Is the QCI framework suited for monitoring outcomes and costs in a teaching hospital using value-based healthcare principles? A retrospective cohort study.

OBJECTIVES: The objective is to develop a pragmatic framework, based on value-based healthcare principles, to monitor health outcomes per unit costs on an institutional level. Subsequently, we investigated the association between health outcomes and healthcare utilisation costs. DESIGN: This is a retrospective cohort study. SETTING: A teaching hospital in Rotterdam, The Netherlands. PARTICIPANTS: The study was performed in two use cases. The bariatric population contained 856 patients of which 639 were diagnosed with morbid obesity body mass index (BMI) <45 and 217 were diagnosed with morbid obesity BMI ≥45. The breast cancer population contained 663 patients of which 455 received a lumpectomy and 208 a mastectomy. PRIMARY AND SECONDARY OUTCOME MEASURES: The quality cost indicator (QCI) was the primary measures and was defined asQCI = (resulting outcome * 100)/average total costs (per thousand Euros)where average total costs entail all healthcare utilisation costs with regard to the treatment of the primary diagnosis and follow-up care. Resulting outcome is the number of patients achieving textbook outcome (passing all health outcome indicators) divided by the total number of patients included in the care path. RESULTS: The breast cancer and bariatric population had the highest resulting outcome values in 2020 Q4, 0.93 and 0.73, respectively. The average total costs of the bariatric population remained stable (avg, €8833.55, min €8494.32, max €9164.26). The breast cancer population showed higher variance in costs (avg, €12 735.31 min €12 188.83, max €13 695.58). QCI values of both populations showed similar variance (0.3 and 0.8). Failing health outcome indicators was significantly related to higher hospital-based costs of care in both populations (p <0.01). CONCLUSIONS: The QCI framework is effective for monitoring changes in average total costs and relevant health outcomes on an institutional level. Health outcomes are associated with hospital-based costs of care.

Hospitalization cost of Pressurized Intraperitoneal Aerosol chemotherapy (PIPAC).

INTRODUCTION: Pressurized Intraperitoneal Aerosol chemotherapy (PIPAC) is a new surgical technique for the treatment of unresectable peritoneal carcinomatosis. Very little data is available on the costs of this treatment in France as there is currently no code for PIPAC in the French Common Classification of Medical Acts (CCAM). Our objective was to estimate the mean cost of hospitalization for PIPAC in two French public teaching hospitals. METHODS: The mean cost of hospitalization was estimated from the mean fixed-rate remuneration paid to the hospital and the mean additional costs of treatment paid by the hospital. At discharge a patient's hospitalization is classified into a diagnosis related group, which determines the fixed-rate remuneration paid to the hospital (obtained from the national hospitals database - PMSI). Costs of medical devices and drug treatments specific to PIPAC, not covered by the fixed-rate remuneration, were obtained from the hospital pharmacies. RESULTS: Between July 2016 and November 2021, 205 PIPAC procedures were performed on 79 patients (mean procedures per patient = 2.6). Mean operating room occupancy was 165 min. The mean fixed-rate remuneration received by the hospitals per PIPAC hospitalization was €4031. The actual mean cost per hospitalization was €6562 for a mean length-of-stay of 3.3 days. Thus, each PIPAC hospitalization cost the hospital €2531 on average. CONCLUSION: The current reimbursement of PIPAC treatment by the national health system is insufficient and represents only 61% of the real cost. The creation of a new fixed-rate remuneration for PIPAC taking into account this cost differential is necessary.

Cost Differences Between Teaching and Nonteaching Hospitals for Older Adults Requiring Emergency General Surgery Procedures in the State of Maryland.

