Association of Extreme Heat and Cardiovascular Mortality in the United States: A County-Level Longitudinal Analysis From 2008 to 2017.

BACKGROUND: Extreme-heat events are increasing as a result of climate change. Prior studies, typically limited to urban settings, suggest an association between extreme heat and cardiovascular mortality. However, the extent of the burden of cardiovascular deaths associated with extreme heat across the United States and in different age, sex, or race and ethnicity subgroups is unclear. METHODS: County-level daily maximum heat index levels for all counties in the contiguous United States in summer months (May-September) and monthly cardiovascular mortality rates for adults ≥20 years of age were obtained. For each county, an extreme-heat day was identified if the maximum heat index was ≥90 °F (32.2 °C) and in the 99th percentile of the maximum heat index in the baseline period (1979-2007) for that day. Spatial empirical Bayes smoothed monthly cardiovascular mortality rates from 2008 to 2017 were the primary outcome. A Poisson fixed-effects regression model was estimated with the monthly number of extreme-heat days as the independent variable of interest. The model included time-fixed effects and time-varying environmental, economic, demographic, and health care-related variables. RESULTS: Across 3108 counties, from 2008 to 2017, each additional extreme-heat day was associated with a 0.12% (95% CI, 0.04%-0.21%; P=0.004) higher monthly cardiovascular mortality rate. Extreme heat was associated with an estimated 5958 (95% CI, 1847-10 069) additional deaths resulting from cardiovascular disease over the study period. In subgroup analyses, extreme heat was associated with a greater relative increase in mortality rates among men compared with women (0.20% [95% CI, 0.07%-0.33%]) and non-Hispanic Black compared with non-Hispanic White adults (0.19% [95% CI, 0.01%-0.37%]). There was a greater absolute increase among elderly adults compared with nonelderly adults (16.6 [95% CI, 14.6-31.8] additional deaths per 10 million individuals per month). CONCLUSIONS: Extreme-heat days were associated with higher adult cardiovascular mortality rates in the contiguous United States between 2008 and 2017. This association was heterogeneous among age, sex, race, and ethnicity subgroups. As extreme-heat events increase, the burden of cardiovascular mortality may continue to increase, and the disparities between demographic subgroups may widen.

Training Health Policy Researchers on Policy Engagement and Research Translation for Greater Impact: Evaluation of the Amplify@LDI Program.

BACKGROUND: Few researchers receive formal training in research translation and dissemination or policy engagement. We created Amplify@LDI, a training program for health services and health policy researchers, to equip them with skills to increase the visibility of their research through translation and dissemination activities. AIMS: To describe the program's participants and curriculum, and evaluate the first 2 years of the program. SETTING: The Leonard Davis Institute (LDI) at the University of Pennsylvania (Penn). PARTICIPANTS: An annual cohort of 12 LDI Senior Fellows (Penn faculty) from multiple schools, disciplines, and ranks at Penn. PROGRAM DESCRIPTION: The Amplify@LDI curriculum includes 6 sessions on different aspects of research translation and dissemination, including media and social engagement, writing Op-Eds, and policy engagement. PROGRAM EVALUATION: Participants reported measurable increases in time spent on translation and dissemination activities, as well as new enthusiasm for and confidence in policy engagement. Participants' reach (as measured by Altmetric) increased during the program, compared to smaller increases or reductions in reach for two comparator groups. DISCUSSION: In our preliminary evaluation of Amplify@LDI, we find strong evidence of positive impact from participant evaluations, and suggestive evidence that participation in the program is associated with significant increases in the reach of their research.

Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions.

BACKGROUND: Enrollment in high-quality Medicare Advantage (MA) plans, measured by a 5-star quality rating system, was lower among racial and ethnic minority enrollees than White enrollees partly due to fewer high-quality plans available in their counties of residence. This may contribute to racial and ethnic disparities in ambulatory care sensitive condition (ACSC) hospitalizations. OBJECTIVE: We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating. METHODS: Using the Medicare enrollment and claims data for 2016, we identified White, Black, Hispanic, and Asian/Pacific Islander enrollees in MA plans. We estimated racial and ethnic disparities in ACSC hospitalizations (per 10,000 enrollees) overall and by star rating. RESULTS: We found that the adjusted rates of ACSC hospitalizations were significantly higher among Black enrollees than White enrollees overall [39.4 (95% confidence interval: 36.3-42.5)]. However, no significant disparities were found among Hispanic and Asian/Pacific Islander enrollees. The adjusted rates of ACSC hospitalizations were higher in lower-rated plans than higher-rated plans in all racial and ethnic groups. The significant disparities in ACSC hospitalizations by star rating were the most pronounced between White and Black enrollees. We found suggestive evidence that enrollment in lower-rated plans was associated with higher disparities in ACSC hospitalizations between White and Black enrollees. CONCLUSIONS: Substantial disparities in ACSC hospitalizations exist between White and Black enrollees in MA plans, especially for lower-rated plans. Policies aimed at reducing racial disparities in ACSC hospitalizations could include improving access to high-rated plans.

