Negotiated Rates for Surgical Cancer Care in the Era of Price Transparency-Prices Reflect Market Competition.

OBJECTIVE: To measure commercial price variation for cancer surgery within and across hospitals. BACKGROUND: Surgical care for solid-organ tumors is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule, enacted in 2021, requires all hospitals to list their negotiated rates on their website, thus opening the door for an examination of pricing for cancer surgery. METHODS: This was a cross-sectional study using 2021 negotiated price data disclosed by US hospitals for the 10 most common cancers treated with surgery. Price variation was measured using within-hospital and across-hospital ratios. Commercial rates relative to cancer center designation and the Herfindahl-Hirschman Index at the facility level were evaluated with mixed effects linear regression with random intercepts per procedural code. RESULTS: In all, 495,200 unique commercial rates from 2232 hospitals resulted for the 10 most common solid-organ tumor cancers. Gynecologic cancer operations had the highest median rates at $6035.8/operation compared with bladder cancer surgery at $3431.0/operation. Compared with competitive markets, moderately and highly concentrated markets were associated with significantly higher rates (HHI 1501, 2500, coefficient $513.6, 95% CI, $295.5, $731.7; HHI >2500, coefficient $1115.5, 95% CI, $913.7, $1317.2). National Cancer Institute designation was associated with higher rates, coefficient $3,451.9 (95% CI, $2853.2, $4050.7). CONCLUSIONS: Commercial payer-negotiated prices for the surgical management of 10 common, solid tumor malignancies varied widely both within and across hospitals. Higher rates were observed in less competitive markets. Future efforts should facilitate price competition and limit health market concentration.

Disparities in Access, Quality, and Clinical Outcome for Latino Californians with Colon Cancer.

OBJECTIVE: To compare access, quality, and clinical outcomes between Latino and non-Latino White Californians with colon cancer. SUMMARY BACKGROUND DATA: Racial and ethnic disparities in cancer care remain understudied, particularly among patients who identify as Latino. Exploring potential mechanisms, including differential utilization of high-volume hospitals, is an essential first step to designing evidence-based policy solutions. METHODS: We identified all adults diagnosed with colon cancer between January 1, 2010 and December 31, 2020 from a statewide cancer registry linked to hospital administrative records. We compared survival, access (stage at diagnosis, receipt of surgical care, treatment at a high-volume hospital), and quality of care (receipt of adjuvant chemotherapy, adequacy of lymph node resection) between patients who identified as Latino and as non-Latino White. RESULTS: 75,543 patients met inclusion criteria, including 16,071 patients who identified as Latino (21.3%). Latino patients were significantly less likely to undergo definitive surgical resection (marginal difference [MD] -0.72 percentage points, 95% CI -1.19,-0.26), have an operation in a timely fashion (MD -3.24 percentage points, 95% CI -4.16,-2.32), or have an adequate lymphadenectomy (MD -2.85 percentage points, 95% CI -3.59,-2.12) even after adjustment for clinical and sociodemographic factors. Latino patients treated at high-volume hospitals were significantly less likely to die and more likely to meet access and quality metrics. CONCLUSIONS: Latino colon cancer patients experienced delays, segregation, and lower receipt of recommended care. Hospital-level colectomy volume appears to be strongly associated with access, quality, and survival--especially for patients who identify as Latino--suggesting that directing at-risk cancer patients to high-volume hospitals may improve health equity.

Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care.

BACKGROUND: There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care. OBJECTIVE: We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels. METHODS: Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics. PRINCIPAL FINDINGS: Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers. CONCLUSIONS: Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.

Evaluation of the Completeness of ALS Case Ascertainment in the US National ALS Registry: Application of the Capture-Recapture Method.