BACKGROUND: Older adults (OAs; ≥ 65 years) comprise a growing population in the United States and are anticipated to require an increasing number of emergency general surgery procedures (EGSPs). The aims of this study were to identify the frequency of EGSPs and compare cost of care in OAs managed at teaching hospitals (THs) vs nonteaching hospitals (NTHs). METHODS: A retrospective review of data from the Maryland Health Services Cost Review Commission database from 2009 to 2018 for OAs undergoing EGSPs was undertaken. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index (CCI), EGSPs (partial colectomy (PC), small bowel resection, cholecystectomy, operative management of peptic ulcers, lysis of adhesions, appendectomy, and laparotomy, categorized hospital charges, length of stay (LOS), and mortality. RESULTS: Of the 55,401 OAs undergoing EGSPs in this study, 28,575 (51.6%) were treated at THs and 26,826 (48.4%) at NTHs. OAs at THs presented with greater APR-ROM (major 25.6% vs 24.9%, extreme 22.6% vs 22.0%, P=.01), and CCI (3.1±3 vs 2.7±2.8, P<.001) compared to NTHs. Lysis of adhesions, cholecystectomy, and PC comprised the overall most common EGSPs. Older adults at THs incurred comparatively higher median hospital charges for every EGSP due to increased room charges and LOS. Mortality was higher at THs (6.13% vs 5.33%, P<.001). CONCLUSION: While acuity of illness appears similar, cost of undergoing EGSPs for OAs is higher in THs vs NTHs due to increased LOS. Future work is warranted to determine and mitigate factors that increase LOS at THs.

Cost-effectiveness analysis of an active 30-day surgical site infection surveillance at a tertiary hospital in Ghana: evidence from HAI-Ghana study.

OBJECTIVE: To assess the cost-effectiveness of an active 30-day surgical site infection (SSI) surveillance mechanism at a referral teaching hospital in Ghana using data from healthcare-associated infection Ghana (HAI-Ghana) study. DESIGN: Before and during intervention study using economic evaluation model to assess the cost-effectiveness of an active 30-day SSI surveillance at a teaching hospital. The intervention involves daily inspection of surgical wound area for 30-day postsurgery with quarterly feedback provided to surgeons. Discharged patients were followed up by phone call on postoperative days 3, 15 and 30 using a recommended surgical wound healing postdischarge questionnaire. SETTING: Korle-Bu Teaching Hospital (KBTH), Ghana. PARTICIPANTS: All prospective patients who underwent surgical procedures at the general surgical unit of the KBTH. MAIN OUTCOME MEASURES: The primary outcome measures were the avoidable SSI morbidity risk and the associated costs from patient and provider perspectives. We also reported three indicators of SSI severity, that is, length of hospital stay (LOS), number of outpatient visits and laboratory tests. The analysis was performed in STATA V.14 and Microsoft Excel. RESULTS: Before-intervention SSI risk was 13.9% (62/446) as opposed to during-intervention 8.4% (49/582), equivalent to a risk difference of 5.5% (95% CI 5.3 to 5.9). SSI mortality risk decreased by 33.3% during the intervention while SSI-attributable LOS decreased by 32.6%. Furthermore, the mean SSI-attributable patient direct and indirect medical cost declined by 12.1% during intervention while the hospital costs reduced by 19.1%. The intervention led to an estimated incremental cost-effectiveness ratio of US$4196 savings per SSI episode avoided. At a national scale, this could be equivalent to a US$60 162 248 cost advantage annually. CONCLUSION: The intervention is a simple, cost-effective, sustainable and adaptable strategy that may interest policymakers and health institutions interested in reducing SSI.

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care. CONTEXT: The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy. METHODS: Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers. FINDINGS: Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures. CONCLUSIONS: Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.

Association of Graduate Medical Education With Hospital Performance and Patient Outcomes.

