Pre-COVID-19 hospital quality and hospital response to COVID-19: examining associations between risk-adjusted mortality for patients hospitalised with COVID-19 and pre-COVID-19 hospital quality.

OBJECTIVES: The extent to which care quality influenced outcomes for patients hospitalised with COVID-19 is unknown. Our objective was to determine if prepandemic hospital quality is associated with mortality among Medicare patients hospitalised with COVID-19. DESIGN: This is a retrospective observational study. We calculated hospital-level risk-standardised in-hospital and 30-day mortality rates (risk-standardised mortality rates, RSMRs) for patients hospitalised with COVID-19, and correlation coefficients between RSMRs and pre-COVID-19 hospital quality, overall and stratified by hospital characteristics. SETTING: Short-term acute care hospitals and critical access hospitals in the USA. PARTICIPANTS: Hospitalised Medicare beneficiaries (Fee-For-Service and Medicare Advantage) age 65 and older hospitalised with COVID-19, discharged between 1 April 2020 and 30 September 2021. INTERVENTION/EXPOSURE: Pre-COVID-19 hospital quality. OUTCOMES: Risk-standardised COVID-19 in-hospital and 30-day mortality rates (RSMRs). RESULTS: In-hospital (n=4256) RSMRs for Medicare patients hospitalised with COVID-19 (April 2020-September 2021) ranged from 4.5% to 59.9% (median 18.2%; IQR 14.7%-23.7%); 30-day RSMRs ranged from 12.9% to 56.2% (IQR 24.6%-30.6%). COVID-19 RSMRs were negatively correlated with star rating summary scores (in-hospital correlation coefficient -0.41, p<0.0001; 30 days -0.38, p<0.0001). Correlations with in-hospital RSMRs were strongest for patient experience (-0.39, p<0.0001) and timely and effective care (-0.30, p<0.0001) group scores; 30-day RSMRs were strongest for patient experience (-0.34, p<0.0001) and mortality (-0.33, p<0.0001) groups. Patients admitted to 1-star hospitals had higher odds of mortality (in-hospital OR 1.87, 95% CI 1.83 to 1.91; 30-day OR 1.46, 95% CI 1.43 to 1.48) compared with 5-star hospitals. If all hospitals performed like an average 5-star hospital, we estimate 38 000 fewer COVID-19-related deaths would have occurred between April 2020 and September 2021. CONCLUSIONS: Hospitals with better prepandemic quality may have care structures and processes that allowed for better care delivery and outcomes during the COVID-19 pandemic. Understanding the relationship between pre-COVID-19 hospital quality and COVID-19 outcomes will allow policy-makers and hospitals better prepare for future public health emergencies.

Crescent calculator: A webtool enabling objective decision-making for assessment of IgA nephropathy immune activity throughout the disease course.

IgA nephropathy (IgAN) is an immune-mediated glomerulonephritis, posing a challenge for the long-term management. It is crucial to monitor the disease's activity over the disease course. Crescent lesions have been known as an active lesion associated with immune activity. We aimed to develop the Crescent Calculator to aid clinicians in making timely and well-informed decisions throughout the long-term disease course, such as renal biopsies and immunosuppressive therapy. 1,761 patients with biopsy-proven IgAN were recruited from four medical centers in Zhejiang Province, China. 16.9% presented crescent lesions. UPCR, URBC, eGFR and C4 were independently associated with the crescent lesions. By incorporating these variables, the Crescent Calculator was constructed to estimate the likelihood of crescent lesions. The predictor achieved AUC values of over 0.82 in two independent testing datasets. In addition, to fulfill varied clinical needs, multiple classification modes were established. The Crescent Calculator was developed to estimate the risk of crescent lesions for patients with IgAN, assisting clinicians in making timely, objective, and well-informed decisions regarding the need for renal biopsies and more appropriate use of immunosuppressive therapy in patients with IgAN.

Racial Differences in Presentation and Outcomes After Peripheral Arterial Interventions: Insights From the NCDR-PVI Registry.

