The Effect of Medicare Annual Wellness Visits on Breast Cancer Screening and Diagnosis.

OBJECTIVE: The Medicare Annual Wellness Visit (AWV)-a prevention-focused annual check-up-has been available to beneficiaries with Part B coverage since 2011. The objective of this study was to estimate the effect of Medicare AWVs on breast cancer screening and diagnosis. DATA SOURCES AND STUDY SETTING: The National Cancer Institute's Surveillance, Epidemiology, and End Results cancer registry data linked to Medicare claims (SEER-Medicare), HRSA's Area Health Resources Files, the FDA's Mammography Facilities database, and CMS "Mapping Medicare Disparities" utilization data from 2013 to 2015. STUDY DESIGN: Using an instrumental variables approach, we estimated the effect of AWV utilization on breast cancer screening and diagnosis, using county Welcome to Medicare Visit (WMV) rates as the instrument. DATA COLLECTION/EXTRACTION METHODS: 66,088 person-year observations from 49,769 unique female beneficiaries. PRINCIPAL FINDINGS: For every 1-percentage point increase in county WMV rate, the probability of AWV increased by 1.7 percentage points. Having an AWV was associated with a 22.4-percentage point increase in the probability of receiving a screening mammogram within 6 months ( P <0.001). There was no statistically significant increase in the probability of breast cancer diagnosis (overall or early stage) within 6 months of an AWV. Findings were robust to multiple model specifications. CONCLUSIONS: Performing routine cancer screening is an evidence-based practice for diagnosing earlier-stage, more treatable cancers. The AWV effectively increases breast cancer screening and may lead to more timely screening. Continued investment in Annual Wellness Visits supports breast cancer screening completion by women who are most likely to benefit, thus reducing the risk of overscreening and overdiagnosis.

Building Data Infrastructure for Disease-Focused Health Economics Research.

BACKGROUND: Data infrastructure for cancer research is centered on registries that are often augmented with payer or hospital discharge databases, but these linkages are limited. A recent alternative in some states is to augment registry data with All-Payer Claims Databases (APCDs). These linkages capture patient-centered economic outcomes, including those driven by insurance and influence health equity, and can serve as a prototype for health economics research. OBJECTIVES: To describe and assess the utility of a linkage between the Colorado APCD and Colorado Central Cancer Registry (CCCR) data for 2012-2017. RESEARCH DESIGN, PARTICIPANTS, AND MEASURES: This cohort study of 91,883 insured patients evaluated the Colorado APCD-CCCR linkage on its suitability to assess demographics, area-level data, insurance, and out-of-pocket expenses 3 and 6 months after cancer diagnosis. RESULTS: The linkage had high validity, with over 90% of patients in the CCCR linked to the APCD, but gaps in APCD health plans limited available claims at diagnosis. We highlight the advantages of the CCCR-APCD, such as granular race and ethnicity classification, area-level data, the ability to capture supplemental plans, medical and pharmacy out-of-pocket expenses, and transitions in insurance plans. CONCLUSIONS: Linked data between registries and APCDs can be a cornerstone of a robust data infrastructure and spur innovations in health economics research on cost, quality, and outcomes. A larger infrastructure could comprise a network of state APCDs that maintain linkages for research and surveillance.

Capitalizing on Central Registries for Expanded Cancer Surveillance and Research.

BACKGROUND: State central cancer registries are an essential component of cancer surveillance and research that can be enriched through linkages to other databases. This study identified and described state central registry linkages to external data sources and assessed the potential for a more comprehensive data infrastructure with registries at its core. METHODS: We identified peer-reviewed papers describing linkages to state central cancer registries in all 50 states, Washington, DC, and Puerto Rico, published between 2010 and 2020. To complement the literature review, we surveyed registrars to learn about unpublished linkages. Linkages were grouped by medical claims (public and private insurers), medical records, other registries (eg, human immunodeficiency virus/acquired immunodeficiency syndrome registries, birth certificates, screening programs), and data from specific cohorts (eg, firefighters, teachers). RESULTS: We identified 464 data linkages with state central cancer registries. Linkages to cohorts and other registries were most common. Registries in predominately rural states reported the fewest linkages. Most linkages are not ongoing, maintained, or available to researchers. A third of linkages reported by registrars did not result in published papers. CONCLUSIONS: Central cancer registries, often in collaboration with researchers, have enriched their data through linkages. These linkages demonstrate registries' ability to contribute to a data infrastructure, but a coordinated and maintained approach is needed to leverage these data for research. Sparsely populated states reported the fewest linkages, suggesting possible gaps in our knowledge about cancer in these states. Many more linkages exist than have been reported in the literature, highlighting potential opportunities to further use the data for research purposes.

