RESUMEN
BACKGROUND: There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown. METHODS: Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-). RESULTS: Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7). CONCLUSIONS: Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation.
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Enfermedad de Alzheimer , Servicio de Urgencia en Hospital , Medicare , Casas de Salud , Humanos , Medicare/estadística & datos numéricos , Estados Unidos/epidemiología , Masculino , Femenino , Enfermedad de Alzheimer/epidemiología , Anciano , Servicio de Urgencia en Hospital/estadística & datos numéricos , Servicio de Urgencia en Hospital/tendencias , Anciano de 80 o más Años , Casas de Salud/estadística & datos numéricos , Demencia/epidemiología , Hospitalización/estadística & datos numéricos , Hospitalización/tendenciasRESUMEN
Climate change is intensifying extreme weather events. Yet a systematic analysis of post-disaster healthcare utilization and outcomes for severe weather and climate disasters, as tracked by the US government, is lacking. Following exposure to 42 US billion-dollar weather disasters (severe storm, flood, flood/severe storm, tropical cyclone and winter storm) between 2011 and 2016, we used a difference-in-differences (DID) approach to quantify changes in the rates of emergency department (ED) visits, nonelective hospitalizations and mortality between fee-for-service Medicare beneficiaries in affected compared to matched control counties in post-disaster weeks 1, 1-2 and 3-6. Overall, disasters were associated with higher rates of ED utilization in affected counties in post-disaster week 1 (DID of 1.22% (95% CI, 0.20% to 2.25%; P < 0.020)) through week 2. Nonelective hospitalizations were unchanged. Mortality was higher in affected counties in week 1 (DID of 1.40% (95% CI, 0.08% to 2.74%; P = 0.037)) and persisted for 6 weeks. Counties with the greatest loss and damage experienced greater increases in ED and mortality rates compared to all affected counties. Thus, billion-dollar weather disasters are associated with excess ED visits and mortality in Medicare beneficiaries. Tracking these outcomes is important for adaptation that protects patients and communities, health system resilience and policy.
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Desastres , Clima Extremo , Anciano , Estados Unidos/epidemiología , Humanos , Medicare , Atención a la Salud , Aceptación de la Atención de SaludRESUMEN
BACKGROUND AND OBJECTIVES: Intubation for acute stroke is common in the United States, with few established guidelines. METHODS: This is a retrospective observational study of acute stroke admissions from 2011 to 2018 among fee-for-service Medicare beneficiaries aged 65-100 years. Patient demographics and chronic conditions as well as hospital characteristics were identified. We identified patient intubation, stroke subtype (ischemic vs intracerebral hemorrhage), and thrombectomy. Factors associated with intubation were identified by a linear probability model with intubation as the outcome and patient characteristics, stroke subtype, and thrombectomy as predictors, adjusting for within-hospital correlation. We compared hospital characteristics between adjusted intubation rate quartiles. We specified a linear probability model with 30-day mortality as the patient-level outcome and hospital intubation rate quartile as the categorical predictor, again adjusting for patient characteristics. We specified an analogous model for quartiles of hospital referral regions. RESULTS: There were 800,467 stroke hospitalizations at 3,581 hospitals. Among 2,588 hospitals with 25 or more stroke hospitalizations, the median intubation rate was 4.8%, while a quarter had intubation rates below 2.4% and 10% had rates above 12.5%. Ischemic strokes had a 21% lower adjusted intubation risk than intracerebral hemorrhages (risk difference [RD] -21.1%, 95% CI -21.3% to -20.9%; p < 0.001), whereas thrombectomy was associated with a 19.2% higher adjusted risk (95% CI RD 18.8%-19.6%; p < 0.001). Women and older patients had lower intubation rates. Large, urban hospitals and academic medical centers were overrepresented in the top quartile of hospital adjusted intubation rates. Even after adjusting for available characteristics, intubated patients had a 44% higher mortality risk than non-intubated patients (p < 0.001). Hospitals in the highest intubation quartile had higher adjusted 30-day mortality (19.3%) than hospitals in the lowest quartile (16.7%), a finding that was similar when restricting to major teaching hospitals (22.3% vs 18.1% in the 4th vs 1st quartiles, respectively). There was no association between market quartile of intubation and patient 30-day mortality. DISCUSSION: Intubation for acute stroke varied by patient and hospital characteristics. Hospitals with higher adjusted rates of intubation had higher patient-level 30-day mortality, but much of the difference may be due to unmeasured patient severity given that no such association was observed for health care markets.
