Nurse Work Environment and Hospital-Onset Clostridioides difficile Infection.

BACKGROUND: Clostridioides difficile is the leading cause of hospital-onset diarrhea and is associated with increased lengths of stay and mortality. While some hospitals have successfully reduced the burden of C. difficile infection (CDI), many still struggle to reduce hospital-onset CDI. Nurses-because of their close proximity to patients-are an important resource in the prevention of hospital-onset CDI. OBJECTIVE: Determine whether there is an association between the nurse work environment and hospital-onset CDI. METHODS: Survey data of 2016 were available from 15,982 nurses employed in 353 acute care hospitals. These data, aggregated to the hospital level, provided measures of the nurse work environments. They were merged with 2016 hospital-onset CDI data from Hospital Compare, which provided our outcome measure-whether a hospital had a standardized infection ratio (SIR) above or below the national average SIR. Hospitals above the average SIR had more infections than predicted when compared to the national average. RESULTS: In all, 188 hospitals (53%) had SIRs higher than the national average. The odds of hospitals having higher than average SIRs were significantly lower, with odds ratios ranging from 0.35 to 0.45, in hospitals in the highest quartile for all four nurse work environment subscales (managerial support, nurse participation in hospital governance, physician-nurse relations, and adequate staffing) than in hospitals in the lowest quartile. CONCLUSIONS: Findings show an association between the work environment of nurses and hospital-onset CDI. A promising strategy to lower hospital-onset CDI and other infections is a serious and sustained commitment by hospital leaders to significantly improve nurse work environments.

Association of Registered Nurse Staffing With Mortality Risk of Medicare Beneficiaries Hospitalized With Sepsis.

Importance: Sepsis is a major physiologic response to infection that if not managed properly can lead to multiorgan failure and death. The US Centers for Medicare & Medicaid Services (CMS) requires that hospitals collect data on core sepsis measure Severe Sepsis and Septic Shock Management Bundle (SEP-1) in an effort to promote the early recognition and treatment of sepsis. Despite implementation of the SEP-1 measure, sepsis-related mortality continues to challenge acute care hospitals nationwide. Objective: To determine if registered nurse workload was associated with mortality in Medicare beneficiaries admitted to an acute care hospital with sepsis. Design Setting and Participants: This cross-sectional study used 2018 data from the American Hospital Association Annual Survey, CMS Hospital Compare, and Medicare claims on Medicare beneficiaries age 65 to 99 years with a primary diagnosis of sepsis that was present on admission to 1 of 1958 nonfederal, general acute care hospitals that had data on CMS SEP-1 scores and registered nurse workload (indicated by registered nurse hours per patient day [HPPD]). Patients with sepsis were identified based on 29 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. Data were analyzed throughout 2021. Exposures: SEP-1 score and registered nurse staffing. Main Outcomes and Measures: The patient outcome of interest was mortality within 60 days of admission. Hospital characteristics included number of beds, ownership, teaching status, technology status, rurality, and region. Patient characteristics included age, sex, transfer status, intensive care unit admission, palliative care, do-not-resuscitate order, and a series of 29 comorbid diseases based on the Elixhauser Comorbidity Index. Results: In total, 702 140 Medicare beneficiaries (mean [SD] age, 78.2 [8.7] years; 360 804 women [51%]) had a diagnosis of sepsis. The mean SEP-1 score was 56.1, and registered nurse HPPD was 6.2. In a multivariable regression model, each additional registered nurse HPPD was associated with a 3% decrease in the odds of 60-day mortality (odds ratio, 0.97; 95% CI 0.96-0.99) controlling for SEP-1 score and hospital and patient characteristics. Conclusions and Relevance: The results of this cross-sectional study suggest that hospitals that provide more registered nurse hours of care could likely improve SEP-1 bundle compliance and decrease the likelihood of mortality in Medicare beneficiaries with sepsis.

The cost-saving effect of continuity of care (COC): an analysis of institutional COC on diabetic treatment costs using panel 2SLS regressions.

