Showing posts with label readmission rates. Show all posts
Showing posts with label readmission rates. Show all posts
Thursday, March 29, 2012
(2nd article) Medicare's Readmissions-Reduction Program — A Positive Alternative — NEJM
Medicare's Readmissions-Reduction Program — A Positive Alternative — NEJM
Hospital readmissions are receiving increasing attention as a largely correctable source of poor quality of care and excessive spending. According to a 2009 study, nearly 20% of Medicare beneficiaries are rehospitalized within 30 days after discharge, at an annual cost of $17 billion.1 Causes of avoidable readmissions include hospital-acquired infections and other complications; premature discharge; failure to coordinate and reconcile medications; inadequate communication among hospital personnel, patients, caregivers, and community-based clinicians; and poor planning for care transitions........
Thirty-Day Readmissions — Truth and Consequences — NEJM
Thirty-Day Readmissions — Truth and Consequences — NEJM
Reducing hospital readmission rates has captured the imagination of U.S. policymakers because readmissions are common and costly and their rates vary — and at least in theory, a reasonable fraction of readmissions should be preventable. Policymakers therefore believe that reducing readmission rates represents a unique opportunity to simultaneously improve care and reduce costs. As part of the Affordable Care Act (ACA), Congress directed the Centers for Medicare and Medicaid Services (CMS) to penalize hospitals with “worse than expected” 30-day readmission rates. This part of the law has stimulated hospitals, professional societies, and independent organizations to invest substantial resources in finding and implementing solutions for the “readmissions problem.”..........
Tuesday, March 13, 2012
Editorial: The Relationship Between Cost and Quality, No Free Lunch - March 14, 2012 — JAMA + link to original article
The Relationship Between Cost and Quality, March 14, 2012, Joynt and Jha 307 (10): 1082 — JAMA
Editorial: The Relationship Between Cost and Quality
No Free Lunch
Since this article does not have an abstract, we have provided the first 150 words of the full text. (Blogger's Note: subscription required to view $$$)
"For the past 30 years, research from
investigators at Dartmouth has demonstrated large and persistent
variations in costs
and quality across the US health care system. Beyond
simply showing that cost and quality vary by geography, the Dartmouth
Atlas has demonstrated that in many communities, care
is so fragmented and ineffective that greater spending on Medicare
beneficiaries
often leads to worse outcomes1,2 because some patients receive services that are redundant and low value and that may even have substantial risks.
However, some US policy makers have
misinterpreted the Dartmouth research and in the troves of data have
found what they believe
to be a free lunch: given the inverse relationship
between costs and quality, it follows that it should be possible to
simultaneously
reduce spending and improve care. Although this notion
is attractive, much of the subtlety of the Dartmouth work has been
lost in translation. What ....."
open access: Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario (Canada) Hospitals, March 14, 2012 — JAMA
Blogger's Note: universal healthcare system, this study included colorectal cancer patients, comparisons between Canadian/U.S. systems, note authors' affiliations
Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals, March 14, 2012
"Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively (and at higher cost) have lower mortality and readmissions and higher quality of care.......We studied 4 common conditions that have moderate to high incidence and mortality, that can be validly ascertained using health administrative data, and for which treatment follows relatively standard protocols. "
Design Overview
We undertook a longitudinal cohort
study of patients hospitalized with selected acute clinical conditions
in Ontario, Canada,
and assessed the content, quality, and outcomes
with respect to “exposure” to the index hospital's medical spending
intensity.
Medical intensity is defined as the quantity of
medical care provided overall to similarly ill patients and is a marker
of
a hospital's propensity to treat similarly ill
patients more (or less) intensively. It reflects the component of
spending
variation attributable to practice style rather
than to differences in illness or price.
Because sicker patients use more
services, higher-spending hospitals may appear to have worse outcomes,
in part because patients
are more severely ill. We used several
techniques to remove this potential “reverse causality,” as in previous
work.1,2,3,4COMMENT
We found that higher hospital spending
intensity was associated with better survival, lower readmission rates,
and better
quality of care for seriously ill, hospitalized
patients in Ontario in a universal health care system with more
selective
access to medical technology. Higher-spending
hospitals were higher-volume teaching or community hospitals with
high-volume
or specialist attending physicians and having
specialized programs, such as regional cancer centers, and specialized
services,
such as on-site cardiac catheterization, cardiac
surgery, and diagnostic imaging facilities. The study also points to
plausible
mechanisms through which higher spending may be
associated with better outcomes.
