Measuring Equity in Readmission as a Distinct Assessment of Hospital Performance.

Importance: Equity is an essential domain of health care quality. The Centers for Medicare & Medicaid Services (CMS) developed 2 Disparity Methods that together assess equity in clinical outcomes. Objectives: To define a measure of equitable readmissions; identify hospitals with equitable readmissions by insurance (dual eligible vs non-dual eligible) or patient race (Black vs White); and compare hospitals with and without equitable readmissions by hospital characteristics and performance on accountability measures (quality, cost, and value). Design, Setting, and Participants: Cross-sectional study of US hospitals eligible for the CMS Hospital-Wide Readmission measure using Medicare data from July 2018 through June 2019. Main Outcomes and Measures: We created a definition of equitable readmissions using CMS Disparity Methods, which evaluate hospitals on 2 methods: outcomes for populations at risk for disparities (across-hospital method); and disparities in care within hospitals' patient populations (within-a-single-hospital method). Exposures: Hospital patient demographics; hospital characteristics; and 3 measures of hospital performance-quality, cost, and value (quality relative to cost). Results: Of 4638 hospitals, 74% served a sufficient number of dual-eligible patients, and 42% served a sufficient number of Black patients to apply CMS Disparity Methods by insurance and race. Of eligible hospitals, 17% had equitable readmission rates by insurance and 30% by race. Hospitals with equitable readmissions by insurance or race cared for a lower percentage of Black patients (insurance, 1.9% [IQR, 0.2%-8.8%] vs 3.3% [IQR, 0.7%-10.8%], P < .01; race, 7.6% [IQR, 3.2%-16.6%] vs 9.3% [IQR, 4.0%-19.0%], P = .01), and differed from nonequitable hospitals in multiple domains (teaching status, geography, size; P < .01). In examining equity by insurance, hospitals with low costs were more likely to have equitable readmissions (odds ratio, 1.57 [95% CI, 1.38-1.77), and there was no relationship between quality and value, and equity. In examining equity by race, hospitals with high overall quality were more likely to have equitable readmissions (odds ratio, 1.14 [95% CI, 1.03-1.26]), and there was no relationship between cost and value, and equity. Conclusion and Relevance: A minority of hospitals achieved equitable readmissions. Notably, hospitals with equitable readmissions were characteristically different from those without. For example, hospitals with equitable readmissions served fewer Black patients, reinforcing the role of structural racism in hospital-level inequities. Implementation of an equitable readmission measure must consider unequal distribution of at-risk patients among hospitals.

Yield and cost of government-organized colorectal cancer screening in young high-risk population in Northeast China.

Guidelines for colorectal cancer (CRC) screening recommend screening at age 40 for high-risk population in China. However, the yield and cost of CRC screening in younger population are lacking. This analysis aimed to evaluate the yield and cost of CRC screening in high-risk 40- to 54-year-olds. Individuals aged 40-54 years who were determined to have a high risk of CRC were recruited from December 2012 to December 2019. We calculated odds ratios (OR) and 95% confidence intervals (CI) for the detection rate of colorectal lesions among the three age groups and further calculated number of colonoscopies needed to screen (NNS) to detect one advanced lesion and cost of each group. The detection rates of advanced colorectal neoplasm in men aged 45-49 years (OR = 2.00, 95% CI: 0.93-4.30) and 50-54 years (OR = 2.19, 95% CI: 1.04-4.62) were higher than that aged 40-44 years. The detection rates of colorectal adenoma in women aged 50-54 years was higher than that aged 40-44 years (OR = 1.64, 95% CI: 1.23-2.19). Among the male screening population, NNS and cost to detect one advanced lesion in participants aged 45-49 years were similar to that aged 50-54 years, saving approximately half endoscopic resources and financial expenses compared with screening that aged 40-44 years. From the perspective of screening results and costs, it might be beneficial to delay the starting age of screening by gender. This study may provide reference for optimizing CRC screening strategies.

Financial toxicity and psychological distress in adults with cancer: A treatment-based analysis.

