared for the two cohorts using t-tests. The percentages of readmissions in each cohort attributable to the top three readmission diagnoses were examined. RESULTS: Highest-performing hospitals readmitted a significantly lower percentage of black patients (p=0.03), were less urban (p<0.01), and had higher Hospital Compare Star ratings (p=0.01). Lowest-performing hospitals readmitted higher percentages of patients for sepsis (9.4% [95%CI: 8.8%-10.0%] vs. 8.1% [95%CI: 7.4%-8.7%]) and complications of device, implant, or graft (3.2% [95%CI: 2.5%-3.9%] vs. 0.2% [95%CI: 0.1%-0.6%]), compared to highest-performing hospitals. CONCLUSIONS: Ongoing efforts to improve care transitions may be strengthened by targeting early infection surveillance, promoting adherence to surgical treatment guidelines, and improving communication between hospitals and post-acute care facilities. [Full article available at http://rimed.org/rimedicaljournal-2017-08.asp].

Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.

OBJECTIVES: Although electronic health record use improves healthcare delivery, adoption into clinical practice is incomplete. We sought to identify the extent of adoption in Rhode Island and the characteristics of physicians and electronic health records associated with positive experience. METHODS: We performed a cross-sectional study of data collected by the Rhode Island Department of Health for the Health Information Technology Survey 2009 to 2013. Survey questions included provider and practice demographics, health record information, and Likert-type scaled questions regarding how electronic health record use affected clinical practice. RESULTS: The survey response rate ranged from 50% to 65%, with 62% in 2013. Increasing numbers of physicians in Rhode Island use an electronic health record. In 2013, 81% of physicians used one, and adoption varied by clinical subspecialty. Most providers think that electronic health record use improves billing and quality improvement but has not improved job satisfaction. Physicians with longer and more sophisticated electronic health record use report positive effects of introduction on all aspects of practice examined (P < .001). Older physician age is associated with worse opinion of electronic health record introduction (P < .001). Of the 18 electronic health record vendors most frequently used in Rhode Island, 5 were associated with improved job satisfaction. CONCLUSIONS: We report the largest statewide study of electronic health record adoption to date. We found increasing physician use in Rhode Island, and the extent of adoption varies by subspecialty. Although older physicians are less likely to be positive about electronic health record adoption, longer and more sophisticated use are associated with more positive opinions, suggesting acceptance will grow over time.

Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge?

BACKGROUND: Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization. OBJECTIVE: To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI). DESIGN: A quasi-experimental cohort study using consecutive convenience sampling. PATIENTS: Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals. INTERVENTION: The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and one to two phone calls. MAIN MEASURES: We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible, but not approached (external control group), using propensity score matching to control for baseline differences. KEY RESULTS: Compared to matched internal controls (N = 321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total health care costs ($14,729 vs. $18,779, P = 0.03). The cost avoided per patient receiving the intervention was $3,752, compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed. CONCLUSIONS: This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.

Association of dementia with early rehospitalization among Medicare beneficiaries.

Preventable hospital readmissions have been recognized as indicators of hospital quality, a source of increased healthcare expenditures, and a burden for patients, families, and caregivers. Despite growth of initiatives targeting risk factors associated with potentially avoidable hospital readmissions, the impact of dementia on the likelihood of rehospitalization is poorly characterized. Therefore, the primary objective of this retrospective cohort study was to investigate whether dementia was an independent predictor of 30-day readmissions. Administrative claims data for all admissions to Rhode Island hospitals in 2009 was utilized to identify hospitalizations of Medicare fee-for-service beneficiaries with a diagnosis of Alzheimer's Disease or other dementias. Demographics, measures of comorbid disease burden, and other potential confounders were extracted from the data and the odds of 30-day readmission to any United States hospital was calculated from conditional logistic regression models. From a sample of 25,839 hospitalizations, there were 3908 index admissions of Medicare beneficiaries who fulfilled the study criteria for a dementia diagnosis. Nearly 20% of admissions (n=5133) were followed by a readmission within thirty days. Hospitalizations of beneficiaries with a dementia diagnosis were more likely to be followed by a readmission within thirty days (adjusted odds ratio (AOR) 1.18; 95% CI, 1.08, 1.29), compared to hospitalizations of those of without dementia. Controlling for discharge site of care did not attenuate the association (AOR 1.21; 95% CI, 1.10, 1.33).

Shifting the dialogue from hospital readmissions to unplanned care.

