Pre-Operative Predictors for Discharge to Post-Acute Care Facilities After Total Knee Arthroplasty.

BACKGROUND: Joint replacement surgery is in increasing demand and is the most common inpatient surgery for Medicare beneficiaries. The venue for post-operative rehabilitation, including early outpatient therapy after surgery, influences recovery and quality of life. As part of a comprehensive total joint program at Kaiser Permanente Colorado, we developed and validated a predictive model to anticipate and plan the disposition for rehabilitation of our patients after total knee arthroplasty (TKA). METHODS: We analyzed data for TKA patients who completed a pre-operative Total Knee Risk Assessment in 2017 (the model development cohort) or during the first 6 months of 2018 (the model validation cohort). The Total Knee Risk Assessment, which is used to guide disposition for rehabilitation, included questions in mobility, social, and environment domains. Multivariable logistic regression was used to predict discharge to post-acute care facilities (PACFs) (ie, skilled nursing facilities or acute rehabilitation centers). RESULTS: Data for a total of 1481 and 631 patients who underwent TKA were analyzed in the development and validation cohorts, respectively. Ninety-three patients (6.3%) in the development cohort and 22 patients (3.5%) in the validation cohort were discharged to PACFs. Eight risk factors for discharge to PACFs were included in the final multivariable model. Patients with a diagnosis of neurological disorder and with a mobility/balance issue had the greatest chance of discharge to PACFs. CONCLUSION: This validated predictive model for discharge disposition following TKA may be used as a tool in shared decision-making and discharge planning for patients undergoing TKA.

Levels of outpatient prescribing for four major antibiotic classes and rates of septicemia hospitalization in adults in different US states - a statistical analysis.

BACKGROUND: Rates of sepsis/septicemia hospitalization in the US have risen significantly during recent years. Antibiotic resistance and use may contribute to those rates through various mechanisms, including lack of clearance of resistant infections following antibiotic treatment, with some of those infections subsequently devolving into sepsis. At the same time, there is limited information on the effect of prescribing of certain antibiotics vs. others on the rates of septicemia and sepsis-related hospitalizations and mortality. METHODS: We used multivariable linear regression to relate state-specific rates of outpatient prescribing overall for oral fluoroquinolones, penicillins, macrolides, and cephalosporins between 2011 and 2012 to state-specific rates of septicemia hospitalization (ICD-9 codes 038.xx present anywhere on a discharge diagnosis) in each of the following age groups of adults: (18-49y, 50-64y, 65-74y, 75-84y, 85 + y) reported to the Healthcare Cost and Utilization Project (HCUP) between 2011 and 2012, adjusting for additional covariates, and random effects associated with the ten US Health and Human Services (HHS) regions. RESULTS: Increase in the rate of prescribing of oral penicillins by 1 annual dose per 1000 state residents was associated with increases in annual septicemia hospitalization rates of 0.19 (95% CI (0.02,0.37)) per 10,000 persons aged 50-64y, of 0.48(0.12,0.84) per 10,000 persons aged 65-74y, and of 0.81(0.17,1.40) per 10,000 persons aged 74-84y. Increase by 1 in the percent of African Americans among state residents in a given age group was associated with increases in annual septicemia hospitalization rates of 2.3(0.32,4.2) per 10,000 persons aged 75-84y, and of 5.3(1.1,9.5) per 10,000 persons aged over 85y. Average minimal daily temperature was positively associated with septicemia hospitalization rates in persons aged 18-49y, 50-64y, 75-84y and over 85y. CONCLUSIONS: Our results suggest positive associations between the rates of prescribing for penicillins and the rates of hospitalization with septicemia in US adults aged 50-84y. Further studies are needed to better understand the potential effect of antibiotic replacement in the treatment of various syndromes, including the potential impact of the recent US FDA guidelines on restriction of fluoroquinolone use, as well as the potential effect of changes in the practices for prescribing of penicillins on the rates of sepsis-related hospitalization and mortality.

Returns to Emergency Department, Observation, or Inpatient Care Within 30 Days After Hospitalization in 4 States, 2009 and 2010 Versus 2013 and 2014.