Importance: Graduate medical education (GME) funding consists of more than $10 billion annual subsidies awarded to academic hospitals to offset the cost of resident training. Critics have questioned the utility of these subsidies and accountability of recipient hospitals. Objective: To determine the association of GME funding with hospital performance by examining 3 domains of hospital operations: financial standing, clinical outcomes, and resident academic performance. Design, Setting, and Participants: This study is an economic evaluation of all academic centers that received GME funding in 2017. GME funding data were acquired from the Hospital Compare Database. Statistical analysis was performed from May 2016 to April 2020. Exposures: GME funding. Main Outcomes and Measures: This study assessed the association between GME funding and each aspect of hospital operations. Publicly available hospital financial data were used to calculate a financial performance score from 0 to 100 for each hospital. Clinical outcomes were defined as 30-day mortality, readmission, and complication rates for a set of predefined conditions. Resident academic performance was determined by Board Certification Examination (BCE) pass rates at 0, 2, and 5 years after GME funding was awarded. Confounder-adjusted linear regression models were used to test association between GME funding data and a hospital's financial standing, clinical outcomes, and resident academic performance. Results: The sample consisted of 1298 GME-funded hospitals, with a median (IQR) of 265 (168-415) beds and 32 (10-101) residents per training site. GME funding was negatively correlated with hospitals' financial scores (ß = -7.9; 95% CI, -10.9 to -4.8, P = .001). Each additional $1 million in GME funding was associated with lower 30-day mortality from myocardial infarction (-2.34%; 95% CI, -3.59% to -1.08%, P < .001), heart failure (-2.59%; 95% CI, -3.93% to -1.24%, P < .001), pneumonia (-2.20%; 95% CI, -3.99% to -0.40%, P = .02), chronic obstructive pulmonary disease ( -1.20%; 95% CI, -2.35% to -0.05%, P = .04), and stroke (-3.40%; 95% CI, -5.46% to -1.33%, P = .001). There was no association between GME funding and readmission rates. There was an association between higher GME funding and higher internal medicine BCE pass rates (0.066% [95% CI, 0.033% to 0.099%] per $1 million in GME funding; P < .001). Conclusions and Relevance: This study found a negative linear correlation between GME funding and patient mortality and a positive correlation between GME funding and resident BCE pass rates in adjusted regression models. The findings also suggest that hospitals that receive more GME funding are not more financially stable.

Clinical Pharmacist-Led Impact on Inappropriate Albumin Utilization and Associated Costs in General Ward Patients.

BACKGROUND: Inappropriate albumin use in clinical practice remains problematic. Health-systems face continued challenges in promoting cost-appropriate use. OBJECTIVE: To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin use in general ward patients. METHODS: A retrospective cohort study evaluated all adult (≥18 years) general ward patients administered ≥1 dose of albumin at a university medical center over a 2-year period. The intervention consisted of a clinical pharmacist-led strategy intervening on all albumin orders not in accordance with institutional guidelines. The primary end point was to compare inappropriate albumin utilization before and after implementation. Secondary end points compared the rates of inappropriate albumin use adjusted for hospital admission and patient-days as well as associated costs by appropriateness between study periods. RESULTS: A total of 4420 patients were screened, with 1971 (44.6%) patients meeting inclusion criteria. The clinical pharmacist strategy significantly reduced inappropriate albumin (grams) utilization by 86.0% (P < 0.001). A 7-fold reduction of inappropriate albumin administered adjusted for the number of patient admissions was found from the preimplementation period following clinical pharmacist intervention strategy implementation (415.3 ± 83.2 vs 57.5 ± 34.2 g per 100 general ward hospital admissions, respectively; P < 0.001). Also, the adjusted inappropriate albumin rate was reduced from 62.2 ± 12.3 to 8.6 ± 5.2 g per 100 patient-days in the preimplementation and postimplementation periods, respectively (P < 0.001). Annual cost savings were $421 455 overall, with $341 930 resulting from mitigation of inappropriate use. CONCLUSION AND RELEVANCE: Clinical pharmacist-led interventions significantly reduced inappropriate albumin use and costs in hospitalized patients.

Drug utilization, rationality, and cost analysis of antimicrobial medicines in a tertiary care teaching hospital of Northern India: A prospective, observational study.