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Medicare , Accidente Cerebrovascular , Anciano , Humanos , Femenino , Estados Unidos , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia , Hospitalización , Hospitales de Enseñanza , Estudios Retrospectivos , IntubaciónRESUMEN
BACKGROUND: United States healthcare has increasingly transitioned to outpatient care delivery. The degree to which Academic Medical Centers (AMCs) have been able to shift surgical procedures from inpatient to outpatient settings despite higher patient complexity is unknown. METHODS: This observational study used a 20% sample of fee-for-service Medicare beneficiaries age 65 and older undergoing eight elective procedures from 2011 to 2018 to model trends in procedure site (hospital outpatient vs. inpatient) and 30-day standardized Medicare costs, overall and by hospital teaching status. RESULTS: Of the 1,222,845 procedures, 15.9% occurred at AMCs. There was a 2.42% per-year adjusted increase (95% CI 2.39%-2.45%; p < .001) in proportion of outpatient hospital procedures, from 68.9% in 2011 to 85.4% in 2018. Adjusted 30-day standardized costs declined from $18,122 to $14,353, (-$560/year, 95% CI -$573 to -$547; p < .001). Patients at AMCs had more chronic conditions and higher predicted annual mortality. AMCs had a lower proportion of outpatient procedures in all years compared to non-AMCs, a difference that was statistically significant but small in magnitude. AMCs had higher costs compared to non-AMCs and a lesser decline over time (p < .001 for the interaction). AMCs and non-AMCs saw a similar decline in 30-day mortality. CONCLUSIONS: There has been a substantial shift toward outpatient procedures among Medicare beneficiaries with a decrease in total 30-day Medicare spending as well as 30-day mortality. Despite a higher complexity population, AMCs shifted procedures to the outpatient hospital setting at a similar rate as non-AMCs. IMPLICATIONS: The trend toward outpatient procedural care and lower spending has been observed broadly across AMCs and non-AMCs, suggesting that Medicare beneficiaries have benefited from more efficient delivery of procedural care across academic and community hospitals.
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Gastos en Salud , Pacientes Ambulatorios , Humanos , Anciano , Estados Unidos , Medicare , Costos y Análisis de Costo , Hospitales de EnseñanzaRESUMEN
BACKGROUND: Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status. METHODS: We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status. RESULTS: We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD. CONCLUSIONS: Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.
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Enfermedad de Alzheimer , Humanos , Anciano , Estados Unidos/epidemiología , Enfermedad de Alzheimer/terapia , Enfermedad de Alzheimer/epidemiología , Medicare , Aceptación de la Atención de Salud , Servicio de Urgencia en Hospital , Instituciones de SaludRESUMEN
STUDY OBJECTIVE: To determine the association between emergency physicians' ages and patient mortality after emergency department visits. METHODS: This observational study used a 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 89 years treated by emergency physicians at EDs from 2016 to 2017. We investigated whether 7-day mortality after ED visits differed by the age of the emergency physician, adjusting for patient and physician characteristics and hospital fixed effects. RESULTS: We observed 2,629,464 ED visits treated by 32,570 emergency physicians (mean age 43.5). We found that patients treated by younger emergency physicians had lower mortality rates compared with those treated by older physicians. Adjusted 7-day mortality was 1.33% for patients treated by emergency physicians aged less than 40 years, 1.36% (adjusted difference, 0.03%; 95% confidence interval [CI], -0.001% to 0.06%) for physicians ages 40 to 49, 1.40% (0.08%; 95% CI 0.04% to 0.12%) for physicians ages 50 to 59, and 1.43% (0.11%; 95% CI 0.06% to 0.16%) for those with a physician age of 60 years and more. Similar patterns were observed when stratified by the patient's disposition (discharged vs admitted), and the association was more pronounced for patients with higher severity of illness. CONCLUSIONS: Medicare patients aged 65 to 89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians aged 50 to 59 years and 60 years or older within the same hospital. Potential mechanisms explaining the association between emergency physician age and patient mortality (eg, differences in training received and other unobservable patient/physician characteristics) are uncertain and require further study.