BACKGROUND: Nationally, readmissions have declined for acute myocardial infarction (AMI) and heart failure (HF) and risen slightly for pneumonia, but less is known about returns to the hospital for observation stays and emergency department (ED) visits. OBJECTIVE: To describe trends in rates of 30-day, all-cause, unplanned returns to the hospital, including returns for observation stays and ED visits. DESIGN: By using Healthcare Cost and Utilization Project data, we compared 210,007 index hospitalizations in 2009 and 2010 with 212,833 matched hospitalizations in 2013 and 2014. SETTING: Two hundred and one hospitals in Georgia, Nebraska, South Carolina, and Tennessee. PATIENTS: Adults with private insurance, Medicaid, or no insurance and seniors with Medicare who were hospitalized for AMI, HF, and pneumonia. MEASUREMENTS: Thirty-day hospital return rates for inpatient, observation, and ED visits. RESULTS: Return rates remained stable among adults with private insurance (15.1% vs 15.3%; P = 0.45) and declined modestly among seniors with Medicare (25.3% vs 25.0%; P = 0.04). Increases in observation and ED visits coincided with declines in readmissions (8.9% vs 8.2% for private insurance and 18.3% vs 16.9% for Medicare, both P ≤ 0.001). Return rates rose among patients with Medicaid (31.0% vs 32.1%; P = 0.04) and the uninsured (18.8% vs 20.1%; P = 0.004). Readmissions remained stable (18.7% for Medicaid and 9.5% for uninsured patients, both P > 0.75) while observation and ED visits increased. CONCLUSIONS: Total returns to the hospital are stable or rising, likely because of growth in observation and ED visits. Hospitalists' efforts to improve the quality and value of hospital care should consider observation and ED care.

National Estimates of Reductions in Acute Gastroenteritis-Related Hospitalizations and Associated Costs in US Children After Implementation of Rotavirus Vaccines.

We compared acute gastroenteritis (AGE)-related hospitalization rates among children <5 years of age during the pre-rotavirus vaccine (2000-2006) and post-rotavirus vaccine (2008-2013) periods to estimate national reductions in AGE-related hospitalizations and associated costs. We estimate that between 2008 and 2013, AGE-related hospitalizations declined by 382000, and $1.228 billion in medical costs were averted.

The Shifting Landscape in Utilization of Inpatient, Observation, and Emergency Department Services Across Payers.

Recent policies by public and private payers have increased incentives to reduce hospital admissions. Using data from four states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, this study compared the payer-specific population-based rates of adults using inpatient, observation, and emergency department (ED) services for 10 common medical conditions in 2009 and in 2013. Patients had an expected primary payer of private insurance, Medicare, Medicaid, or no insurance. Across all four payer populations, inpatient admissions declined, and care shifted toward treat-and-release observation stays and ED visits. The percentage of hospitalizations that began with an observation stay increased. Implications for quality of care and costs to patients warrant further examination. Journal of Hospital Medicine 2017;12:443-446.

Identifying in-patient costs attributable to the clinical sequelae and comorbidities of alcoholic liver disease in a national hospital database.

BACKGROUND AND AIMS: The clinical sequelae and comorbidities of alcoholic liver disease (ALD) often require hospitalization. The aims of this study were to (1) compare the average costs of hospitalizations with ALD and the costs of hospitalizations with other alcohol-related diagnoses that do not involve the liver; and (2) estimate the percentage of the difference in costs between the ALD and non-ALD hospitalizations that may be attributed to ascites, protein-calorie malnutrition and other conditions. DESIGN: The 2012 National Inpatient Sample is a population-based cross-sectional database representing more than 94% of all discharges from community hospitals in the United States. SETTING: Community hospitals in the United States. PARTICIPANTS: The sample included 72 531 hospitalizations with ALD and 287 047 hospitalizations with other alcohol-related diagnoses. MEASUREMENTS: The dependent variable was total in-patient costs. We estimated the contribution of ascites, protein-calorie malnutrition and other conditions to the difference in costs between patients with ALD and patients with other diagnoses. FINDINGS: Average costs for ALD patients were $3188.4 higher than those for patients with other diagnoses ($13 543 versus $10 355; P < 0.001). Among all conditions in the analysis, protein-calorie malnutrition had the largest impact on costs [$6501; 95% confidence interval (CI) = 5956, 7045; P < 0.001] accounting for 12% of the higher costs of ALD stays. CONCLUSIONS: Costs of hospital care for patients with alcoholic liver disease are higher than those for patients with other alcohol-related diagnoses. These increased costs are associated with specific clinical sequelae and comorbidities, with protein-calorie malnutrition-a largely preventable condition-making a substantial contribution.