Nonprofit Hospital Community Benefits: Collaboration With Local Health Departments to Address the Drug Epidemic.

BACKGROUND: Nonprofit hospitals (NFPs) are required to provide community benefits, which have been historically focused on provision of medical care, to keep their tax exemption status. To increase hospital investment in community health, the Patient Protection and Affordable Care Act required NFPs to conduct community health needs assessments and address identified needs. Some states have leveraged this provision to encourage collaboration between NFPs and local health departments (LHDs) in local health planning. OBJECTIVE: The objective of this study was to examine the association of NFP-LHD collaboration in local health planning targeting drug use, with drug-induced mortality. RESEARCH DESIGN: We conducted difference-in-differences analyses using drug-induced mortality data from 2009 to 2016, encompassing the first 3 years after NFP-LHD collaboration in local health planning specific to drug use. We evaluated drug-induced mortality in 22 counties in which collaboration was required in comparison with that in 198 control counties. We used data collected from implementation strategy reports by NFPs and combined it with data on hospital characteristics, as well as state-level and county-level factors associated with drug-induced mortality. MEASURES: The primary outcome was county-level drug-induced mortality per 100,000 population. RESULTS: Counties, in which NFP-LHD collaboration in local health planning was required and in which NFPs and LHDs jointly prioritized drug use, experienced a deceleration in drug-induced mortality of ~8 deaths per 100,000 population compared with the mortality rate they would have experienced without collaboration. CONCLUSIONS: Collaboration between NFPs and LHDs to address drug use was associated with a deceleration in drug-induced mortality. Policymakers can leverage community benefit regulation to encourage NFP-LHD collaboration in local health planning.

Can Collaboration Between Nonprofit Hospitals and Local Health Departments Influence Population Health Investments by Nonprofit Hospitals?

BACKGROUND: The patient protection and Affordable Care Act (ACA) sought to improve population health by requiring nonprofit hospitals (NFPs) to conduct triennial community health needs assessments and address the identified needs. In this context, some states have encouraged collaboration between hospitals and local health department (LHD) to increase the focus of community benefit spending onto population health. OBJECTIVES: The aim was to examine whether a 2012 state law that required NFPs to collaborate with LHDs in local health planning influenced hospital population health improvement spending. RESEARCH DESIGN: We merged Internal Revenue Service data on NFP community benefit spending with data on hospital, county and state-level characteristics and estimated a difference-in-differences specification of hospital population health spending in 2009-2016 that compared the difference between hospitals that were required to collaborate with LHDs to those that were not, before and after the requirement. MEASURES: The primary outcome was population health spending divided by operating expenses. RESULTS: We found that the requirement for hospital-LHD collaboration was associated with increased mean population health spending of ∼$393,000-$786,000 (P=0.03). This association was significant in 2015-2016, perhaps reflecting the lag between assessments and implementation. Urban hospitals were responsible for most of the increased spending. CONCLUSIONS: Policymakers have sought to encourage hospitals to increase their investment in population health; however, overall community benefit spending on population health has remained flat. We found that requiring hospital-LHD collaboration was associated with increased hospital investment in population health. It may be that hospitals increase population health spending because collaboration improves expected effectiveness or increases hospital accountability.

Ethnoracial Disparity in Hospital Survival following Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Variceal Bleeding in the United States.