Objective: To evaluate disparities in financial toxicity and psychological distress in patients with cancer as a function of treatment and reveal the relationship between financial toxicity and psychological distress. Methods: This was a multicenter cross-sectional study. Patients were recruited from March 2017 to October 2018, and questionnaires were completed regarding their demographics, financial toxicity, and psychological distress. A multiple linear regression model was used to examine factors associated with financial and psychological distress. Results: Significant financial toxicity and psychological distress occurred in 47.9% and 56.5% of patients, respectively. Financial toxicity (P â€‹= â€‹0.032) and psychological distress (P â€‹< â€‹0.001) were statistically different among the single chemotherapy, adjuvant therapy, and surgery groups. Multivariable analysis revealed that patients aged 50-59 years (P â€‹= â€‹0.035), 60-69 years (P â€‹= â€‹0.007), and 70 years or older (P â€‹= â€‹0.002) had higher the Comprehensive Score for financial Toxicity (COST) scores compared with patients less than 50 years old. Patients with personal annual income > 40,000 CNY reported higher COST scores than those who had < 20,000 CNY (P â€‹< â€‹0.001). Patients who had Urban Resident Basic Medical Insurance (URBMI) (P â€‹= â€‹0.030) or New Rural Cooperative Medical Scheme (NRCMS) (P â€‹= â€‹0.006) compared with Urban Employee Basic Medical Insurance (UEBMI) presented lower COST scores than patients with UEBMI. The multiple analysis model of psychological distress showed that an age of more than 70 years (P â€‹= â€‹0.010) was significantly associated with low the Distress Thermometer (DT) scores, and patients with colorectal cancer (P â€‹= â€‹0.009), the surgery group (P â€‹< â€‹0.001) and adjuvant therapy group (P â€‹< â€‹0.001) were significantly associated with high DT scores. The correlations between financial toxicity and psychological distress were mild but statistically significant in the chemotherapy-related treatment groups. Conclusions: The research highlights the high rates of financial and psychological distress in adult patients. Multidimensional distress screening and psychosocial interventions should be provided for patients with cancer according to related factors.

Identifying high-value care for Medicare beneficiaries: a cross-sectional study of acute care hospitals in the USA.

OBJECTIVES: High-value care is providing high quality care at low cost; we sought to define hospital value and identify the characteristics of hospitals which provide high-value care. DESIGN: Retrospective observational study. SETTING: Acute care hospitals in the USA. PARTICIPANTS: All Medicare beneficiaries with claims included in Center for Medicare & Medicaid Services Overall Star Ratings or in publicly available Medicare spending per beneficiary data. PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome was value defined as the difference between Star Ratings quality score and Medicare spending; the secondary outcome was classification as a 4 or 5 star hospital with lowest quintile Medicare spending ('high value') or 1 or 2 star hospital with highest quintile spending ('low value'). RESULTS: Two thousand nine hundred and fourteen hospitals had both quality and spending data, and were included. The value score had a mean (SD) of 0.58 (1.79). A total of 286 hospitals were classified as high value; these represented 28.6% of 999 4 and 5 star hospitals and 46.8% of 611 low cost hospitals. A total of 258 hospitals were classified as low value; these represented 26.6% of 970 1 and 2 star hospitals and 49.3% of 523 high cost hospitals. In regression models ownership, non-teaching status, beds, urbanity, nurse to bed ratio, percentage of dual eligible Medicare patients and percentage of disproportionate share hospital payments were associated with the primary value score. CONCLUSIONS: There are high quality hospitals that are not high value, and a number of factors are strongly associated with being low or high value. These findings can inform efforts of policymakers and hospitals to increase the value of care.

Incorporating Present-on-Admission Indicators in Medicare Claims to Inform Hospital Quality Measure Risk Adjustment Models.