Infectious Disease Hospitalizations Among American Indian/Alaska Native and Non-American Indian/Alaska Native Persons in Alaska, 2010-2011.

OBJECTIVE: Reports about infectious disease (ID) hospitalization rates among American Indian/Alaska Native (AI/AN) persons have been constrained by data limited to the tribal health care system and by comparisons with the general US population. We used a merged state database to determine ID hospitalization rates in Alaska. METHODS: We combined 2010 and 2011 hospital discharge data from the Indian Health Service and the Alaska State Inpatient Database. We used the merged data set to calculate average annual age-adjusted and age-specific ID hospitalization rates for AI/AN and non-AI/AN persons in Alaska. We stratified the ID hospitalization rates by sex, age, and ID diagnosis. RESULTS: ID diagnoses accounted for 19% (6501 of 34 160) of AI/AN hospitalizations, compared with 12% (7397 of 62 059) of non-AI/AN hospitalizations. The average annual age-adjusted hospitalization rate was >3 times higher for AI/AN persons (2697 per 100 000 population) than for non-AI/AN persons (730 per 100 000 population; rate ratio = 3.7, P < .001). Lower respiratory tract infection (LRTI), which occurred in 38% (2486 of 6501) of AI/AN persons, was the most common reason for ID hospitalization. AI/AN persons were significantly more likely than non-AI/AN persons to be hospitalized for LRTI (rate ratio = 5.2, P < .001). CONCLUSIONS: A substantial disparity in ID hospitalization rates exists between AI/AN and non-AI/AN persons, and the most common reason for ID hospitalization among AI/AN persons was LRTI. Public health programs and policies that address the risk factors for LRTI are likely to benefit AI/AN persons.

A Nationwide Assessment of the Association of Smoking Bans and Cigarette Taxes With Hospitalizations for Acute Myocardial Infarction, Heart Failure, and Pneumonia.

Multiple studies claim that public place smoking bans are associated with reductions in smoking-related hospitalization rates. No national study using complete hospitalization counts by area that accounts for contemporaneous controls including state cigarette taxes has been conducted. We examine the association between county-level smoking-related hospitalization rates and comprehensive smoking bans in 28 states from 2001 to 2008. Differences-in-differences analysis measures changes in hospitalization rates before versus after introducing bans in bars, restaurants, and workplaces, controlling for cigarette taxes, adjusting for local health and provider characteristics. Smoking bans were not associated with acute myocardial infarction or heart failure hospitalizations, but lowered pneumonia hospitalization rates for persons ages 60 to 74 years. Higher cigarette taxes were associated with lower heart failure hospitalizations for all ages and fewer pneumonia hospitalizations for adults aged 60 to 74. Previous studies may have overestimated the relation between smoking bans and hospitalizations and underestimated the effects of cigarette taxes.

Potentially preventable hospitalizations for acute and chronic conditions in Alaska, 2010-2012.

OBJECTIVE: The U.S. Agency for Healthcare Research and Quality's Prevention Quality Indicators comprise acute and chronic conditions for which hospitalization can be potentially prevented by high-quality ambulatory care. The Healthy Alaska 2020 initiative (HA2020) targeted reducing potentially preventable hospitalizations (PPH) for acute and chronic conditions among its health indicators. We estimated the PPH rate for adults aged ≥ 18 years in Alaska during 2010-2012. METHODS: We conducted a cross-sectional analysis of state-wide hospital discharge data obtained from the Healthcare Cost and Utilization Project and the Indian Health Service. We calculated average annual PPH rates/1000 persons for acute/chronic conditions. Age-adjusted rate ratios (aRRs) were used for evaluating PPH rate disparities between Alaska Native (AN) and non-AN adults. RESULTS: Among 127,371 total hospitalizations, 4911 and 6721 were for acute and chronic PPH conditions, respectively. The overall crude PPH rate was 7.3 (3.1 for acute and 4.2 for chronic conditions). AN adults had a higher rate than non-AN adults for acute (aRR: 4.7; p < 0.001) and chronic (aRR: 2.6; p < 0.001) PPH conditions. Adults aged ≥ 85 years had the highest PPH rate for acute (43.5) and chronic (31.6) conditions. Acute conditions with the highest PPH rate were bacterial pneumonia (1.8) and urinary tract infections (0.8). Chronic conditions with the highest PPH rate were chronic obstructive pulmonary disease (COPD; 1.6) and congestive heart failure (CHF; 1.3). CONCLUSION: Efforts to reduce PPHs caused by COPD, CHF, and bacterial pneumonia, especially among AN people and older adults, should yield the greatest benefit in achieving the HA2020 goal.