PURPOSE: To investigate the magnitude of racial/ethnic differences in hospital mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding and whether hospital care processes contribute to them. METHODS: Patients aged ≥18 years undergoing TIPS creation for acute variceal bleeding in the United States (n = 10,331) were identified from 10 years (2007-2016) available in the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between patient race and inpatient mortality, controlling for disease severity, treatment utilization, and hospital characteristics. RESULTS: A total of 6,350 (62%) patients were White, 1,780 (17%) were Hispanic, and 482 (5%) were Black. A greater proportion of Black patients were admitted to urban teaching hospitals (Black, n = 409 (85%); Hispanic, n = 1,310 (74%); and White, n = 4,802 (76%); P < .001) and liver transplant centers (Black, n = 215 (45%); Hispanic, n = 401 (23%); and White, n = 2,267 (36%); P < .001). Being Black was strongly associated with mortality (Black, 32% vs non-Black, 15%; odds ratio, 3.0 [95% confidence interval, 1.6-5.8]; P = .001), as assessed using the risk-adjusted regression model. This racial disparity disappeared in a sensitivity analysis including only patients with a maximum Child-Pugh score of 13 (odds ratio 1.2 [95% confidence interval, 0.4-3.6]; P = .68), performed to compensate for the absence of Model for End-stage Liver Disease scores. Ethnoracial differences in access to teaching hospitals, liver transplant centers, first-line endoscopy, and transfusion did not significantly contribute (P > .05) to risk-adjusted mortality. CONCLUSIONS: Black patients have a 2-fold higher inpatient mortality than non-Black patients following TIPS creation for acute variceal bleeding, possibly related to greater disease severity before the procedure.

Cost Analysis of Dialysis Access Maintenance Interventions across Physician Specialties in U.S. Medicare Beneficiaries.

Background Dialysis maintenance interventions account for billions of dollars in U.S. Medicare spending and are performed by multiple medical specialties. Whether Medicare costs differ by physician specialty is, to the knowledge of the authors, not known. Purpose To assess patency-adjusted costs of endovascular dialysis access maintenance by physician specialty. Materials and Methods In this retrospective longitudinal cohort study, patients who were beneficiaries of Medicare undergoing their first arteriovenous access placement in 2009 were identified by using billing codes in the 5% Limited Data Set. By tracking their utilization data through 2014, postintervention primary patency and aggregate payments associated with maintenance interventions were calculated. Unadjusted payments per year of access patency gain were compared across physician specialty. A general linear mixed-effects model adjusted for covariates was used, as follows: patient characteristics, access type (fistula vs graft), clinical severity, type of intervention (angioplasty, stent, thrombolysis), clinical location (hospital outpatient vs office-based laboratory), and resource utilization (operating room use, anesthesia use). Results First arteriovenous access was performed in 1479 beneficiaries (mean age, 63 years ± 15 [standard deviation]; 820 men) in 2009. Through 2014, 8166 maintenance interventions were performed in this cohort. Unadjusted mean Medicare payments for each incremental year of patency were as follows: $71 000 for radiologists, $89 000 for nephrologists, and $174 000 for surgeons. Billing for operating room (41.8% [792 of 1895], surgery; 10.2% [277 of 2709], nephrology; and 31.1% [1108 of 3562], radiology) and anesthesia (19.9% [377 of 1895], surgery; 2.6% [70 of 2709], nephrology; 4.7% [170 of 3562], radiology) varied by specialty and accounted for 407% and 132% higher payments, respectively. After adjusting for clinical severity and location, type of intervention, and resource utilization, nephrologists and surgeons had 59% (95% confidence interval: 44%, 73%; P < .001) and 57% (95% confidence interval: 43%, 72%; P < .001) higher payments, respectively, for the same patency gain compared with radiologists. Operating room use and anesthesia services were major drivers of higher cost, with 407% (95% confidence interval: 374%, 443%; P < .001) and 132% (95% confidence interval: 116%, 150%; P < .001) higher costs, respectively. Conclusion Patency-adjusted payments for hemodialysis access maintenance differed by physician specialty, driven partly by discrepant rates of billing for operating room and anesthesia use. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by White in this issue.

A Quasi-Experimental Analysis of Lethal Means Assessment and Risk for Subsequent Suicide Attempts and Deaths.

