The Marginal Costs of Adverse Drug Events Associated With Exposures to Anticoagulants and Hypoglycemic Agents During Hospitalization.

BACKGROUND: Anticoagulants and hypoglycemic agents are 2 of the most challenging drug classes for medical management in the hospital resulting in many adverse drug events (ADEs). OBJECTIVE: Estimating the marginal cost (MC) of ADEs associated with anticoagulants and hypoglycemic agents for adults in 5 patient groups during their hospital stay and the total annual ADE costs for all patients exposed to these drugs during their stay. RESEARCH DESIGN AND SUBJECT: Data are from 2010 to 2013 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and Medicare Patient Safety Monitoring System (MPSMS). Deidentified patients were linked using probabilistic matching in the same hospital and year for 5 patient groups. ADE information was obtained from the MPSMS using retrospective structured record review. Costs were derived using HCUP cost-to-charge ratios. MC estimates were made using Extended Estimating Equations controlling for patient characteristics, comorbidities, hospital procedures, and hospital characteristics. MC estimates were applied to the 2013 HCUP National Inpatient Sample to estimate annual ADE costs. RESULTS: Adjusted MC estimates were smaller than unadjusted measures with most groups showing estimates that were at least 50% less. Adjusted anticoagulant ADE costs added >45% and Hypoglycemic ADE costs added >20% to inpatient costs. The 2013 hospital cost estimates for ADEs associated with anticoagulants and hypoglycemic agents were >$2.5 billion for each drug class. CONCLUSIONS: This study demonstrates the importance of accounting for confounders in the estimation of ADEs, and the importance of separate estimates of ADE costs by drug class.

Marginal Hospital Cost of Surgery-related Hospital-acquired Pressure Ulcers.

BACKGROUND: Patients who develop hospital-acquired pressure ulcers (HAPUs) are more likely to die, have longer hospital stays, and are at greater risk of infections. Patients undergoing surgery are prone to developing pressure ulcers (PUs). OBJECTIVE: To estimate the hospital marginal cost of a HAPU for adults patients who were hospitalized for major surgeries, adjusted for patient characteristics, comorbidities, procedures, and hospital characteristics. RESEARCH DESIGN AND SUBJECTS: Data are from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and the Medicare Patient Safety Monitoring System for 2011 and 2012. PU information was obtained using retrospective structured record review from trained MPMS data abstractors. Costs are derived using HCUP hospital-specific cost-to-charge ratios. Marginal cost estimates were made using Extended Estimating Equations. We estimated the marginal cost at the 25th, 50th, and 75th percentiles of the cost distribution using Simultaneous Quantile Regression. RESULTS: We find that 3.5% of major surgical patients developed HAPUs and that the HAPUs added ∼$8200 to the cost of a surgical stay after adjusting for comorbidities, patient characteristics, procedures, and hospital characteristics. This is an ∼44% addition to the cost of a major surgical stay but less than half of the unadjusted cost difference. In addition, we find that for high-cost stays (75th percentile) HAPUs added ∼$12,100, whereas for low-cost stays (25th percentile) HAPUs added ∼$3900. CONCLUSIONS: This paper suggests that HAPUs add ∼44% to the cost of major surgical hospital stays, but the amount varies depending on the total cost of the visit.

Inpatient admissions from the ED for adults with injuries: the role of clinical and nonclinical factors.

INTRODUCTION: Inpatient hospital costs represent nearly a third of heath care spending. The proportion of inpatients visits that originate in the emergency department (ED) has been growing, approaching half of all inpatient admissions. Injury is the most common reason for adult ED visits, representing nearly one-quarter of all ED visits. OBJECTIVE: The objective was to explore the association of clinical and nonclinical factors with the decision to admit ED patients with injury. RESEARCH DESIGN AND PARTICIPANTS: This is a retrospective cohort study of injury-related ED encounters by adults in select states in 2009. We limited the study to ED visits of persons with moderately severe injuries. We used logistic regression to calculate the marginal effects, estimating 4 equations to account for different risk patterns for older and younger adults, and types of injuries. Regression models controlled for comorbidities, injury characteristics, demographic characteristics, and state fixed effects. RESULTS: Injury location, type, and mechanism and comorbidities had large effects on hospitalization rates as expected. We found higher inpatient admission rates by level of trauma center designation and hospital size, but findings differed by age and type of injury. For younger adults, patients with private insurance and patients who traveled more than 30 miles were more likely to be admitted. CONCLUSIONS: There is great variation in inpatient admission decisions for moderately injured patients in the ED. Decisions appear to be dominated by clinical factors such as injury characteristics and comorbidities; however, nonclinical factors, such as type of insurance, hospital size, and trauma center designation, also play an important role.

