Diabetes-Focused Health Care Utilization Among Adolescents and Young Adults With Type 1 Diabetes.

OBJECTIVE: To describe the current rates of health services use with various types of providers among adolescents and young adults (AYA) with type 1 diabetes (T1D) and evaluate which patient factors are associated with rates of service use from different provider types. METHODS: Using 2012-16 claims data from a national commercial insurer, we identified 18,927 person-years of AYA with T1D aged 13 to 26 years and evaluated the frequency at which: 1) AYA skipped diabetes care for a year despite being insured; 2) received care from pediatric or non-pediatric generalists or endocrinologists if care was sought; and 3) received annual hemoglobin A1c (HbA1c) testing as recommended for AYA. We used descriptive statistics and multivariable regression to examine patient, insurance, and physician characteristics associated with utilization and quality outcomes. RESULTS: Between ages 13 and 26, the percentage of AYA with: any diabetes-focused visits declined from 95.3% to 90.3%; the mean annual number of diabetes-focused visits, if any, decreased from 3.5 to 3.0; receipt of ≥2 HbA1c tests annually decreased from 82.3% to 60.6%. Endocrinologists were the majority providers of diabetes care across ages, yet the relative proportion of AYA whose diabetes care was endocrinologist-dominated decreased from 67.3% to 52.7% while diabetes care dominated by primary care providers increased from 19.9% to 38.2%. The strongest predictors of diabetes care utilization were younger age and use of diabetes technology (pumps and continuous glucose monitors). CONCLUSIONS: Several provider types are involved in the care of AYA with T1D, though predominate provider type and care quality changes substantially across age in a commercially-insured population.

Impairment Types and Combinations Among Adolescents and Young Adults with Disabilities: Colorado 2014-2018.

OBJECTIVE: Understanding the types of functional challenges faced by adolescents and young adults with disabilities (AYA-WD) can help payers, clinicians, community-based service providers, and policymakers recognize and meet needs. This paper describes state-level prevalence rates for 1) AYA-WD overall and for 2) impairment types singly and in combinations; and 3) examines how rates may differ between those insured by Medicaid versus commercial insurance. METHODS: This descriptive study uses Colorado's All Payer Claims Dataset 2014-2018 to identify insured 10- to 26-year-olds (Medicaid only: 333,931; commercially only: 392,444). It then applies the previously validated Children with Disabilities Algorithm (CWDA) and its companion, the Diagnosis-to-Impairment-Type Algorithm (DITA), to compare state-level prevalence rates by insurance source for disability overall and for each of five impairment types singly and in combination. RESULTS: Disability prevalence was greater among the Medicaid-insured AYA-WD by +7.6% points (pp)-Medicaid: 11.9% (47,654/333,931), commercial: 4.3% (16,907/392,444). Most AYA-WD had a single impairment, but the prevalence of AYA-WD with two or more impairments was greater among the Medicaid-insured than the commercially insured (+9.9 pp; Medicaid: 33.5% [15,963/47,654], commercial: 23.7% [3992/16, 907]), as was the prevalence of impairment types that were physical (+6.7 pp; Medicaid: 54.7% [26,054/47,654], commercial: 48.0% [8121/16,907]); developmental (+4.1 pp; Medicaid: 35.4% [16,874/47,654], commercial: 31.3% [5290/16,907]); psychiatric (+6.7 pp; Medicaid 21.3% [10,175/47,654], commercial: 14.6% [2470/16,907]), and intellectual (+9.3 pp; Medicaid: 26.2% [12,501/47,654], commercial: 16.9% [2858/16,907]). CONCLUSIONS: CWDA and DITA can be used to understand the rates at which impairment types and combinations occur in a population with childhood-onset disabilities.

Enabling System Functionalities of Primary Care Practices for Team Dynamics in Transformation to Team-Based Care: A Qualitative Comparative Analysis (QCA).