Importance: Present-on-admission (POA) indicators in administrative claims data allow researchers to distinguish between preexisting conditions and those acquired during a hospital stay. The impact of adding POA information to claims-based measures of hospital quality has not yet been investigated to better understand patient underlying risk factors in the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision setting. Objective: To assess POA indicator use on Medicare claims and to assess the hospital- and patient-level outcomes associated with incorporating POA indicators in identifying risk factors for publicly reported outcome measures used by the Centers for Medicare & Medicaid Services (CMS). Design, Setting, and Participants: This comparative effectiveness study used national CMS claims data between July 1, 2015, and June 30, 2018. Six hospital quality measures assessing readmission and mortality outcomes were modified to include POA indicators in risk adjustment models. The models using POA were then compared with models using the existing complications-of-care algorithm to evaluate changes in risk model performance. Patient claims data were included for all Medicare fee-for-service and Veterans Administration beneficiaries aged 65 years or older with inpatient hospitalizations for acute myocardial infarction, heart failure, or pneumonia within the measurement period. Data were analyzed between September 2019 and March 2020. Main Outcomes and Measures: Changes in patient-level (C statistics) and hospital-level (quintile shifts in risk-standardized outcome rates) model performance after including POA indicators in risk adjustment. Results: Data from a total of 6 027 988 index admissions were included for analysis, ranging from 491 366 admissions (269 209 [54.8%] men; mean [SD] age, 78.2 [8.3] years) for the acute myocardial infarction mortality outcome measure to 1 395 870 admissions (677 158 [48.5%] men; mean [SD] age, 80.3 [8.7] years) for the pneumonia readmission measure. Use of POA indicators was associated with improvements in risk adjustment model performance, particularly for mortality measures (eg, the C statistic increased from 0.728 [95% CI, 0.726-0.730] to 0.774 [95% CI, 0.773-0.776] when incorporating POA indicators into the acute myocardial infarction mortality measure). Conclusions and Relevance: The findings of this quality improvement study suggest that leveraging POA indicators in the risk adjustment methodology for hospital quality outcome measures may help to more fully capture patients' risk factors and improve overall model performance. Incorporating POA indicators does not require extra effort on the part of hospitals and would be easy to implement in publicly reported quality outcome measures.

The COmprehensive Score for financial Toxicity in China: Validation and Responsiveness.

CONTEXT: Financial toxicity is a priority concern faced by cancer patients and oncology providers. A validated instrument is important to measure this toxicity and improve health-related quality of life of patients. OBJECTIVES: To assess the validity and responsiveness of the Chinese version of the COmprehensive Score for financial Toxicity (COST) and to measure financial toxicity using the COST instrument in Chinese health care systems. METHODS: A longitudinal observational study was performed at three cancer centers from March 2017 to October 2018 for eligible patients. Construct validity was assessed by exploratory and confirmatory factor analysis. The convergent and discriminant validity was tested by examining the correlation coefficient. Responsiveness was tested using the standardized response mean and effect size. Associations between the financial toxicity and variables were assessed by multivariable linear analysis. RESULTS: There were 440 participants at baseline and 268 participants at 6-month follow up. A two-factor solution better represented the Chinese version of COST structure with good internal consistency and test-retest reliability. Convergent validity showed mild to moderate correlations between the domains of COST and the similar domains of Self-Perceived Burden Scale and Quality of Life Discriminant validity showed a low correlation between the COST and the subjective support of Social Support Rate Scale. Sensitivity to change at the sixth month showed effect sizes with global COST scores of 0.3. Multivariable analysis showed that age, household income, and health insurance were significantly associated with financial toxicity. CONCLUSIONS: The Chinese version of COST is a valid and clinically responsive instrument. The identified baseline variables can be used to provide evidence for a financial toxicity intervention study.

Quality Measure Public Reporting Is Associated with Improved Outcomes Following Hip and Knee Replacement.

BACKGROUND: Given the inclusion of orthopaedic quality measures in the Centers for Medicare & Medicaid Services national hospital payment programs, the present study sought to assess whether the public reporting of total hip arthroplasty (THA) and total knee arthroplasty (TKA) risk-standardized readmission rates (RSRRs) and complication rates (RSCRs) was temporally associated with a decrease in the rates of these outcomes among Medicare beneficiaries. METHODS: Annual trends in national observed and hospital-level RSRRs and RSCRs were evaluated for patients who underwent hospital-based inpatient hip and/or knee replacement procedures from fiscal year 2010 to fiscal year 2016. Hospital-level rates were calculated with use of the same measures and methodology that were utilized in public reporting. Annual trends in the distribution of hospital-level outcomes were then examined with use of density plots. RESULTS: Complication and readmission rates and variation declined steadily from fiscal year 2010 to fiscal year 2016. Reductions of 33% and 25% were noted in hospital-level RSCRs and RSRRs, respectively. The interquartile range decreased by 18% (relative reduction) for RSCRs and by 34% (relative reduction) for RSRRs. The frequency of risk variables in the complication and readmission models did not systematically change over time, suggesting no evidence of widespread bias or up-coding. CONCLUSIONS: This study showed that hospital-level complication and readmission rates following THA and TKA and the variation in hospital-level performance declined during a period coinciding with the start of public reporting and financial incentives associated with measurement. The consistently decreasing trend in rates of and variation in outcomes suggests steady improvements and greater consistency among hospitals in clinical outcomes for THA and TKA patients in the 2016 fiscal year compared with the 2010 fiscal year. The interactions between public reporting, payment, and hospital coding practices are complex and require further study. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The prevalence, trends, and geographical distribution of human papillomavirus infection in China: The pooled analysis of 1.7 million women.