BACKGROUND: The high costs of chronic conditions call for new treatment approaches that reduce costs while ensuring desirable health outcomes. There has been a growing transformation of care delivery models from conventional referral systems to integrated care models. This study seeks to evaluate the cost-saving impact of integrated care delivery model under pay-for-performance (P4P) scheme with continuity of care at institution level (ICOC). METHODS: We analyzed the Taiwan National Health Insurance claim data of 21,725 diabetic patients who visited clinics and/or hospitals at least four times a year for 8 years. Using average local provider P4P participation rate (for each accreditation level) as an instrumental variable in two-stage least squares (2SLS) regressions, we have estimated consistent estimates of the ICOC elasticities for all-cause inpatient and outpatient costs. RESULTS: Our results show that ICOC significantly reduced inpatient costs but increased outpatient costs with the elasticity for treatment costs of -11.6 and 1.03, respectively. The decrease in inpatient costs offset the increase in outpatient costs and the resulting total cost saving showed significant association with ICOC. The saving effect of ICOC is especially robust among patients who used clinics as their principal source of care. CONCLUSIONS: Institutional continuity of care has a substantial impact on the treatment costs of diabetes patients. In the context where inpatient care costs are significantly higher than that of the outpatient care, ICOC would lead to a meaningful cost-saving effect. For new diabetes patients, care by clinics demonstrated the strongest saving effect.

Urban-rural differences in healthcare utilization among beneficiaries in China's new cooperative medical scheme.

BACKGROUND: The New Cooperative Medical Scheme (NCMS) is a voluntary social health insurance program launched in 2002 for rural Chinese residents where 80% of people were without health insurance of any kind. Over time, several concerns about this program have been raised related to healthcare utilization disparities for NCMS participants in urban versus rural regions. Our study uses 2015 national survey data to evaluate the extent of these urban and rural disparities among NCMS beneficiaries. METHODS: Data for our study are based on the Chinese Health and Retirement Longitudinal Study (CHARLS) for 2015. Our 12,190-patient sample are urban and rural patients insured by NCMS. We use logistic regression analyses to compare the extent of disparities for urban and rural residence of NCMS beneficiaries in (1) whether individuals received any inpatient or outpatient care during 2015 and (2) for those individuals that did receive care, the extent of the variation in the number of inpatient and outpatient visits among each group. RESULTS: Our regression results reveal that for urban and rural NCMS patients in 2015, there were no significant differences in inpatient or outpatient utilization for either of the dependent variables - 1) whether or not the patient had a visit during the last year, or 2) for those that had a visit, the number of visits they had. Patient characteristics: age, sex, employment, health status, chronic conditions, and per capita annual expenditures - all had significant impacts on whether or not there was an inpatient or outpatient visit but less influence on the number of inpatient or outpatient visits. CONCLUSIONS: For both access to inpatient and outpatient facilities and the level of utilization of these facilities, our results reveal that both urban and rural NCMS patients have similar levels of resource utilization. These results from 2015 indicate that utilization angst about urban and rural disparities in NCMS patients do not appear to be a significant concern.

Trends in In-hospital Coronary Artery Bypass Surgery Mortality by Gender and Race/Ethnicity --1998-2015: Why Do the Differences Remain?