INTRODUCTION: The Centers for Disease Control and Prevention (CDC) National Amyotrophic Lateral Sclerosis (ALS) Registry is the first national registry for a chronic neurologic disease in the USA and uses a combination of case-finding methods including administrative healthcare data and patient self-registration. METHODS: We applied capture-recapture methodology to estimate the completeness of the Registry for ascertaining patients with ALS for the first full year and the fourth year of the Registry (2011, 2014). The Registry uses the combination of two national administrative claims databases (Medicare and Veterans Affairs) with a self-register option at the registry portal. We conducted descriptive analyses of the demographic and clinical characteristics of the ALS cases identified by each of the sources and estimated the completeness of case ascertainment for each of the three ALS Registry sources individually, pairwise, and in all combinations. RESULTS: Case-finding completeness was 54% in 2011 and improved to 56% in 2014. A smaller proportion of ALS patients under age 65 were ascertained than those 65 or older, and ascertainment was also lower for nonwhite than white patients. The uncorrected ALS prevalence was 4.3/100,000 in 2011 (in 2014, 5.0/100,000), but after correction for underascertainment, annual prevalence in 2011 was 7.9/100,000 (95% CI: 7.6-8.2) (in 2014 was 8.9/100,000 [95% CI: 8.7-9.2]). DISCUSSION/CONCLUSION: Our findings indicate that administrative healthcare databases are a very efficient method for identifying the majority of ALS prevalent cases in the National ALS Registry and that the inclusion of a web registry portal for patients to self-register is important to ensure a more representative population for estimating ALS prevalence. Nonetheless, more than 40% of ALS cases were not ascertained by the Registry, with individuals younger than age 65 and people of color underrepresented. Recommendations are provided for additional methods that can be considered to improve the completeness of case ascertainment.

One-Year Costs Associated With the Veterans Affairs National TeleStroke Program.

OBJECTIVES: Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP). METHODS: We identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect. RESULTS: NTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P < .0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care. CONCLUSIONS: Telestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.

Alcohol use disorder pharmacotherapy and treatment in primary care (ADaPT-PC) trial: Impact on identified barriers to implementation.

Background: A minority of individuals meeting diagnostic criteria for alcohol use disorders (AUD) receive any type of formal treatment. Developing options for AUD treatment within primary care settings is imperative to increase treatment access. A multi-faceted implementation intervention including provider and patient education, clinician reminders, development of local champions and ongoing facilitation was designed to enhance access to AUD pharmacotherapy in primary care settings at three large Veterans Health Administration (VHA) facilities. This qualitative study compared pre-implementation barriers to post-implementation barriers identified via provider interviews to identify those barriers addressed and not addressed by the intervention to better understand the limited impact of the intervention. Methods: Following the nine-month implementation period, primary care providers at the three participating facilities took part in qualitative interviews to collect perceptions regarding which pre-implementation barriers had and had not been successfully addressed by the intervention. Participants included 20 primary care providers from three large VHA facilities. Interviews were coded using common coding techniques for qualitative data using the Consolidated Framework for Implementation Research (CFIR) codebook. Summary reports were created for each CFIR construct for each facility and the impact of each CFIR construct on implementation was coded as positive, neutral, or negative. Results: Some barriers identified during pre-implementation interviews were no longer identified as barriers in the post-implementation interviews. These included Relative Advantage, Relative Priority, and Knowledge & Beliefs about the Innovation. However, Compatibility, Design Quality & Packaging, and Available Resources remained barriers at the end of the implementation period. No substantial new barriers were identified. Conclusions: The implementation intervention appears to have been successful at addressing barriers that could be mitigated with traditional educational approaches. However, the intervention did not adequately address structural and organizational barriers to implementation. Recommendations for enhancing future interventions are provided.

Laboratory-wide association study of survival with prostate cancer.