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Medicare , Médicos , Humanos , Anciano , Estados Unidos/epidemiología , Adulto , Persona de Mediana Edad , Hospitalización , Hospitales , Servicio de Urgencia en HospitalRESUMEN
Importance: Studies suggest that academic medical centers (AMCs) have better outcomes than nonteaching hospitals. However, whether AMCs have spillover benefits for patients treated at neighboring community hospitals is unknown. Objective: To examine whether market-level AMC presence is associated with outcomes for patients treated at nonteaching hospitals within the same markets. Design, Setting, and Participants: This retrospective, population-based cohort study assessed traditional Medicare beneficiaries aged 65 years and older discharged from US acute care hospitals between 2015 and 2017 (100% sample). Data were analyzed from August 2021 to December 2022. Exposures: The primary exposure was market-level AMC presence. Health care markets (ie, hospital referral regions) were categorized by AMC presence (percentage of hospitalizations at AMCs) as follows: no presence (0%), low presence (>0% to 20%), moderate presence (>20% to 35%), and high presence (>35%). Main Outcomes and Measures: The primary outcomes were 30-day and 90-day mortality and healthy days at home (HDAH), a composite outcome reflecting mortality and time spent in facility-based health care settings. Results: There were 22â¯509â¯824 total hospitalizations, with 18â¯865â¯229 (83.8%) at non-AMCs. The median (IQR) age of patients was 78 (71-85) years, and 12â¯568â¯230 hospitalizations (55.8%) were among women. Of 306 hospital referral regions, 191 (62.4%) had no AMCs, 61 (19.9%) had 1 AMC, and 55 (17.6%) had 2 or more AMCs. Markets characteristics differed significantly by category of AMC presence, including mean population, median income, proportion of White residents, and physicians per population. Compared with markets with no AMC presence, receiving care at a non-AMC in a market with greater AMC presence was associated with lower 30-day mortality (9.5% vs 10.1%; absolute difference, -0.7%; 95% CI, -1.0% to -0.4%; P < .001) and 90-day mortality (16.1% vs 16.9%; absolute difference, -0.8%; 95% CI, -1.2% to -0.4%; P < .001) and more HDAH at 30 days (16.49 vs 16.12 HDAH; absolute difference, 0.38 HDAH; 95% CI, 0.11 to 0.64 HDAH; P = .005) and 90 days (61.08 vs 59.83 HDAH; absolute difference, 1.25 HDAH; 95% CI, 0.58 to 1.92 HDAH; P < .001), after adjustment. There was no association between market-level AMC presence and mortality for patients treated at AMCs themselves. Conclusions and Relevance: AMCs may have spillover effects on outcomes for patients treated at non-AMCs, suggesting that they have a broader impact than is traditionally recognized. These associations are greatest in markets with the highest AMC presence and persist to 90 days.
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Hospitales Comunitarios , Medicare , Humanos , Anciano , Estados Unidos/epidemiología , Femenino , Estudios Retrospectivos , Estudios de Cohortes , Centros Médicos AcadémicosRESUMEN
BACKGROUND: The delivery and financing of health care services were altered in unprecedented ways by COVID-19 and subsequent policy responses. We estimated reimbursement losses to emergency physicians in 2020 compared to 2019 related to shifting acute care utilization during COVID-19. METHODS: This was an observational analysis of the Clinical Emergency Department Registry (CEDR) and the Nationwide Emergency Department Sample (NEDS). Study sample included all ED visits from a sample of 214 emergency department (ED) sites in the CEDR in 2019 and 2020 as well as all ED visits in the NEDS in 2019. We identified level of service billing code for evaluation and management (E&M) services, insurance payer, and geographic location of ED visits across sites in the CEDR and linked these to fee schedules to estimate total professional reimbursement across sites. Our primary analysis was to estimate reimbursement in 2020 compared to 2019 across the CEDR sites. In our secondary analysis, we linked sites in the CEDR to those in NEDS to estimate nationwide reimbursement. RESULTS: Total E&M reimbursement for emergency physicians in the CEDR was $1.6 billion in 2019 and $1.3 billion in 2020, reflecting a 19.7% decline year over year ($308 million loss). In our secondary analysis, we estimate nationwide losses of $6.6 billion, a -19.4% decline year over year. If emergency physicians had received maximum allowable federal relief funds via CARES Act Phases 1 to 3 (2% of 2019 revenue) this would sum to $680 million (2% of the $34 billion) or 10.3% of the estimated $6.6 billion pandemic-related losses. CONCLUSIONS: Our analyses provide an estimate of the scale of economic impacts of the COVID-19 pandemic. These findings warrant consideration for policymaker relief and future redesign of emergency care financing. Ultimately, the COVID-19 pandemic likely expanded known cracks in the financing of health care into steep fault lines.