BACKGROUND: We assess the rates of device use and outcomes by race among patients undergoing lower extremity peripheral arterial intervention using the American College of Cardiology National Cardiovascular Data Registry-Peripheral Vascular Intervention (PVI) registry. METHODS: Patients who underwent PVI between April 2014 and March 2019 were included. Socioeconomic status was evaluated using the Distressed Community Index score for patients' zip codes. Multivariable logistic regression was used to assess factors associated with utilization of drug-eluting technologies, intravascular imaging, and atherectomy. Among patients with Centers for Medicare and Medicaid Services data, we compared 1-year mortality, rates of amputation, and repeat revascularizations. RESULTS: Of 63 150 study cases, 55 719 (88.2%) were performed in White patients and 7431 (11.8%) in Black patients. Black patients were younger (67.9 versus 70.0 years), had higher rates of hypertension (94.4% versus 89.5%), diabetes (63.0% versus 46.2%), less likely to be able to walk 200 m (29.1% versus 24.8%), and higher Distressed Community Index scores (65.1 versus 50.6). Black patients were provided drug-eluting technologies at a higher rate (adjusted odds ratio, 1.14 [95% CI, 1.06-1.23]) with no difference in atherectomy (adjusted odds ratio, 0.98 [95% CI, 0.91-1.05]) or intravascular imaging (adjusted odds ratio, 1.03 [95% CI, 0.88-1.22]) use. Black patients experienced a lower rate of acute kidney injury (adjusted odds ratio, 0.79 [95% CI, 0.72-0.88]). In Centers for Medicare and Medicaid Services-linked analyses of 7429 cases (11.8%), Black patients were significantly less likely to have surgical (adjusted hazard ratio, 0.40 [95% CI, 0.17-0.96]) or repeat PVI revascularization (adjusted hazard ratio, 0.42 [95% CI, 0.30-0.59]) at 1 year compared with White patients. There was no difference in mortality (adjusted hazard ratio [0.8-1.4]) or major amputation (adjusted hazard ratio, 2.5 [95% CI, 0.8-7.6]) between Black and White patients. CONCLUSIONS: Black patients presenting for PVI were younger, had higher prevalence of comorbidities and lower socioeconomic status. After adjustment, Black patients were less likely to have surgical or repeat PVI revascularization after the index PVI procedure.

Comparative Outcomes of Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction Among Medicare Beneficiaries With Multivessel Coronary Artery Disease: An National Cardiovascular Data Registry Research to Practice Project.

[Figure: see text].

Administrative Claims Measure for Profiling Hospital Performance Based on 90-Day All-Cause Mortality Following Coronary Artery Bypass Graft Surgery.

BACKGROUND: Coronary artery bypass graft (CABG) surgery is a focus of bundled and alternate payment models that capture outcomes up to 90 days postsurgery. While clinical registry risk models perform well, measures encompassing mortality beyond 30 days do not currently exist. We aimed to develop a risk-adjusted hospital-level 90-day all-cause mortality measure intended for assessing hospital performance in payment models of CABG surgery using administrative data. METHODS: Building upon Centers for Medicare and Medicaid Services hospital-level 30-day all-cause CABG mortality measure specifications, we extended the mortality timeframe to 90 days after surgery and developed a new hierarchical logistic regression model to calculate hospital risk-standardized 90-day all-cause mortality rates for patients hospitalized for isolated CABG. The model was derived from Medicare claims data for a 3-year cohort between July 2014 to June 2017. The data set was randomly split into 50:50 development and validation samples. The model performance was evaluated with C statistics, overfitting indices, and calibration plot. The empirical validity of the measure result at the hospital level was evaluated against the Society of Thoracic Surgeons composite star rating. RESULTS: Among 137 819 CABG procedures performed in 1183 hospitals, the unadjusted mortality rate within 30 and 90 days were 3.1% and 4.7%, respectively. The final model included 27 variables. Hospital-level 90-day risk-standardized mortality rates ranged between 2.04% and 11.26%, with a median of 4.67%. C statistics in the development and validation samples were 0.766 and 0.772, respectively. We identified a strong positive correlation between 30- and 90-day risk-standardized mortality rates, with a regression slope of 1.09. Risk-standardized mortality rates also showed a stepwise trend of lower 90-day mortality with higher Society of Thoracic Surgeons composite star ratings. CONCLUSIONS: We present a measure of hospital-level 90-day risk-standardized mortality rates following isolated CABG. This measure complements Centers for Medicare and Medicaid Services' existing 30-day CABG mortality measure by providing greater insight into the postacute recovery period. It offers a balancing measure to ensure efforts to reduce costs associated with CABG recovery and rehabilitation do not result in unintended consequences.

Timely estimation of National Admission, readmission, and observation-stay rates in medicare patients with acute myocardial infarction, heart failure, or pneumonia using near real-time claims data.

BACKGROUND: To estimate, prior to finalization of claims, the national monthly numbers of admissions and rates of 30-day readmissions and post-discharge observation-stays for Medicare fee-for-service beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. METHODS: The centers for Medicare & Medicaid Services (CMS) Integrated Data Repository, including the Medicare beneficiary enrollment database, was accessed in June 2015, February 2017, and February 2018. We evaluated patterns of delay in Medicare claims accrual, and used incomplete, non-final claims data to develop and validate models for real-time estimation of admissions, readmissions, and observation stays. RESULTS: These real-time reporting models accurately estimate, within 2 months from admission, the monthly numbers of admissions, 30-day readmission and observation-stay rates for patients with AMI, HF, or pneumonia. CONCLUSIONS: This work will allow CMS to track the impact of policy decisions in real time and enable hospitals to better monitor their performance nationally.