BACKGROUND: Counseling on access to lethal means is highly recommended for patients with suicide risk, but there are no formal evaluations of its impact in real-world settings. OBJECTIVE: Evaluate whether lethal means assessment reduces the likelihood of suicide attempt and death outcomes. DESIGN: Quasi-experimental design using an instrumental variable to overcome confounding due to unmeasured patient characteristics that could influence provider decisions to deliver lethal means assessment. SETTING: Kaiser Permanente Colorado, an integrated health system serving over 600,000 members, with comprehensive capture of all electronic health records, medical claims, and death information. PARTICIPANTS: Adult patients who endorsed suicide ideation on the Patient Health Questionnaire-9 (PHQ-9) depression screener administered in behavioral health and primary care settings from 2010 to 2016. INTERVENTIONS: Provider documentation of lethal means assessment in the text of clinical notes, collected using a validated Natural Language Processing program. MEASUREMENTS: Main outcome was ICD-9 or ICD-10 codes for self-inflicted injury or suicide death within 180 days of index PHQ-9 event. RESULTS: We found 33% of patients with suicide ideation reported on the PHQ-9 received lethal means assessment in the 30 days following identification. Lethal means assessment reduced the risk of a suicide attempt or death within 180 days from 3.3 to 0.83% (p = .034, 95% CI = .069-.9). LIMITATIONS: Unmeasured suicide prevention practices that co-occur with lethal means assessment may contribute to the effects observed. CONCLUSIONS: Clinicians should expand the use of counseling on access to lethal means, along with co-occurring suicide prevention practices, to all patients who report suicide ideation.

Urban-Rural Differences in Service Utilization and Costs of Care for Racial-Ethnic Groups Hospitalized With Poststroke Aphasia.

OBJECTIVE: Although residence is a key contributor to cost and utilization in stroke patient care, its contribution to the care of persons with aphasia (PWA) is unknown. The objective of this study was to use discharge-level hospital inpatient data to examine the influence of patient residence (rural vs urban) and race-ethnicity on service utilization and cost of care among PWA. DESIGN: Cross-sectional. SETTING: Administrative data from acute care hospitals in the state of North Carolina. PARTICIPANTS: Individuals (N=4381) with poststroke aphasia. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Length of stay (LOS), speech-language pathology (SLP) service utilization, costs of care. METHODS: The 2011-2012 Healthcare Cost and Utilization Project State Inpatient Database data were analyzed to examine the effect of rural or urban residence on LOS, SLP service utilization, as well as total inpatient and SLP service costs. These outcomes were further analyzed across both residence and racial groups (non-Hispanic white and non-Hispanic black). Outcomes were analyzed using generalized linear model. RESULTS: Both rural and urban black PWA experienced longer average LOS after controlling for demographics, illness severity, and the hospital where they received care. Rural blacks experienced longer LOS, received greater SLP services, and incurred greater average total hospital costs than their rural white counterparts after adjusting for differences in their demographics and stroke or illness severity. The differences were attenuated after controlling for the hospital where they received care. CONCLUSIONS: For PWA, race-ethnicity has a larger effect on average total medical costs, SLP service utilization, and LOS than residence. It is unclear how and why blacks with aphasia have greater service utilization and costs in acute care, yet their aphasia outcomes are worse. Future studies are required to explore potential factors such as quality of care.

State Laws and Nonprofit Hospital Community Benefit Spending.

OBJECTIVE: To determine the association of state laws on nonprofit hospital community benefit spending. DESIGN: We used multivariate models to estimate the association between different types of state-level community benefit laws and nonprofit hospital community benefit spending from tax filings. SETTING: All 50 US states. PARTICIPANTS: A total of 2421 nonprofit short-term acute care hospital organizations that filled an internal revenue service Form 990 and Schedule H for calendar during years 2009-2015. RESULTS: Between 2009 and 2015, short-term acute care hospitals spent an average of $46 billion per year in total, or $20 million per hospital on community benefit activities. Exposure to a state-level community benefit law of any type was associated with an $8.42 (95% confidence interval: 1.20-15.64) per $1000 of total operating expense greater community benefit spending. Spending amounts and patterns varied on the basis of the type of community benefit law and hospital urbanicity. CONCLUSIONS: State laws are associated with nonprofit hospital community benefit spending. Policy makers can use community benefit laws to increase nonprofit hospital engagement with public health.

Ethnoracial Disparities in Medicare Annual Wellness Visit Utilization: Evidence From a Nationally Representative Database.

INTRODUCTION: In 2011, Medicare began offering annual preventive care visits (annual wellness visit; AWV) to beneficiaries at no charge. Providing free preventive care supports primary and secondary prevention of chronic disease and may reduce ethnoracial disparities in health outcomes. OBJECTIVES: To estimate AWV utilization trends by ethnoracial group in a nationally representative sample of the Medicare population. RESEARCH DESIGN: We estimated the probability of AWV utilization using probit regression models with beneficiary-reported ethnoracial group as the primary predictor and demographics, socioeconomic indicators, and factors related to access and utilization of health care as covariates. SUBJECTS: In total, 14,687 fee-for-service Medicare beneficiaries aged 66 years or older who participated in the Medicare Current Beneficiary Survey 2011-2013. MEASURES: AWV utilization was identified using procedure codes. RESULTS: Overall AWV utilization increased from 8.1% (2011) to 13.4% (2013). In 2011, utilization was highest in non-Hispanic white (8.5%) and lowest in non-Hispanic black (4.5%) beneficiaries. Utilization increased the most in non-Hispanic black beneficiaries, to 15.4% in 2013. Significant differences in AWV utilization by non-Hispanic black and Hispanic/Latino beneficiaries were found in unadjusted models, but did not persist after controlling for income and education. Having a usual (nonemergent) place of care and a nonrural residence were strong predictors of utilization. CONCLUSIONS: Utilization of the AWV has increased modestly since its introduction, but remains low. Utilization varies by ethnoracial group, with disparities largely explained by differences in income and education. Further efforts are needed to evaluate AWV utilization and effectiveness, especially among low socioeconomic status ethnoracial minorities.

Recommendations for Methicillin-Resistant Staphylococcus aureus Prevention in Adult ICUs: A Cost-Effectiveness Analysis.

OBJECTIVE: Patients in the ICU are at the greatest risk of contracting healthcare-associated infections like methicillin-resistant Staphylococcus aureus. This study calculates the cost-effectiveness of methicillin-resistant S aureus prevention strategies and recommends specific strategies based on screening test implementation. DESIGN: A cost-effectiveness analysis using a Markov model from the hospital perspective was conducted to determine if the implementation costs of methicillin-resistant S aureus prevention strategies are justified by associated reductions in methicillin-resistant S aureus infections and improvements in quality-adjusted life years. Univariate and probabilistic sensitivity analyses determined the influence of input variation on the cost-effectiveness. SETTING: ICU. PATIENTS: Hypothetical cohort of adults admitted to the ICU. INTERVENTIONS: Three prevention strategies were evaluated, including universal decolonization, targeted decolonization, and screening and isolation. Because prevention strategies have a screening component, the screening test in the model was varied to reflect commonly used screening test categories, including conventional culture, chromogenic agar, and polymerase chain reaction. MEASUREMENTS AND MAIN RESULTS: Universal and targeted decolonization are less costly and more effective than screening and isolation. This is consistent for all screening tests. When compared with targeted decolonization, universal decolonization is cost-saving to cost-effective, with maximum cost savings occurring when a hospital uses more expensive screening tests like polymerase chain reaction. Results were robust to sensitivity analyses. CONCLUSIONS: As compared with screening and isolation, the current standard practice in ICUs, targeted decolonization, and universal decolonization are less costly and more effective. This supports updating the standard practice to a decolonization approach.

Value of Public Health Funding in Preventing Hospital Bloodstream Infections in the United States.

OBJECTIVES: To estimate the association of 1 activity of the Prevention and Public Health Fund with hospital bloodstream infections and calculate the return on investment (ROI). METHODS: The activity was funded for 1 year (2013). A difference-in-differences specification evaluated hospital standardized infection ratios (SIRs) before funding allocation (years 2011 and 2012) and after funding allocation (years 2013 and 2014) in the 15 US states that received the funding compared with hospital SIRs in states that did not receive the funding. We estimated the association of the funded public health activity with SIRs for bloodstream infections. We calculated the ROI by dividing cost offsets from infections averted by the amount invested. RESULTS: The funding was associated with a 33% (P < .05) reduction in SIRs and an ROI of $1.10 to $11.20 per $1 invested in the year of funding allocation (2013). In 2014, after the funding stopped, significant reductions were no longer evident. CONCLUSIONS: This activity was associated with a reduction in bloodstream infections large enough to recoup the investment. Public health funding of carefully targeted areas may improve health and reduce health care costs.

Establishing a Baseline: Community Benefit Spending by Not-for-Profit Hospitals Prior to Implementation of the Affordable Care Act.