Team-based primary care has been shown to be an important initiative for transforming primary care to achieve whole-person care, enhance health equity, and reduce provider burnout. Organizational approaches have been explored to better implement team-based care but a thorough understanding of the role of system functions is lacking. We aimed to identify the combinations of system functionalities in primary care practices that most enable effective teamwork. We used a novel method, qualitative comparative analysis (QCA), to identify cross-case patterns in 19 primary care practices in the Harvard Academic Innovations Collaborative (AIC), an initiative for transforming primary care practices by establishing teams and implementing team-based care. QCA findings identified that primary care practices with strong team dynamics exhibited strengths in three operational care process functionalities, including management of abnormal test results, cancer screening and medication management for high-priority patients, care transitions, and in health information technology (HIT) functionality. HIT functionality alone was not sufficient to achieve the desired outcomes. System functionalities in a primary care practice that support physicians and their teams in identifying patients with urgent and complex acute illnesses requiring immediate response and care and overcoming barriers to collaboration within and across institutional settings, may be essential for sustaining strong team-based primary care.

Specialist use among privately insured children with disabilities.

OBJECTIVE: To investigate primary care practice ownership and specialist-use patterns for commercially insured children with disabilities. DATA SOURCES AND STUDY SETTING: A national commercial claims database and the Health Systems and Provider Database from 2012 to 2016 are the data sources for this study. STUDY DESIGN: This cross-sectional, descriptive study examines: (1) the most visited type of pediatric primary care physician and practice (independent or system-owned); (2) pediatric and non-pediatric specialist-use patterns; and (3) how practice ownership relates to specialist-use patterns. DATA COLLECTION/EXTRACTION METHODS: This study identifies 133,749 person-years of commercially insured children with disabilities aged 0-18 years with at least 24 months of continuous insurance coverage by linking a national commercial claims data set with the Health Systems and Provider Database and applying the validated Children with Disabilities Algorithm. PRINCIPAL FINDINGS: Three-quarters (75.9%) of children with disabilities received their pediatric primary care in independent practices. Nearly two thirds (59.6%) used at least one specialist with 45.1% using nonpediatric specialists, 28.8% using pediatric ones, and 17.0% using both. Specialist-use patterns varied by both child age and specialist type. Children with disabilities in independent practices were as likely to see a specialist as those in system-owned ones: 57.1% (95% confidence interval [95% CI] 56.7%-57.4%) versus 57.3% (95% CI 56.6%-58.0%), respectively (p = 0.635). The percent using two or more types of specialists was 46.1% (95% CI 45.4%-46.7%) in independent practices, comparable to that in systems 47.1% (95% CI 46.2%-48.0%) (p = 0.054). However, the mean number of specialist visits was significantly lower in independent practices than in systems-4.0 (95% CI 3.9%-4.0%) versus 4.4 (95% CI 4.3%-4.6%) respectively-reaching statistical significance with p < 0.0001. CONCLUSIONS: Recognizing how privately insured children with disabilities use pediatric primary care from pediatric and nonpediatric primary care specialists through both independent and system-owned practices is important for improving care quality and value.

Value-Based Purchasing Design And Effect: A Systematic Review And Analysis.

During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.

Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population: A Randomized Clinical Trial.

Importance: Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes. Objective: To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality. Design, Setting, and Participants: This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021. Interventions: Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group. Main Outcomes and Measures: There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery. Results: Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups. Conclusions and Relevance: In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03360539.

Exploring system features of primary care practices that promote better providers' clinical work satisfaction: A qualitative comparative analysis.