BACKGROUND AND AIMS: Between 1998 and 2015, the national coronary artery bypass graft surgery (CABG) in-hospital mortality rate fell nearly 45% to just 2.2% of CABG in-patients. By almost any standards, this large decline in the nation's in-hospital mortality for CABG inpatients has been extraordinary. Yet, over this time period, no studies have detailed these notable trends in in-hospital CABG mortality with an emphasis on the differences by gender and racial/ethnicity. The in-hospital CABG treatment period is the approximately 9 day inpatient length-of-stay the patient is completely under the care of hospital and its staff. Our research seeks to fill this research gap with analyses of 18 years of national data of over 5 million CABG inpatient discharges distinguishing gender by six categories of race/ethnicity (Asian, black, Hispanic, white, other known races/ethnicities, and unknown race/ethnicities) to evaluate three broad questions related to in-hospital CABG mortality: 1) What have been the 18-year national trends in CABG surgeries, length-of-stay, mortality, and type of discharge by gender and race/ethnicity? 2) Over time, what have been the in-hospital mortality trends by gender and race-ethnicity? 3) Using multivariate techniques to control for patient characteristics, risk factors and socioeconomic characteristics of the hospital setting and environment, what is the extent of the variations in in-hospital mortality among the 12 groupings of gender and race-ethnicity? DATA AND METHODS: Data are from the Nationwide Inpatient Sample (NIS) data from the Healthcare Utilization Project (HCUP-NIS) collected yearly. These data represent 858 hospitals, a 20% national sample representing 5,032,985 CABG patient discharges from hospitals over an 18-year period -- 1998 to 2015. Descriptive and logistic regression analyses are used to evaluate the outcomes. RESULTS: The national decline in in-hospital CABG mortality trends over the 18-year period has been dramatic. These declines have substantially impacted all 12 racial/ethnic and gender groupings analyzed during this timeframe. However, over the 18-year period, both univariate and logistic regression results reveal the disadvantages females and black males have in in-hospital CABG mortality rates when compared to the comparison group, white male CABG inpatients. Female CABG inpatients consistently, regardless of their race/ethnicity, have significantly higher in-hospital mortality rates than their corresponding male counterparts even after controlling for patient characteristics and socio-economic status. For males, however, the likelihood of dying in the hospital from a CABG procedure showed wide variation across the four racial/ethnic categories. Compared with white male patients undergoing CABG surgery in the nation's hospitals, after controlling for confounding factors, Hispanic and Asian-American had significantly lower in-hospital CABG mortality rates -9.7% and -17.9% respectively. In contrast, black male CABG patients had a 35.1% higher in-hospital CABG mortality rate than white males. CONCLUSIONS: While considerable progress has been made reducing overall in-hospital CABG mortality over the past 18-years across all gender and racial/ethnic inpatients, significant gaps persist between black males and other racial/ethnic groups.

Trends in U.S. Community hospitalizations due to herpes zoster: 2001-2015.

BACKGROUND: In 2007, based on decisions by the U.S. Advisory Committee on Immunization Practices, the CDC recommended a booster dose at 4-6 years in the varicella vaccine schedule. In 2008, a herpes zoster vaccine was recommended for use in persons age ≥60 years. The purpose of this study was to examine trends in herpes zoster hospitalization rates and assess the impact of both policy recommendations using U.S. hospital discharge data. METHODS: Nationwide Inpatient Sample discharge data from 2001 to 2015 were used to identify primary or secondary herpes zoster diagnoses. Trends in annual total and age-specific herpes zoster hospitalization rates and average length of stay were examined. Average annual rates for the pre (2001-2005) and post (2012-2015)-zoster vaccine policy eras were compared. Absolute change in herpes zoster hospitalizations were calculated. RESULTS: The rate difference of U.S. herpes zoster hospitalizations in the post vs. pre-zoster vaccine policy era was -1.9 per 100,000 population (6,200 fewer hospitalizations in 2015 than expected). Key age group rate differences: 0-3 years (-0.4 per 100,000; 50 fewer), 4-6 years (-0.6 per 100,000; 50 fewer), 7-14 years (-1.3 per 100,000; 400 fewer), 50-59 years (0.7 per 100,000; 300 more), 60-69 years (-2.5 per 100,000; 900 fewer), 70-79 years (-10.2 per 100,000; 2,000 fewer), 80+ years (-29.9 per 100,000; 3,600 fewer). CONCLUSIONS: Reduction of wild-type varicella due to the 2-dose varicella vaccination recommendation may have impacted declining herpes zoster hospitalization rates among children ≤14 years. The 2008 herpes zoster vaccine may have impacted declining herpes zoster hospitalization rates for adults age ≥60 years despite vaccination coverage <31% by 2015.

The Impact of Electronic Medical Records on Hospital-Acquired Adverse Safety Events: Differential Effects Between Single-Source and Multiple-Source Systems.

The objective was to examine differential impacts between single-source and multiple-source electronic medical record (EMR) systems, as measured by number of vendor products, on hospital-acquired patient safety events. The data source was the 2009-2010 State Inpatient Databases of the Healthcare Cost and Utilization Project for California, New York, and Florida, and the Information Technology Supplement to the American Hospital Association's Annual Survey. Multivariable regression analyses were conducted to estimate the differential impacts of EMRs between single-source and multiple-source EMR systems on hospital-acquired patient safety events. In all, 1.98% of adult surgery hospitalizations had at least 1 hospital-acquired patient safety event. Basic EMRs with a single vendor or self-developed EMR systems were associated with a significant decrease in patient safety events by 0.38 percentage point, or 19.2%, whereas basic EMRs with multiple vendors had an insignificant association. A single-source EMR system enhances the impact of EMRs on reducing patient safety events.

