Background

A variety of approaches have been used to contain escalating hospital costs. One approach is intensifying price competition. The increase in price based competition, which changes the incentives hospitals face, coupled with the fact that consumers can more easily evaluate the quality of hotel services compared with the quality of clinical care, may lead hospitals to allocate more resources into hotel rather than clinical services.

Methods

To test this hypothesis we studied hospitals in California in 1982 and 1989, comparing resource allocations prior to and following selective contracting, a period during which the focus of competition changed from quality to price. We estimated the relationship between clinical outcomes, measured as risk-adjusted-mortality rates, and resources.

Results

In 1989, higher competition was associated with lower clinical expenditures levels compared with 1982. The trend was stronger for non-profit hospitals. Lower clinical resource use was associated with worse risk adjusted mortality outcomes.

Conclusions

This study raises concerns that cost reductions may be associated with increased mortality.

Background

Quality report cards have been shown to be effective in influencing patients' referrals and promoting quality improvement in some instances and not others. In this study, we investigate one of the mechanisms that may detract from their effectiveness: voluntary versus mandatory participation of nursing homes in public quality reporting.

Objectives

To answer 2 questions: (1) Were the nursing homes choosing not to participate low-quality performers relative to those who chose to participate? (2) Once participation became mandatory, did those that did not voluntarily participate initially, improve more than those that participated voluntarily?

Research design

Massachusetts published the Massachusetts Satisfaction Survey report card for nursing homes for the years 2005, 2007, and 2009. Nursing homes' participation was voluntary in 2005 and mandatory in 2007 and 2009. We performed a retrospective statistical analysis of the relationship between nursing homes' decision to participate in quality reporting and 12 quality outcomes: deficiency citations, staffing, and 8 survey domains.

Subjects

A total of 424 Massachusetts nursing homes.

Results

Sixty-seven percent of nursing homes participated in reporting voluntarily. Volunteer nursing homes had better quality for all measures (significant at the 0.05 level or trending toward significance at the 0.10 level for all but 2). Once reporting became mandatory, nonvolunteers improved more than volunteers in all but 2 staffing measures (trending toward significance at the 0.10 level in 5).

Conclusions

Report cards are more effective if nursing homes' participation is mandated. Nonmandatory reporting systems, as those implemented by some states and professional associations, lead to missed opportunities for quality improvements.

Objectives

To identify consumers' preferences over care settings, such as physicians' offices, emergency rooms (ERs), urgent care centers, retail clinics, and virtual physicians on smartphones, for minor illnesses.

Data sources

A survey conducted between 9/27/16 and 12/7/16 emailed to all University of California, Irvine employees.

Study design

Participants were presented with 10 clinical scenarios and asked to choose the setting in which they wanted to receive care. We estimated multinomial conditional logit regression models, conditioning the choice on out-of-pocket costs, wait time, travel time, and chooser characteristics.

Data collection

5451 out of 21 037 employees responded.

Principal findings

Out-of-pocket costs and wait time had minimal impact on patient's preference for site of care. Choices were driven primarily by the clinical scenario and patient characteristics. For chronic conditions and children's well-visits, the doctor's office was the preferred choice by a strong majority, but for most acute conditions, either the ER (for high severity) or urgent care clinics (for lower severity) were preferred to the office setting, particularly among younger patients and those with less education.

Conclusions

Patients have several alternatives to traditional physicians' offices and ERs. The low impact of out-of-pocket costs suggests that insurers interested in encouraging increased utilization of alternatives would need to consider substantial changes to benefit structure.

Do insurance plans offered through the Marketplace implemented by the State of California under the Affordable Care Act restrict consumers' access to hospitals relative to plans offered on the commercial market? And are the hospitals included in Marketplace networks of lower quality compared to those included in the commercial plans? To answer these questions, we analyzed differences in hospital networks across similar plan types offered both in the Marketplace and commercially, by region and insurer. We found that the common belief that Marketplace plans have narrower networks than their commercial counterparts appears empirically valid. However, there does not appear to be a substantive difference in geographic access as measured by the percentage of people residing in at least one hospital market area. More surprisingly, depending on the measure of hospital quality employed, the Marketplace plans have networks with comparable or even higher average quality than the networks of their commercial counterparts.

Background

High-quality care for long-term nursing home residents should include discussions and follow-up on patients' end-of-life care wishes. Yet, recent changes to the Minimum Data Set data collection exclude this information from routine assessment of patients mandated by the Centers for Medicare & Medicaid Services, making the provision of high-quality end-of-life care less likely. We examined the stability of cardiopulmonary resuscitation (CPR) and do-not-resuscitate (DNR) orders to offer guidance to policy and care practice developments.