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COVID-19 , Servicios Médicos de Urgencia , Médicos , Humanos , Estados Unidos/epidemiología , Pandemias , COVID-19/epidemiología , COVID-19/terapia , Servicio de Urgencia en HospitalRESUMEN
BACKGROUND: Telehealth delivery expanded quickly during the COVID-19 pandemic after the reduction of payment and regulatory barriers, but older adults are the least likely to benefit from this expansion. Little is known about physician experiences initiating telehealth and factors that fostered or discouraged adoption during the COVID-19 pandemic with older adult patients. Therefore, our objective was to understand experiences of frontline physicians caring for older adults via telehealth during the COVID-19 pandemic. METHODS: We conducted semi-structured interviews from September 2020 to November 2020 with 48 physicians. We recruited a diverse sample of geriatricians (n = 18), primary care (n = 15), and emergency (n = 15) physicians from all United Stated (US) regions, rural-urban settings, and academic-community practices who cared for older adult patients during the pandemic using purposive sampling methods. We completed framework analysis of the transcribed interviews to identify emerging themes and used the Quadruple Aim to organize themes. RESULTS: Frontline physicians described telehealth as a more flexible, value-based, and patient-centered mode of health care delivery. Benefits of using telehealth to treat older adults included reducing deferred care and increasing timely care, improving efficiency for physicians, enhancing communication with caregivers and patients, reducing patient travel burdens, and facilitating health outreach and education. Challenges included unequal access for rural, older, or cognitively impaired patients. Physicians noted that payment parity with in-person visits, between video and telephone visits, and relaxation of restrictive regulations would enhance their ability to continue to offer telehealth. CONCLUSIONS: Frontline physicians who treated older adults during the COVID-19 pandemic were largely in favor of continuing telehealth use beyond the pandemic; however, they noted that sustainability would depend on enacting policies that address access inequities and reimbursement concerns. Our data provide policy insights that if placed into action could facilitate the long-term success of telehealth and encourage a more flexible healthcare delivery system in the US.
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COVID-19 , Médicos , Telemedicina , Anciano , COVID-19/epidemiología , Humanos , Pandemias , SARS-CoV-2 , Telemedicina/métodosRESUMEN
OBJECTIVE: To examine patient outcomes for nine cancer-specific procedures performed in teaching versus non-teaching hospitals. SUMMARY BACKGROUND DATA: Few contemporary studies have evaluated patient outcomes in teaching versus non-teaching hospitals across a comprehensive set of cancer-specific procedures. METHODS: Use of national Medicare data to compare 30-, 60-, and 90-day mortality rates in teaching and non-teaching hospitals for cancer-specific procedures. Risk-adjusted 30-day, all-cause, postoperative mortality overall and for each specific surgery, as well as overall 60- and 90-day mortality rates, were assessed. RESULTS: The sample consisted of 159,421 total cancer surgeries at 3,151 hospitals. Overall thirty-day mortality rates, adjusted for procedure type, state, and invasiveness of procedure were 1.3% lower at major teaching hospitals (95%CI=-1.6% to -1.1%; p<0.001) relative to non-teaching hospitals. After accounting for patient characteristics, major teaching hospitals continued to demonstrate lower mortality rates compared with non-teaching hospitals (-1.0% difference [95%CI -1.2% to -0.7%]; p<0.001). Further adjustment for surgical volume as a mediator reduced the difference to -0.7% (95%CI -0.9% to -0.4%, p<0.001). Cancer surgeries for four of the nine disease sites (bladder, lung, colorectal and ovarian) followed this overall trend. Sixty- and ninety-day overall mortality rates, adjusted for procedure type, state, and invasiveness of procedure showed that major teaching hospitals had a 1.7% (95%CI -2.1% to -1.4%; p<0.001) and 2.0% (95%CI -2.4 to -1.6%, p<0.001) lower mortality relative to non-teaching hospitals. These trends persisted after adjusting for patient characteristics. CONCLUSIONS: Among cancer-specific procedures for Medicare beneficiaries, major teaching hospital status was associated with lower 30-, 60-, and 90-day mortality rates overall and across four of the nine cancer types.