Epidemiology of Hospitalizations Associated with Invasive Candidiasis, United States, 2002-20121.

Invasive candidiasis is a major nosocomial fungal disease in the United States associated with high rates of illness and death. We analyzed inpatient hospitalization records from the Healthcare Cost and Utilization Project to estimate incidence of invasive candidiasis-associated hospitalizations in the United States. We extracted data for 33 states for 2002-2012 by using codes from the International Classification of Diseases, 9th Revision, Clinical Modification, for invasive candidiasis; we excluded neonatal cases. The overall age-adjusted average annual rate was 5.3 hospitalizations/100,000 population. Highest risk was for adults >65 years of age, particularly men. Median length of hospitalization was 21 days; 22% of patients died during hospitalization. Median unadjusted associated cost for inpatient care was $46,684. Age-adjusted annual rates decreased during 2005-2012 for men (annual change -3.9%) and women (annual change -4.5%) and across nearly all age groups. We report a high mortality rate and decreasing incidence of hospitalizations for this disease.

Impact of Race/Ethnicity and Socioeconomic Status on Risk-Adjusted Hospital Readmission Rates Following Hip and Knee Arthroplasty.

BACKGROUND: Readmission rates following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are increasingly used to measure hospital performance. Readmission rates that are not adjusted for race/ethnicity and socioeconomic status, patient risk factors beyond a hospital's control, may not accurately reflect a hospital's performance. In this study, we examined the extent to which risk-adjusting for race/ethnicity and socioeconomic status affected hospital performance in terms of readmission rates following THA and TKA. METHODS: We calculated 2 sets of risk-adjusted readmission rates by (1) using the Centers for Medicare & Medicaid Services standard risk-adjustment algorithm that incorporates patient age, sex, comorbidities, and hospital effects and (2) adding race/ethnicity and socioeconomic status to the model. Using data from the Healthcare Cost and Utilization Project, 2011 State Inpatient Databases, we compared the relative performances of 1,194 hospitals across the 2 methods. RESULTS: Addition of race/ethnicity and socioeconomic status to the risk-adjustment algorithm resulted in (1) little or no change in the risk-adjusted readmission rates at nearly all hospitals; (2) no change in the designation of the readmission rate as better, worse, or not different from the population mean at >99% of the hospitals; and (3) no change in the excess readmission ratio at >97% of the hospitals. CONCLUSIONS: Inclusion of race/ethnicity and socioeconomic status in the risk-adjustment algorithm led to a relative-performance change in readmission rates following THA and TKA at <3% of the hospitals. We believe that policymakers and payers should consider this result when deciding whether to include race/ethnicity and socioeconomic status in risk-adjusted THA and TKA readmission rates used for hospital accountability, payment, and public reporting. LEVEL OF EVIDENCE: Prognostic Level III. See instructions for Authors for a complete description of levels of evidence.

Marginal Hospital Cost of Surgery-related Hospital-acquired Pressure Ulcers.

BACKGROUND: Patients who develop hospital-acquired pressure ulcers (HAPUs) are more likely to die, have longer hospital stays, and are at greater risk of infections. Patients undergoing surgery are prone to developing pressure ulcers (PUs). OBJECTIVE: To estimate the hospital marginal cost of a HAPU for adults patients who were hospitalized for major surgeries, adjusted for patient characteristics, comorbidities, procedures, and hospital characteristics. RESEARCH DESIGN AND SUBJECTS: Data are from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and the Medicare Patient Safety Monitoring System for 2011 and 2012. PU information was obtained using retrospective structured record review from trained MPMS data abstractors. Costs are derived using HCUP hospital-specific cost-to-charge ratios. Marginal cost estimates were made using Extended Estimating Equations. We estimated the marginal cost at the 25th, 50th, and 75th percentiles of the cost distribution using Simultaneous Quantile Regression. RESULTS: We find that 3.5% of major surgical patients developed HAPUs and that the HAPUs added ∼$8200 to the cost of a surgical stay after adjusting for comorbidities, patient characteristics, procedures, and hospital characteristics. This is an ∼44% addition to the cost of a major surgical stay but less than half of the unadjusted cost difference. In addition, we find that for high-cost stays (75th percentile) HAPUs added ∼$12,100, whereas for low-cost stays (25th percentile) HAPUs added ∼$3900. CONCLUSIONS: This paper suggests that HAPUs add ∼44% to the cost of major surgical hospital stays, but the amount varies depending on the total cost of the visit.