Genome-wide assessment of genetic risk for systemic lupus erythematosus and disease severity.

Using three European and two Chinese genome-wide association studies (GWAS), we investigated the performance of genetic risk scores (GRSs) for predicting the susceptibility and severity of systemic lupus erythematosus (SLE), using renal disease as a proxy for severity. We used four GWASs to test the performance of GRS both cross validating within the European population and between European and Chinese populations. The performance of GRS in SLE risk prediction was evaluated by receiver operating characteristic (ROC) curves. We then analyzed the polygenic nature of SLE statistically. We also partitioned patients according to their age-of-onset and evaluated the predictability of GRS in disease severity in each age group. We found consistently that the best GRS in the prediction of SLE used SNPs associated at the level of P < 1e-05 in all GWAS data sets and that SNPs with P-values above 0.2 were inflated for SLE true positive signals. The GRS results in an area under the ROC curve ranging between 0.64 and 0.72, within European and between the European and Chinese populations. We further showed a significant positive correlation between a GRS and renal disease in two independent European GWAS (Pcohort1 = 2.44e-08; Pcohort2 = 0.00205) and a significant negative correlation with age of SLE onset (Pcohort1 = 1.76e-12; Pcohort2 = 0.00384). We found that the GRS performed better in the prediction of renal disease in the 'later onset' compared with the 'earlier onset' group. The GRS predicts SLE in both European and Chinese populations and correlates with poorer prognostic factors: young age-of-onset and lupus nephritis.

Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States.

OBJECTIVES: To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. DESIGN: Retrospective cohort study. SETTING: Medicare claims data for 2008-16 in the United States. PARTICIPANTS: Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia-conditions included in the US Hospital Readmissions Reduction Program. MAIN OUTCOME MEASURES: Post-discharge 30 day mortality according to patients' 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. RESULTS: 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (-0.09% to -0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. CONCLUSIONS: The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.

Myocardial infarction with non-obstructive coronary arteries as compared with myocardial infarction and obstructive coronary disease: outcomes in a Medicare population.

AIMS: The prognosis of patients with MINOCA (myocardial infarction with non-obstructive coronary arteries) is poorly understood. We examined major adverse cardiac events (MACE) defined as all-cause mortality, re-hospitalization for acute myocardial infarction (AMI), heart failure (HF), or stroke 12-months post-AMI in patients with MINOCA versus AMI patients with obstructive coronary artery disease (MICAD). METHODS AND RESULTS: Multicentre, observational cohort study of patients with AMI (≥65 years) from the National Cardiovascular Data Registry CathPCI Registry (July 2009-December 2013) who underwent coronary angiography with linkage to the Centers for Medicare and Medicaid (CMS) claims data. Patients were classified as MICAD or MINOCA by the presence or absence of an epicardial vessel with ≥50% stenosis. The primary endpoint was MACE at 12 months, and secondary endpoints included the components of MACE over 12 months. Among 286 780 AMI admissions (276 522 unique patients), 16 849 (5.9%) had MINOCA. The 12-month rates of MACE (18.7% vs. 27.6%), mortality (12.3% vs. 16.7%), and re-hospitalization for AMI (1.3% vs. 6.1%) and HF (5.9% vs. 9.3%) were significantly lower for MINOCA vs. MICAD patients (P < 0.001), but was similar between MINOCA and MICAD patients for re-hospitalization for stroke (1.6% vs. 1.4%, P = 0.128). Following risk-adjustment, MINOCA patients had a 43% lower risk of MACE over 12 months (hazard ratio = 0.57, 95% confidence interval 0.55-0.59), in comparison to MICAD patients. This pattern was similar for adjusted risks of the MACE components. CONCLUSION: This study confirms an unfavourable prognosis in elderly patients with MINOCA undergoing coronary angiography, with one in five patients with MINOCA suffering a major adverse event over 12 months.

Association of Hospital Payment Profiles With Variation in 30-Day Medicare Cost for Inpatients With Heart Failure or Pneumonia.