Index of cardiometabolic health: a new method of measuring allostatic load using electronic health records.

OBJECTIVE: We developed a measure of allostatic load from electronic medical records (EMRs), which we named "Index of Cardiometabolic Health" (ICMH). METHODS: Data were collected from participants' EMRs and a written survey in 2005. We computed allostatic load scores using the ICMH score and two previously described approaches. RESULTS: We included 1865 employed adults who were 25-59 years old. Although the magnitude of the association was small, all methods of were predictive of SF-12 physical component subscales (all p < 0.001). CONCLUSION: We found that the ICMH had similar relationships with health-related quality of life as previously reported in the literature.

Evidence that electronic health records can promote physician counseling for healthy behaviors.

BACKGROUND: Health behavior counseling services may help patients manage chronic conditions effectively and slow disease progression. Studies show, however, that many providers fail to provide these services because of time constraints and inability to tailor counseling to individual patient needs. Electronic health records (EHRs) have the potential to increase appropriate counseling by providing pertinent patient information at the point of care and clinical decision support. PURPOSE: This study estimates the impact of select EHR functionalities on the rate of health behavior counseling provided during primary care visits. METHODOLOGY: Multivariable regression analyses of the 2007-2010 National Ambulatory Medical Care Survey were conducted to examine whether eight EHR components representing four core functionalities of EHR systems were correlated with the rate of health behavior counseling services. Propensity score matching was used to control for confounding factors given the use of observational data. To address concerns that EHR may only lead to improved documentation of counseling services and not necessarily improved care, the association of EHR functionalities with prescriptions for smoking cessation medications was also estimated. FINDINGS: The use of an EHR system with health information and data, order entry and management, result management, decision support, and a notification system for abnormal test results was associated with an approximately 25% increase in the probability of health behavior counseling delivered. Clinical reminders were associated with more health behavior counseling services when available in combination with patient problem lists. The laboratory results viewer was also associated with more counseling services when implemented with a notification system for abnormal results. PRACTICE IMPLICATION: An EHR system with key supportive functionalities can enhance delivery of preventive health behavior counseling services in primary care settings. Meaningful use criteria should be evaluated to ensure that they encourage the adoption of EHR systems with those functionalities shown to improve clinical care.

Addressing Medicaid Expansion from the Perspective of Patient Experience in Hospitals.

BACKGROUND: More Medicaid holders are entering the healthcare system consequential to Medicaid expansion. Their experience has financial consequences for hospitals and crucial implications for the provision of patient-centered care. This study examined how the hospital characteristics, especially the rates of Medicaid coverage and racial/ethnic minorities, impact the quality of inpatient care. METHODS: Using data for years 2009-2011 for 870 observations of California hospitals, and data collected from patients via the Hospital Consumer Assessment of Healthcare Providers and Systems survey coupled with data from the Healthcare Cost and Utilization Project and American Hospital Association Annual Survey, we used a generalized estimating equation approach to evaluate patients' experience with hospital care. Our multivariate model includes a comprehensive set of characteristics capturing market, structural, process, and patient demographics associated with the patient's hospital stay. RESULTS: The findings indicate that high concentrations of Medicaid patients in the hospital negatively impact the perceived patient experience. In addition, all things being equal, hospitals with higher concentrations of Hispanic, Black, and Asian patients received lower patient satisfaction results on 28 of the 30 regression coefficients capturing patient satisfaction, with 22 of the 30 negative coefficients statistically significant. CONCLUSIONS: Hospitals serving higher concentrations of Medicaid patients and more racial/ethnic diverse patients experienced a less satisfactory patient experience than patients utilizing other payers or patients who were White. Our research magnifies the challenge for addressing the disparities that exist in healthcare. Further research is called for clarifying the underlying reasons for these disparities and the optimal strategies for addressing these problems.