BACKGROUND: Estimates of overall patient health are essential to inform treatment decisions for patients diagnosed with cancer. The authors applied XWAS methods, herein referred to as "laboratory-wide association study (LWAS)", to evaluate associations between routinely collected laboratory tests and survival in veterans with prostate cancer. METHODS: The authors identified 133,878 patients who were diagnosed with prostate cancer between 2000 and 2013 in the Veterans Health Administration using any laboratory tests collected within 6 months of diagnosis (3,345,083 results). Using the LWAS framework, the false-discovery rate was used to test the association between multiple laboratory tests and survival, and these results were validated using training, testing, and validation cohorts. RESULTS: A total of 31 laboratory tests associated with survival met stringent LWAS criteria. LWAS confirmed markers of prostate cancer biology (prostate-specific antigen: hazard ratio [HR], 1.07 [95% confidence interval (95% CI), 1.06-1.08]; and alkaline phosphatase: HR, 1.22 [95% CI, 1.20-1.24]) as well laboratory tests of general health (eg, serum albumin: HR, 0.78 [95% CI, 0.76-0.80]; and creatinine: HR, 1.05 [95% CI, 1.03-1.07]) and inflammation (leukocyte count: HR, 1.23 [95% CI, 1.98-1.26]; and erythrocyte sedimentation rate: HR, 1.33 [95% CI, 1.09-1.61]). In addition, the authors derived and validated separate models for patients with localized and advanced disease, identifying 28 laboratory markers and 15 laboratory markers, respectively, in each cohort. CONCLUSIONS: The authors identified routinely collected laboratory data associated with survival for patients with prostate cancer using LWAS methodologies, including markers of prostate cancer biology, overall health, and inflammation. Broadening consideration of determinants of survival beyond those related to cancer itself could help to inform the design of clinical trials and aid in shared decision making. LAY SUMMARY: This article examined routine laboratory tests associated with survival among veterans with prostate cancer. Using laboratory-wide association studies, the authors identified 31 laboratory tests associated with survival that can be used to inform the design of clinical trials and aid patients in shared decision making.

Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery.

BACKGROUND: The Veterans Choice Act of 2014 increased the number of Veterans eligible for Department of Veterans Affairs (VA)-purchased care delivered in non-VA community care (CC) facilities. Driving >40 miles from home to a VA facility is a key eligibility criterion for CC. It remains unclear whether this policy change improved geographical access by reducing drive distance for Veterans. OBJECTIVES: Describe the driving distance for Veterans receiving cataract surgery in VA and CC facilities, and if they visited the closest-to-home facility or if they drove to farther facilities. SUBJECTS: Veterans who had cataract surgery in federal fiscal year 2015. MEASURES: We calculated driving miles to the Closest VA and CC facilities that performed cataract surgeries, and to the location where Veterans received care. RESULTS: A total of 61,746 Veterans received 83,875 cataract surgeries. More than 50% of CC surgeries occurred farther than the Closest CC facility providing cataract surgery (median Closest CC facility 8.7 miles vs. Actual CC facility, 19.7 miles). Most (57%) Veterans receiving cataract surgery at a VA facility used the Closest VA facility (median Closest VA facility 28.1 miles vs. Actual VA facility at 31.2 miles). In all, 26.1% of CC procedures occurred in facilities farther away than the Closest VA facility. CONCLUSIONS: Although many Veterans drove farther than needed to get cataract surgery in CC, this was not true for obtaining care in the VA. Our findings suggest that there may be additional reasons, besides driving distance, that affect whether Veterans choose CC and, if they do, where they seek CC.

County-level Predictors of Growth in Community-based Primary Care Use Among Veterans.

BACKGROUND: The 2014 Choice Act expanded the Veterans Health Administration's (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans' primary care use in community settings. OBJECTIVES: The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities. DATA AND SAMPLE: A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings. ANALYSIS: We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth. RESULTS: Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2-3 percentage point (pp) increase in CBPC penetration growth (P<0.001). The presence of a VA facility was associated with a 1.7 pp decrease in CBPC penetration growth (P<0.001), while lower primary care provider supply was associated with a 0.6 pp increase in CBPC growth (P<0.001). CONCLUSION: CBPC as a proportion of all VA-purchased primary care was small but increased nearly 3-fold between 2015 and 2018. Greater increases in CBPC penetration were concentrated in rural counties and counties without a VA facility, suggesting that community care may enhance primary care access in rural areas with less VA presence.

Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach.

BACKGROUND: Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities. OBJECTIVE: To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems. DESIGN: Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017). PARTICIPANTS: Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative. INTERVENTIONS: Identification of a "positive deviant" and dissemination of this system's best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching). MAIN MEASURES: We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics. KEY RESULTS: BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0-9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5-13.5), Hispanic (10.5%, 95% CI 8.4-12.5), and African American (9.0%, 95% CI 7.7-10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2-19.5; moderate: 5.2%, 95% CI 0.8-9.5; low: 0.2%, 95% CI-3.9 to 4.3). CONCLUSIONS: Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.

Timing and Cost of Wound Complications After Colorectal Resection.

BACKGROUND: More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery. OBJECTIVE: We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications. DESIGN: This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data. SETTING: This study was conducted at a Veterans Affairs medical center. SETTING: Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014. MAIN OUTCOME MEASURES: The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery. RESULTS: Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001). LIMITATIONS: This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system. CONCLUSIONS: Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient. TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL: ANTECEDENTES:Más del 50% de complicaciones postoperatorias de la herida ocurren después del alta. Es la complicación postoperatoria más común y el motivo más frecuente de reingreso después del procedimiento quirúrgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida después del alta quirúrgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las características de las complicaciones de la herida, identificadas después del alta hospitalaria, en pacientes sometidos a cirugía colorrectal, en comparación con las complicaciones intrahospitalarias.DISEÑO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirúrgica de la Administración de Salud de Veteranos.ENTORNO CLÍNICO:Administración de Veteranos.PACIENTES:Pacientes sometidos a resección colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACIÓN:Costos de atención ajustados al alta, 30 días y 90 días después de la cirugía.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicación de la herida dentro de los 30 días de la cirugía. (49,2% índice hospitalario, 50,8% después del alta). En comparación con los pacientes, del índice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p <0,01), más infecciones de órganos/espacios quirúrgicos (14,3% frente a 10,1%, p <0,01), tasas más altas de diabetes (29,1% versus 25,0%, p = 0,02), y deberían de haber tenido un abordaje laparoscópico para su cirugía (24,7% versus 18,2%, p <0,01). El costo promedio, incluida la cirugía a los 30 días, fue de $ 37,315 (desviación estándar = $ 29,319). En comparación con el índice de complicaciones de las herida hospitalaria, las complicaciones de la herida después del alta fueron $ 9,500 (22%, p <0,001) menor costo a los 30 días y $ 9,736 (15%, p<0,001) y menor costo a los 90 días. Los pacientes con índice de complicación de la herida hospitalaria, tenían un 40% menos de probabilidades de requerir reingreso a los 30 días, pero sus reingresos eran $ 12,518 más costosos que los reingresos entre los pacientes presentando complicación de la herida recién identificada después del alta (p <0,001).LIMITACIONES:Limitado a las características del paciente y los costos acumulados solo dentro del sistema VA.CONCLUSIONES:Pacientes con complicaciones de la herida post alta, tienen menores costos postoperatorios a los 30 y 90 días, que aquellos con complicaciones de la herida identificadas durante su índice de hospitalización y aproximadamente la mitad fueron tratados de forma ambulatoria.

Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass.