Importance: Some uncertainty exists about whether hospital variations in cost are largely associated with differences in case mix. Objective: To establish whether the same patients admitted with the same diagnosis (heart failure or pneumonia) at 2 different hospitals incur different costs associated with the hospital's Medicare payment profile. Design, Setting, and Participants: This observational cohort study used Centers for Medicare & Medicaid Services (CMS) discharge data of patients with a principal diagnosis of heart failure (n = 1615) or pneumonia (n = 708) occurring between July 1, 2013, and June 30, 2016. Patients were individuals aged 65 years or older who were enrolled in Medicare fee-for-service Part A and Part B and were discharged from nonfederal, short-term, acute care or critical access hospitals in the United States. Data were analyzed from March 16, 2018, to September 25, 2019. Main Outcomes and Measures: The CMS heart failure and pneumonia payment measure cohorts were divided into 2 random samples. In the first sample, hospitals were classified into payment quartiles for heart failure and pneumonia. In the second sample, patients with 2 admissions for heart failure or pneumonia, one in a lowest-quartile hospital and one in a highest-quartile hospital more than 1 month apart, were identified. Standardized Medicare payments for these patients were compared for the lowest- and the highest-quartile payment hospitals. Results: The study sample included 1615 patients with heart failure (mean [SD] age, 78.7 [8.0] years; 819 [50.7%] male) and 708 with pneumonia (mean [SD] age, 78.3 [8.0] years; 401 [56.6%] male). The observed 30-day mortality rates for patients among lowest- compared with highest-payment hospitals were not significantly different. The median (interquartile range) hospital 30-day risk-standardized mortality rates were 8.1% (7.7%-8.5%) for heart failure and 11.3% (10.7%-12.1%) for pneumonia. The 30-day episode payment for hospitalization for the same patients at the lowest-payment hospitals was $2118 (95% CI, $1168-$3068; P < .001) lower for heart failure and $2907 (95% CI, $1760-$4054; P < .001) lower for pneumonia than at the highest-payment hospitals. More than half of the difference was associated with the payment during the index hospitalization ($1425 [95% CI, $695-$2154; P < .001] for heart failure and $1659 [95% CI, $731-$2588; P < .001] for pneumonia). Conclusions and Relevance: This study found that the same Medicare beneficiaries who were admitted with the same diagnosis to hospitals with the highest payment profiles incurred higher costs than when they were admitted to hospitals with the lowest payment profiles. The findings suggest that variations in payments to hospitals are, at least in part, associated with the hospitals independently of non-time-varying patient characteristics.

Association of Physician Specialty With Long-Term Implantable Cardioverter-Defibrillator Complication and Reoperations Rates.

Background Patients undergoing implantable cardioverter-defibrillator (ICD) implantations have high rates of long-term device-related complications and reoperations. Whether physician specialty training is associated with differences in long-term outcomes following ICD implantation is unclear. Methods and Results We linked data from the National Cardiovascular Data Registry ICD Registry with Medicare fee-for-service claims to identify physicians who performed ≥10 index ICDs from 2006 to 2009. We used data from the American Board of Medical Specialties to group the specialty of the implanting physician into mutually exclusive categories: electrophysiologists, interventional cardiologists, general cardiologists, thoracic surgeons, and other specialties. Primary outcomes were long-term device-related complications requiring reoperations or hospitalizations and reoperations for reasons other than complications. We compared the cumulative incidence rates and case-mix adjusted rates of long-term outcomes of index ICD implantations across physician specialties. Our analysis had a median follow-up of 47 months and included 107 966 index ICD implantations. Electrophysiologists had the lowest rates of incident long-term device-related complications (14.1%; interventional cardiologists, 15.3%; general cardiologists, 15.4%; thoracic surgeons, 16.4%; other specialists, 15.2%; P<0.001) and reoperations for reasons other than complications (electrophysiologists, 16.7%; interventional cardiologists, 17.0%; general cardiologists, 18.0%; thoracic surgeons, 18.4%; other specialists, 18.0%; P<0.001). Compared with patients whose ICDs were implanted by electrophysiologists, patients with implantations performed by nonelectrophysiologists were at higher risk of having long-term device-related complications (relative risk for interventional cardiologists: 1.16 [95% CI, 1.08-1.25]; general cardiologists: 1.13 [1.08-1.18]; thoracic surgeons: 1.20 [1.06-1.37]; all P<0.001, but not other specialists: 1.08 [0.99-1.17]; P=0.07). Compared to patients with implantations performed by electrophysiologists, patients with implantations performed by general cardiologists and thoracic surgeons were at higher risk of reoperation for noncomplication causes (relative risk for general cardiologists: 1.10 [1.05-1.15]; thoracic surgeons: 1.16 [1.00-1.33]; both P<0.05). Conclusions Patients with ICD implantations performed by electrophysiologists had the lowest risks of having long-term device-related complications and reoperations for noncomplication causes. Consideration of physician specialty before ICD implantation may represent an opportunity to minimize long-term adverse outcomes.

