Race, Ethnicity, Neighborhood Characteristics, and In-Hospital Coronavirus Disease-2019 Mortality.

BACKGROUND: Despite many studies reporting disparities in coronavirus disease-2019 (COVID-19) incidence and outcomes in Black and Hispanic/Latino populations, mechanisms are not fully understood to inform mitigation strategies. OBJECTIVE: The aim was to test whether neighborhood factors beyond individual patient-level factors are associated with in-hospital mortality from COVID-19. We hypothesized that the Area Deprivation Index (ADI), a neighborhood census-block-level composite measure, was associated with COVID-19 mortality independently of race, ethnicity, and other patient factors. RESEARCH DESIGN: Multicenter retrospective cohort study examining COVID-19 in-hospital mortality. SUBJECTS: Inclusion required hospitalization with positive SARS-CoV-2 test or COVID-19 diagnosis at three large Midwestern academic centers. MEASURES: The primary study outcome was COVID-19 in-hospital mortality. Patient-level predictors included age, sex, race, insurance, body mass index, comorbidities, and ventilation. Neighborhoods were examined through the national ADI neighborhood deprivation rank comparing in-hospital mortality across ADI quintiles. Analyses used multivariable logistic regression with fixed site effects. RESULTS: Among 5999 COVID-19 patients median age was 61 (interquartile range: 44-73), 48% were male, 30% Black, and 10.8% died. Among patients who died, 32% lived in the most disadvantaged quintile while 11% lived in the least disadvantaged quintile; 52% of Black, 24% of Hispanic/Latino, and 8.5% of White patients lived in the most disadvantaged neighborhoods.Living in the most disadvantaged neighborhood quintile predicted higher mortality (adjusted odds ratio: 1.74; 95% confidence interval: 1.13-2.67) independent of race. Age, male sex, Medicare coverage, and ventilation also predicted mortality. CONCLUSIONS: Neighborhood disadvantage independently predicted in-hospital COVID-19 mortality. Findings support calls to consider neighborhood measures for vaccine distribution and policies to mitigate disparities.

Weighting of Measures in the Safety of Care Group of the Overall Hospital Quality Star Rating Program: An Alternative Approach.

The Centers for Medicare & Medicaid Services' Overall Hospital Quality Star Rating program has raised concerns since its introduction in 2016. Using both national data and data from a large urban teaching hospital, the authors examined a few methodological issues of one heavily weighted measure group, the Safety of Care group. The authors investigated the validity of the assumption that a single underlying quality trait exists among the 8 Safety measures, and the sensitivity of the Safety group score in response to a range of measure improvement scenarios. Also explored were the effects of an alternative weighting method and an alternative measure score calculation method on the results of a single hospital's Safety group score. Evidence was found for 4 (rather than 1) underlying quality dimensions among the 8 Safety measures, and the Safety group score calculated using the current method was notably different from that calculated using the alternative methods.

Adjusting for social risk factors impacts performance and penalties in the hospital readmissions reduction program.

OBJECTIVE: Medicare's Hospital Readmissions Reduction Program (HRRP) does not account for social risk factors in risk adjustment, and this may lead the program to unfairly penalize safety-net hospitals. Our objective was to determine the impact of adjusting for social risk factors on HRRP penalties. STUDY DESIGN: Retrospective cohort study. DATA SOURCES/STUDY SETTING: Claims data for 2 952 605 fee-for-service Medicare beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia from December 2012 to November 2015. PRINCIPAL FINDINGS: Poverty, disability, housing instability, residence in a disadvantaged neighborhood, and hospital population from a disadvantaged neighborhood were associated with higher readmission rates. Under current program specifications, safety-net hospitals had higher readmission ratios (AMI, 1.020 vs 0.986 for the most affluent hospitals; pneumonia, 1.031 vs 0.984; and CHF, 1.037 vs 0.977). Adding social factors to risk adjustment cut these differences in half. Over half the safety-net hospitals saw their penalty decline; 4-7.5 percent went from having a penalty to having no penalty. These changes translated into a $17 million reduction in penalties to safety-net hospitals. CONCLUSIONS: Accounting for social risk can have a major financial impact on safety-net hospitals. Adjustment for these factors could reduce negative unintended consequences of the HRRP.

Associations Between Community Sociodemographics and Performance in HEDIS Quality Measures: A Study of 22 Medical Centers in a Primary Care Network.