BACKGROUND: Coronary-artery bypass grafting (CABG) surgery may be performed either with cardiopulmonary bypass (on pump) or without cardiopulmonary bypass (off pump). We report the 5-year clinical outcomes in patients who had been included in the Veterans Affairs trial of on-pump versus off-pump CABG. METHODS: From February 2002 through June 2007, we randomly assigned 2203 patients at 18 medical centers to undergo either on-pump or off-pump CABG, with 1-year assessments completed by May 2008. The two primary 5-year outcomes were death from any cause and a composite outcome of major adverse cardiovascular events, defined as death from any cause, repeat revascularization (CABG or percutaneous coronary intervention), or nonfatal myocardial infarction. Secondary 5-year outcomes included death from cardiac causes, repeat revascularization, and nonfatal myocardial infarction. Primary outcomes were assessed at a P value of 0.05 or less, and secondary outcomes at a P value of 0.01 or less. RESULTS: The rate of death at 5 years was 15.2% in the off-pump group versus 11.9% in the on-pump group (relative risk, 1.28; 95% confidence interval [CI], 1.03 to 1.58; P=0.02). The rate of major adverse cardiovascular events at 5 years was 31.0% in the off-pump group versus 27.1% in the on-pump group (relative risk, 1.14; 95% CI, 1.00 to 1.30; P=0.046). For the 5-year secondary outcomes, no significant differences were observed: for nonfatal myocardial infarction, the rate was 12.1% in the off-pump group and 9.6% in the on-pump group (P=0.05); for death from cardiac causes, the rate was 6.3% and 5.3%, respectively (P=0.29); for repeat revascularization, the rate was 13.1% and 11.9%, respectively (P=0.39); and for repeat CABG, the rate was 1.4% and 0.5%, respectively (P=0.02). CONCLUSIONS: In this randomized trial, off-pump CABG led to lower rates of 5-year survival and event-free survival than on-pump CABG. (Funded by the Department of Veterans Affairs Office of Research and Development Cooperative Studies Program and others; ROOBY-FS ClinicalTrials.gov number, NCT01924442 .).

The Urine Albumin-to-Creatinine Ratio and Kidney Function after Nephrectomy.

PURPOSE: Patients with kidney cancer are at risk for chronic kidney disease after radical and partial nephrectomy. We determined if the urine albumin-to-creatinine ratio is independently associated with progressive chronic kidney disease after nephrectomy. MATERIALS AND METHODS: We performed a cohort study based within a large, integrated health care system. We identified patients who underwent radical or partial nephrectomy from 2004 to 2014 with urine albumin-to-creatinine ratio measured in the 12 months before surgery. We fit multivariable models to determine if the urine albumin-to-creatinine ratio was associated with the time to chronic kidney disease progression (defined as reaching stage 4 or 5 chronic kidney disease, estimated glomerular filtration rate less than 30 ml/minute/1.73 m2). We performed a parallel analysis measuring the time to stage 3b, 4 or 5 chronic kidney disease (estimated glomerular filtration rate less than 45 ml/minute/1.73 m2) among patients with normal or near normal preoperative kidney function (estimated glomerular filtration rate 60 ml/minute/1.73 m2 or greater). We also examined the association between urine albumin-to-creatinine ratio and survival. RESULTS: A total of 1,930 patients underwent radical or partial nephrectomy and had preoperative urine albumin-to-creatinine ratio and preoperative and postoperative estimated glomerular filtration rate. Of these patients 658 (34%) and 157 (8%) had moderate (urine albumin-to-creatinine ratio 30 to 300 mg/gm) or severe albuminuria (urine albumin-to-creatinine ratio greater than 300 mg/gm), respectively. Albuminuria severity was independently associated with progressive chronic kidney disease after radical (moderate albuminuria HR 1.7, 95% CI 1.4-2.2; severe albuminuria HR 2.3, 95% CI 1.7-3.1) and partial nephrectomy (moderate albuminuria HR 1.8, 95% CI 1.2-2.7; severe albuminuria HR 4.3, 95% CI 2.7-7.0). Albuminuria was also associated with survival following radical and partial nephrectomy. CONCLUSIONS: In patients undergoing radical or partial nephrectomy the severity of albuminuria can stratify risk of progressive chronic kidney disease.