CONTEXT: Community Benefit spending by not-for-profit hospitals has served as a critical, formalized part of the nation's safety net for almost 50 years. This has occurred mostly through charity care. This article examines how not-for-profit hospitals spent Community Benefit dollars prior to full implementation of the Affordable Care Act (ACA). METHODS: Using data from 2009 to 2012 hospital tax and other governmental filings, we constructed national, hospital-referral-region, and facility-level estimates of Community Benefit spending. Data were collected in 2015 and analyzed in 2015 and 2016. Data were matched at the facility level for a non-profit hospital's IRS tax filings (Form 990, Schedule H) and CMS Hospital Cost Report Information System and Provider of Service data sets. RESULTS: During 2009, hospitals spent about 8% of total operating expenses on Community Benefit. This increased to between 8.3% and 8.5% in 2012. The majority of spending (>80%) went toward charity care, unreimbursed Medicaid, and subsidized health services, with approximately 6% going toward both community health improvement and health professionals' education. By 2012, national spending on Community Benefit likely exceeded $60 billion. The largest hospital systems spent the vast majority of the nation's Community Benefit; the top 25% of systems spent more than 80 cents of every Community Benefit dollar. DISCUSSION: Community Benefit spending has remained relatively steady as a proportion of total operating expenses and so has increased over time-although charity care remains the major focus of Community Benefit spending overall. IMPLICATIONS: More than $60 billion was spent on Community Benefit prior to implementation of the ACA. New reporting and spending requirements from the IRS, alongside changes by the ACA, are changing incentives for hospitals in how they spend Community Benefit dollars. In the short term, and especially the long term, hospital systems would do well to partner with public health, other social services, and even competing hospitals to invest in population-based activities. The mandated community health needs assessment process is a logical home for these sorts of collaborations. Relatively modest investments can improve the baseline level of health in their communities and make it easier to improve population health. Aside from a population health justification for a partnership model, a business case is necessary for widespread adoption of this approach. Because of their authorities, responsibilities, and centuries of expertise in community health, public health agencies are in a position to help hospitals form concrete, sustainable collaborations for the improvement of population health. CONCLUSION: The ACA will likely change the delivery of uncompensated and charity care in the United States in the years to come. How hospitals choose to spend those dollars may be influenced greatly by the financial and political environments, as well as the strength of community partnerships.

Therapy Use for Children With Developmental Conditions: Analysis of Colorado Medicaid Data.

STUDY PURPOSE: To examine therapy use and spending for Medicaid-enrolled infants and toddlers with developmental conditions. METHODS: Sample infants and toddlers had a diagnosis (eg, cerebral palsy) or developmental delay (DD). Colorado Children's Medicaid administrative outpatient therapy claims (2006-2008) were used to estimate differences, by condition type and number of comorbid chronic conditions (CCCs), of any physical therapy (PT)/occupational therapy (OT) and Medicaid PT/OT spending. RESULTS: The sample included 20 959 children. Children with at least 2 CCCs had higher odds of PT/OT than children with no CCC. Children with DD had 12-fold higher odds of having any PT/OT compared with children with diagnosis. Children with a DD and 2 CCCs had the highest PT/OT spending. CONCLUSIONS: Medicaid PT/OT use and spending are higher for children with more CCCs and those with DD because children with DD receive more specialized PT/OT.

Modern Management Practices and Hospital Admissions.

We investigate whether the modern management practices and publicly reported performance measures are associated with choice of hospital for patients with acute myocardial infarction (AMI). We define and measure management practices at approximately half of US cardiac care units using a novel survey approach. A patient's choice of a hospital is modeled as a function of the hospital's performance on publicly reported quality measures and the quality of its management. The estimates, based on a grouped conditional logit specification, reveal that higher management scores and better performance on publicly reported quality measures are positively associated with hospital choice. Management practices appear to have a direct correlation with admissions for AMI--potentially through reputational effects--and indirect association, through better performance on publicly reported measures. Overall, a one standard deviation change in management practice scores is associated with an 8% increase in AMI admissions.

National Trends in Emergency Department Visits by Adults With Mental Health Disorders.