Methods

We examined changes in DNR status of a national long-term care nursing home cohort, following them for 5 years after admission. A competing risk model was estimated to identify covariates predicting changes from CPR to DNR status and vice versa.

Results

About half the cohort chose DNR at admission and did not change its status. Of those who entered with CPR status, 40% changed to DNR. The most important factors influencing change were hospitalizations and nursing home transfers, followed by race and ethnicity with black race (relative to white) in particular having the largest effect on change. Other individual and nursing home characteristics influenced the likelihood of changing from CPR to DNR as well.

Conclusions

Long-term nursing home patients who enter with full-code CPR have a high probability of changing their status to DNR during their stay. High-quality care should offer them the opportunity to revisit their choice periodically, documenting changes in end-of-life choices when they occur, thus ensuring that care will match patients' wishes. As the Minimum Data Set plays a prominent role in patients' care, Centers for Medicare & Medicaid Services should consider reinstating information about advance directive in it.

Objectives

To examine the incidence of, variations in, and costs of potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents at the end of life and to identify the association between NH characteristics and a facility-level quality measure (QM) for PAH.

Design

Retrospective.

Setting

Hospitalizations originating from NHs.

Participants

Long-term care NH residents who died in 2007.

Measurements

A risk-adjusted QM was constructed for PAH. A Poisson regression model was used to predict the count of PAH given residents' risk factors. For each facility, the QM was defined as the difference between the observed facility-specific rate (per 1,000 person-years) of PAH (O) and the expected risk-adjusted rate (E). A logistic regression model with state fixed-effects was then fit to examine the association between facility characteristics and the likelihood of having higher-than-expected rates of PAH (O-E > 0). QM values greater than 0 indicate worse-than-average quality.

Results

Almost 50% of hospital admissions for NH residents in their last year of life were for potentially avoidable conditions, costing Medicare $1 billion. Five conditions were responsible for more than 80% of PAHs. PAH QM across facilities showed significant variation (mean 12.0 ± 142.3 per 1,000 person-years, range -399.48 to 398.09 per 1,000 person-years). Chain and hospital-based facilities were more likely to exhibit better performance (O-E < 0). Facilities with higher nursing staffing were more likely to have better performance, as were facilities with higher skilled staff ratio, those with nurse practitioners or physician assistants, and those with on-site X-ray services.

Conclusion

Variations in facility-level PAHs suggest that a potential for reducing hospital admissions for these conditions may exist. Presence of modifiable facility characteristics associated with PAH performance could help us formulate interventions and policies for reducing PAHs at the end of life.

Objectives

To examine whether racial differences in end-of-life (EOL) hospitalizations vary according to the presence of advance directives, specifically do-not-hospitalize (DNH) orders, and individual cognitive status in nursing home (NH) residents.

Design

National data, including Medicare data and Minimum Data Set (MDS) 2.0, between January 1, 2007, and September 30, 2010, were linked. EOL hospitalizations were hospitalizations in the last 30 days of life. Linear probability models with an interaction term (between race and DNH) and NH fixed-effects were estimated. The analyses were stratified according to cognitive status.

Setting

Nursing homes in the United States.

Participants

Dually eligible Medicare-Medicaid decedents enrolled in Medicare fee-for-service plans and long-stay NH residents (in NHs ≥ 90 days before death) (N = 394,948).

Measurements

Racial difference in EOL hospitalizations from a NH.

Results

End-of-life hospitalization rate was 31.7% for whites and 42.8% for blacks. For participants without DNH orders, adjusted probability of EOL hospitalization was higher for blacks than for whites: 2.7 percentage points in those with moderate cognitive impairment (P < .001) and 4.7 percentage points in those with severe cognitive impairment (P < .001). For those with DNH orders, adjusted racial differences in EOL hospitalization were not statistically significant in those with moderate (P = .25) or severe (P = .93) cognitive impairment, but blacks had a higher probability of EOL hospitalization than whites if they had relatively intact cognitive status.

Conclusion

Racial differences in EOL hospitalization varied with DNH orders and cognitive status in dying residents. Future research is necessary to understand the reasons behind these variations.

Background

Reducing 30-day hospital readmissions has become a focus of the current national payment policies. Medicare requires that hospitals collect and report patients' experience with their care as a condition of payment. However, the extent to which patients' experience with hospital care is related to hospital readmission is unknown.