OBJECTIVES: To propose a new measurement strategy to evaluate the intended impact of hospital readmission reduction programs on healthcare utilization. STUDY DESIGN: In Rhode Island, Healthcentric Advisors, the Medicare Quality Improvement Organization, has implemented a readmissions reduction program since 2008. We use data fromthis program to illustrate our proposed use of a bundled measure of unplanned post-hospital care. METHODS: We examined Medicare Part A claims for all Rhode Island fee-for-service Medicare beneficiaries from January 1, 2009, through December 31, 2011.To capture potential cost shifting, we evaluated emergency department (ED) visits, observation stays, and hospital admission and readmission rates annually, and in the 30 days after discharge from an inpatient stay. We also aggregated these data into 2 composite measures: acute-care utilization and post-hospital unplanned care. RESULTS: From 2009 through 2011 Rhode Island's annual and post-hospital ED and inpatient admissions rates decreased, while the corresponding observation stay rates (annual and post-hospital) increased. Both the acute-care utilization and post-hospital unplanned care decreased. CONCLUSIONS: These data highlight the need to examine impact in the context of temporal trends and other environmental factors. Because readmissions are common and costly, national readmission reduction programs are proliferating. However, readmission rates provide an incomplete picture of unplanned care and costs and may lead to unintended consequences, such as increased observation stay rates. Our findings strengthen our argument that payers and policy makers should broaden their focus from readmission measures to unplanned care composite measures.

Beyond the focus group: understanding physicians' barriers to electronic medical records.

BACKGROUND: Although electronic medical records (EMRs) have potential to improve quality of care, physician adoption remains low. Rhode Island physicians' perceptions of barriers to EMRs and the association between these barriers and physician characteristics were examined. It was hypothesized that physicians with and without EMRs would differ in the types and magnitude of barriers identified. METHODS: Data were drawn from the Rhode Island Department of Health's mandatory 2009 Physician Health Information Technology (HIT) survey of physicians licensed and in active practice in Rhode Island or an adjacent state. Some 1,888 (58.1% of the target population of 3,248 physicians) responded. Respondents, who were invited to provide open-ended comments, were asked to consider 11 issues as barriers to EMR use: Access to technical support, lack of computer skills, availability of a computer in the appropriate location, impact of a computer on doctor-patient interaction, lack of interoperability, privacy or security concerns, start-up financial costs, ongoing financial costs, technic limitations of systems, training and productivity impact, and lack of uniform industry standards. RESULTS: Respondents with EMRs consistently perceived significantly fewer barriers than those without them (p < .0001). For example, 78.9% of physicians without EMRs viewed start-up financial costs as a major barrier versus only 45.8% of physicians with EMRs. CONCLUSIONS: An understanding of physicians' reluctance to use EMRs is critical for developing adoption strategies. Policies to increase EMR adoption should be tailored to different physician groups to achieve maximum effectiveness. Further research into the differences between current EMR users' and nonusers' perceptions of barriers may help elucidate how to facilitate subsequent adoption.

The care transitions intervention: translating from efficacy to effectiveness.

BACKGROUND: Well-executed communication among hospital providers, patients, and receiving providers at the time of hospital discharge contributes to better health outcomes and lower overall health care costs. The Care Transitions Intervention has reduced 30-day hospital readmissions by 30% in a randomized controlled trial in an integrated health system but requires real-world testing to establish effectiveness in other settings. We hypothesized that coaching would reduce 30-day readmission rates for fee-for-service Medicare beneficiaries, even in open, urban health care delivery systems. METHODS: This was a quasi-experimental prospective cohort study. From January 1, 2009, through June 30, 2010, coaches recruited a convenience sample of fee-for-service Medicare patients in 6 Rhode Island hospitals to receive the Care Transitions Intervention. We paired coaching data with Medicare claims and enrollment data and used logistic regression to compare the odds of 30-day readmission for the intervention group vs internal and external control groups. RESULTS: Compared with individuals who did not receive any part of the intervention (20.0% readmission rate), 30-day readmissions were fewer for participants who received coaching (12.8%; odds ratio, 0.61; 95% confidence interval, 0.42-0.88). Individuals in the internal control group (declined to participate or were lost to follow-up before completing a home visit) had readmission rates similar to those of the external control group (18.6%; odds ratio, 0.94, 95% confidence interval, 0.77-1.14). CONCLUSIONS: The Care Transitions Intervention appears to be effective in this real-world implementation. This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings.