Hospital-based skilled nursing facility survival: Organizational and market-level predictors.

BACKGROUND: Rising health care costs and consequent increases in Medicare reimbursements have led to many payment reforms over the years. Implementation of the prospective payment system (PPS) for hospitals in 1983 incentivized hospitals to either purchase skilled nursing facilities (SNFs) or utilize their excess capacity to establish one within the hospital. With PPS reimbursement being applied to SNFs in 1998, prior monetary incentives for hospitals to own an SNF disappeared. However, despite the reduction in numbers, many hospitals continued to operate their hospital-based skilled nursing facilities (HBSNFs). PURPOSE: This study examines the organizational and market-level factors associated with the survival of HBSNFs using the population ecology of organizations framework. METHODOLOGY: Using American Hospital Association survey data, event histories of all U.S. acute care hospitals with an open HBSNF in 1998 were plotted to examine if a hospital closed its HBSNF during a 22-year period (1998-2020). The primary independent variables included hospital size, ownership, total margin, market competition, and Medicare Advantage penetration. The independent and control variables were lagged by 1 year. Cox regressions were conducted to estimate the hazard ratios capturing the risk of HBSNF closure. RESULTS: The results showed that HBSNFs located in large, not-for-profit hospitals and those operating in less competitive markets had greater odds of surviving. PRACTICE IMPLICATIONS: The HBSNF administrators of small, for-profit hospitals and those operating in highly competitive markets could utilize the findings of this study to judiciously allocate slack resources to their HBSNFs to keep those open given the current emphasis on continuity of care by regulatory bodies.

The role of patient and family advisory boards in promoting greater attention to patient social needs by U.S. acute care hospitals.

BACKGROUND: There is growing attention to individual-level patient social needs such as unstable housing and food insecurity. Such considerations, however, have historically been the purview of public health and have not been a priority of more traditional health care delivery organizations, such as acute care hospitals. PURPOSE: The purpose of this study was to examine whether the presence of patient and family advisory boards (PFABs) among acute care community hospitals was associated with screening for and programs to address patient social needs. METHODS: We used a secondary data set derived from the American Hospital Association's 2020 and 2021 annual surveys, along with multinomial and negative binomial regression models to assess the relationship between the presence/absence of a PFAB and the likelihood of offering and the number of areas addressed by social needs screening programs. RESULTS: More than half (55.9%) of all responding hospitals reported having a PFAB in 2020 (55.9%) and 2021 (52.7%). The presence of a PFAB among hospitals was significantly associated with patient social needs screening, more areas addressed by programs, and more types of partners to address these needs. CONCLUSIONS: Community hospitals with a PFAB have more robust programs and partnerships to address patient social needs. PRACTICE IMPLICATIONS: Hospital leaders should consider going beyond simply establishing programs to address social needs but also consider comprehensiveness of these programs to recognize the intersectionality of social needs. One way to do this is to formally establish a PFAB to help hospitals better identify and prioritize the needs in local communities and design social needs programs/solutions that are patient- and family-centric.

Understanding Barriers to Guideline-Concordant Treatment in Foregut Cancer: From Data to Solutions.

BACKGROUND: A large proportion of patients with foregut cancers do not receive guideline-concordant treatment (GCT). This study sought to understand underlying barriers to GCT through a root cause analysis approach. METHODS: A single-institution retrospective review of 498 patients with foregut (gastric, pancreatic, and hepatobiliary) adenocarcinoma from 2018 to 2022 was performed. Guideline-concordant treatment was defined based on National Comprehensive Cancer Network guidelines. The Ishikawa cause and effect model was used to establish main contributing factors to non-GCT. RESULTS: Overall, 34% did not receive GCT. Root causes of non-GCT included Patient, Physician, Institutional Environment and Broader System-related factors. In decreasing order of frequency, the following contributed to non-GCT: receipt of incomplete therapy (N = 28, 16.5%), deconditioning on chemotherapy (N = 26, 15.3%), delays in care because of patient resource constraints followed by loss to follow-up (N = 19, 11.2%), physician factors (N = 19, 11.2%), no documentation of treatment plan after referral to oncologic expertise (N = 19, 11.2%), loss to follow-up before oncology referral (N = 17, 10%), nonreferral to medical oncologic expertise (N = 16, 9.4%), nonreferral to surgical oncology in patients with resectable disease (N = 15, 8.8%), and complications preventing completion of treatment (N = 11, 6.5%). Non-GCT often was a function of multiple intersecting patient, physician, and institutional factors. CONCLUSIONS: A substantial percentage of patients with foregut cancer do not receive GCT. Solutions that may improve receipt of GCT include development of automated systems to improve patient follow-up; institutional prioritization of resources to enhance staffing; financial counseling and assistance programs; and development and integration of structured prehabilitation programs into cancer treatment pathways.