Inpatient Gastroenterology Consultation and Outcomes of Cirrhosis-Related Hospitalizations in Two Large National Cohorts.

BACKGROUND: Little is known about use of specialty care among patients admitted with cirrhosis complications. AIMS: We sought to characterize the use and impact of gastroenterology/hepatology (GI/HEP) consultations in hospitalized patients with cirrhosis. We studied two national cohorts-the Veterans Affairs Costs and Outcomes in Liver Disease (VOCAL) and a nationally representative database of commercially insured patients (Optum Clinformatics™ DataMart). METHODS: Cirrhosis-related admissions were classified by ICD9/10 codes for ascites, hepatic encephalopathy, alcohol-associated hepatitis, spontaneous bacterial peritonitis, or infection related. We included 20,287/222,166 index admissions from VOCAL/Optum from 2010 to 2016. Propensity-matched analyses were conducted to balance clinical characteristics. Mortality and readmission were evaluated using competing risk regression (subhazard ratios, sHR), and length of stay (LOS) was assessed using negative binomial regression. RESULTS: GI/HEP consultations were completed among 37% and 42% patients in VOCAL and Optum, respectively. In propensity-matched analyses for VOCAL, GI/HEP consultation was associated with adjusted estimates of increased LOS (1.55 + 1.03 additional days), 90-day mortality (sHR 1.23, 95% CI 1.14-1.36), and lower 30-day readmissions (sHR 0.82, 95% CI 0.75-0.89). In Optum, inpatient consultation was associated with higher LOS (1.13 + 1.01 additional days), higher 90-day mortality (sHR 1.57, 95% CI 1.43-1.72), and higher 30-day readmission risk (sHR 1.04, 95% CI 1.02-1.05). Post-discharge primary and specialty care was higher among admissions receiving GI/HEP consultation in both cohorts. CONCLUSIONS: Use of GI/HEP consultation for cirrhosis-related admissions was low. Patients who received consultation had higher disease severity, and consultation was not associated with lower mortality but was associated with lower 30-day readmissions in the VA cohort only.

Understanding Drivers of Coronavirus Disease 2019 Vaccine Hesitancy Among Blacks.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has disproportionately affected communities of color, with black persons experiencing the highest rates of disease severity and mortality. A vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has the potential to reduce the race mortality gap from COVID-19; however, hesitancy toward the vaccine in the black community threatens vaccine uptake. METHODS: We conducted focus groups with black barbershop and salon owners living in zip codes of elevated COVID-19 prevalence to assess their attitudes, beliefs, and norms around a COVID-19 vaccine. We used a modified grounded theory approach to analyze the transcripts. RESULTS: We completed 4 focus groups (N = 24 participants) in July and August 2020. Participants were an average age of 46 years, and 89% were black non-Hispanic. Hesitancy against the COVID-19 vaccine was high due to mistrust in the medical establishment, concerns with the accelerated timeline for vaccine development, limited data on short- and long-term side effects, and the political environment promoting racial injustice. Some participants were willing to consider the vaccine once the safety profile is robust and reassuring. Receiving a recommendation to take the vaccine from a trusted healthcare provider served as a facilitator. Health beliefs identified were similar to concerns around other vaccines and included the fear of getting the infection with vaccination and preferring to improve one's baseline physical health through alternative therapies. CONCLUSIONS: We found that hesitancy of receiving the COVID-19 vaccine was high; however, provider recommendation and transparency around the safety profile might help reduce this hesitancy.

The Impact of Medicare's Alternative Payment Models on the Value of Care.

Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this goal has been to implement alternative payment models (APMs) that encourage high-value care by holding providers financially accountable for both the quality and the costs of care. In particular, the CMS has implemented and scaled up two types of APMs: population-based models that emphasize accountability for overall quality and costs for defined patient populations, and episode-based payment models that emphasize accountability for quality and costs for discrete care. Both APM types have been associated with modest reductions in Medicare spending without apparent compromises in quality. However, concerns about the unintended consequences of these APMs remain, and more work is needed in several important areas. Nonetheless, both APM types represent steps to build on along the path toward a higher-value national health care system.

Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis.

Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7 years (interquartile range, 1.1-5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30 days (HR, 1.53; 1.46-1.60) and 90 days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.

Hospitalist Vs. Non-Hospitalist Care Outcomes and Costs for Medicare Beneficiaries Discharged to Skilled Nursing Facilities in 2012-2014.

BACKGROUND: Hospitals are increasingly at risk for post-acute care outcomes and spending, such as those in skilled nursing facilities (SNFs). While hospitalists are thought to improve patient outcomes of acute care, whether these effects extend to the post-acute setting in SNFs is unknown. OBJECTIVE: To compare longer term outcomes of patients discharged to SNFs who were treated by hospitalists vs. non-hospitalists during their hospitalization. DESIGN: This was a retrospective cohort study. PARTICIPANTS: Participants are Medicare fee-for-service beneficiaries over 66 years of age who were hospitalized and discharged to a SNF in 2012-2014 (N = 2,839,779). MAIN MEASURES: We estimated the effect of being treated by a hospitalist on 30-day rehospitalization and mortality, 60-day episode Medicare payments (Parts A and B), and successful discharge to community. Patients discharged to the community within 100 days of SNF admission who remained alive and not readmitted to a hospital or SNF for at least 30 days were considered successfully discharged. All outcomes were adjusted for demographics and clinical characteristics. To account for heterogeneity across facilities, we included hospital fixed effects. KEY RESULTS: The 30-day rehospitalization rate was 17.59% for hospitalists' vs. 17.31% for non-hospitalists' patients (adjusted difference, 0.28%; 95% CI, 0.13 to 0.44). Sixty-day payments were $26,301 for hospitalists' vs. $25,996 for non-hospitalists' patients (adjusted difference, $305; 95% CI, $243 to $367). There was a non-significant trend toward lower successful discharge to the community rate (adjusted difference, - 0.26%; 95% CI, - 0.48 to - 0.04) and lower mortality for patients of hospitalists (adjusted difference, - 0.12%; 95% CI, - 0.22 to - 0.02). CONCLUSIONS: Among hospitalized Medicare beneficiaries who were discharged to SNFs, readmissions and Medicare costs were slightly higher for stays under the care of hospitalists compared with those of non-hospitalist generalist physicians, but there was a non-significant trend toward lower mortality.

Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study.

BACKGROUND: Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA. OBJECTIVE: To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose. DESIGN: Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses. PARTICIPANTS: Adults aged 23-25 years old and 27-29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose. MAIN MEASURES: Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults. KEY RESULTS: There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]). CONCLUSIONS: Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.

Transesophageal Echocardiography, Acute Kidney Injury, and Length of Hospitalization Among Adults Undergoing Coronary Artery Bypass Graft Surgery.

OBJECTIVE: To test the association between transesophageal echocardiography (TEE) and incidence of acute kidney injury and length of hospitalization among United States adults undergoing isolated coronary artery bypass graft (CABG) surgery. DESIGN: This was an observational, retrospective cohort analysis. SETTING: This study used a multicenter claims dataset from a commercially insured population undergoing CABG surgery in the United States between 2004 and 2016. PARTICIPANTS: Adults aged 18 years or older with continuous insurance enrollment and an absence of renal-related diagnoses before the index CABG surgery. INTERVENTIONS: Receipt of TEE within 1 calendar day of the index CABG surgery date. MEASUREMENTS AND MAIN RESULTS: Of 51,487 CABG surgeries, 5,361 (10.4%; [95% confidence interval [CI]: 10.1-10.7%]) developed acute kidney injury and the mean length of hospitalization was 8.8 days (95% CI: 8.7-8.8). The TEE group demonstrated a greater absolute risk difference (RD) for acute kidney injury by multiple linear regression, overall, (RD=+1.0; [95% CI: 0.4-1.5%]; p < 0.001) and among a low-risk subgroup (RD=+1.0; [95% CI: 0.4-1.6; p = 0.002), but not by instrumental variable analysis (RD=+0.9 [95% CI: -1.1 to 2.9%]; p = 0.362). The TEE group demonstrated a longer length of hospitalization by multiple linear regression, overall (+2.0%; [95% CI: 1.1-2.9%]; p < 0.001), among a low-risk subgroup (+2.2%; [95% CI: 1.2-3.2%]; p < 0.001), and by instrumental variable analysis (+10.3%; [95% CI: 7.0-13.7%]; p < 0.001). CONCLUSIONS: TEE monitoring in CABG surgery was not associated with a lower incidence of acute kidney injury or decreased length of hospitalization. These findings highlight the importance of additional work to study the clinical effectiveness of TEE in CABG surgery.