BACKGROUND: Although mental health disorders (MHDs) affect as many as 1 in 4 adults in the U.S., the national trends in emergency department (ED) use for adults who have MHD comorbidities are unknown. OBJECTIVE: To evaluate the role of mental health disorder co-morbidities for adults who use the ED and how this utilization differs by insurance type. METHODS: This is a retrospective analysis of the National Emergency Department Survey (NEDS) dataset of adults 18 to 64 years of age that was conducted from 2006 to 2011. We defined individuals with MHD comorbidities by applying the MHD Clinical Classification Software groupings to any of the 1 to 15 diagnostic fields available in the NEDS. We further evaluated ED visits made for a primary diagnosis of MHD by applying the same aforementioned codes to the primary diagnosis. We constructed ED visit rates using the U.S. Census Bureau's Current Population Survey. We used descriptive statistics and tested for differences in trends in visits and visit rates by payer using an ordinary least squares regression. RESULTS: The number of ED visits increased by 8.6% from 2006 to 2011. The number of ED visits made by adults primarily for MHDs and with MHD comorbidities increased by 20.5% and 53.3%, respectively (p < 0.0001); ED visits made adults without MHDs decreased by 1.1% (p = 0.72) for the same time period. When accounting for the population growth rate, ED visit rates made by adults with MHD comorbidities increased for all insurance types, but decreased for those without MHD comorbidities. CONCLUSION: MHD comorbidities play a significant role in the increasing number of ED visits, regardless of insurance coverage. Additional studies are needed to understand the role of patients with MHDs and ED use.

Economic evaluation of the 80% baccalaureate nurse workforce recommendation: a patient-level analysis.

BACKGROUND: Higher proportions of BSN-educated nurses were associated with improved outcomes in hospital-level studies. A recent Institute of Medicine report calls for increasing the proportion of BSN-educated nurses to 80% by 2020. Patient-level evidence of cost and quality implications of the 80% BSN threshold is needed for a business case to support these efforts. OBJECTIVES: To conduct the economic analysis of meeting the 80% BSN threshold on patient outcomes and costs, using linked patient-nurse data. RESEARCH DESIGN: Retrospective observational patient-level analysis of electronic data. Linear and logistic regression modeling with patient controls and diagnosis and unit fixed effects. SUBJECTS: A total of 8526 adult medical-surgical patients matched with 1477 direct care nurses from an Eastern US academic medical center, during June 1, 2011-December 31, 2011. MEASURES: Outcomes include hospital mortality, all-cause same-facility 30-day readmission, length-of-stay, and total hospitalization cost. BSN proportion is a continuous measure for the proportion of nurse assessment inputs into the patient's electronic medical record made by BSN-educated nurses; a dichotomous indicator for BSN proportion is 0.8-1.0. RESULTS: Continuous BSN proportion was associated with lower mortality (OR=0.891, P<0.01). Compared with patients with <80% BSN care, patients receiving ≥ 80% of care from BSN nurses had lower odds of readmission (OR=0.813, P=0.04) and 1.9% shorter length-of-stay (P=0.03). Economic simulations support a strong business case for increasing the proportion of BSN-educated nurses to 80%. CONCLUSIONS: A combined approach of increasing the hospital-level BSN proportion to 80% and assuring a high BSN dose through individual patient-level staffing assignments is needed to achieve projected quality and costs benefits.

Is there a business case for magnet hospitals? Estimates of the cost and revenue implications of becoming a magnet.

BACKGROUND: Although Magnet hospitals (MHs) are known for their better nursing care environments, little is known about whether MHs achieve this at a higher (lower) cost of health care or whether a superior nursing environment yields higher net patient revenue versus non-MHs over an extended period of time. OBJECTIVE: To examine how achieving Magnet status is related to subsequent inpatient costs and revenues controlling for other hospital characteristics. DATA AND METHODS: Data from the American Hospital Association Annual Survey, Hospital Cost Reporting Information System reports collected by Centers for Medicare & Medicaid Services, and Magnet status of hospitals from American Nurses Credentialing Center from 1998 to 2006 were combined and used for the analysis. Descriptive statistics, propensity score matching, fixed-effect, and instrumental variable methods were used to analyze the data. RESULTS: Regression analyses revealed that MH status is positively and significantly associated with both inpatient costs and net inpatient revenues for both urban hospitals and all hospitals. MH status was associated with an increase of 2.46% in the inpatient costs and 3.89% in net inpatient revenue for all hospitals, and 2.1% and 3.2% for urban hospitals. CONCLUSIONS: Although it is costly for hospitals to attain Magnet status, the cost of becoming a MH may be offset by higher net inpatient income. On average, MHs receive an adjusted net increase in inpatient income of $104.22-$127.05 per discharge after becoming a Magnet which translates to an additional $1,229,770-$1,263,926 in income per year.

US Hospital Service Availability and New 340B Program Participation.

Importance: The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective: To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants: Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures: New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures: Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results: The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance: The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.