The Impact of Hospital Size on CMS Hospital Profiling.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) profile hospitals using a set of 30-day risk-standardized mortality and readmission rates as a basis for public reporting. These measures are affected by hospital patient volume, raising concerns about uniformity of standards applied to providers with different volumes. OBJECTIVES: To quantitatively determine whether CMS uniformly profile hospitals that have equal performance levels but different volumes. RESEARCH DESIGN: Retrospective analysis of patient-level and hospital-level data using hierarchical logistic regression models with hospital random effects. Simulation of samples including a subset of hospitals with different volumes but equal poor performance (hospital effects=+3 SD in random-effect logistic model). SUBJECTS: A total of 1,085,568 Medicare fee-for-service patients undergoing 1,494,993 heart failure admissions in 4930 hospitals between July 1, 2005 and June 30, 2008. MEASURES: CMS methodology was used to determine the rank and proportion (by volume) of hospitals reported to perform "Worse than US National Rate." RESULTS: Percent of hospitals performing "Worse than US National Rate" was ∼40 times higher in the largest (fifth quintile by volume) compared with the smallest hospitals (first quintile). A similar gradient was seen in a cohort of 100 hospitals with simulated equal poor performance (0%, 0%, 5%, 20%, and 85% in quintiles 1 to 5) effectively leaving 78% of poor performers undetected. CONCLUSIONS: Our results illustrate the disparity of impact that the current CMS method of hospital profiling has on hospitals with higher volumes, translating into lower thresholds for detection and reporting of poor performance.

Impact of socioeconomic status measures on hospital profiling in New York City.

BACKGROUND: Current 30-day readmission models used by the Center for Medicare and Medicaid Services for the purpose of hospital-level comparisons lack measures of socioeconomic status (SES). We examined whether the inclusion of an SES measure in 30-day congestive heart failure readmission models changed hospital risk-standardized readmission rates in New York City (NYC) hospitals. METHODS AND RESULTS: Using a Centers for Medicare & Medicaid Services (CMS)-like model, we estimated 30-day hospital-level risk-standardized readmission rates by adjusting for age, sex, and comorbid conditions. Next, we examined how hospital risk-standardized readmission rates changed relative to the NYC mean with inclusion of the Agency for Healthcare Research and Quality (AHRQ)-validated SES index score. In a secondary analysis, we examined whether inclusion of the AHRQ SES index score in 30-day readmission models disproportionately impacted the risk-standardized readmission rates of minority-serving hospitals. Higher AHRQ SES scores, indicators of higher SES, were associated with lower odds (0.99) of 30-day readmission (P<0.019). The addition of the AHRQ SES index did not change the model's C statistic (0.63). After adjustment for the AHRQ SES index, 1 hospital changed status from worse than the NYC average to no different than the NYC average. After adjustment for the AHRQ SES index, 1 NYC minority-serving hospital was reclassified from worse to no different than average. CONCLUSIONS: Although patients with higher SES were less likely to be admitted, the impact of SES on readmission was small. In NYC, inclusion of the AHRQ SES score in a CMS-based model did not impact hospital-level profiling based on 30-day readmission.

Payer status and access to laparoscopic subtotal colectomy for ulcerative colitis.