Rates of Hospital Readmission Among Medicare Beneficiaries With Gastrointestinal Bleeding Vary Based on Etiology and Comorbidities.

BACKGROUND & AIMS: Gastrointestinal bleeding results in significant morbidity, mortality, and healthcare costs in the United States. The Center for Medicare and Medicaid Services' payment reform programs assess quality and value based on rates of hospital readmission for patients with gastrointestinal bleeding, but they identify these patients using Medicare Severity Diagnosis Related Groups (MS-DRGs), which include many types of gastrointestinal bleeding and do not account for the clinical heterogeneity among these patients. We aimed to characterize heterogeneity in outcomes of subgroups of patients with gastrointestinal bleeding. METHODS: We performed was a cross-sectional, claims-based retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding in 2014 (159,000 hospitalizations). The primary outcome was unplanned readmission within 30 days of discharge from the hospital (30-day readmission). Secondary outcomes included length of stay, inpatient mortality, and death within 30 days of admission to the hospital (30-day mortality). Analyses were adjusted for age, sex, race, and Elixhauser comorbidities using logistic and Poisson regression, adjusting for clustering within hospitals. RESULTS: The 30-day readmission rate was 16.0%. Readmission rates varied among patients with different types of gastrointestinal bleeding, ranging from 13.5% for diverticular bleeding to 18.6% for small bowel bleeding. The mean length of stay was 4.2 days and 30-day mortality was 6.9% (ranging from 3.4% for diverticular bleeding to 12.1% for upper gastrointestinal bleeding not otherwise specified). When hospitalizations were stratified by MS-DRGs, the main source of variation in rates of readmission and mortality was MS-DRGs. CONCLUSIONS: In a retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding, we found that 16% of these patients are readmitted to the hospital. Rates of hospital readmission, length of stay, and mortality vary with type of gastrointestinal bleeding, but MS-DRGs account for the largest source of variation. Policies focused on quality and value should account for this heterogeneity.

Use of instrumental variables for endogenous treatment at the provider level.

Health economists are often interested in the effects of provider-level attributes (e.g., nonprofit status or quality rating) on patient outcomes, but estimation is subject to selection bias due to correlation with other omitted provider-level attributes that also affect patient outcomes. Recently, researchers have attempted to use patient-level instrumental variables, such as differential distance, to solve this problem of a provider-level endogenous treatment variable in settings where patients are nested within providers. However, to satisfy validity assumptions, an instrumental variable for a provider attribute must be at the provider level or a larger unit of aggregation, not at the patient level. A patient-level instrument cannot predict variation in a provider attribute separately from other, potentially unmeasured, provider attributes. In this paper, we explain this misapplication, review the extent of this problem in recent literature, and offer alternative approaches to avoid this misapplication of patient-level instrumental variables.

Organizational Processes and Patient Experiences in the Patient-centered Medical Home.

BACKGROUND: There is increasing emphasis on the use of patient-reported experience data to assess practice performance, particularly in the setting of patient-centered medical homes. Yet we lack understanding of what organizational processes relate to patient experiences. OBJECTIVE: Examine associations between organizational processes practices adopt to become PCMH and patient experiences with care. RESEARCH DESIGN: We analyzed visit data from patients (n=8356) at adult primary care practices (n=22) in a large health system. We evaluated the associations between practice organizational processes and patient experience using generalized estimating equations (GEE) with an exchangeable correlation structure to account for patient clustering by practice in multivariate models, adjusting for several practice-level and patient-level characteristics. We evaluated if these associations varied by race/ethnicity, insurance type, and the degree of patient comorbidity MEASURES:: Predictors include overall PCMH adoption and adoption of six organizational processes: access and communications, patient tracking and registry, care management, test referral tracking, quality improvement and external coordination. Primary outcome was overall patient experience. RESULTS: In our full sample, overall PCMH adoption score was not significantly associated with patient experience outcomes. However, among subpopulations with higher comorbidities, the overall PCMH adoption score was positively associated with overall patient experience measures [0.2 (0.06, 0.4); P=0.006]. Differences by race/ethnicity and insurance type in associations between specific organizational processes and patient experience were noted. CONCLUSION: Although some organizational processes relate to patients' experiences with care irrespective of the background of the patient, further efforts are needed to align practice efforts with patient experience.