Status of public-private partnership recognition and willingness to pay for private health care in China.

OBJECTIVES: The Chinese government has been increasingly engaging and interacting with the private sectors to initiate public-private partnerships (PPPs) to enhance the capacity of the health care system. Thus, the availability of private health services and copays are increasing. However, Chinese residents appear to be more accustomed to public health care because it has long been the dominant health service provider in China. Therefore, learning how the Chinese recognize PPPs, whether they would like to use private health services and how much they are willing to pay out of pocket are important for policymakers. METHODS: A bibliographical search was performed through PubMed in Medline, the Chinese National Knowledge Infrastructure and key government websites using a combination of keywords from seminal papers on PPPs and then sequentially added "willingness to pay (WTP), health, and private." The papers selected were closely related to PPPs and WTP for health care in China, and then, over 100 peer-reviewed literature, opinion, or commentary papers and postgraduate theses on the particular topics were carefully reviewed. RESULTS: Out of 139 papers closely related to WTP for private health care, 37 were extensively reviewed and substantially analyzed. The results corroborate that Chinese residents are generally willing to pay for high-risk disease screening, improved therapies, and health insurance, although the WTP intentions and the amounts they are willing to pay are different among distinct populations for the various types of health services. The results also present conditions that the responders are not explicitly willing to pay for or are willing to pay additional fees for their health promotion. Education level, family per capita income, self-reported health status, and dwelling districts (such as urban or rural residents) are the main factors that affect cost-sharing intention. CONCLUSIONS: PPPs are increasingly recognized as an effective means to mobilize resources in the private sector to relieve the pressure/burden placed on the public system during medical reform in China. Responders in China are generally willing to pay reasonable fees out of pocket for primary health care services or for improved therapies; however, cost-sharing intentions are affected by multiple factors. Health-related policymakers should learn the general health concerns/demands of the residents and their WTP status to perfect the design of PPPs for the benefit of the majority population in China.

Measuring hospital-specific disparities by dual eligibility and race to reduce health inequities.

OBJECTIVE: To propose and evaluate a metric for quantifying hospital-specific disparities in health outcomes that can be used by patients and hospitals. DATA SOURCES/STUDY SETTING: Inpatient admissions for Medicare patients with acute myocardial infarction, heart failure, or pneumonia to all non-federal, short-term, acute care hospitals during 2012-2015. STUDY DESIGN: Building on the current Centers for Medicare and Medicaid Services methodology for calculating risk-standardized readmission rates, we developed models that include a hospital-specific random coefficient for either patient dual eligibility status or African American race. These coefficients quantify the difference in risk-standardized outcomes by dual eligibility and race at a given hospital after accounting for the hospital's patient case mix and proportion of dual eligible or African American patients. We demonstrate this approach and report variation and performance in hospital-specific disparities. PRINCIPAL FINDINGS: Dual eligibility and African American race were associated with higher readmission rates within hospitals for all three conditions. However, this disparity effect varied substantially across hospitals. CONCLUSION: Our models isolate a hospital-specific disparity effect and demonstrate variation in quality of care for different groups of patients across conditions and hospitals. Illuminating within-hospital disparities can incentivize hospitals to reduce inequities in health care quality.

MR textural analysis on contrast enhanced 3D-SPACE images in assessment of consistency of pituitary macroadenoma.

OBJECTIVES: To explore the value of magnetic resonance textural analysis (MRTA) in assessing consistency of pituitary macroadenoma (PMA) based on contrast enhanced (CE) three-dimensional sampling perfection with application-optimized contrasts by using different flip angle evolution (3D-SPACE) images. MATERIALS AND METHODS: Fifty-three patients with PMAs that underwent CE 3D-SPACE scanning by 3.0 T MRI and endoscopic trans-sphenoidal surgery were included in the present study. Consistency levels of PMAs were evaluated intraoperatively by two neurosurgeons. Each resection specimen was stained with H&E and anti-collagen IV. MRTA was conducted and texture features were calculated. An unpaired t-test was used to analyze the differences of texture features between soft and hard PMAs. ROC curves by individual and combined features were used to calculate the diagnostic accuracy of MRTA in predicting PMA consistency. RESULTS: First-order energy and second-order correlation negatively correlated with hard PMAs, while first-order entropy and second-order variance, sum variance, and sum entropy positively correlated with stiffness. All showed significant differences between soft and hard PMAs (P < 0.05). Diagnostic accuracy of combined negative features could achieve an AUC of 0.819, sensitivity of 88.9%, specificity of 61.5%, PPV of 70.6%, NPV of 84.2% and positive features could achieve an AUC of 0.836, sensitivity of 85.2%, specificity of 69.2%, PPV of 74.2%, NPV of 81.8% (P < 0.001). CONCLUSION: MRTA using CE 3D-SPACE images is helpful for assessing PMA consistency preoperatively and noninvasively.