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BACKGROUND: Healthy Days at Home (HDAH) is a novel population-based outcome measure. In this study, its use as a potential measure for cancer patients at the end of life (EOL) was explored. METHODS: Patient demographics and health care use among Medicare beneficiaries with cancer who died over the years 2014 to 2017 were identified. The HDAH was calculated by subtracting the following components from 180 days: number of days spent in inpatient and outpatient hospital observation, the emergency room, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation, long-term hospitals, and inpatient hospice. How HDAH and its components varied by beneficiary demographics and health care market were evaluated. A patient-level linear regression model with HDAH as the outcome, hospital referral region (HRR) random effects, and market fixed effects were specified, as well as beneficiary age, sex, and comorbidities as covariates. RESULTS: The 294,751 beneficiaries at the EOL showed a mean number of 154.0 HDAH (out of 180 days). Inpatient (10.7 days) and SNF (9.7 days) resulted in the most substantial reductions in HDAH. Males had fewer adjusted HDAH (153.1 vs 155.7, P < .001) than females; Medicaid-eligible patients had fewer HDAH compared with non-Medicaid-eligible patients (152.0 vs 154.9; P < .001). Those with hematologic malignancies had the fewest number of HDAH (148.9). Across HRRs, HDAH ranged from 10.8 fewer to 10.9 more days than the national mean. At the HRR-level, home hospice was associated with greater HDAH, whereas home health was associated with fewer HDAH. CONCLUSIONS: HDAH may be a useful measure to understand, quantify, and improve patient-centered outcomes for cancer patients at EOL.
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Neoplasias , Indicadores de Calidad de la Atención de Salud , Anciano , Muerte , Femenino , Ambiente en el Hogar , Humanos , Masculino , Medicare , Neoplasias/terapia , Evaluación de Resultado en la Atención de Salud , Cuidado Terminal , Enfermo Terminal , Estados Unidos/epidemiologíaRESUMEN
Importance: Ambulatory follow-up care is frequently recommended after an emergency department (ED) visit. However, the frequency with which follow-up actually occurs and the degree to which follow-up is associated with postdischarge outcomes is unknown. Objectives: To examine the frequency and variation in ambulatory follow-up among Medicare beneficiaries discharged from US EDs and the association between ambulatory follow-up and postdischarge outcomes. Design, Setting, and Participants: This cohort study of 9â¯470â¯626 ED visits to 4728 US EDs among Medicare beneficiaries aged 65 and older from 2011 to 2016 who survived the ED visit and were discharged to home used Kaplan-Meier curves and proportional hazards regression. Data analysis was conducted from December 2019 to July 2020. Exposures: Ambulatory follow-up after discharge from the ED. Main Outcomes and Measures: Postdischarge mortality, subsequent ED visit, or inpatient hospitalization within 30 days of an index ED visit. Results: The study sample consisted of 9â¯470â¯626 index outpatient ED visits to 4684 EDs; most visits (5â¯776â¯501 [61.0%]) were among women, and the mean (SD) age of patients was 77.3 (8.4) years. In this sample, the cumulative incidence of ambulatory follow-up was 40.5% (3â¯822â¯133 patients) at 7 days and 70.8% (6â¯662â¯525 patients) at 30 days, after accounting for censoring and for mortality as a competing risk. Characteristics associated with lower rates of ambulatory follow-up included beneficiary Medicaid eligibility (hazard ratio [HR], 0.77; 95% CI, 0.77-0.78; P < .001), Black race (HR, 0.82; 95% CI, 0.81-0.83; P < .001), and treatment at a rural ED (HR, 0.75; 95% CI, 0.73-0.77; P < .001) in the multivariable regression model. Ambulatory follow-up was associated with lower risk of postdischarge mortality (HR, 0.49; 95% CI, 0.49-0.50; P < .001) but higher risk of subsequent inpatient hospitalization (HR, 1.22; 95% CI, 1.21-1.23; P < .001) and ED visits (HR, 1.01; 95% CI, 1.00-1.01; P < .001), adjusting for visit diagnosis, patient demographic characteristics, and chronic conditions. Conclusions and Relevance: In this cohort study of Medicare beneficiaries discharged from the ED, nearly 30% lacked ambulatory follow-up at 30 days, with variation in follow-up rates by patient and hospital characteristics. Having an ambulatory follow-up visit was associated with higher risk of subsequent hospitalization but lower risk of mortality. Ambulatory care access may be an important driver of clinical outcomes after an ED visit.