BACKGROUND: The burden of bacterial infections is huge and grossly under-represented in the current health-care system. Inappropriate use of antimicrobial medicines (AMMs) poses a potential hazard to patients by causing antibiotic resistance. This study was conducted to assess the: (i) AMM consumption and use patterns in patients attending the outpatients and inpatients of Medicine and Surgery departments of the hospital. (ii) Appropriateness of the AMM in the treatment prescribed, and (iii) cost incurred on their use in admitted patients. MATERIALS AND METHODS: An observational, prospective study was conducted among inpatients and outpatients of the Medicine and Surgery departments of a tertiary care hospital of northern India. Analysis of 2128 prescriptions and 200 inpatient records was performed using a predesigned format. The use of AMMs was reviewed using anatomical therapeutic chemical classification and defined daily doses (DDDs). To evaluate the expenditure incurred on AMMs, ABC analysis was performed. RESULTS: AMMs were prescribed to 37.9% outpatients and 73% of admitted patients. The percentage encounters with AMMs was 40.6% (medicine) and 25.6% (surgery) outpatients. The total DDDs/100 patient days of AMMs in medicine and surgery were 3369 and 2247. Bacteriological evidence of infection and AMM sensitivity was present in only 8.5% of cases. Over 90% of AMMs were prescribed from the hospital essential medicines list. Most of the AMMs were administered parenterally (64.9%). Multiple AMMs were prescribed more to inpatients (84.2% vs. 4.2% outpatients). Overall, expenditure on AMM was 33% of the total cost of treatment on medicine. ABC analysis showed that 74% of the expenditure was due to newer, expensive AMM, which constituted only 9% of the AMM used. The AMM therapy was found to be appropriate in 88% of cases as per Kunin's criteria for rationality. CONCLUSION: AMMs are being commonly prescribed without confirmation of AMM sensitivity in the hospital. A large proportion of expenditure is being incurred on expensive AMM used in a few number of patients. There is a need for developing a policy for rational use of AMM in the health facility.

Transit Care Hub pharmacist: improving patient flow within the hospital.

Background The Transit Care Hub (TCH) is an inpatient ward traditionally used as a waiting area for patients who require transport to return home. In July 2018, a six-month pilot of a TCH pharmacist was funded to improve the flow of patients through the hospital. Setting Major Australian teaching hospital. Objective(s) To determine the effect that the TCH pharmacist had on patient flow within the hospital and on the time saved for other clinical pharmacists, as well as estimating cost savings. Methods A service delivery framework for the TCH pharmacist was developed and tested. This involved a proactive approach to patient discharge with ward-based staff. Data were collected from July to November 2018, 20 weeks prior to and 20 weeks after the commencement of the pilot. Main outcome measure Measurements included the number of best possible medication histories (BPMHs) completed during admission, improvements in arrival time to TCH from inpatient wards and cost savings. Results During the pilot study period (20 weeks), 791 patients were discharged by the TCH pharmacist, arriving an average of 70 minutes earlier than other patients discharging through TCH. There was a 16% increase in patients discharging through TCH which released ward beds. The TCH pharmacist increased the number of BPMHs on day of admission by 14%. There was an estimated annual saving of AU$252,008 for the hospital. Conclusions The TCH pharmacist service enhanced patient flow by coordinating earlier discharges, increasing the timely completion of BPMHs, and saving ward pharmacist time. Significant cost savings supported a permanently funded position.

How efficient are surgical treatments in Japan? The case of a high-volume Japanese hospital.

Japan's healthcare expenditures, which are largely publicly funded, have been growing dramatically due to the rapid aging of the population as well as the innovation and diffusion of new medical technologies. Annual costs for surgical treatments are estimated to be approximately USD 20 billion. Using unique longitudinal clinical data at the individual surgeon level, this study aims to estimate the technical efficiency of surgical treatments across surgical specialties in a high-volume Japanese teaching hospital by employing stochastic frontier analysis (SFA) with production frontier models. We simultaneously examine the impacts of potential determinants that are likely to affect inefficiency in operating rooms. Our empirical results show a relatively high average technical efficiency of surgical production, with modest disparity across surgical specialties. We also demonstrate that an increase in the number of operations performed by a surgeon significantly reduces operating room inefficiency, whereas the revision of the fee-for-service schedule for surgical treatments does not have a significant impact on inefficiency. In addition, we find higher technical efficiency among surgeons who perform multiple daily surgeries than those who perform a single operation in a day. We suggest that it is important for hospital management to retain efficient surgeons and physicians and provide efficient healthcare services given the competitive Japanese healthcare market.

Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids' Inpatient Database.

BACKGROUND: Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment. METHODS: A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids' Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates. RESULTS: A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P<0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P<0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P<0.001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012. CONCLUSIONS: Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications. LEVEL OF EVIDENCE: Level III-case series, database study.