BACKGROUND: Health care delivery system features can have a profound effect on how frontline physicians and other clinical personnel in primary care practices (primary care providers [PCPs]) view the quality and safety of what they deliver and, ultimately, their clinical work satisfaction. PURPOSE: The aim of this study was to investigate the combinations of system features (i.e., team dynamics, provider-perceived safety culture, and patient care coordination between PCPs) that are most conducive to positively enhancing PCPs' clinical work satisfaction. APPROACH: Nineteen Harvard-affiliated primary care practice sites participated in the Academic Innovations Collaborative 2012-2016, which aimed to establish team-based care and improve patient safety. An All-Staff Survey was administered to 854 PCPs in 2015. The survey measured provider experience of team dynamics, provider-perceived safety culture, patient care coordination between PCPs, and providers' clinical work satisfaction. We performed a qualitative comparative analysis to identify "recipes," that is, combinations of conditions necessary and sufficient for enhancing PCPs' clinical work satisfaction. RESULTS: Strong provider-perceived safety culture and effective team dynamics constitute sufficient conditions that, when present in practices, could best support PCPs to achieve greater clinical work satisfaction. CONCLUSIONS: Our findings suggest the importance of creating and sustaining a strong safety culture and of establishing and implementing highly functioning teams in primary care practices for enhancing PCPs' clinical work satisfaction. PRACTICE IMPLICATIONS: Conducting the qualitative comparative analysis provides a new perspective for informing primary care and encouraging primary care practices to pursue strategic priorities for enhancing PCPs' clinical work satisfaction and providing safe, high-quality care.

Difficulty Obtaining Behavioral Health Services for Children: A National Survey of Multiphysician Practices.

PURPOSE: In the United States, primary care practices rely on scarce resources to deliver evidence-based care for children with behavioral health disorders such as depression, anxiety, other mental illness, or substance use disorders. We estimated the proportion of practices that have difficulty accessing these resources and whether practices owned by a health system or participating in Medicaid accountable care organizations (ACOs) report less difficulty. METHODS: This national cross-sectional study examined how difficult it is for practices to obtain pediatric (1) medication advice, (2) evidence-based psychotherapy, and (3) family-based therapy. We used the National Survey of Healthcare Organizations and Systems 2017-2018 (46.9% response rate), which sampled multiphysician primary and multispecialty care practices including 1,410 practices that care for children. We characterized practices' experience as "difficult" relative to "not at all difficult" using a 4-point ordinal scale. We used mixed-effects generalized linear models to estimate differences comparing system-owned vs independent practices and Medicaid ACO participants vs nonparticipants, adjusting for practice attributes. RESULTS: More than 85% of practices found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. Adjusting for practice attributes, the percent experiencing difficulty was similar between system-owned and independent practices but was less for Medicaid ACO participants for medication advice (81% vs 89%; P = .021) and evidence-based psychotherapy (81% vs 90%; P = .006); differences were not significant for family-based treatment (85% vs 91%; P = .107). CONCLUSIONS: Most multiphysician practices struggle to obtain advice and services for child behavioral health needs, which are increasing nationally. Future studies should investigate the source of observed associations.

Increases in Inpatient Psychiatry Beds Operated by Systems, For-Profits, and Chains, 2010-2016.

OBJECTIVE: This study explored trends in the quantity of inpatient psychiatry beds and in facility characteristics. METHODS: Using the National Bureau of Economic Research's Health Systems and Provider Database, the authors examined changes in the number of psychiatric facilities and beds, focusing on system ownership, profit status, facility type (general acute care versus freestanding), and affiliation with psychiatric hospital chains from 2010 to 2016. RESULTS: The number of psychiatric beds was relatively unchanged from 2010 (N=112,182 beds) to 2016 (N=111,184). However, the number of beds operated by systems increased by 39.8% (N=15,803); for-profits, by 56.9% (N=8,572); and chains, by 16.7% (N=6,256). Net increases in beds were primarily concentrated in for-profit freestanding psychiatric hospitals. In 2016, most for-profit beds were part of chains (70.2%) and systems (61.3%). CONCLUSIONS: Inpatient psychiatry has shifted toward increased ownership by systems, for-profits, and chains. Payers and policy makers should safeguard against profiteering, and future research should investigate the implications of these trends on quality of care.

Patterns of Use of a Price Transparency Tool for Childbirth Among Pregnant Individuals With Commercial Insurance.