Preoperative Education is Associated with Adherence to Downstream Components and Outcomes in a Colorectal Surgery Enhanced Recovery Program.

Objective: This study evaluated the association between preoperative education and adherence to downstream components of enhanced recovery programs (ERPs) and surgical outcomes among patients undergoing elective colorectal surgery. Background: ERPs improve outcomes for surgical patients. While preoperative education is an essential component of ERPs, its relationship with other components is unclear. Methods: This was a retrospective cohort study of all ERP patients undergoing elective colorectal surgery from 2019 to 2022. Our institutional ERP database was linked with American College of Surgeons National Surgical Quality Improvement Program data and stratified by adherence to preoperative education. Primary outcomes included adherence to individual ERP components and secondary outcomes included high-level ERP adherence (>70% of components), length of stay (LOS), readmissions, and 30-day complications. Results: A total of 997 patients were included. The mean (SD) age was 56.5 (15.8) years, 686 (57.3%) were female, and 717 (71.9%) were white. On adjusted analysis, patients who received preoperative education (n = 877, 88%) had higher adherence rates for the following ERP components: no prolonged fasting (estimate = +19.6%; P < 0.001), preoperative blocks (+8.0%; P = 0.02), preoperative multimodal analgesia (+18.0%; P < 0.001), early regular diet (+15.9%; P < 0.001), and postoperative multimodal analgesia (+6.4%; P < 0.001). High-level ERP adherence was 13.4% higher (P < 0.01) and LOS was 2.0 days shorter (P < 0.001) for those who received preoperative education. Classification and regression tree analysis identified preoperative education as the first-level predictor for adherence to early regular diet, the second-level predictor for LOS, and the third-level predictor for ERP high-level adherence. Conclusion: Preoperative education is associated with adherence to ERP components and improved surgical outcomes.

Patient Perspectives on a Decision Aid for Systemic Lupus Erythematosus: Insights and Future Considerations.

OBJECTIVE: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide spectrum of clinical manifestations. A decision aid (DA) for SLE was developed and implemented in 15 rheumatology clinics throughout the United States. This study explored the experiences of patients who viewed the DA to understand how patients engage with and respond to the SLE DA. METHODS: We conducted a qualitative descriptive study using semistructured interviews with a convenience sample of 24 patients during May to July 2022. RESULTS: Patients recognized the value of the SLE DA in providing general knowledge about SLE and different treatment options. However, patients expressed a desire for more comprehensive lifestyle information to better manage their condition. Another theme was the importance of having multiple formats available to cater to their different needs, as well as tailoring the DA to different stages of SLE. CONCLUSION: This study contributes to a broader understanding of how to provide patient-centered care for patients with SLE by offering practical insights that can inform the development of more effective, patient-centric health information technologies for managing chronic diseases, ultimately improving patient outcomes. Overall, this study underscores the significance of optimizing both the information content and determining the appropriate delivery of the tool for its future sustainability.

Assessing the Impact of Social Determinants of Health on HIV Care Engagement in the Southern United States: A Cross-Sectional Study.

Recent studies have shown social determinants of health (SDOH) to impact HIV care engagement. This cross-sectional study (Oct 20-Apr 21) assessed the impact of a range of SDOH on HIV care engagement using data from HIV Care Connect, a consortium of three HIV care facility-led programs (Alabama, Florida, Mississippi). The exposures were captured using the PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences) scale. The outcome was captured using the Index of Engagement in HIV Care scale. Participants (n = 132) were predominantly non-White (87%) and male (52%) with a median age of 41 years. Multivariable logistic regression adjusted for various sociodemographics showed lower HIV care engagement to be associated with being uninsured/publicly insured, having 1-3 unmet needs, socially integrating ≤five times/week, and having stable housing. Factors such as unmet needs, un-/underinsurance, and social integration may be addressed by healthcare and community organizations.

Assessing How Social Drivers of Health Affect Engagement in HIV Care in the Southern United StatesIt has been found that social factors that have a direct impact on health affect engagement in HIV Care among people living with HIV. We included various social drivers of health to see how they affect engagement in HIV Care. We used data between October 2020 and April 2021 from a project titled HIV Care Connect, which is a group of three facilities providing HIV care in Alabama, Florida, and Mississippi. We used social drivers of health as risk factors from a scale called PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences). Engagement in HIV care was measured by using a scale called Index of Engagement in HIV Care. A total of 132 participants were included. Majority of the participants were of races other than white (87%), male (52%) and were aged 41 years on average. Statistical analysis showed that participants without insurance or with public insurance, participants with 1-3 unsatisfied needs, participants that met with other people less than or equal to five times a week, and participants that had reliable housing had lower engagement in HIV care. These factors have a potential to be addressed by healthcare and community organizations.