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Cuidados Posteriores/estadística & datos numéricos , Atención Ambulatoria/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Servicios de Salud para Ancianos/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Anciano , Estudios de Cohortes , Estudios de Seguimiento , Humanos , Evaluación de Resultado en la Atención de Salud , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Estados UnidosRESUMEN
Providing quality healthcare for homeless patients is a major public health challenge, and some hospitals may be better at treating homeless patients than others. However, whether the quality of care that homeless patients receive differs by the teaching status of hospitals remains unclear. Using statewide databases that include all hospital admissions and emergency department (ED) visits in four states (Florida, Massachusetts, Maryland, and New York) in 2014, we compared 30-day readmission and ED revisit rates for homeless and non-homeless patients discharged from teaching hospitals versus non-teaching hospitals, after adjusting for patient and hospital characteristics. Among 3,438,538 patients (median age [IQR]: 63 [49-77] years) analyzed, 132,025 (4%) were homeless patients. Overall, homeless patients had a higher readmission rate (28.3% vs. 17.7%; average marginal effects [AME], 10.5%; 95% confidence interval [CI], 8.2%-12.9%; p < 0.001) and a higher ED revisit rate (37.6% vs. 23.9%; AME, 13.7%; 95%CI, 10.9%-16.6%; p < 0.001) than non-homeless patients. Patients from teaching hospitals had similar readmission rate (18.2% vs. 18.3%; AME, -0.1%; 95%CI, -0.8%-0.5%; p = 0.69) and slightly lower ED revisit rate than those from non-teaching hospitals (24.1% vs. 25.2%; AME, -1.1%; 95%CI, -1.9% to -0.3%; p < 0.01). When we focus on joint effects of homelessness and hospital teaching status, we found that homeless patients treated at teaching hospitals had lower rates of 30-day readmission (AME, -5.8%; 95%CI, -9.7% to -1.8%; p < 0.01) and ED revisit (AME, -9.3%; 95%CI, -13.1% to -5.5%; p < 0.001) compared to those treated at non-teaching hospitals. For non-homeless patients, in contrast, we found no evidence that rates of hospital readmission (AME, 0%, 95%CI, -0.1%-0.1%; p = 0.94) or ED revisit (AME, -0.9%; 95%CI, -1.7% to -0.1%; p = 0.02) differ between teaching and non-teaching hospitals. These findings suggest the healthcare settings in which homeless patients receive care have important implications for their patient outcomes.