Benefits appeared early, suggesting an
acute-phase hospital effect. For acute conditions, timely access to
preoperative and
in-hospital specialist care, skilled nursing staff,
rapid response teams, cardiac high-technology services, and regional
cancer
centers, all found in the higher-spending systems,
are related to better outcomes.21,27,34,35,36,37,38,39 These systems also provided consistently, but not strikingly, higher levels of evidence-based care and collaborative ambulatory
care, both shown to improve care.22,23,40 Higher spending on evidence-based services delivered in the acute phase of care for severely ill hospitalized patients—by
far the largest component of spending for our cohorts—is indeed likely to be beneficial.
It would be facile to interpret this
study as demonstrating that higher spending is causally related to
better outcomes and
that providing more money to lower-spending
hospitals would necessarily improve their outcomes. Higher-spending
hospitals
differed in many ways, such as greater use of
evidence-based care, skilled nursing and critical care staff, more
intensive
inpatient specialist services, and high technology,
all of which are more expensive.
To place the study in context, the United
States has a 3- to 4-times higher per capita supply of specialized
technology, such
as computed tomography and magnetic resonance
imaging scanners, but a similar supply of acute care beds and nurses.41 Ontario 2001 population rates of cardiac testing and revascularization lagged behind corresponding 1992 US rates and paralleled
the supply of cardiologists and catheterization facilities.42,43,44
It is therefore possible that Canadian hospitals, with fewer
specialized resources, selective access to medical technology,
and global budgets, are using these resources more
efficiently, especially during the inpatient episode for care-sensitive
conditions.45,46 Canada's health care expenditures per capita are about 57% of those in the United States.47
At this spending level, there might still be a positive association
between spending and outcomes. For example, the same-day
PCI rate for patients with AMI in low-intensity
hospitals in 2008 was 3.5%, leaving room for improvement. This pattern
is
consistent with studies in the United States
showing a positive association between spending and outcomes among
low-intensity
hospitals or regions but no association at average
or higher intensity levels.5,6
Strengths of the study include the
population-based, longitudinal cohort design; the consistency of
findings across cardiac,
cancer, medical, and surgical patients; the
examination of plausible clinical mechanisms whereby higher intensity
may be associated
with better outcomes; and the examination of
readmissions. The “look-back” (EOL-EI) and “look-forward” (AC-EI)
measures of
spending intensity were highly correlated and
produced similar findings, as in US studies.2
Several limitations should be considered.
Because the design precludes strong inferences about causation, we
cannot know which
components of care may have led to better outcomes.
In observational studies, comparisons of exposure groups may be biased
because of unobserved selection bias.13
It is unlikely that the findings are the result of unmeasured case mix,
because patients in higher-spending hospitals had
similar or higher illness severity at admission,
which would, if anything, bias toward finding worse outcomes. We cannot
rule
out the possibility that higher-intensity hospitals
coded more aggressively, but there is less incentive to do so in a
system
with global hospital budgets. Although admission
severity would be determined more accurately using clinical detail from
medical
charts, previous work has shown high concordance
between risk-adjusted hospital outcomes using chart and administrative
data.48,49 Canadian data distinguish between comorbidities present at admission and complications, leading to improved admission severity
coding. The EOL-EI has been critiqued for the purpose of estimating hospital efficiency50,51 but is used here simply to distinguish high- and low-intensity hospitals, as in other US studies.1,2,3,4
The findings may not generalize to chronic conditions, for which
avoiding exacerbations of disease that lead to hospitalization
through coordinated ambulatory care is key. The
findings also may not generalize to jurisdictions in which hospital
resources
are more abundant and are used in cost-effective as
well as cost-ineffective ways, leading to inefficiency.45,46
This study shows that in Ontario, a
province with global hospital budgets and fewer specialized health care
resources than
the United States, outcomes following an acute
hospitalization are positively associated with higher hospital spending
intensity.
Higher spending intensity, in turn, is associated
with greater use of specialists, better patient care, and more use of
advanced
procedures. These results suggest that it is
critical to understand not simply how much money is spent but whether it
is spent
on effective procedures and services.
pdf file:
http://jama.ama-assn.org/content/307/10/1037.full.pdf
pdf file:
http://jama.ama-assn.org/content/307/10/1037.full.pdf
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