Importance: When introduced a decade ago, patient-facing price transparency tools had low use rates and were largely not associated with changes in spending. Little is known about how such tools are used by pregnant individuals in anticipation of childbirth, a shoppable service with increasing out-of-pocket spending. Objective: To measure changes over time in the patterns and characteristics of use of a price transparency tool by pregnant individuals, and to identify the association between price transparency tool use, coinsurance, and childbirth spending. Design, Setting, and Participants: This descriptive cross-sectional study of 2 cohorts used data from a US commercial health insurance company that launched a web-based price transparency tool in 2010. Data on all price transparency tool queries for 2 periods (January 1, 2011, to December 31, 2012, and January 1, 2015, to December 31, 2016) were obtained. The sample included enrollees aged 19 to 45 years who had a delivery episode during 2 periods (November 1, 2011, to December 31, 2012, or November 1, 2015, to December 31, 2016) and were continuously enrolled for the 10 months prior to delivery (N = 253 606). Exposures: Access to a web-based price transparency tool that provided individualized out-of-pocket price estimates for vaginal and cesarean deliveries. Main Outcomes and Measures: The primary outcomes were searches on the price transparency tool by delivery mode (vaginal or cesarean), timing (first, second, or third trimester), and individual characteristics (age at childbirth, rurality, pregnancy risk status, coinsurance exposure, area educational attainment, and area median household income). Another outcome was the association of out-of-pocket childbirth spending with price transparency tool use. Results: The sample included 253 606 pregnant individuals, of whom 131 224 (51.7%) were in the 2011 to 2012 cohort and 122 382 (48.3%) were in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, the mean (SD) age was 31 years (5.2 years) and most individuals had coinsurance for delivery (94 251 [77.0%]). Price searching increased from 5.9% in the 2011 to 2012 cohort to 13.0% in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, 43.9% of searchers' first price query was in their first trimester. The adjusted probability of searching was lower for individuals with a high-risk pregnancy due to a previous cesarean delivery (11.5%; 95% CI, 11.0%-12.1%) vs individuals with low-risk pregnancy (13.4%; 95% CI, 12.9%-14.0%). Use increased monotonically with coinsurance, from 9.2% (95% CI, 8.7%-9.8%) among individuals with no coinsurance to 15.0% (95% CI, 14.4%-15.5%) among individuals with 11% or higher coinsurance. After adjusting for covariates, searching was positively associated with out-of-pocket delivery episode spending. Among patients with 11% coinsurance or higher, early and late searchers spent more out of pocket ($59.57 [95% CI, $33.44-$85.96] and $73.33 [95% CI, $32.04-$115.29], respectively), compared with never searchers. Conclusions and Relevance: The results of this cross-sectional study indicate that the proportion of pregnant individuals who sought price information before childbirth more than doubled within the first 6 years of availability of a price transparency tool. These findings suggest that price information may help individuals anticipate their out-of-pocket childbirth costs.

Availability of Pediatric Inpatient Services in the United States.

OBJECTIVES: We sought to evaluate trends in pediatric inpatient unit capacity and access and to measure pediatric inpatient unit closures across the United States. METHODS: We performed a retrospective study of 4720 US hospitals using the 2008-2018 American Hospital Association survey. We used linear regression to describe trends in pediatric inpatient unit and PICU capacity. We compared trends in pediatric inpatient days and bed counts by state. We examined changes in access to care by calculating distance to the nearest pediatric inpatient services by census block group. We analyzed hospital characteristics associated with pediatric inpatient unit closure in a survival model. RESULTS: Pediatric inpatient units decreased by 19.1% (34 units per year; 95% confidence interval [CI] 31 to 37), and pediatric inpatient unit beds decreased by 11.8% (407 beds per year; 95% CI 347 to 468). PICU beds increased by 16.0% (66.9 beds per year; 95% CI 53 to 81), primarily at children's hospitals. Rural areas experienced steeper proportional declines in pediatric inpatient unit beds (-26.1% vs -10.0%). Most states experienced decreases in both pediatric inpatient unit beds (median state -18.5%) and pediatric inpatient days (median state -10.0%). Nearly one-quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit. Low-volume pediatric units and those without an associated PICU were at highest risk of closing. CONCLUSIONS: Pediatric inpatient unit capacity is decreasing in the United States. Access to inpatient care is declining for many children, particularly those in rural areas. PICU beds are increasing, primarily at large children's hospitals. Policy and surge planning improvements may be needed to mitigate the effects of these changes.