Outcomes following implantable cardioverter-defibrillator generator replacement in patients with recovered left ventricular systolic function: The National Cardiovascular Data Registry.

BACKGROUND: Some patients with heart failure (HF) experience recovery of left ventricular (LV) systolic function by the end of their implantable cardioverter-defibrillator (ICD) generator battery life. Outcomes following generator replacement in this setting are poorly understood. OBJECTIVE: We sought to describe outcomes following ICD generator replacement associated with recovery of LV systolic function. METHODS: We evaluated 26,197 Medicare beneficiaries enrolled in the American College of Cardiology's National Cardiovascular Data Registry ICD Registry who underwent primary prevention ICD generator replacement between 2006 and 2009, stratified by LV ejection fraction (LVEF): reduced (LVEF ≤35%), partially recovered (LVEF >35% and ≤50%), and recovered (LVEF >50%). RESULTS: At the time of generator replacement, 1915 (7.3%) patients had recovered LVEF and 4576 (17.5%) had partially recovered LVEF. Periprocedural events were rare (<1%) in all patients. In patients with reduced LVEF, the incidence of HF readmission and mortality at 3 years was 27.5% and 32.7%, respectively. In comparison, the rates of HF readmission and mortality were lower for patients with partially recovered LVEF (readmission: 15.9%; hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.61-0.72; mortality: 23.0%; HR 0.82; 95% CI 0.76-0.87) and those with recovered LVEF (readmission: 12.2%; HR 0.55; 95% CI 0.48-0.63; mortality: 18.2%; HR 0.72; 95% CI 0.64-0.80). CONCLUSION: Patients with partially recovered and recovered LVEF have lower risks of mid-term adverse outcomes than do those with reduced LVEF following ICD generator replacement. Approximately 3 in 4 patients continue to have reduced LVEF at the time of generator replacement and are at high risk of HF readmission and mortality. These data highlight the prognostic associations of LVEF in patients undergoing generator replacement as well as the clinical encounter for generator replacement as an opportunity to identify those at increased risk of adverse outcomes.

Trends in 30-Day Readmission Rates for Medicare and Non-Medicare Patients in the Era of the Affordable Care Act.

BACKGROUND: Temporal changes in the readmission rates for patient groups and conditions that were not directly under the purview of the Hospital Readmissions Reduction Program (HRRP) can help assess whether efforts to lower readmissions extended beyond targeted patients and conditions. METHODS: Using the Nationwide Readmissions Database (2010-2015), we assessed trends in all-cause readmission rates for 1 of the 3 HRRP conditions (acute myocardial infarction, heart failure, pneumonia) or conditions not targeted by the HRRP in age-insurance groups defined by age group (≥65 years or <65 years) and payer (Medicare, Medicaid, or private insurance). RESULTS: In the group aged ≥65 years, readmission rates for those covered by Medicare, Medicaid, and private insurance decreased annually for acute myocardial infarction (risk-adjusted odds ratio [OR; 95% confidence interval] among Medicare patients, 0.94 [0.94-0.95], among Medicaid patients, 0.93 [0.90-0.97], and among patients with private-insurance, 0.95 [0.93-0.97]); heart failure (ORs, 0.96 [0.96-0.97], 0.96 [0.94-0.98], and 0.97 [0.96-0.99], for the 3 payers, respectively), and pneumonia (ORs, 0.96 [0.96-0.97), 0.94 [0.92-0.96], and 0.96 [0.95-0.97], respectively). Readmission rates also decreased in the group aged <65 years for acute myocardial infarction (ORs: Medicare 0.97 [0.96-0.98], Medicaid 0.94 [0.92-0.95], and private insurance 0.93 [0.92-0.94]), heart failure (ORs, 0.98 [0.97-0.98]: 0.96 [0.96-0.97], and 0.97 [0.95-0.98], for the 3 payers, respectively), and pneumonia (ORs, 0.98 [0.97-0.99], 0.98 [0.97-0.99], and 0.98 [0.97-1.00], respectively). Further, readmission rates decreased significantly for non-target conditions. CONCLUSIONS: There appears to be a systematic improvement in readmission rates for patient groups beyond the population of fee-for-service, older, Medicare beneficiaries included in the HRRP.

Association Between Postdischarge Emergency Department Visitation and Readmission Rates.