Differences in severity at admission for heart failure between rural and urban patients: the value of adding laboratory results to administrative data.

BACKGROUND: Rural/urban variations in admissions for heart failure may be influenced by severity at hospital presentation and local practice patterns. Laboratory data reflect clinical severity and guide hospital admission decisions and treatment for heart failure, a costly chronic illness and a leading cause of hospitalization among the elderly. Our main objective was to examine the role of laboratory test results in measuring disease severity at the time of admission for inpatients who reside in rural and urban areas. METHODS: We retrospectively analyzed discharge data on 13,998 hospital discharges for heart failure from three states, Hawai'i, Minnesota, and Virginia. Hospital discharge records from 2008 to 2012 were derived from the State Inpatient Databases of the Healthcare Cost and Utilization Project, and were merged with results of laboratory tests performed on the admission day or up to two days before admission. Regression models evaluated the relationship between clinical severity at admission and patient urban/rural residence. Models were estimated with and without use of laboratory data. RESULTS: Patients residing in rural areas were more likely to have missing laboratory data on admission and less likely to have abnormal or severely abnormal tests. Rural patients were also less likely to be admitted with high levels of severity as measured by the All Patient Refined Diagnosis Related Groups (APR-DRG) severity subclass, derivable from discharge data. Adding laboratory data to discharge data improved model fit. Also, in models without laboratory data, the association between urban compared to rural residence and APR-DRG severity subclass was significant for major and extreme levels of severity (OR 1.22, 95% CI 1.03-1.43 and 1.55, 95% CI 1.26-1.92, respectively). After adding laboratory data, this association became non-significant for major severity and was attenuated for extreme severity (OR 1.12, 95% CI 0.94-1.32 and 1.43, 95% CI 1.15-1.78, respectively). CONCLUSION: Heart failure patients from rural areas are hospitalized at lower severity levels than their urban counterparts. Laboratory test data provide insight on clinical severity and practice patterns beyond what is available in administrative discharge data.

Burden of encephalitis-associated hospitalizations in the United States, 1998-2010.

OBJECTIVE: To estimate the burden of encephalitis-associated hospitalizations in the United States for 1998-2010. METHODS: Using the Nationwide Inpatient Sample, a nationally representative database of hospitalizations, estimated numbers and rates of encephalitis-associated hospitalizations for 1998-2010 were calculated. Etiology and outcome of encephalitis-associated hospitalizations were examined, as well as accompanying diagnoses listed along with encephalitis on the discharge records. Total hospital charges (in 2010 US dollars) were assessed. RESULTS: An estimated 263,352 (standard error: 3,017) encephalitis-associated hospitalizations occurred in the United States during 1998-2010, which corresponds to an average of 20,258 (standard error: 232) encephalitis-associated hospitalizations per year. A fatal outcome occurred in 5.8% (95% confidence interval [CI]: 5.6%-6.0%) of all encephalitis-associated hospitalizations and in 10.1% (95% CI: 9.2%-11.2%) and 17.1% (95% CI: 14.6%-20.0%) of encephalitis-associated hospitalizations in which a code for HIV or a tissue or organ transplant was listed, respectively. The proportion of encephalitis-associated hospitalizations in which an etiology for encephalitis was specified was 50.3% (95% CI: 49.6%-51.0%) and that for which the etiology was unspecified was 49.7% (95% CI: 49.0%-50.4%). Total charges for encephalitis-associated hospitalizations in 2010 were an estimated $2.0 billion. CONCLUSIONS: Encephalitis remains a major public health concern in the United States. Among the large number of encephalitis-associated hospitalizations for which an etiology is not reported may be novel infectious and noninfectious forms of encephalitis. Associated conditions such as HIV or transplantation increase the risk of a fatal outcome from an encephalitis-associated hospitalization and should be monitored.