Trends in U.S. hospitalizations and inpatient deaths from pneumonia and influenza, 1996-2011.

BACKGROUND: To reduce excess morbidity and mortality of pneumonia and influenza (PI), the Advisory Committee on Immunization Practices has recommended the use of 7-valent pneumococcal conjugate vaccine (PCV7), and incrementally expanded the target group for annual influenza vaccination of healthy persons, to ultimately include all persons ≥6 months of age without contraindications as of the 2010-2011 influenza season. We aimed to capture broader epidemiologic changes by looking at PI collectively. METHODS: Using interrupted time series, we evaluated the changes in the rates of PI hospitalization and inpatient death across three periods defined according to the changes in vaccination policy. We assessed linear trends adjusting for seasonality, sex, and age group, allowing for differential impact across age groups. PI hospitalizations were defined as a principal diagnosis of PI, or a principal diagnosis of sepsis or respiratory failure, accompanied by a secondary diagnosis of PI. RESULTS: Overall annual rates of PI hospitalizations and inpatient deaths declined by 95 per 100,000 (95% CI: 45-145) and by 4.4 per 100,000 (95% CI: 0.9-7.8), respectively. This translates to 295,000 fewer PI hospitalizations and 13,600 fewer PI inpatient deaths than expected based on the average rates from 1996 through 1999. PI hospitalizations dropped the most among seniors aged 65+ by 487 per 100,000, followed by children aged <2, by 228 per 100,000. PI inpatient deaths declined most among seniors aged 65+, by 25.3 per 100,000. CONCLUSIONS: In this nationally representative study, PI hospitalizations and inpatient deaths decreased in U.S. between 1996 and 2011. There is a temporal association with the introduction and widespread use of pneumococcal conjugate vaccines, and the expansion of the target group for annual influenza vaccination to include all persons ≥6 months of age, while it is difficult to attribute these changes directly to specific vaccines used in this era.

The Financial Effect of Value-Based Purchasing and the Hospital Readmissions Reduction Program on Safety-Net Hospitals in 2014: A Cohort Study.

BACKGROUND: Medicare's value-based purchasing (VBP) and the Hospital Readmissions Reduction Program (HRRP) could disproportionately affect safety-net hospitals. OBJECTIVE: To determine whether safety-net hospitals incur larger financial penalties than other hospitals under VBP and HRRP. DESIGN: Cross-sectional analysis. SETTING: United States in 2014. PARTICIPANTS: 3022 acute care hospitals participating in VBP and the HRRP. MEASUREMENTS: Safety-net hospitals were defined as being in the top quartile of the Medicare disproportionate share hospital (DSH) patient percentage and Medicare uncompensated care (UCC) payments per bed. The differences in penalties in both total dollars and dollars per bed between safety-net hospitals and other hospitals were estimated with the use of bivariate and graphical regression methods. RESULTS: Safety-net hospitals in the top quartile of each measure were more likely to be penalized under VBP than other hospitals (62.9% vs. 51.0% under the DSH definition and 60.3% vs. 51.5% under the UCC per-bed definition). This was also the case under the HRRP (80.8% vs. 69.0% and 81.9% vs. 68.7%, respectively). Safety-net hospitals also had larger payment penalties ($115 900 vs. $66 600 and $150 100 vs. $54 900, respectively). On a per-bed basis, this translated to $436 versus $332 and $491 versus $314, respectively. Sensitivity analysis setting the cutoff at the top decile rather than the top quartile decile led to similar conclusions with somewhat larger differences between safety-net and other hospitals. The quadratic fit of the data indicated that the larger effect of these penalties is in the middle of the distribution of the DSH and UCC measures. LIMITATION: Only 2 measures of safety-net status were included in the analyses. CONCLUSION: Safety-net hospitals were disproportionately likely to be affected under VBP and the HRRP, but most incurred relatively small payment penalties in 2014. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Screening Mammography in a Public Hospital Serving Predominantly African-American Women: A Stage-Survival-Cost Model.