BACKGROUND: Hospital readmission rates are publicly reported by the Centers for Medicare & Medicaid Services (CMS); however, the implications of emergency department (ED) visits following hospital discharge on readmissions are uncertain. We describe the frequency, diagnoses, and hospital-level variation in ED visitation following hospital discharge, including the relationship between risk-standardized ED visitation and readmission rates. METHODS: This is a cross-sectional analysis of Medicare beneficiaries hospitalized for acute myocardial infarction (AMI), heart failure, and pneumonia between July 2011 and June 2012. We used Medicare Standard Analytic Files to identify admissions, readmissions, and ED visits consistent with CMS measures. Postdischarge ED visits were defined as treat-and-discharge ED services within 30 days of hospitalization without readmission. We utilized hierarchical generalized linear models to calculate hospital risk-standardized postdischarge ED visit rates and readmission rates. RESULTS: We included 157,035 patients hospitalized at 1656 hospitals for AMI, 391,209 at 3044 hospitals for heart failure, and 342,376 at 3484 hospitals for pneumonia. After hospitalization for AMI, heart failure, and pneumonia, there were 14,714 (9%), 31,621 (8%), and 26,681 (8%) ED visits, respectively. Hospital-level variation in postdischarge ED visit rates was substantial: AMI (median: 8.3%; 5th and 95th percentile: 2.8%-14.3%), heart failure (median: 7.3%; 5th and 95th percentile: 3.0%-13.3%), and pneumonia (median: 7.1%; 5th and 95th percentile: 2.4%-13.2%). There was statistically significant inverse correlation between postdischarge ED visit rates and readmission rates: AMI (-0.23), heart failure (-0.29), and pneumonia (-0.18). CONCLUSIONS: Following hospital discharge, ED treatand- discharge visits are half as common as readmissions for Medicare beneficiaries. There is wide hospital-level variation in postdischarge ED visitation, and hospitals with higher ED visitation rates demonstrated lower readmission rates.

Hospital Characteristics Associated With Postdischarge Hospital Readmission, Observation, and Emergency Department Utilization.

BACKGROUND: Whether types of hospitals with high readmission rates also have high overall postdischarge acute care utilization (including emergency department and observation care) is unknown. DESIGN: Cross-sectional analysis. SUBJECTS: Nonfederal United States acute care hospitals. MEASURES: Using methodology established by the Centers for Medicare & Medicaid Services, we calculated each hospital's "excess days in acute care" for fee-for-service (FFS) Medicare beneficiaries aged over 65 years discharged after hospitalization for acute myocardial infarction, heart failure (HF), or pneumonia, representing the mean difference between predicted and expected total days of acute care utilization in the 30 days following hospital discharge, per 100 discharges. We assessed the multivariable association of 8 hospital characteristics with excess days in acute care and the proportion of hospitals with each characteristic that were statistical outliers (95% credible interval estimate does not include 0). RESULTS: We included 2184 hospitals for acute myocardial infarction [228 (10.4%) better than expected, 549 (25.1%) worse than expected], 3720 hospitals for HF [484 (13.0%) better and 840 (22.6%) worse], and 4195 hospitals for pneumonia [673 (16.0%) better, 1005 (24.0%) worse]. Results for all conditions were similar. Worse than expected outliers for pneumonia included: 18.8% of safety net hospitals versus 26.1% of nonsafety net hospitals; 16.7% of public hospitals versus 33.1% of for-profit hospitals; 19.5% of nonteaching hospitals versus 52.2% of major teaching hospitals; 7.9% of rural hospitals versus 42.1% of large urban hospitals; 5.9% of hospitals with 24-<50 beds versus 58% of hospitals with >500 beds; and 29.0% of hospitals with nurse-to-bed ratios >1.0-1.5 versus 21.7% of hospitals with ratios >2.0. CONCLUSIONS: Including emergency department and observation stays in measures of postdischarge utilization produces similar results as measuring only readmissions in that major teaching, urban and for-profit hospitals still perform disproportionately poorly versus nonteaching or public hospitals. However, it enables identification of more outliers and a more granular assessment of the association of hospital factors and outcomes.

Geographic variation in health insurance benefits in Qianjiang District, China: a cross-sectional study.