Factors associated with adoption of robotic surgical technology in US hospitals and relationship to radical prostatectomy procedure volume.

OBJECTIVE: Robotic technology has diffused rapidly despite high costs and limited additive reimbursement by major payers. We aimed to identify the factors associated with hospitals' decisions to adopt robotic technology and the consequences of these decisions. METHODS: This observational study used data on hospitals and market areas from 2005 to 2009. Included were hospitals in census-based statistical areas within states in the State Inpatient Database that participated in the American Hospital Association annual surveys and performed radical prostatectomies. The likelihood that a hospital would acquire a robotic facility and the rates of radical prostatectomy relative to the prevalence of robots in geographic market areas were assessed using multivariable analysis. RESULTS: Hospitals in areas where a higher proportion of other hospitals had already acquired a robot were more likely to acquire one (P=0.012), as were those with more than 300 beds (P<0.0001) and teaching hospitals (P<0.0001). There was a significant association between years with a robot and the change in the number of radical prostatectomies (P<0.0001). More radical prostatectomies were performed in areas where the number of robots per 100,000 men was higher (P<0.0001). Adding a single robot per 100,000 men in an area was associated with a 30% increase in the rate of radical prostatectomies. CONCLUSIONS: Local area robot competition was associated with the rapid spread of robot technology in the United States. Significantly more radical prostatectomies were performed in hospitals with robots and in market areas of hospitals with robotic technology.

Influenza hospitalizations among american indian/alaska native people and in the United States general population.

BACKGROUND: Historically, American Indian/Alaska Native (AI/AN) people have experienced a disproportionate burden of infectious disease morbidity compared with the general US population. We evaluated whether a disparity in influenza hospitalizations exists between AI/AN people and the general US population. METHODS: We used Indian Health Service hospital discharge data (2001-2011) for AI/AN people and 13 State Inpatient Databases (2001-2008) to provide a comparison to the US population. Hospitalization rates were calculated by respiratory year (July-June). Influenza-specific hospitalizations were defined as discharges with any influenza diagnoses. Influenza-associated hospitalizations were calculated using negative binomial regression models that incorporated hospitalization and influenza laboratory surveillance data. RESULTS: The mean influenza-specific hospitalization rate/100 000 persons/year during the 2001-2002 to 2007-2008 respiratory years was 18.6 for AI/AN people and 15.6 for the comparison US population. The age-adjusted influenza-associated hospitalization rate for AI/AN people (98.2; 95% confidence interval [CI], 51.6-317.8) was similar to the comparison US population (58.2; CI, 34.7-172.2). By age, influenza-associated hospitalization rates were significantly higher among AI/AN infants (<1 year) (1070.7; CI, 640.7-2969.5) than the comparison US infant population (210.2; CI, 153.5-478.5). CONCLUSIONS: American Indian/Alaska Native people had higher influenza-specific hospitalization rates than the comparison US population; a significant influenza-associated hospitalization rate disparity was detected only among AI/AN infants because of the wide CIs inherent to the model. Taken together, the influenza-specific and influenza-associated hospitalization rates suggest that AI/AN people might suffer disproportionately from influenza illness compared with the general US population.

Hospital utilization, costs, and mortality for adults with multiple chronic conditions, Nationwide Inpatient Sample, 2009.

OBJECTIVE: Our objective was to provide a national estimate across all payers of the distribution and cost of selected chronic conditions for hospitalized adults in 2009, stratified by demographic characteristics. ANALYSIS: We analyzed the Nationwide Inpatient Sample (NIS), the largest all-payer inpatient database in the United States. Use, cost, and mortality estimates across payer, age, sex, and race/ethnicity are produced for grouped or multiple chronic conditions (MCC). The 5 most common dyads and triads were determined. RESULTS: In 2009, there were approximately 28 million adult discharges from US hospitals other than those related to pregnancy and maternity; 39% had 2 to 3 MCC, and 33% had 4 or more. A higher number of MCC was associated with higher mortality, use of services, and average cost. The percentages of Medicaid, privately insured patients, and ethnic/racial groups with 4 or more MCC were highly sensitive to age. SUMMARY: This descriptive analysis of multipayer inpatient data provides a robust national view of the substantial use and costs among adults hospitalized with MCC.

Likelihood of hospital readmission after first discharge: Medicare Advantage vs. fee-for-service patients.