Improving Patient-centered Care: How Clinical Staff Overcome Barriers to Patient Engagement at the VHA.

BACKGROUND: While patient engagement can be beneficial for patient care, there are barriers to engaging patients. These barriers exist for health care organizations, for health care personnel, and for the patients themselves. Solutions to barriers are not well documented. OBJECTIVES: Our objective was to explore barriers to patient engagement efforts and their corresponding solutions. RESEARCH DESIGN: Qualitative interviews and site visits from a national sample of primary care facilities within the Veterans Health Administration were analyzed to understand patient engagement barriers and solutions. SAMPLING: We conducted a total of 155 phone and in-person semistructured interviews with primary care providers, mental health staff, social workers, pharmacists, patient advocates, health behavior coaches, and administrative staff at 27 Veterans Health Administration sites. Participants were asked to describe the obstacles they had to overcome in their efforts to improve patient engagement at their site. RESULTS: Barriers to patient engagement are overcome by strategically updating data analytics; enhancing organization-wide processes and procedures; being creative with space design, staff hiring, and time commitments; cultivating staff collaborations; and addressing patient care issues such as access, customer service, and patient education. A key component of successful implementation is to create a culture, supported by leadership that promotes patient engagement. CONCLUSIONS: Participants understood the patient centered approach, despite experiencing a lack of resources and training and could push through solutions to patient engagement barriers while working within the limits of their settings.

Do Changes in Post-acute Care Use at Hospitals Participating in an Accountable Care Organization Spillover to All Medicare Beneficiaries?

BACKGROUND: While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown. OBJECTIVE: The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare Shared Savings Program (MSSP). DESIGN: Observational study using a difference-in-differences design comparing changes in PAC utilization and spending among beneficiaries admitted to ACO-participating hospitals before and after the start of the ACO contracts, compared to those admitted to non-ACO hospitals. SETTING: A total of 233 hospitals participate in MSSP ACOs and 3103 non-ACO hospitals. PARTICIPANTS: A national sample of 11,683,573 Medicare beneficiaries experiencing 26,503,086 hospital admissions from 2010 to 2013. EXPOSURE: Admission to a hospital participating in an MSSP ACO. MAIN MEASURES: The probability of discharge and Medicare payments to inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and home health agencies (HHA). KEY RESULTS: For beneficiaries admitted to hospitals that joined an ACO, the likelihood of being discharged to PAC did not change after the hospital joined the ACO compared with non-ACO hospitals over the same period (differential change in probability of discharge to any PAC was 0.000 (P = 0.89), SNF was 0.000 (P = 0.73), IRF was 0.000 (P = 0.96), and HHA was 0.001 (P = 0.57)). Payments reduced significantly for PAC overall (- $130.41, P = 0.03), but not for any individual PAC type alone. These results were consistent in samples that were conditional on discharge to any PAC, across conditions with high PAC use nationally, and among ACO-participating hospitals that also had a PAC participant. CONCLUSIONS: Hospital participation in an ACO did not result in spillovers in PAC utilization or payments to all beneficiaries, even when considering high PAC-use conditions and ACO hospitals that also have an ACO-participating PAC.

Association Between 5-Star Nursing Home Report Card Ratings and Potentially Preventable Hospitalizations.

Nursing homes' publicly reported star ratings increased substantially since Centers for Medicare & Medicaid Services's Nursing Home Compare adopted a 5-star rating system. Our objective was to test whether the improvements in nursing home 5-star ratings were correlated with reductions in rates of hospitalization. We hypothesized that increased attention to 5-star star ratings motivated nursing homes to make changes that improved their star ratings but did not affect their hospitalization rate, resulting in a weakened association between ratings and hospitalizations. We used 2007-2010 Medicare hospital claims and nursing home clinical assessment data to compare the correlation between nursing home 5-star ratings and hospitalization rates before versus after 5-star ratings were publicly released. The correlation between the rate of hospitalization and a nursing home's 5-star rating weakened slightly after the ratings became publicly available. This decrease in correlation was concentrated among patients receiving post-acute care, who experienced relatively more hospitalizations from best-rated nursing homes. The improvements in nursing home star ratings after the release of Medicare's 5-star rating system were not accompanied by improvements in a broader measure of outcomes for post-acute care patients. Although this dissociation may be due to better matching of sicker patients to higher-quality nursing homes or superficial improvements by nursing homes to increase their ratings without substantial investments in quality improvement, the 5-star ratings nonetheless became less meaningful as an indicator of nursing home quality for post-acute care patients.