The association of hospital teaching intensity with 30-day postdischarge heart failure readmission and mortality rates.

OBJECTIVE: To investigate risk-adjusted, 30-day postdischarge heart failure mortality and readmission rates stratified by hospital teaching intensity. DATA SOURCES AND STUDY SETTING: A total of 709 221 Medicare fee-for-service beneficiaries discharged from 3135 US hospitals between 1/1/2013 and 11/30/2014 with a principal diagnosis of heart failure. STUDY DESIGN: Hospitals were classified as Council of Teaching Hospitals and Health Systems (COTH) major teaching hospitals, non-COTH teaching hospitals, and nonteaching hospitals. Hospital teaching status was linked with MedPAR patient data and FY2016 Hospital Readmission Reduction Program penalties. Index hospitalization survival probabilities were estimated with hierarchical logistic regression and used to stratify index hospitalization survivors into severity deciles. Decile-specific models were estimated for 30-day postdischarge readmission and mortality. Thirty-day postdischarge outcomes were estimated by teaching intensity and penalty categories. PRINCIPAL FINDINGS: Averaged across deciles, adjusted 30-day COTH hospital readmission rates were, on a relative scale ([COTH minus nonteaching] ÷ nonteaching), 1.63 percent higher (95% CI: 0.89 percent, 2.25 percent) than at nonteaching hospitals, but their average adjusted 30-day postdischarge mortality rates were 11.55 percent lower (95% CI: -13.78 percent, -9.37 percent). Penalized COTH hospitals had the highest readmission rates of all categories (23.99 percent [95% CI: 23.50 percent, 24.49 percent]) but the lowest 30-day postdischarge mortality (8.30 percent [95% CI: 7.99 percent, 8.57 percent] vs 9.84 percent [95% CI: 9.69 percent, 9.99 percent] for nonpenalized, nonteaching hospitals). CONCLUSIONS: Heart failure readmission penalties disproportionately impact major teaching hospitals and inadequately credit their better postdischarge survival.

Determining the Cost and Length of Stay at Intensive Care Units and the Factors Influencing Them in a Teaching Hospital in Malaysia.

OBJECTIVES: Escalating healthcare costs calls for the efficiency of health services, especially in the intensive care unit (ICU) where the bulk of resources are used. This study aims to identify the length of stay (LOS) and cost of care at ICUs, which are proxy indicators of efficiency and the factors determining them. METHODS: A cross-sectional study of patients requiring ICU admissions in a teaching hospital in Malaysia from 2013 to 2015 was conducted. The cost at the ICU was estimated using the step down approach. Factors that determined the cost and LOS at the ICU were also explored by using multivariate regression analysis. RESULTS: Each day of stay cost $427 (USD) at the pediatric intensive care unit and $1324 at the general intensive care unit. The mean LOS at the ICU was 5.7 days (standard deviation [SD]: 8.4) with a median of 4 days (95% confidence interval [CI] 1-16.7 days). Average cost of care at the ICU per episode of care was $5473 (SD $6499), and the median was $3463. ICU patients spent 29.3% of the total stay and 47.2% of the cost at ICU units. Upon multivariate regression analysis, severity, case base-group, and type of ICU that the patient was admitted to were associated with the cost and LOS at ICU. CONCLUSIONS: Compared with critical care practices in hospitals from more developed nations, a Malaysian teaching hospital required a longer length of ICU stay. Hence, implementations of strategies that can reduce the length of stay and hospital costs without compromising healthcare quality are required.

The Financial Impact of an Avoided Readmission for Teaching and Safety-Net Hospitals Under Medicare's Hospital Readmission Reduction Program.