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Personas con Mala Vivienda , Readmisión del Paciente , Servicio de Urgencia en Hospital , Florida , Hospitales de Enseñanza , Humanos , Maryland , Massachusetts , Persona de Mediana Edad , New York , Estudios RetrospectivosRESUMEN
Importance: There is little evidence regarding how total costs of care associated with an emergency department (ED) visit have changed, despite increasing policy focus on the value of acute care. Objective: To examine trends in total standardized 30-day costs of care associated with an ED visit. Design, Setting, and Participants: This cross-sectional study of 14â¯113â¯088 ED visits at 4730 EDs from 2011 to 2016 included a 20% national sample of traditional Medicare beneficiaries aged 65 years and older. Data analysis was conducted from August 2018 to April 2020. Exposures: Time (year) as a continuous variable. Main Outcomes and Measures: Trends in disposition from the ED and 30-day total standardized costs for all ED visits as well as the following spending components: index visit cost, physician costs, subsequent ED visit costs, subsequent inpatient costs, subsequent observation costs, non-ED outpatient care, postacute care, and aggregated total spending after the index ED visit. Results: The analytic sample consisted of 14â¯113â¯088 ED visits at 4730 EDs. The mean (SD) beneficiary age was 78.6 (8.6) years, 8â¯573â¯652 visits (60.7%) were among women, and 11â¯908â¯691 visits (84.7%) were among white patients. The proportion of patients discharged from the ED rose from 1â¯233â¯701 of 2â¯309â¯563 visits (53.4%) in 2011 to 1â¯279â¯701 of 2â¯268â¯363 visits (56.4%) in 2016. Total adjusted 30-day standardized costs of care declined from a mean (SE) of $8851 ($35.3) in 2011 to a mean (SE) of $8143 ($35.4) in 2016 (-$126/y; 95% CI, -$130 to -$121; P < .001) for all ED visits. This decrease was primarily associated with a decline in total spending on the index ED visit (-$48/y; 95% CI, -$50 to -$47; P < .001) as well as lower spending on postacute care (-$42/y; 95% CI, -$44 to -$41; P < .001) and subsequent inpatient care (-$34/y; 95% CI, -$36 to -$32; P < .001). There was an increase in spending after the index visit on downstream observation care ($3.6/y; 95% CI, $3.5 to $3.7; P < .001), outpatient ED care ($4.6/y; 95% CI, $4.4 to $4.8; P < .001), and other outpatient care ($15/y; 95% CI, $12 to $18; P < .001). Conclusions and Relevance: In this study, total 30-day standardized costs of ED care for Medicare beneficiaries decreased in recent years. It may be that more intensive ED spending up front is associated with reductions in total costs of an acute episode.
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Servicio de Urgencia en Hospital/economía , Costos de la Atención en Salud/estadística & datos numéricos , Medicare , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Medicare/economía , Medicare/estadística & datos numéricos , Alta del Paciente , Estados Unidos/epidemiologíaRESUMEN
Racial disparities in hospitalization rates for ambulatory care-sensitive conditions are concerning and may signal differential access to high-quality ambulatory care. Whether racial disparities are improving as a result of better ambulatory care versus artificially narrowing because of increased use of observation status is unclear. Using Medicare data for 2011-15, we sought to determine whether black-white disparities in avoidable hospitalizations were improving and evaluated the degree to which changes in observations for ambulatory care-sensitive conditions may be contributing to changes in these gaps. We found that while the racial gap in avoidable hospitalizations due to such conditions has decreased, that seems to be explained by a concomitant increase in the gap of avoidable observation stays. This suggests that changes from inpatient admissions to observation status seem to be driving the reduction in racial disparities in avoidable hospitalizations, rather than changes in the ambulatory setting.
Asunto(s)
Disparidades en Atención de Salud , Medicare , Anciano , Atención Ambulatoria , Hospitalización , Humanos , Estados Unidos , Población BlancaRESUMEN
BACKGROUND: Healthy Days at Home (HDAH) is a novel population-based outcome measure developed in conjunction with the Medicare Payment Advisory Commission. METHODS: We identified beneficiary age, sex, race, and Medicaid eligibility, death date, chronic conditions and healthcare utilization among a 20% sample of Medicare beneficiaries in 2016. For each beneficiary we calculated HDAH for the year by subtracting the following measure components from 365 days: mortality days, the total number of days spent in inpatient, observation, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation and long-term hospital settings as well as the number of outpatient emergency department and home health visits. We examined how HDAH and its components varied by beneficiary demographic characteristics and chronic condition burden as well as by healthcare market (Hospital Referral Region). We specified a patient-level linear regression adjustment model with HDAH as the outcome and incorporated market fixed effects as well as beneficiary age, sex, and Chronic Conditions Warehouse categories as covariates. We examined the impact of including home health visits in the measure, as well as the association between market demographics and health system characteristics and mean market HDAH. We examined how HDAH changed from 2013 to 2016. RESULTS: The 6,637,568 beneficiaries age 65 and older in our sample had a mean of 347.2 HDAH, those 80 and older had a mean of 325.3 while those with three or more chronic conditions had a mean of 333.7. The components that led to the largest reduction in HDAH were mortality (7.4 days), home health (2.7 visits), SNF utilization (2.4 days) and inpatient care (1.5 days). The worst performing market had 5.8 fewer adjusted HDAH on average compared to the national mean, while beneficiaries in the best-performing market had 5.0 more HDAH on average compared to the national mean, among all beneficiaries age 65 and older. CONCLUSIONS: HDAH is a population-based quality measure with substantial market-level variation. IMPLICATIONS: HDAH recognizes the multidimensional nature of healthcare and may afford providers greater flexibility to tailor quality-improvement initiatives to the unique needs of their patients. LEVEL OF EVIDENCE: Level II.