Methods

We established multivariate regression models in which 30-day risk-adjusted readmission rates were the dependent variables and patients' perceptions of the responsiveness of the hospital staff and communication (as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores) were the independent variables of interest. We selected six different clinical conditions for analyses, including acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure, hip/knee surgery, pneumonia, and stroke. Data included all acute care hospitals reporting in Hospital Compare in 2014.

Results

The number of hospitals with reported readmissions ranged from 2234 hospitals for AMI to 3758 hospitals for pneumonia. The average 30-day readmission rates ranged from 5.19% for knee/hip surgery to 22.7% for COPD. Patient experience of hospital-staff responsiveness as "top-box" ranged from 64% to 67% across the six clinical conditions, communication with nurses ranged from 77% to 79% and communication with doctors ranged from 80% to 81% (higher numbers are better). Our finding suggests that hospitals with better staff responsiveness were significantly more likely to have lower 30-day readmissions for all conditions. The effect size depended on the baseline readmission rates, with the largest effect on hospitals in the upper 75th quartile. A ten-percentage-point increase in staff responsiveness led to a 0.03-0.18 percentage point decrease in readmission rates. We found that neither communication with physicians nor communication with nurses was significantly associated with hospital readmissions.

Conclusions

Our findings suggest that elements of care related to staff responsiveness during patients' stay may influence rehospitalization rates. Changes in staff responsiveness may offer an additional tool for hospitals to employ ongoing efforts to achieve reductions in readmissions, an important objective both financially and for patient health outcomes.

Throughout life, patients with multiple sclerosis (MS) require increasing levels of support, rehabilitative services, and eventual skilled nursing facility (SNF) care. There are concerns that access to SNF care for MS patients is limited because of perceived higher costs of their care. This study compares costs of caring for an MS patient versus those of a typical SNF patient. We merged SNF cost report data with the 2001-2006 Nursing Home Minimum Data Set (MDS) to calculate percentage of MS residents-days and facility case-mix indices (CMIs). We estimated the average facility daily cost using hybrid cost functions, adjusted for facility ownership, average facility wages, CMI-adjusted number of SNF days, and percentage of MS residents-days. We describe specific characteristics of SNF with high and low MS volumes and examine any sources of variation in cost. MS patients were no longer more costly than typical SNF patients. A greater proportion of MS patients had no significant effect on facility daily costs (P = 0.26). MS patients were more likely to receive care in government-owned facilities (OR = 1.904) located in the Western (OR = 2.133) and Midwestern (OR = 1.3) parts of the USA (P < 0.05). Cost of SNF care is not a likely explanation for the perceived access barriers that MS patients face.

Objectives

Although many prior studies have shown that high average levels of nurse staffing in nursing homes are associated with fewer hospitalizations, some studies have not, suggesting that the average nursing level may mask a more complex relationship. This study examines this issue by investigating the associations of daily staffing patterns and daily hospitalizations and emergency department (ED) visits.

Design

Retrospective analyses of national Payroll Based Journal (PBJ) staffing data merged with the Minimum Data Set.

Setting and participants

A total of 15,718 nursing homes nationally reporting PBJ data during 2017-2019, their staff, and residents.

Methods

We estimated facility-day-level models as conditional facility fixed-effect Poisson regressions with robust standard errors. The dependent variables were daily numbers of hospitalization and ED visits and the independent variables of interest were the number of registered nurse (RN), licensed practical nurse (LPN), and certified nurse assistant (CNA) hours on the same and prior days.

Results

The daily number of hospital transfers averaged 0.28 (SD 0.21). Daily total direct-care staffing hours averaged 288.7 (SD 188.2), with RNs accounting for 35.0, LPNs for 68.7, and CNAs for 185.0. Higher staffing was associated with more hospitalizations on the concurrent day. Higher staffing on the day prior was associated with fewer hospitalizations. The effect size was larger for RNs and LPNs (same day = ∼2%; prior day = approximately -0.7% to -0.9%) than for CNAs (same day <1%; prior day < -0.5%). ED visits not leading to hospitalizations, and analyses for subsamples exhibited similar findings.

Conclusions and implications

Our findings suggest that staff can address developing problems and prevent admissions the next day and identify emergent problems and hospitalize the same day. They also underscore the complex array of nursing home factors involved in hospitalization and ED visits, including the influence of daily staffing variation, suggesting the need for further research to better understand the associations between staffing and appropriate resident transfers to the hospital or the ED, and the potential implications for quality metrics in these domains.