Emergency Medicaid Acquisition Through the Affordable Care Act: The Association Between Hospital Enrollment in California and Hospital Revenue.

BACKGROUND: Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue. OBJECTIVE: We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals. RESEARCH DESIGN: We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges. RESULTS: Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, ∼33,000 adults and children were enrolled in California's HPE program per month. CONCLUSION: Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.

Evaluating the Role of Past Clinical Information on Risk Adjustment.

OBJECTIVE: The objective of this study was to evaluate whether incorporating historical clinical information beyond 1 year improves risk adjustment. DATA SOURCES: Administrative data from the Department of Veterans Affairs and Medicare (for veterans concurrently enrolled in Medicare) for fiscal years (FYs) 2011-2015. STUDY DESIGN: We regressed total annual costs on Medicare hierarchical condition category indicators and risk scores for FY 2015 in both a concurrent and a prospective model using 5-fold cross-validation. Regressions were repeated incorporating clinical information from FY 2011 to 2015. Model fit was appraised using R and mean squared predictive error (MSPE). DATA COLLECTION: All veterans affairs users (n=3,254,783) with diagnostic information FY 2011-2015. PRINCIPAL FINDINGS: In a concurrent model, adding additional years of historical clinical information (FY 2011-2014) did not result in substantive gains in fit (R from 0.671 to 0.673) or predictive capability (MSPE from 1956 to 1950). In a prospective model, adding additional years of historical clinical information also did not result in substantive gains in fit (R from 0.334 to 0.344) or predictive capability (MSPE from 3988 to 3940). CONCLUSION: Incorporating historical clinical information yielded no material gain in risk adjustment fit.

Events Associated With Changes in Reliance on the Veterans Health Administration Among Medicare-eligible Veterans.

OBJECTIVES: We can learn something about how Veterans value the Veterans Health Administration (VHA) versus community providers by observing Veterans' choices between VHA and Medicare providers after they turn 65. For a cohort of Veterans who were newly age-eligible for Medicare, we estimated the change in VHA reliance (VHA outpatient visits divided by total VHA and Medicare visits) associated with specific events: receiving a life-threatening diagnosis, having a Medicare-paid hospitalization, or moving further from the VHA. RESEARCH DESIGN: A longitudinal cohort study of VHA and Medicare administrative data. SUBJECTS: A total of 5932 VHA users who completed a health survey in 1999 and became age-eligible for Medicare from 1998 to 2000 were followed through 2016. PRINCIPAL FINDINGS: More Veterans chose to rely on the VHA than Medicare (64% vs. 36.%). For a VHA-reliant Veteran, a Medicare-paid hospital stay was associated with a decrease of 7.8 percentage points (pps) (P<0.001) in VHA reliance in the subsequent 12 months, but by 36 months reliance increased to near prehospitalization levels (-1.5 pps; P=0.138). Moving further from the VHA, or receiving a diagnosis of cancer, heart failure, or renal failure had no significant association with subsequent VHA reliance; however, a diagnosis of dementia was associated with a decrease in VHA reliance (-8.6 pps; P=0.026). CONCLUSIONS: A significant majority of newly Medicare-eligible VHA users voted with their feet in favor of sustaining the VHA as a provider of comprehensive medical care for Veterans. These VHA-reliant Veterans maintained their reliance even after receiving a life-threatening diagnosis, and after experiencing Medicare-provided hospital care.

Rethinking How We Measure Costs in Implementation Research.