Asunto(s)
Planificación en Salud Comunitaria/métodos , Evaluación de Resultado en la Atención de Salud/métodos , Anciano , Atención Ambulatoria/organización & administración , Atención Ambulatoria/estadística & datos numéricos , Planificación en Salud Comunitaria/estadística & datos numéricos , Femenino , Humanos , Masculino , Massachusetts , Evaluación de Resultado en la Atención de Salud/normas , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Proveedores de Redes de Seguridad/métodos , Proveedores de Redes de Seguridad/estadística & datos numéricosRESUMEN
Importance: Emergency department (ED) visits are common and increasing. Whether outcomes associated with care in the ED are improving over time is largely unknown to date. Objective: To examine trends in 30-day mortality rates associated with ED care among Medicare beneficiaries aged 65 years or older. Design, Setting, and Participants: This cross-sectional study used a random 5% sample in 2009 and 2010 and a 20% sample from 2011 to 2016, for a total of 15â¯416â¯385 ED visits from 2009 to 2016 among Medicare beneficiaries aged 65 years or older. Exposures: Time (year) as a continuous variable. Main Outcomes and Measures: The primary outcome was 30-day mortality, overall and stratified by illness severity and hospital characteristics. Secondary outcomes included mortality rates on the day of the ED visit (day 0) as well as at 7 and 14 days. Changes in disposition from the ED (admission, observation, transfer, died in the ED, and discharged) over time were also examined. Results: The sample included 15â¯416â¯385 ED visits (60.8% women and 39.2% men; mean [SD] age, 78.6 [8.5] years) at 4828 acute care hospitals. The percentage of patients discharged from the ED increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality declined from 5.1% in 2009 to 4.6% in 2016 (-0.068% per year; 95% CI, -0.074% to -0.063% per year; P < .001). After adjusting for hospital random effects, patient demographics, and chronic conditions, the adjusted 30-day mortality trend was -0.198% per year (95% CI, -0.204% to -0.193% per year; P < .001). The magnitude of this trend was greatest for patients with a high severity of illness (-0.662%; 95% CI, -0.681% to -0.644%; P < .001), followed by those with a medium severity of illness (-0.103% per year; 95% CI, -0.108% to -0.097% per year; P < .001) and those with a low severity of illness (-0.009% per year; 95% CI, -0.006% to -0.011% per year; P < .001). Declines in mortality were seen in each category of ED disposition, including visits resulting in admission (-0.356% per year; 95% CI, -0.368% to -0.343% per year; P < .001) as well as those resulting in discharge (-0.059% per year; 95% CI, -0.064% to -0.055% per year; P < .001). The decline was greater for major teaching hospitals (compared with nonteaching hospitals), nonprofit hospitals (compared with for-profit hospitals), and urban hospitals (compared with rural hospitals). Conclusions and Relevance: Among Medicare beneficiaries receiving ED care in the United States, mortality within 30 days of an ED visit appears to have declined in recent years, particularly for patients with the highest severity of illness, even as fewer patients are being admitted from an ED visit. This study's findings suggest that further study is needed to understand the reasons for this decline and why certain types of hospitals are seeing greater improvements in outcomes.