We examined the financial incentives to avoid readmissions under Medicare's Hospital Readmission Reduction Program for safety-net hospitals (SNHs) and teaching hospitals (THs) compared with other hospitals. Using Medicare's FY2016 Hospital Compare and readmissions data for 2,465 hospitals, we tested for differential revenue gains for SNHs (n = 658) relative to non-SNHs (n = 1,807), and for major (n = 231) and minor (n = 591) THs relative to non-THs (n = 1,643). We examined hospital-level factors predicting differences in revenue gains by hospital type. The revenue gains of an avoided readmission were 10% to 15% greater for major THs compared with non-THs ($18,047 vs. $15,478 for acute myocardial infarction) but no different for SNHs compared with non-SNHs. The greater revenue gains for THs were strongly positively predicted by hospitals' poor initial readmission performance. We found little evidence that the Hospital Readmission Reduction Program creates disincentives for SNHs and THs to invest in readmission reduction efforts, and THs have greater returns from readmissions avoidance than non-THs.

Financial and Clinical Impact of Transfer Patients at Major Teaching Hospitals.

PURPOSE: The authors examined the "hub-and-spoke" health care system in the United States for patients transferred from one hospital ("spoke") to a major teaching hospital ("hub") and assessed the financial and clinical impact of this system on major teaching hospitals. METHOD: The authors surveyed Council of Teaching Hospitals and Health Systems members to collect detailed financial and clinical data from fiscal year 2015 for transfer cases and nontransfer cases (cases directly admitted to the teaching hospital). Data included computed margins (the difference between revenue received and direct and indirect facility costs as estimated by the hospitals) as well as case severity, average length of stay (ALOS), time of admission, surgical or medical status, and other situational variables for All Patient Refined Diagnosis Related Groups (APR-DRGs). The authors used an ordinary least-squares regression model with fixed effects to analyze the data. RESULTS: Twenty-six hospitals provided data. The average difference between transfer and nontransfer cases was a 2.18 day longer ALOS and a $1,716 lower computed margin, for a case in the same APR-DRG and hospital (P < .001 for both outcomes). Transfer cases had a 19% higher case severity of illness rating and were disproportionately represented among complex APR-DRGs. Transfer patients were 14% more likely to be Medicaid beneficiaries. CONCLUSIONS: Compared with nontransfer cases, transfer cases at major teaching hospitals were more complex and resulted in greater resource utilization, affecting the financial margins on which teaching hospitals rely to support their multipart mission.

Comparing Outcomes and Costs of Surgical Patients Treated at Major Teaching and Nonteaching Hospitals: A National Matched Analysis.

OBJECTIVE: To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics. BACKGROUND: Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear. METHODS: A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios < 0.05).We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery. RESULTS: In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of -0.95%, <0.0001), and overall paired cost difference = $915 (P < 0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = -2.24%, P < 0.0001), and paired cost difference = $3773 (P < 0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals. CONCLUSIONS: Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.

Going "Big Bang" into an Electronic Health Record: Four Recommendations from Leading a Dynamic Academic Health Sciences Hospital through Transformational Change on Time, in Scope and within Budget.

At 4 a.m. on December 2, 2017, St. Joseph's Healthcare Hamilton - a multi-site, clinically diverse, tertiary academic and research hospital - deployed an electronic health record (EHR) system across the organization using a "big bang" approach. This effectively required all inpatient, emergency and many ambulatory services to put down their pens and document everything electronically at one moment in time without skipping a beat in providing excellent clinical care. The hospital leapt from the bottom to nearly the top of the internationally recognized measurement for EHR adoption - on time, in scope and within budget. This article presents the leadership's view on essential lessons learned with key recommendations for healthcare systems seeking successful implementation with this approach.

Strategic Differentiation of High-Tech Services in Local Hospital Markets.

This study assesses organizational and market factors related to high-tech service differentiation in local hospital markets. The sample includes 1704 nonfederal, general acute hospitals in urban counties in the United States. We relate organizational and market factors in 2011 to service differentiation in 2013, using ordinary least squares regression. Data are compiled from the American Hospital Association Annual Survey of Hospitals, Area Resource File, and Centers for Medicare and Medicaid Services. Results show that hospitals differentiate more services relative to market rivals if they are larger than the rival and if the hospitals are further apart geographically. Hospitals differentiate more services if they are large, teaching, and nonprofit or public and if they face more market competition. Hospitals differentiate fewer services from rivals if they belong to multihospital systems. The findings underscore the pressures that urban hospitals face to offer high-tech services despite the potential of high-tech services to drive hospital costs upward.