BACKGROUND: Ethnic and socioeconomic disparities pervade breast cancer patterns and outcomes. Mammography guidelines reflect the difficulty in optimizing mortality reduction and cost-effectiveness, with controversy still surrounding the 2009 U.S. Preventive Services Task Force (USPSTF) recommendations. This study simulates USPSTF and American Cancer Society (ACS) guidelines' effects on stage, survival, and cost of treatment in an urban public hospital. METHODS: Charts of 274 women diagnosed with stage I, II, or III breast cancer (2008-2010) were reviewed. Published tumor doubling times were used to predict size at diagnosis under simulated screening guidelines. Stage distributions under ACS and USPSTF guidelines were compared with those observed. Cohort survival for observed and hypothetical scenarios was estimated using national statistics. Treatment costs by stage, calculated from Georgia Medicaid claims data, were similarly applied. RESULTS: Mean age at diagnosis was 56 years. African Americans predominated (82.5%), with 96% publically insured or uninsured. Simulated stages at diagnosis significantly favored ACS guidelines (43.1% stage 1/38.3% stage 2/9.9% stage 3 vs. USPSTF 23.0%/53.3 %/15.0%), as did 5-year survival and cost of treatment relative to both observed and USPSTF-predicted schema (p<.0001). Following USPSTF guidelines predicted lower survival and additional costs. CONCLUSIONS: Following ACS guidelines seems to lead to earlier diagnosis for low-income African-American women and increase 5-year survival with lower overall and breast-specific costs. The data suggest that adjusting screening practices for lower socioeconomic status, ethnic minority women may prove essential in addressing cancer disparities.

Safety-net hospitals more likely than other hospitals to fare poorly under Medicare's value-based purchasing.

Medicare's value-based purchasing (VBP) program potentially puts safety-net hospitals at a financial disadvantage compared to other hospitals. In 2014, the second year of the program, patient mortality measures were added to the VBP program's algorithm for assigning penalties and rewards. We examined whether the inclusion of mortality measures in the second year of the program had a disproportionate impact on safety-net hospitals nationally. We found that safety-net hospitals were more likely than other hospitals to be penalized under the VBP program as a result of their poorer performance on process and patient experience scores. In 2014, 63 percent of safety-net hospitals versus 51 percent of all other sample hospitals received payment rate reductions under the program. However, safety-net hospitals' performance on mortality measures was comparable to that of other hospitals, with an average VBP survival score of thirty-two versus thirty-one among other hospitals. Although safety-net hospitals are still more likely than other hospitals to fare poorly under the VBP program, increasing the weight given to mortality in the VBP payment algorithm would reduce this disadvantage.

Cost of intraocular lens versus contact lens treatment after unilateral congenital cataract surgery in the infant aphakia treatment study at age 5 years.

PURPOSE: To analyze differences in the cost of treatment for infants randomized to primary intraocular lens (IOL) implantation versus optical correction with a contact lens (CL) after unilateral cataract surgery in the Infant Aphakia Treatment Study (IATS). DESIGN: Retrospective cost analysis of a prospective, randomized clinical trial based on Georgia Medicaid reimbursement data as well as actual costs of supplies used during the study, adjusted for inflation. PARTICIPANTS: The IATS is a multicenter (n = 12), randomized clinical trial comparing the optical treatment of aphakia with either primary IOL implantation (n = 57) or CL correction (n = 57) in 114 infants with unilateral congenital cataract. INTERVENTION: One hundred fourteen infants underwent unilateral cataract surgery and were either corrected optically by primary IOL implantation at the time of surgery or were corrected with a CL after surgery. MAIN OUTCOME MEASURES: The mean cost of cataract surgery and all additional surgeries, examinations, and supplies used up to 5 years of age. RESULTS: The 5-year treatment cost of an infant with a unilateral congenital cataract corrected optically with an IOL was $27 090 versus $25 331 for a patient treated with a CL after initial cataract surgery. The total cost of supplies was $3204 in the IOL group versus $7728 in the CL group. CONCLUSIONS: Unilateral cataract surgery in infancy coupled with primary IOL implantation is approximately 7% more expensive than aphakia and CL correction. Patient costs are more than double with CL versus IOL treatment.

California safety-net hospitals likely to be penalized by ACA value, readmission, and meaningful-use programs.