Evaluation and payment for health plans and providers have been increasingly tied to their performance on quality metrics, which can be influenced by patient- and community-level sociodemographic factors. The aim of this study was to examine whether performance on Healthcare Effectiveness Data and Information Set (HEDIS) measures varied as a function of community sociodemographic characteristics at the primary care clinic level. Twenty-two primary care sites of a large multispecialty group practice were studied during the period of April 2013 to June 2016. Significant associations were found between sites' performance on selected HEDIS measures and their neighborhood sociodemographic characteristics. Outcome measures had stronger associations with sociodemographic factors than did process measures, with a range of significant correlation coefficients (absolute value, regardless of sign) from 0.44 to 0.72. Sociodemographic factors accounted for as much as 25% to 50% of the observed variance in measures such as HbA1c or blood pressure control.

A slow start: Use of preventive services among seniors following the Affordable Care Act's enhancement of Medicare benefits in the U.S.

OBJECTIVE: Beginning January 1st, 2011 in the United States the Affordable Care Act enhanced Medicare coverage for preventive services by eliminating patient cost-sharing under Part B and by introducing an "Annual Wellness Visit," also free-of-charge. We evaluated the early effects of these reforms on utilization of preventive services. METHOD: We analyzed nationally representative data on 15,044 Medicare seniors from the 2008-2010, and 2012 Medical Expenditure Panel Survey, and examined self-reported cholesterol test, blood pressure check, flu vaccination, endoscopy, fecal occult blood test, prostate specific antigen test, breast examination, and mammography. RESULTS: Enhanced Medicare benefits had no effects on preventive service utilization among Medicare seniors in 2012, including those with traditional Medicare and no other supplemental insurance, who stood to benefit the most from Part B enhancements. CONCLUSION: The muted overall response can be partly attributed to the fact that most seniors already held insurance that fully covered preventive services. While insurance enhancements can sometimes raise utilization, in the case of preventive services there are other fundamental barriers that require attention. Educating and incentivizing physicians about the need to refer/recommend screenings, and enhancing knowledge among seniors about the importance of preventive care are two steps that would likely go a long way towards increasing utilization.

Socioeconomic status and readmissions: evidence from an urban teaching hospital.

The Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program has focused attention on ways to reduce thirty-day readmissions and on factors affecting readmission risk. Using inpatient data from an urban teaching hospital, we examined how elements of individual characteristics and neighborhood socioeconomic status influenced the likelihood of readmission under a single fixed organizational and staffing structure. Patients living in high-poverty neighborhoods were 24 percent more likely than others to be readmitted, after demographic characteristics and clinical conditions were adjusted for. Married patients were at significantly reduced risk of readmission, which suggests that they had more social support than unmarried patients. These and previous findings that document socioeconomic disparities in readmission raise the question of whether CMS's readmission measures and associated financial penalties should be adjusted for the effects of factors beyond hospital influence at the individual or neighborhood level, such as poverty and lack of social support.

Cataract Blindness and Simulation-Based Training for Cataract Surgeons: An Assessment of the HelpMeSee Approach.

Cataracts account for about half of all cases of blindness worldwide, with the vast majority in developing countries, where blindness and visual impairment can reduce life expectancy and economic productivity. Most of these cases can be cured by quick, inexpensive surgical procedures, but a shortage of trained surgeons makes it unlikely that the need for such surgeries-estimated to reach 32 million cases globally by 2020-can be met under current practices. HelpMeSee Inc. (HMS) is developing an approach to surgery training and delivery that includes use of high-fidelity simulator technology and associated curricula for high-volume training, development of a system of independent private practitioners, and training where necessary of individuals without medical degrees. RAND researchers determined that the program has the potential to scale up surgical capacity rapidly and that under optimistic assumptions, the HMS program could largely close the backlog of surgical cases in the four major regions studied, resulting in 21 million cases of cataract-caused visual impairment in 2030, compared with 134 million cases under the status quo. The program also promises to have large impacts on health and productivity, and the estimated costs per year of disability averted suggest that the intervention would be highly cost-effective in each of the regions researched. However, a number of significant challenges need to be met, particularly in the areas of outreach, remote monitoring of independent practitioners (especially non-doctors), and public and legal acceptance of non-doctors as surgeons. It is important to carefully pilot and monitor the approach before fully scaling up.

The risk-benefit balance in the United States: who decides?

A health policy decision often requires a balancing of risks, costs, and benefits. In this paper we illustrate that there is no uniform answer in the United States to the question of who decides the risk-benefit balance. We use a wide range of case examples from medicine and public health to show the different approaches that are used to allocate decision-making responsibility. Our ultimate purpose is to urge the U.S. health policy community to develop a more consistent way of thinking about how risk-benefit decisions could be guided by general principles.