This study tests whether the likelihood of hospital readmission within 30 days of discharge is different for enrollees in Medicare Advantage plans versus the standard fee-for-service program. A key requirement is to control for self-selection into Advantage plans. The study uses statewide inpatient databases maintained by the Agency for Healthcare Research and Quality for five states in 2006. The type of Medicare coverage is known, along with an encrypted patient identifier. We identify eligible first discharges and the first readmission within 30 days. We use selected area characteristics as instrumental variables for enrollment in Advantage plans and apply a bivariate probit analysis. Descriptively, there is a slightly lower likelihood of readmission for Advantage plan enrollees. However, the Advantage plan patients are younger and less severely ill. After risk adjustment and control for self-selection, the enrollees in Advantage plans have a substantially higher likelihood of readmission. Recognizing caveats and limitations, the study supports informing Medicare beneficiaries about the rates of readmission for Advantage plans in their area. Analytical methods to adjust for self-selection into particular plans or plan types should be considered when possible.

All-cause gastroenteritis and rotavirus-coded hospitalizations among US children, 2000-2009.

BACKGROUND: Rotavirus vaccine was recommended for US infants in 2006. We estimated baseline prevaccine burden and monitored postvaccine trends in gastroenteritis-coded and rotavirus-coded hospitalizations among US children. METHODS: We analyzed data from the State Inpatient Databases (SID) for 29-44 US states over a 10-year period (2000-2009) to calculate gastroenteritis and rotavirus-coded hospitalization rates by age group, sex, and region, among children <5 years of age. By extrapolating observed pre- and postvaccine gastroenteritis hospitalization rates to the US population <5 years and based on the 2009 cost of a diarrhea hospitalization, we estimated national reductions in diarrhea hospitalizations and associated treatment costs. RESULTS: The prevaccine (2000-2006) annual average gastroenteritis-coded hospitalization rate among children <5 years of age was 74 per 10,000 (annual range, 71-82 per 10,000), and declined to 51 and 50 per 10,000 in 2008 and 2009, respectively (P < .001). The prevaccine (2000-2006) annual average rotavirus-coded hospitalization rate among children <5 years of age was 15 per 10,000 (annual range, 13-18 per 10,000), and declined to 5 and 6 per 10,000 in 2008 and 2009, respectively (P < .001). The decreases in rotavirus-coded hospitalization rates in 2008 and 2009 compared with rates in prevaccine years were observed among all age groups and US regions. Nationally, during 2008 and 2009 combined, we estimated a reduction of approximately 77,000 diarrhea hospitalizations and approximately $242 million in hospital costs. CONCLUSIONS: Since implementation of the US rotavirus vaccination program, a marked reduction in diarrhea hospitalizations and related hospital charges has occurred among US children.

Disparities in infectious disease hospitalizations for American Indian/ Alaska Native people.

OBJECTIVES: We described disparities in infectious disease (ID) hospitalizations for American Indian/Alaska Native (AI/AN) people. METHODS: We analyzed hospitalizations with an ID listed as the first discharge diagnosis in 1998-2006 for AI/AN people from the Indian Health Service National Patient Information Reporting System and compared them with records for the general U.S. population from the Nationwide Inpatient Survey. RESULTS: The ID hospitalization rate for AI/AN people declined during the study period. The 2004-2006 mean annual age-adjusted ID hospitalization rate for AI/AN people (1,708 per 100,000 populiation) was slightly higher than that for the U.S. population (1,610 per 100,000 population). The rate for AI/AN people was highest in the Southwest (2,314 per 100,000 population), Alaska (2,063 per 100,000 population), and Northern Plains West (1,957 per 100,000 population) regions, and among infants (9,315 per 100,000 population). ID hospitalizations accounted for approximately 22% of all AI/AN hospitalizations. Lower-respiratory-tract infections accounted for the largest proportion of ID hospitalizations among AI/AN people (35%) followed by skin and soft tissue infections (19%), and infections of the kidney, urinary tract, and bladder (11%). CONCLUSIONS: Although the ID hospitalization rate for AI/AN people has declined, it remains higher than that for the U.S. general population, and is highest in the Southwest, Northern Plains West, and Alaska regions. Lower-respiratory-tract infections; skin and soft tissue infections; and kidney, urinary tract, and bladder infections contributed most to these health disparities. Future prevention strategies should focus on high-risk regions and age groups, along with illnesses contributing to health disparities.