BACKGROUND: Hospitals and other health care delivery organizations are sometimes resistant to implementing evidence-based programs, citing unknown budgetary implications. OBJECTIVE: In this paper, I discuss challenges when estimating health care costs in implementation research. DESIGN: A case study with intensive care units highlights how including fixed costs can cloud a short-term analysis. PARTICIPANTS: None. INTERVENTIONS: None. MAIN MEASURES: Health care costs, charges and payments. KEY RESULTS: Cost data should accurately reflect the opportunity costs for the organization(s) providing care. Opportunity costs are defined as the benefits foregone because the resources were not used in the next best alternative. Because there is no database of opportunity costs, cost studies rely on accounting data, charges, or payments as proxies. Unfortunately, these proxies may not reflect the organization's opportunity costs, especially if the goal is to understand the budgetary impact in the next few years. CONCLUSIONS: Implementation researchers should exclude costs that are fixed in the time period of observation because these assets (e.g., space) cannot be used in the next best alternative. In addition, it is common to use costs from accounting databases where we implicitly assume health care providers are uniformly efficient. If providers are not operating efficiently, especially if there is variation in their efficiency, then this can create further problems. Implementation scientists should be judicious in their use of cost estimates from accounting data, otherwise research results can misguide decision makers.

Acute pain after breast surgery and reconstruction: A two-institution study of surgical factors influencing short-term pain outcomes.

BACKGROUND AND OBJECTIVES: Acute postoperative pain following surgery is known to be associated with chronic pain development and lower quality of life. We sought to analyze the relationship between differing breast cancer excisional procedures, reconstruction, and short-term pain outcomes. METHODS: Women undergoing breast cancer excisional procedures with or without reconstruction at two systems: an academic hospital (AH) and Veterans Health Administration (VHA) were included. Average pain scores at the time of discharge and at 30-day follow-up were analyzed across demographic and clinical characteristics. Linear mixed effects modeling was used to assess the relationship between patient/clinical characteristics and interval pain scores with a random slope to account for differences in baseline pain. RESULTS: Our study included 1402 patients at AH and 1435 at VHA, of which 426 AH and 165 patients with VHA underwent reconstruction. Pain scores improved over time and were found to be highest at discharge. Time at discharge, 30-day follow-up, and preoperative opioid use were the strongest predictors of high pain scores. Younger age and longer length of stay were independently associated with worse pain scores. CONCLUSIONS: Younger age, preoperative opioid use, and longer length of stay were associated with higher levels of postoperative pain across both sites.

Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients.

OBJECTIVE: Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization? METHODS: We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010-September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed. RESULTS: The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14-1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants. CONCLUSIONS: Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.

Co-Operative Pain Education and Self-management (COPES) Expanding Treatment for Real-World Access (ExTRA): Pragmatic Trial Protocol.

BACKGROUND: Given access barriers to cognitive behavioral therapy for chronic pain (CBT-CP), this pragmatic superiority trial will determine whether a remotely delivered CBT-CP intervention that addresses these barriers outperforms in-person and other synchronous forms of CBT-CP for veterans with musculoskeletal pain. DESIGN: This pragmatic trial compares an asynchronous form of CBT-CP that uses interactive voice response (IVR) to allow patients to participate from their home (IVR CBT-CP) with synchronous CBT-CP delivered by a Department of Veterans Affairs (VA) clinician. Veterans (n=764; 50% male) with chronic musculoskeletal pain throughout nine VA medical centers will participate. The primary outcome is pain interference after treatment (4 months). Secondary outcomes, including pain intensity, depression symptom severity, sleep, self-efficacy, and global impression of change, are also measured after treatment. Where possible, outcomes are collected via electronic health record extraction, with remaining measures collected via IVR calls to maintain blinding. Quantitative and qualitative process evaluation metrics will be collected to evaluate factors related to implementation. A budget impact analysis will be performed. SUMMARY: This pragmatic trial compares the outcomes, cost, and implementation of two forms of CBT-CP as delivered in the real-world setting. Findings from the trial can be used to guide future policy and implementation efforts related to these interventions and their use in the health system. If one of the interventions emerges as superior, resources can be directed to this modality. If both treatments are effective, patient preferences and health care system factors will take precedence when making referrals. Implications of COVID-19 on treatment provision and trial outcomes are discussed.