Human papillomavirus (HPV) infection which continues to be the most common sexually transmitted disease, has been identified as a major risk factor for cervical cancer. Therefore, it is very important to understand and grasp the distribution of HPV in Chinese population, and make the foundation for the development of cervical cancer vaccine in China. An extensive search strategy was conducted in multiple literature databases. All retrieved studies were screened by October 31, 2018. The prevalence of HPV infection was analyzed using random effects model. A total of 68 studies satisfied the inclusion criteria for our study. The national overall prevalence of HPV infection was 15.54% (95% CI: 13.83%-17.24%). we also performed subgroup analysis by age, geographic location, level of economic development, HPV assay method, and type of HPV infection. The top 5 common HPV types detected in general population, were HPV 16 (3.52%, 95% CI: 3.18%-3.86%), 52 (2.20%, 95% CI: 1.93%-2.46%), 58 (2.10%, 95% CI: 1.88%-2.32%), 18 (1.20%, 95% CI: 1.05%-1.35%), and 33 (1.02%, 95% CI: 0.89%-1.14%). Except for the higher prevalence of HPV infection in 2009 and 2010, the prevalence of HPV infection in other years changed little, ranged from 13.2% to 17.4%. HPV type in Chinese women was quite distinctive. HPV infection played a critical role in the occurrence of cervical cancer, understanding the distribution of HPV type and performing the HPV type testing had important clinical value for colposcopy referral and increasing the detection rate. Therefore, our findings could provide evidence for cervical cancer screening and vaccine, in order to reduce the burden of cervical cancer.

Patterns and Costs of 90-Day Readmission for Surgical and Medical Complications Following Total Hip and Knee Arthroplasty.

BACKGROUND: Unplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications. METHODS: We performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories. RESULTS: Among THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all). CONCLUSION: Readmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.

Trends in Hospital Readmission of Medicare-Covered Patients With Heart Failure.

BACKGROUND: The Medicare Hospital Readmissions Reduction Program has led to fewer readmissions following hospitalizations with a principal diagnosis of heart failure (HF). Patients with HF are frequently hospitalized for other causes. OBJECTIVES: This study sought to compare trends in Medicare risk-adjusted, 30-day readmissions following principal HF hospitalizations and other hospitalizations with HF. METHODS: This was a retrospective study of 12,973,853 Medicare hospitalizations with a principal or secondary diagnosis of HF between January 2008 and June 2015. Hospitalizations were categorized as follows: principal HF hospitalizations; principal acute myocardial infarction or pneumonia hospitalizations with secondary HF; and other hospitalizations with secondary HF. The study examined trends in risk-adjusted, 30-day, all-cause readmission rates for each cohort and trends in differences in readmission rates among cohorts by using linear spline regression models. RESULTS: Before passage of the Affordable Care Act in March 2010, risk-adjusted, 30-day readmission rates were stable for all 3 cohorts, with mean monthly rates of 26.1%, 24.9%, and 24.4%, respectively. Risk-adjusted readmission rates started declining after passage of the Affordable Care Act by 1.09% (95% confidence interval [CI]: 0.51% to 1.68%), 1.24% (95% CI: 0.92% to 1.57%), and 1.05% (95% CI: 0.52% to 1.58%) per year, respectively, until implementation of the Hospital Readmissions Reduction Program in October 2012 and then stabilized for all 3 cohorts. CONCLUSIONS: Patients with HF are often hospitalized for other causes, and these hospitalizations have high readmission rates. Policy changes led to decreases in readmission rates for both principal and secondary HF hospitalizations. Readmission rates in both groups remain high, suggesting that initiatives targeting all hospitalized patients with HF continue to be warranted.