Evaluation of AHRQ's on-time pressure ulcer prevention program: a facilitator-assisted clinical decision support intervention for nursing homes.

BACKGROUND: Pressure ulcers present serious health and economic consequences for nursing home residents. The Agency for Healthcare Research & Quality, in partnership with the New York State Department of Health, implemented the pressure ulcer module of On-Time Quality Improvement for Long Term Care (On-Time), a clinical decision support intervention to reduce pressure ulcer incidence rates. OBJECTIVE: To evaluate the effectiveness of the On-Time program in reducing the rate of in-house-acquired pressure ulcers among nursing home residents. RESEARCH DESIGN AND SUBJECTS: We employed an interrupted time-series design to identify impacts of 4 core On-Time program components on resident pressure ulcer incidence in 12 New York State nursing homes implementing the intervention (n=3463 residents). The sample was purposively selected to include nursing homes with high baseline prevalence and incidence of pressure ulcers and high motivation to reduce pressure ulcers. Differential timing and sequencing of 4 core On-Time components across intervention nursing homes and units enabled estimation of separate impacts for each component. Inclusion of a nonequivalent comparison group of 13 nursing homes not implementing On-Time (n=2698 residents) accounts for potential mean-reversion bias. Impacts were estimated via a random-effects Poisson model including resident-level and facility-level covariates. RESULTS: We find a large and statistically significant reduction in pressure ulcer incidence associated with the joint implementation of 4 core On-Time components (incidence rate ratio=0.409; P=0.035). Impacts vary with implementation of specific component combinations. CONCLUSIONS: On-Time implementation is associated with sizable reductions in pressure ulcer incidence.

Potentially avoidable hospitalizations for elderly long-stay residents in nursing homes.

BACKGROUND: Hospitalizations of long-stay nursing home (NH) residents are common. The high estimates of potentially avoidable hospitalizations in NHs suggest that efforts to reduce avoidable hospitalizations may be effective in lowering health care expenditures as well as improving the quality of care for NH residents. OBJECTIVE: To determine the relationship between clinical risk factors, facility characteristics and State policy variables, and both avoidable and unavoidable hospitalizations. METHOD: Hospitalization risk is estimated using competing risks proportional hazards regressions. Three hospitalization measures were constructed: (1) ambulatory care-sensitive conditions (ACSCs); (2) additional NH-sensitive avoidable conditions (ANHACs); and (3) nursing home "unavoidable" conditions (NHUCs). In all models, we include clinical risk factors, facility characteristics, and State policy variables that may influence the decision to hospitalize. SUBJECTS: The population of interest is a cohort of long-stay NH residents. Data are from the Nursing Home Stay file, a sample of residents in 10% of certified NHs in the United States (2006-2008). RESULTS: Three fifths of hospitalizations were potentially avoidable and the majority was for infections, injuries, and congestive heart failure. Clinical risk factors include renal disease, diabetes, and a high number of medications among others. Staffing, quality, and reimbursement affect avoidable, but not unavoidable hospitalizations. CONCLUSIONS: A NH-sensitive measure of avoidable hospitalizations identifies both clinical facility and policy risk factors, emphasizing the potential for both reimbursement and clinical strategies to reduce hospitalizations from NHs.

Exploratory study of nursing home factors associated with successful implementation of clinical decision support tools for pressure ulcer prevention.

OBJECTIVES: To determine those factors that are associated with nursing homes' success in implementing the On-Time quality improvement (QI) for pressure ulcer prevention program and integrating health information technology (HIT) tools into practice at the unit level. DESIGN: Observational study with quantitative analysis of nursing home characteristics, team participation levels, and implementation milestones collected as part of a QI program. SETTING: Fourteen nursing homes in Washington, District of Columbia, participating in the On-Time Pressure Ulcer Prevention program. MAIN OUTCOME MEASURES: The nursing home level of implementation was measured by counting the number of implementation milestones achieved after at least 9 months of implementation effort. MAIN RESULTS: After at least 9 months of implementation effort, 36% of the nursing homes achieved level III, a high level of implementation, of the On-Time QI-HIT program. Factors significantly associated with high implementation were high level of involvement from the administrator or director of nursing, high level of nurse manager participation, presence of in-house dietitian, high level of participation of staff educator and QI personnel, presence of an internal champion, and team's openness to redesign. One factor that was identified as a barrier to high level of implementation was higher numbers of health inspection deficiencies per bed. CONCLUSION: The learning from On-Time QI offers several lessons associated with facility factors that contribute to high level of implementation of a QI-HIT program in a nursing home.

Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay.

BACKGROUND: Policymakers are exploring ways to reduce readmission rates. Much attention has been given to readmissions for conditions such as heart failure, acute myocardial infarction, and pneumonia, but little attention has been given to readmissions of patients with injury-related index admissions. METHODS: This analysis is a retrospective cohort study of elderly persons who are admitted to a community hospital for a principal diagnosis of injury. We use 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases from 11 States. With logistic regression we identify factors associated with a 30-day, all-cause inpatient readmission. Factors include: patient characteristics, injury characteristics, clinical experiences during the hospital stay, and hospital characteristics. RESULTS: About 1 in 7 elderly patients with an injury-related admission were readmitted in 30 days (13.7%). We found that severe injuries had higher predicted readmission rates. Patients receiving transfusions, experiencing a Patient Safety Indicator event, and with infections had higher readmission rates. Patients discharged to nursing homes or home health care had higher readmission rates compared with patients discharged to the community. CONCLUSIONS: This study expands evidence for the influence of injury characteristics on readmission rates. It also provides evidence about hospital experiences that affect readmissions. These findings suggest that a focus on preventing complications during the hospital stay may help reduce hospital-specific readmissions for patients with injury-related conditions. It also suggests that a strategy to reduce readmission rates should not only focus on hospitals but also nursing homes and home health care.

The costs of turnover in nursing homes.

BACKGROUND: Turnover rates in nursing homes have been persistently high for decades, ranging upwards of 100%. OBJECTIVES: To estimate the net costs associated with turnover of direct care staff in nursing homes. DATA AND SAMPLE: Nine hundred two nursing homes in California in 2005. Data included Medicaid cost reports, the Minimum Data Set, Medicare enrollment files, Census, and Area Resource File. RESEARCH DESIGN: We estimated total cost functions, which included in addition to exogenous outputs and wages, the facility turnover rate. Instrumental variable limited information maximum likelihood techniques were used for estimation to deal with the endogeneity of turnover and costs. RESULTS: The cost functions exhibited the expected behavior, with initially increasing and then decreasing returns to scale. The ordinary least square estimate did not show a significant association between costs and turnover. The instrumental variable estimate of turnover costs was negative and significant (P = 0.039). The marginal cost savings associated with a 10% point increase in turnover for an average facility was $167,063 or 2.9% of annual total costs. CONCLUSION: The net savings associated with turnover offer an explanation for the persistence of this phenomenon over the last decades, despite the many policy initiatives to reduce it. Future policy efforts need to recognize the complex relationship between turnover and costs.

Exploring racial and ethnic disparities in prescription drug spending and use among Medicare beneficiaries.

BACKGROUND: Little is known about why minority Medicare beneficiaries spend less on and use fewer prescription drugs than white Medicare beneficiaries. OBJECTIVE: We explored whether population differences in demographic characteristics, socioeconomic status, and health status were associated with observed disparities by race and ethnicity in the prescription drug spending and use of noninstitutionalized elderly Medicare beneficiaries. METHODS: We used a nationally representative sample of 8101 white, 816 black, and 642 Hispanic Medicare beneficiaries from the 1999 Medicare Current Beneficiary Survey Cost and Use files. For each of these groups, we calculated total prescription drug spending, out-of-pocket spending, and number of prescriptions. We then used the Oaxaca-Blinder decomposition method to separate the impact of race and ethnicity on disparities in spending and use from the impact of differences in population characteristics across racial and ethnic groups. RESULTS: Much of the disparity in spending between whites and blacks and some of the disparity between whites and Hispanics can be attributed to race/ethnicity. Because of race/ethnicity, total spending for whites was 8.9% more than for blacks and 5.4% more than for Hispanics. Similarly, total out-of pocket spending for whites was 28.8% more than for blacks and 10.7% more than for Hispanics. Race/ethnicity also influenced the amount of prescription drug use. Whites used 2.3 more prescriptions than blacks and 1.6 more than Hispanics. However, these differences in use were offset by the impact of differences in population characteristics. CONCLUSIONS: Differences in factors identified in the Andersen model of access to care do not fully explain observed disparities in prescription drug use and spending. The portion of the disparities due to race and ethnicity may reflect patients' skepticism about medicine and medical care in general, patients' adherence to medical advice, patient-physician communication, physicians' prescribing habits, and usual source of care. Future research should explore whether these and other unobserved factors associated with race and ethnicity are responsible for disparities in drug spending and use.

