Hospital Teaching Status and Medicare Expenditures for Hepato-Pancreato-Biliary Surgery.

BACKGROUND: The association of hospital teaching status and overall expenditures has not been studied among patients undergoing hepato-pancreato-biliary (HPB) surgery. We sought to define the impact of hospital teaching intensity on payments and charges associated with (HPB) surgery from the payer perspective. METHODS: Surgical patients undergoing HPB procedures were identified using 2013-2015 Medicare Provider Analysis and Review (MEDPAR) data. Hospital teaching intensity was categorized based on hospital resident-to-bed ratio: non-teaching (NTH: 0), minor teaching (minor-TH: 0-0.363), and major teaching (major-TH: > 0.363). Risk-adjusted price-standardized Medicare payments were assessed and compared among HPB surgical patients at NTH versus major-TH. RESULTS: A total of 8863 patients underwent HPB (NTH: n = 1239, 14.0%; minor-TH: n = 3202, 36.1%; major-TH: n = 4422, 49.9%). Patient comorbidities did not vary across hospital according to teaching intensity (p = 0.27). Mean risk-adjusted Medicare payment at a major-TH was $29,541 versus $19,345 at a NTH (Δ-payment: + $10,195; p < 0.001). Differences in Medicare payments associated with hospital teaching status persisted when the risk-adjusted price was standardized to remove social subsidies and regional variation in costs (NTH: $19,760 vs. major-TH: $28,382; Δ-payment: + $8623). Major-TH had higher total charges submitted to Medicare versus NTH (NTH: $100,583 vs. major-TH: $120,498; Δ-charge = + $19,915), including charges for accommodations, laboratory, and blood utilization (all p < 0.05). Compared with NTH, major-TH had lower morbidity (22.6 vs. 19.0%), serious complications (13.0 vs. 10.5%) and 30-day mortality (4.8 vs. 2.3%) (all p < 0.05). CONCLUSIONS: Major-TH was associated with higher Medicare expenditures than NTH among HPB surgical patients. These differences were attributable, in part, to higher submitted charges for hospital-based services. While associated with higher payments and charges, TH did have better short-term outcomes compared with NTH.

Socioeconomic impact on device-associated infections in limited-resource neonatal intensive care units: findings of the INICC.

PURPOSE: To evaluate the impact of country socioeconomic status and hospital type on device-associated healthcare-associated infections (DA-HAIs) in neonatal intensive care units (NICUs). METHODS: Data were collected on DA-HAIs from September 2003 to February 2010 on 13,251 patients in 30 NICUs in 15 countries. DA-HAIs were defined using criteria formulated by the Centers for Disease Control and Prevention. Country socioeconomic status was defined using World Bank criteria. RESULTS: Central-line-associated bloodstream infection (CLA-BSI) rates in NICU patients were significantly lower in private than academic hospitals (10.8 vs. 14.3 CLA-BSI per 1,000 catheter-days; p < 0.03), but not different in public and academic hospitals (14.6 vs. 14.3 CLA-BSI per 1,000 catheter-days; p = 0.86). NICU patient CLA-BSI rates were significantly higher in low-income countries than in lower-middle-income countries or upper-middle-income countries [37.0 vs. 11.9 (p < 0.02) vs. 17.6 (p < 0.05) CLA-BSIs per 1,000 catheter-days, respectively]. Ventilator-associated-pneumonia (VAP) rates in NICU patients were significantly higher in academic hospitals than in private or public hospitals [13.2 vs. 2.4 (p < 0.001) vs. 4.9 (p < 0.001) VAPs per 1,000 ventilator days, respectively]. Lower-middle-income countries had significantly higher VAP rates than low-income countries (11.8 vs. 3.8 per 1,000 ventilator-days; p < 0.001), but VAP rates were not different in low-income countries and upper-middle-income countries (3.8 vs. 6.7 per 1,000 ventilator-days; p = 0.57). When examined by hospital type, overall crude mortality for NICU patients without DA-HAIs was significantly higher in academic and public hospitals than in private hospitals (5.8 vs. 12.5%; p < 0.001). In contrast, NICU patient mortality among those with DA-HAIs was not different regardless of hospital type or country socioeconomic level. CONCLUSIONS: Hospital type and country socioeconomic level influence DA-HAI rates and overall mortality in developing countries.

Hospital religious affiliation and emergency contraceptive prescribing practices.

With access to reproductive health care eroding, examination of prescribing of contraception, including emergency contraception (EC), is important. We examined whether working in a family practice affiliated with a religious institution changes the likelihood of a provider prescribing EC. Our survey asked about EC prescribing practices in a range of situations. As predicted, practitioners in non-religiously affiliated practices reported higher rates of prescribing EC than those in religiously affiliated practices. In both cases, however, the practitioners' prescribing patterns were inadequate.