Examining Knowledge Management and the Culture Change Movement in Long-Term Care: A Study of High-Medicaid-Census Nursing Homes.

High-quality nursing home (NH) care has long been a challenge within the United States. For decades, policymakers at the state and federal levels have adopted and implemented regulations to target critical components of NH care outcomes. Simultaneously, our delivery system continues to change the role of NHs in patient care. For example, more acute patients are cared for in NHs, and the Center for Medicare and Medicaid Services (CMS) has implemented value payment programs targeting NH settings. As a part of these growing pressures from the broader healthcare delivery system, the culture-change movement has emerged among NHs over the past two decades, prompting NHs to embody more person-centered care as well as promote settings which resemble someone's home, as opposed to institutionalized healthcare settings. Researchers have linked culture change to high-quality outcomes and the ability to adapt and respond to the ever-changing pressures brought on by changes in our regulatory and delivery system. Making enduring culture change within organizations has long been a challenge and focus in NHs. Despite research suggesting that culture-change initiatives that promote greater resident-centered care are associated with several desirable patient outcomes, their adoption and implementation by NHs are resource intensive, and research has shown that NHs with high percentages of low-income residents are especially challenged to adopt these initiatives. This chapter takes a novel approach to examine factors that impact the adoption of culture-change initiatives by assessing knowledge management and the role of knowledge management activities in promoting the adoption of innovative care delivery models among under-resourced NHs throughout the United States. Using primary data from a survey of NH administrators, we conducted logistic regression models to assess the relationship between knowledge management and the adoption of a culture-change initiative as well as whether these relationships were moderated by leadership and staffing stability. Our study found that NHs were more likely to adopt a culture-change initiative when they had more robust knowledge management activities. Moreover, knowledge management activities were particularly effective at promoting adoption in NHs that struggle with leadership and nursing staff instability. Our findings support the notion that knowledge management activities can help NHs acquire and mobilize informational resources to support the adoption of care delivery innovations, thus highlighting opportunities to more effectively target efforts to stimulate the adoption and spread of these initiatives.

Time Kills: Impact of Socioeconomic Deprivation on Timely Access to Guideline-Concordant Treatment in Foregut Cancer.

BACKGROUND: Receipt of guideline-concordant treatment (GCT) is associated with improved prognosis in foregut cancers. Studies show that patients living in areas of high neighborhood deprivation have worse healthcare outcomes; however, its effect on GCT in foregut cancers has not been evaluated. We studied the impact of the area deprivation index (ADI) as a barrier to GCT. STUDY DESIGN: A single-institution retrospective review of 498 foregut cancer patients (gastric, pancreatic, and hepatobiliary adenocarcinoma) from 2018 to 2022 was performed. GCT was defined based on National Comprehensive Cancer Network guidelines. ADI, a validated measure of neighborhood disadvantage was divided into terciles (low, medium, and high) with high ADI indicating the most disadvantage. RESULTS: Of 498 patients, 328 (66%) received GCT: 66%, 72%, and 59% in pancreatic, gastric, and hepatobiliary cancers, respectively. Median (interquartile range) time from symptoms to workup was 6 (3 to 13) weeks, from diagnosis to oncology appointment was 4 (1 to 10) weeks, and from oncology appointment to treatment was 4 (2 to 10) weeks. Forty-six percent were diagnosed in the emergency department. On multivariable analyses, age 75 years or older (odds ratio [OR] 0.39 [95% CI 0.18 to 0.87]), Black race (OR 0.52 [95% CI 0.31 to 0.86]), high ADI (OR 0.25 (95% CI 0.14 to 0.48]), 6 weeks or more from symptoms to workup (OR 0.44 [95% CI 0.27 to 0.73]), 4 weeks or more from diagnosis to oncology appointment (OR 0.76 [95% CI 0.46 to 0.93]), and 4 weeks or more from oncology appointment to treatment (OR 0.63 [95% CI 0.36 to 0.98]) were independently associated with nonreceipt of GCT. CONCLUSIONS: Residence in an area of high deprivation predicts nonreceipt of GCT. This is due to multiple individual- and system-level barriers. Identifying these barriers and developing effective interventions, including community outreach and collaboration, leveraging telehealth, and increasing oncologic expertise in underserved areas, may improve access to GCT.

Does Interdisciplinary Care Team Care Management Improve Health Quality and Demonstrate Cost-Effectiveness?