BACKGROUND: Medicaid populations have been shown to have inferior surgical outcomes, but less is known about their access to advanced surgical procedures. OBJECTIVE: The aim of this study was to evaluate if patients with Medicaid and ulcerative colitis who presented for subtotal colectomy would have reduced access to the laparoscopic approach in comparison with a similar population with private insurance. DESIGN/SETTINGS/PATIENTS: Using the Nationwide Inpatient Sample database from 2008 to 2010, we identified all patients who underwent subtotal colectomy for ulcerative colitis. The χ test and multivariable logistic regression were used to identify predictors for laparoscopic subtotal colectomy for ulcerative colitis. MAIN OUTCOME MEASURES: The primary end point was the use of open or laparoscopic subtotal colectomy. Secondary end points included hospital length of stay and surgical outcomes. RESULTS: We identified a total of 2589 subtotal colectomy hospitalizations for ulcerative colitis (435 with Medicaid and 2154 with private insurance). The private insurance and Medicaid groups did not have significantly different mean age, sex, or Charlson scores (p > 0.05). Although 43% of the private insurance cohort received laparoscopic subtotal colectomy during their hospitalization, only 23% of the Medicaid population received equivalent care (p < 0.001). In a multivariate analysis that included age, sex, emergency status, hospital location, hospital size, teaching status, income, and Charlson score, urban teaching hospital status (p < 0.01), emergency status (p = 0.045), age <40 (p < 0.01), northeast location (p = 0.01), and private insurance status (p < 0.01) were independent predictors of the laparoscopic approach. LIMITATIONS: Administrative data have the potential for unrecognized miscoding or incomplete risk adjustment. Disease severity is not accounted for in the Nationwide Inpatient Sample database. CONCLUSION: Medicaid payer status was associated with reduced use of laparoscopic subtotal colectomy for ulcerative colitis. Although this finding may be due in part to physician preference or patient characteristics, health system factors appear to contribute to selection of the surgical approach.

Analysis of Florida and New York state hospital discharges suggests that carotid stenting in symptomatic women is associated with significant increase in mortality and perioperative morbidity compared with carotid endarterectomy.

BACKGROUND: Although large randomized studies have established the efficacy and safety of carotid endarterectomy (CEA) and, recently, carotid artery stenting (CAS), the under-representation of women in these trials leaves the comparison of risks to benefits of performing these procedures on women an open question. To address this issue, we reviewed the hospital outcomes and delineated patient characteristics predicting outcome in women undergoing carotid interventions using New York and Florida statewide hospital discharge databases. METHODS: We analyzed in-hospital mortality, postoperative stroke, cardiac postoperative complications, and combined postoperative stoke and mortality in 20,613 CEA or CAS hospitalizations for the years 2007 to 2009. Univariate and multiple logistic regression analyses of variables were performed. RESULTS: CEA was performed in 16,576 asymptomatic and 1744 symptomatic women and CAS in 1943 asymptomatic and 350 symptomatic women. Compared with CAS, CEA rates, in asymptomatic vs symptomatic, were significantly lower for in-hospital mortality (0.3% vs 0.8% and 0.4% vs 3.4%), stroke (1.5% vs 2.6% and 3.5% vs 9.4%), and combined stroke/mortality (1.7% vs 3.1% and 3.8% vs 10.9%). In cohorts matched by propensity scores, the same trend favoring CEA remained significant in symptomatic women. There was no difference in cardiac complication rates among asymptomatic women, but among symptomatic woman cardiac complications were more frequent after CAS (10.6% vs 6.5%; P = .0077). Among symptomatic women, the presence of renal disease, coronary artery disease, or age ≥80 years increased the risk of CAS over CEA threefold for the composite end point of stroke or death. For asymptomatic women only in those with coronary artery disease or diabetes, there was a statistical difference in the composite mortality/stroke rates favoring CEA (1.9% vs 3.3% and 1.7% vs 3.4%, respectively). After adjusting for relevant clinical and demographic risk factors and hospital annual volume, for CAS vs CEA, the risk of the composite end point of stroke or mortality was 1.7-fold higher in symptomatic and 3.4-fold higher in asymptomatic patients. Medicaid insurance, symptomatic patient, history of cancer, and presence of heart failure on admission were among other strong predictors of composite stroke/mortality outcome. CONCLUSIONS: Databases reflecting real-world practice performance and management of carotid disease in women suggest that CEA compared with CAS has overall better perioperative outcomes in women. Importantly, CAS is associated with significantly higher morbidity in certain clinical settings and this should be taken into account when choosing a revascularization procedure.