BACKGROUND: Health insurance contributes to reducing the economic burden of disease and improving access to healthcare. In 2016, the Chinese government announced the integration of the New Cooperative Medical Scheme (NCMS) and Urban Resident Basic Medical Insurance (URBMI) to reduce system segmentation. Nevertheless, it was unclear whether there would be any geographic variation in health insurance benefits if the two types of insurance were integrated. The aim of this study was to identify the potential geographic variation in health insurance benefits and the related contributing factors. METHODS: This cross-sectional study was carried out in Qianjiang District, where the NCMS and URBMI were integrated into Urban and Rural Resident Basic Medical Insurance Scheme (URRBMI) in 2010. All beneficiaries under the URRBMI were hospitalized at least once in 2013, totaling 445,254 persons and 65,877 person-times, were included in this study. Town-level data on health insurance benefits, healthcare utilization, and socioeconomic and geographical characteristics were collected through health insurance system, self-report questionnaires, and the 2014 Statistical Yearbook of Qianjiang District. A simplified Theil index at town level was calculated to measure geographic variation in health insurance benefits. Colored maps were created to visualize the variation in geographic distribution of benefits. The effects of healthcare utilization and socioeconomic and geographical characteristics on geographic variation in health insurance benefits were estimated with a multiple linear regression analysis. RESULTS: Different Theil index values were calculated for different towns, and the Theil index values for compensation by person-times and amount were 2.5028 and 1.8394 in primary healthcare institutions and 1.1466 and 0.9204 in secondary healthcare institutions. Healthcare-seeking behavior and economic factors were positively associated with health insurance benefits in compensation by person-times significantly, meanwhile, geographical accessibility and economic factors had positive effects (p < 0.05). CONCLUSIONS: The geographic variation in health insurance benefits widely existed in Qianjiang District and the distribution of health insurance benefits for insured inpatients in primary healthcare institutions was distinctly different from that in secondary healthcare institutions. When combining the NRCM and URMIS in China, the geographical accessibility, healthcare-seeking behavior and economic factors required significant attention.

Association of Racial and Socioeconomic Disparities With Outcomes Among Patients Hospitalized With Acute Myocardial Infarction, Heart Failure, and Pneumonia: An Analysis of Within- and Between-Hospital Variation.

Importance: Although studies have described differences in hospital outcomes by patient race and socioeconomic status, it is not clear whether such disparities are driven by hospitals themselves or by broader systemic effects. Objective: To determine patterns of racial and socioeconomic disparities in outcomes within and between hospitals for patients with acute myocardial infarction, heart failure, and pneumonia. Design, Setting, and Participants: Retrospective cohort study initiated before February 2013, with additional analyses conducted during the peer-review process. Hospitals in the United States treating at least 25 Medicare fee-for-service beneficiaries aged 65 years or older in each race (ie, black and white) and neighborhood income level (ie, higher income and lower income) for acute myocardial infarction, heart failure, and pneumonia between 2009 and 2011 were included. Main Outcomes and Measures: For within-hospital analyses, risk-standardized mortality rates and risk-standardized readmission rates for race and neighborhood income subgroups were calculated at each hospital. The corresponding ratios using intraclass correlation coefficients were then compared. For between-hospital analyses, risk-standardized rates were assessed according to hospitals' proportion of patients in each subgroup. These analyses were performed for each of the 12 analysis cohorts reflecting the unique combinations of outcomes (mortality and readmission), demographics (race and neighborhood income), and conditions (acute myocardial infarction, heart failure, and pneumonia). Results: Between 74% (3545 of 4810) and 91% (4136 of 4554) of US hospitals lacked sufficient racial and socioeconomic diversity to be included in this analysis, with the number of hospitals eligible for analysis varying among cohorts. The 12 analysis cohorts ranged in size from 418 to 1265 hospitals and from 144 417 to 703 324 patients. Within included hospitals, risk-standardized mortality rates tended to be lower among black patients (mean [SD] difference between risk-standardized mortality rates in black patients compared with white patients for acute myocardial infarction, -0.57 [1.1] [P = .47]; for heart failure, -4.7 [1.3] [P < .001]; and for pneumonia, -1.0 [2.0] [P = .05]). However, risk-standardized readmission rates among black patients were higher (mean [SD] difference between risk-standardized readmission rates in black patients compared with white patients for acute myocardial infarction, 4.3 [1.4] [P < .001]; for heart failure, 2.8 [1.8] [P < .001], and for pneumonia, 3.7 [1.3] [P < .001]). Intraclass correlation coefficients ranged from 0.68 to 0.79, indicating that hospitals generally delivered consistent quality to patients of differing races. While the coefficients in the neighborhood income analysis were slightly lower (0.46-0.60), indicating some heterogeneity in within-hospital performance, differences in mortality rates and readmission rates between the 2 neighborhood income groups were small. There were no strong, consistent associations between risk-standardized outcomes for white or higher-income neighborhood patients and hospitals' proportion of black or lower-income neighborhood patients. Conclusions and Relevance: Hospital performance according to race and socioeconomic status was generally consistent within and between hospitals, even as there were overall differences in outcomes by race and neighborhood income. This finding indicates that disparities are likely to be systemic, rather than localized to particular hospitals.