This study evaluated the impact of an interdisciplinary care teams (IDCT) care management program on cost and quality outcomes using a novel algorithm to identify 400 high-risk patients out of 48,235 Medicare Advantage (MA) beneficiaries. Of the 400, 252 were enrolled in the IDCT care management intervention program, while the remaining 148 were not enrolled. A second comparison group consisted of 660 who were referred to the IDCT program but not selected by the algorithm. The program's effectiveness was evaluated 1-year postintervention. Analyses found that health care costs for members enrolled in the IDCT program were reduced by US$1,121.76 and US$1,625.61 per member per month, respectively, relative to those not enrolled and those enrolled by referral. The cost reduction from the program generated a net savings of US$1.9MM, covering the program's cost. Findings suggest IDCTs can cost-effectively manage populations of high-risk patients with better selection and fostering greater interdependence.

Association between Rural Residence and Processes of Care in Pancreatic Cancer Treatment.

BACKGROUND: Pancreatic adenocarcinoma (PDAC) is an aggressive malignancy associated with poor outcomes. Surgical resection and receipt of multimodal therapy have been shown to improve outcomes in patients with potentially resectable PDAC; however treatment and outcome disparities persist on many fronts. The aim of this study was to analyze the relationship between rural residence and receipt of quality cancer care in patients diagnosed with non-metastatic PDAC. METHODS: Using the National Cancer Database, patients with non-metastatic pancreatic cancer were identified from 2006-2016. Patients were classified as living in metropolitan, urban, or rural areas. Multivariable logistic regression was used to identify predictors of cancer treatment and survival. RESULTS: A total of 41,786 patients were identified: 81.6% metropolitan, 16.2% urban, and 2.2% rural. Rural residing patients were less likely to receive curative-intent surgery (p = 0.037) and multimodal therapy (p < 0.001) compared to their metropolitan and urban counterparts. On logistic regression analysis, rural residence was independently associated with decreased surgical resection [OR 0.82; CI 95% 0.69-0.99; p = 0.039] and multimodal therapy [OR 0.70; CI 95% 0.38-0.97; p = 0.047]. Rural residence independently predicted decreased overall survival [OR 1.64; CI 95% 1.45-1.93; p < 0.001] for all patients that were analyzed. In the cohort of patients who underwent surgical resection, rural residence did not independently predict overall survival [OR 0.97; CI 95% 0.85-1.11; p = 0.652]. CONCLUSIONS: Rural residence impacts receipt of optimal cancer care in patients with non-metastatic PDAC but does not predict overall survival in patients who receive curative-intent treatment.

Patterns and trends in local health departments' efforts to promote access to care in local communities throughout the United States: The contributions of governance structures.

Public health agencies like local health departments (LHDs) play an important role in addressing healthcare access disparities and service delivery gaps in local communities throughout the United States. Previous research has provided important snapshots into specific access issues confronted by LHDs; however, the literature lacks a more comprehensive view of LHDs' efforts to ensure broad access to care, how these have evolved over time more recently, and whether certain types of LHDs governance structures are more likely to engage in activities to ensure access to care. The purpose of this study was to address these gaps in the literature by exploring the prevalence of different activities to ensure access to care, describing how the prevalence of these activities have evolved over time, and examining whether the prevalence of these activities varied as a function of different governance structures. Using pooled, cross-sectional survey data from four waves of a survey (2009, 2013, 2016, 2019) of LHDs in the United States, the univariate and bivariate analysis revealed that, over time, LHDs have generally increased their efforts to assess gaps in access to healthcare services and across all healthcare categories (i.e., medical, dental, behavioural health) but especially for behavioural health. Poisson regression models showed that LHDs with a more decentralised decision-making structure were associated with more activities to ensure access to care, as compared to more centralised structures. Collectively, our findings indicate that despite growth in the number and percentage of LHDs assessing and addressing gaps in services, opportunities still exist to enhance access to healthcare services in local communities, particularly in the areas of dental and behavioural health. Our findings also suggest that stakeholders interested in improving LHDs' efforts to ensure access to care in local communities may want to pay close attention to governance features of LHDs.

Assessing the Impact of Interorganizational Linkages on Medical Home Model Adoption by U.S. Acute Care Hospitals.

The medical home model aims to increase care coordination and health care quality. While the adoption of the model has been increasing, the role of U.S. acute care hospitals' interorganizational linkages on adoption is yet to be explored. Using a national sample of hospitals throughout the United States, we examined what interorganizational linkage features are associated with medical home adoption of hospital-owned physician practices and assess the pattern of adoption by acute care hospitals between 2011 and 2019. A generalized estimating equation with binomial distribution was utilized to assess the association between interorganizational linkages and medical home adoption. Hospitals with structural linkages and institutional linkages were more likely to have adopted the medical home. Moreover, the likelihood of medical home adoption increased relative to an increasing number of interorganizational linkages. Medical home adoption and dissemination efforts may be more effective when focused on hospitals possessing interorganizational linkages, specifically those with structural linkages.