Pediatric Primary Care-Based Social Needs Services and Health Care Utilization.

OBJECTIVE: To evaluate the relationship between use of primary care-based social needs services and subsequent utilization of ambulatory, emergency, and inpatient services. METHODS: This retrospective 2012 to 2015 cohort study uses electronic medical record data from an academic pediatric primary care practice that screens universally for social needs and delivers services via in-house social work staff. Logistic regression (N = 7300) examines how patient characteristics relate to practice-based social service use. Negative binomial models with inverse probability of treatment weights (N = 4893) estimate adjusted incidence rate ratios for ambulatory, emergency, and inpatient service use among those who used social services compared to those who did not. RESULTS: Forty-five percent of patients used primary care-based social needs services. This use was significantly greater among those with disabling or complex medical conditions than those without (adjusted odds ratio and 95% confidence interval (CI) of 9.81 [7.39-13.01] and 2.76 [2.44-3.13], respectively); those from low-income versus high-income backgrounds (1.40 [1.21-1.61]); and Blacks and Latinos than Whites (1.33 [1.09-1.62] and 1.29 [1.05-1.59], respectively). Patients who used social services subsequently utilized ambulatory, emergency, and inpatient services at significantly higher rates than those who did not (adjusted incidence rate ratios and 95% CI of 1.54 [1.45-1.63], 1.50 [1.36-1.65], and 3.23 [2.31-4.51], respectively). CONCLUSIONS: Primary care-based social needs service use was associated with increased utilization of ambulatory services without reductions in emergency or inpatient admissions. This pattern suggests increased health care needs or access and could have payment model-dependent financial implications for practices.

Protocol for a randomized controlled trial evaluating the impact of the Nurse-Family Partnership's home visiting program in South Carolina on maternal and child health outcomes.

BACKGROUND: Policy-makers are increasingly seeking rigorous evidence on the impact of programs that go beyond typical health care settings to improve outcomes for low-income families during the critical period around the transition to parenthood and through early childhood. METHODS: This study is a randomized controlled trial evaluating the impact of the Nurse-Family Partnership's expansion in South Carolina. The scientific trial was made possible by a "Pay for Success" program embedded within a 1915(b) Waiver from Medicaid secured by the South Carolina Department of Health and Human Services. This protocol describes study procedures and defines primary and secondary health-related outcomes that can be observed during the intervention period (including pregnancy through the child's first 2 years of life). Primary study outcomes include (1) a composite indicator for adverse birth outcomes including being born small for gestational age, low birth weight (less than 2500 g), preterm birth (less than 37 weeks' gestation), or perinatal mortality (fetal death at or after 20 weeks of gestation or mortality in the first 7 days of life), (2) a composite outcome indicating health care utilization or mortality associated with major injury or concern for abuse or neglect occurring during the child's first 24 months of life, and (3) an indicator for an inter-birth interval of < 21 months. Secondary outcomes are defined similarly in three domains: (1) improving pregnancy and birth outcomes, (2) improving child health and development, and (3) altering the maternal life course through changes in family planning. DISCUSSION: Evidence from this trial on the impact of home visiting services delivered at scale as part of a Medicaid benefit can provide policy-makers and stakeholders with crucial information about the effectiveness of home visiting programs in improving health and well-being for low-income mothers and children and about novel financing mechanisms for cross-silo interventions. TRIAL REGISTRATION: The trial was registered prospectively on the American Economic Association Trial Registry (the primary registry for academic economists doing policy trials) on 16 February 2016 ( AEARCTR-0001039 ). ClinicalTrials.gov NCT03360539 . Registered on 28 November 2017.

Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates.

Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices' successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

Women's Coverage, Utilization, Affordability, And Health After The ACA: A Review Of The Literature.

Women of working age (ages 19-64) faced specific challenges in obtaining health insurance coverage and health care before the Affordable Care Act. Multiple factors contributed to women's experiencing uninsurance, underinsurance, and increased financial burdens related to obtaining health care. This literature review summarizes evidence on the law's effects on women's health care and health and finds improvements in overall coverage, access to health care, affordability, preventive care use, mental health care, use of contraceptives, and perinatal outcomes. Despite major progress after the Affordable Care Act's implementation, barriers to coverage, access, and affordability remain, and serious threats to women's health still exist. Highlighting the law's effects on women's health is critical for informing future policies directed toward the continuing improvement of women's health care and health.

Suitability of elderly adult hospital readmission rates for profiling readmissions in younger adult and pediatric populations.

OBJECTIVE: To determine the correlation between hospital 30-day risk-standardized readmission rates (RSRRs) in elderly adults and those in nonelderly adults and children. DATA SOURCES/STUDY SETTING: US hospitals (n = 1760 hospitals admitting adult patients and 235 hospitals admitting both adult and pediatric patients) in the 2013-2014 Nationwide Readmissions Database. STUDY DESIGN: Cross-sectional analysis comparing 30-day RSRRs for elderly adult (≥65 years), middle-aged adult (40-64 years), young adult (18-39 years), and pediatric (1-17 years) patients. PRINCIPAL FINDINGS: Hospital elderly adult RSRRs were strongly correlated with middle-aged adult RSRRs (Pearson R2 .69 [95% confidence interval (CI) 0.66-0.71]), moderately correlated with young adult RSRRs (Pearson R2 .44 [95% CI 0.40-0.47]), and weakly correlated with pediatric RSRRs (Pearson R2 .28 [95% CI 0.17-0.38]). Nearly identical findings were observed with measures of interquartile agreement and Kappa statistics. This stepwise relationship between age and strength of correlation was consistent across every hospital characteristic. CONCLUSIONS: Hospital readmission rates in elderly adults, which are currently used for public reporting and hospital comparisons, may reflect broader hospital readmission performance in middle-aged and young adult populations; however, they are not reflective of hospital performance in pediatric populations.

Physician and facility drivers of spending variation in locoregional prostate cancer.

BACKGROUND: Prostate cancer is the most common male cancer, with a wide range of treatment options. Payment reform to reduce unnecessary spending variation is an important strategy for reducing waste, but its magnitude and drivers within prostate cancer are unknown. METHODS: In total, 38,971 men aged ≥66 years with localized prostate cancer who were enrolled in Medicare fee-for-service and were included in the Surveillance, Epidemiology, and End Results-Medicare database from 2009 to 2014 were included. Multilevel linear regression with physician and facility random effects was used to examine the contributions of urologists, radiation oncologists, and their affiliated facilities to variation in total patient spending in the year after diagnosis within geographic region. The authors assessed whether spending variation was driven by patient characteristics, disease risk, or treatments. Physicians and facilities were sorted into quintiles of adjusted patient-level spending, and differences between those that were high-spending and low-spending were examined. RESULTS: Substantial variation in spending was driven by physician and facility factors. Differences in cancer treatment modalities drove more variation across physicians than differences in patient and disease characteristics (72% vs 2% for urologists, 20% vs 18% for radiation oncologists). The highest spending physicians spent 46% more than the lowest and had more imaging tests, inpatient care, and radiotherapy spending. There were no differences across spending quintiles in the use of robotic surgery by urologists or the use of brachytherapy by radiation oncologists. CONCLUSIONS: Significant differences were observed for patients with similar demographics and disease characteristics. This variation across both physicians and facilities suggests that efforts to reduce unnecessary spending must address decision making at both levels.