Did recent changes in Medicare reimbursement hit teaching hospitals harder?

PURPOSE: To inform the policy debate on Medicare reimbursement by examining the financial effects of the Balanced Budget Act of 1997 (BBA) and subsequent adjustments on major academic medical centers, minor teaching hospitals, and nonteaching hospitals. METHOD: The authors simulated the impacts of BBA and subsequent BBA adjustments to predict the independent effects of changes in Medicare reimbursement on hospital revenues using 1997-2001 Medicare Cost Reports for all short-term acute-care hospitals in the United States. The authors also calculated actual (nonsimulated) operating and total margins among major teaching, minor teaching, and nonteaching hospitals to account for hospital response to the changes. RESULTS: The BBA and subsequent refinements reduced Medicare revenues to a greater degree in major teaching hospitals, but the fact that such hospitals had a smaller proportion of Medicare patients meant that the BBA reduced overall revenues by similar percentages across major, minor, and nonteaching hospitals. Consistently lower margins may have made teaching hospitals more vulnerable to cuts in Medicare support. CONCLUSIONS: Recent Medicare changes affected revenues at teaching and nonteaching hospitals more similarly than is commonly believed. However, the Medicare cuts under the BBA probably exacerbated preexisting financial strain on major teaching hospitals, and increased Medicare funding may not suffice to eliminate the strain. This report's findings are consistent with recent calls to support needed services of teaching hospitals through all-payer or general funds.

The relationship of insurance status, hospital ownership, and teaching status with interhospital transfers in California in 2000.

PURPOSE: Public hospitals and academic medical centers may admit more poorly insured transfer patients than do other institutions. The authors investigated the relationship of patient insurance status, hospital ownership, and hospital teaching status with interhospital transfers in California. METHOD: In 2003, data were derived from the hospital discharge abstract database for the year 2000 from the California Office of Statewide Health Planning and Development. Hospitals were categorized by ownership and teaching status; patients were categorized as being "good" or "poor" payers depending on the level of expected insurance reimbursement. Descriptive and multivariate analyses were used to assess the number of poor payer transfers admitted by each hospital group. RESULTS: In 2000, there were 58,509 transfer and 2,320,479 direct admissions. All hospital groups admitted a higher percentage of good payer than poor payer transfer patients (85% vs. 15% respectively for all groups combined). Adjusted for total number of admissions and teaching status, the number of poor payer transfer patients admitted to county-owned and University of California hospitals was significantly higher than the statewide average (both p values < .001), while the number admitted to independent teaching hospitals was significantly lower than the statewide average (p < .001). The number of poor payer transfer patients admitted to independent teaching hospitals more closely resembled that of for-profit hospitals than that of University of California teaching hospitals. CONCLUSIONS: In 2000, the likelihood of a hospital admitting a transfer patient appears to have been affected by both the patient's insurance status and the hospital's ownership. In general, good payer patients were more likely to be transferred than were poor payer patients, with poor payer transfer patients more likely to be admitted to publicly owned hospitals.

Hospital outcomes in major teaching, minor teaching, and nonteaching hospitals in New York state.

PURPOSE: The possible benefit that hospital teaching status may confer in the care of patients with cardiovascular disease is unknown. Our purpose was to determine the effect of hospital teaching status on in-hospital mortality, use of invasive procedures, length of stay, and charges in patients with myocardial infarction, heart failure, or stroke. SUBJECTS AND METHODS: We analyzed a New York State hospital administrative database containing information on 388 964 consecutive patients who had been admitted with heart failure (n = 173 799), myocardial infarction (n = 121 209), or stroke (n = 93 956) from 1993 to 1995. We classified the 248 participating acute care hospitals by teaching status (major, minor, nonteaching). The primary outcomes were standardized in-hospital mortality ratios, defined as the ratio of observed to predicted mortality. RESULTS: Standardized in-hospital mortality ratios were significantly lower in major teaching hospitals (0.976 for heart failure, 0.945 for myocardial infarction, 0.958 for stroke) than in nonteaching hospitals (1.01 for heart failure, 1.01 for myocardial infarction, 0.995 for stroke). Standardized in-hospital mortality ratios were significantly higher for patients with stroke (1.06) but not heart failure (1.0) or myocardial infarction (1.06) in minor teaching hospitals than in nonteaching hospitals. Compared with nonteaching hospitals, use of invasive cardiac procedures and adjusted hospital charges were significantly greater in major and minor teaching hospitals for all three conditions. The adjusted length of stay was also shorter for myocardial infarction in major teaching hospitals and longer for stroke in minor teaching hospitals. CONCLUSION: Major teaching hospital status was an important determinant of outcomes in patients hospitalized with myocardial infarction, heart failure, or stroke in New York State.