The Affordable Care Act includes provisions to increase the value obtained from health care spending. A growing concern among health policy experts is that new Medicare policies designed to improve the quality and efficiency of hospital care, such as value-based purchasing (VBP), the Hospital Readmissions Reduction Program (HRRP), and electronic health record (EHR) meaningful-use criteria, will disproportionately affect safety-net hospitals, which are already facing reduced disproportionate-share hospital (DSH) payments under both Medicare and Medicaid. We examined hospitals in California to determine whether safety-net institutions were more likely than others to incur penalties under these programs. To assess quality, we also examined whether mortality outcomes were different at these hospitals. Our study found that compared to non-safety-net hospitals, safety-net institutions had lower thirty-day risk-adjusted mortality rates in the period 2009-11 for acute myocardial infarction, heart failure, and pneumonia and marginally lower adjusted Medicare costs. Nonetheless, safety-net hospitals were more likely than others to be penalized under the VBP program and the HRRP and more likely not to meet EHR meaningful-use criteria. The combined effects of Medicare value-based payment policies on the financial viability of safety-net hospitals need to be considered along with DSH payment cuts as national policy makers further incorporate performance measures into the overall payment system.

The impact of electronic health records on workflow and financial measures in primary care practices.

OBJECTIVE: To estimate a commercially available ambulatory electronic health record's (EHR's) impact on workflow and financial measures. DATA SOURCES/STUDY SETTING: Administrative, payroll, and billing data were collected for 26 primary care practices in a fee-for-service network that rolled out an EHR on a staggered schedule from June 2006 through December 2008. STUDY DESIGN: An interrupted time series design was used. Staffing, visit intensity, productivity, volume, practice expense, payments received, and net income data were collected monthly for 2004-2009. Changes were evaluated 1-6, 7-12, and >12 months postimplementation. DATA COLLECTION/EXTRACTION METHODS: Data were accessed through a SQLserver database, transformed into SAS®, and aggregated by practice. Practice-level data were divided by full-time physician equivalents for comparisons across practices by month. PRINCIPAL FINDINGS: Staffing and practice expenses increased following EHR implementation (3 and 6 percent after 12 months). Productivity, volume, and net income decreased initially but recovered to/close to preimplementation levels after 12 months. Visit intensity did not change significantly, and a secular trend offset the decrease in payments received. CONCLUSIONS: Expenses increased and productivity decreased following EHR implementation, but not as much or as persistently as might be expected. Longer term effects still need to be examined.

Antipsychotic polypharmacy prescribing patterns and costs in the Florida adult and child Medicaid populations.

The rapid growth in the use of antipsychotic medications and their related costs have resulted in states developing programs to measure, monitor, and insure their beneficial relevance to public program populations. One such program developed in the state of Florida has adopted an evidence-based approach to identify prescribers with unusual psychotherapeutic prescription patterns and track their utilization and costs among Florida Medicaid patients. This study reports on the prescriber prescription and cost patterns for adults and children using three measures of unusual antipsychotic prescribing patterns: (1) two antipsychotics for 60 days (2AP60), (2) three antipsychotics for 60 days (3AP60), and (2) two antipsychotics for 90 or more days (2AP90). We find that over the four-year study period there were substantial increases in several aspects of the Florida Medicaid behavioral drug program. Overall, for adults and children, patient participation increased by 29 percent, the number of prescriptions grew by 30 percent, and the number of prescribers that wrote at least one prescription grew 48.5 percent, while Medicaid costs for behavioral drugs increased by 32 percent. But the results are highly skewed. We find that a relatively small number of prescribers account for a disproportionately large share of prescriptions and costs of the unusual antipsychotic prescriptions. In general, the top 350 Medicaid prescribers accounted for more than 70 percent of the unusual antipsychotic prescriptions, and we find that this disparity in unusual prescribing patterns appears to be substantially more pronounced in adults than in children prescribers. For just the top 13 adult and children prescribers, their practice patterns accounted for 11 percent to 21 percent of the unusual prescribing activity and, overall, these 13 top prescribers accounted for 13 percent of the total spent on antipsychotics by the Florida Medicaid program and 9.3 percent of the total expenditure by the state for all drugs. Our findings suggest that a strategy to monitor and ensure patient safety and prescribing patterns that targets a relatively small number of Medicaid providers could have a substantial benefit and prove to be cost effective.