Support for emergency department screening for intimate partner violence depends on perceived risk.

Emergency department (ED) screening for intimate partner violence (IPV) faces logistic difficulties and has uncertain efficacy. We surveyed 146 ED visitors and 108 ED care providers to compare their support for ED IPV screening in three hypothetical scenarios of varying IPV risk. Visitor support for screening was 5 times higher for the high-risk (86%) than for the low-risk (17%) scenario. Providers showed significantly more support for the need for ED IPV screening than visitors. Controlling for confounding by gender, race, experience with IPV, hospital, and marital status did not affect comparisons between groups. These responses indicate greater support for IPV screening in the ED for high-risk than for low-risk cases, particularly among visitors.

Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.

OBJECTIVES: To test whether nationally required drug use reviews reduce exposure to inappropriate medications in nursing homes. DESIGN: Quasi-experimental, longitudinal study. SETTING: Data source is the 1997-2000 Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries. PARTICIPANTS: Nationally representative population sample of 8 million nursing home (NH) residents (unweighted n=2,242) and a comparative group of 2 million assisted living facility (ALF) residents (unweighted n=664). MEASUREMENTS: Prevalence and incident use of 38 potentially inappropriate medications compared before and after the policy: 32 restricted for all NH residents and six for residents with certain conditions. Inappropriate medications were stratified by potential for legitimate exceptions: always avoid, rarely appropriate, or some acceptable indications. RESULTS: In July 1999, the Centers for Medicare and Medicaid Services (CMS) mandated expansions to the drug use review policy for nursing home certification. Using explicit criteria, surveyors and consultant pharmacists must evaluate resident records for potentially inappropriate medication exposures and related adverse drug reactions. Nursing homes in noncompliance may receive citations for deficient care. Before the CMS policy, 28.8% (95% confidence interval (CI)=27.3-30.3) of Medicare beneficiaries in NHs and 22.4% (95% CI=19.8-25.0) in ALFs received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable indications: 23.4% in NHs (95% CI=20.4-26.4) and 18.0% in ALFs (95% CI=15.6-20.4). After the policy, exposures in NHs declined to 25.6% (95% CI=24.1-27.1, P<.05), but similar declines occurred in ALFs (19.0%, 95% CI=16.7-21.3, nonsignificant). Postpolicy use of inappropriate medications with exempted indications remained high, and more than half was incident use: 20.6% of NH residents (95% CI=19.0-22.0) and 15.6% of ALF residents (95% CI=15.2-15.7). Use of drugs that are restricted with certain diseases increased 33% in NHs between 1997 and 2000 (from 9.3% to 13.2%; P<.05). Multivariate results detected no postpolicy differences in inappropriate drug use between long-term care facilities with mandatory drug use reviews and those without. CONCLUSION: Some postpolicy declines were noted in NH use of potentially inappropriate medications, but the decrease was uneven and could not be attributed to the national drug use reviews. This study is the first evaluation of the CMS policy, and it highlights the unclear effectiveness of drug use reviews to improve patient safety in NHs even though state and federal agencies have widely adopted this strategy.

Racial and ethnic disparities in prescription coverage and medication use.

This study compared drug coverage and prescription drug use by race and Hispanic ethnicity for Medicare beneficiaries with three chronic conditions: diabetes, hypertension, or heart disease. We found that among beneficiaries without any drug coverage black persons and Hispanics used 10 to 40 percent fewer medications, on average, than white persons with the same illness, and spent up to 60 percent less in total drug costs. Having drug coverage somewhat lessened these differences although the effect was consistent with only M + C prescription benefits. Substantially lower medication use remained for dually eligible black beneficiaries and Hispanics with employer-sponsored drug benefits.

Perceptions of help resources for victims of intimate partner violence.

Intimate partner violence (IPV) constitutes a major public health problem in the United States. This cross-sectional survey of 108 emergency department (ED) care providers and 146 ED visitors at three metropolitan EDs compared the beliefs of ED health care providers with those of community members about the relative benefits of the helpfulness of resources for IPV victims using hypothetical case scenarios. Although providers generally indicated that help resources were helpful in all scenarios, visitors were more discriminating, showing less support for resources in the lower-risk scenario. Regarding differences between groups, visitors selected police and attorneys more frequently than providers as a helpful resource, whereas providers selected shelters and counselors more frequently than visitors. Adjustment for previous experience with IPV did not change these results. Understanding the differences between health care providers' and community members' perceptions of resources for victims of IPV may improve the effectiveness of referral to IPV resources.