Acute Care Episode Research Articles

Cost Burden of 30-Day Readmissions Following Medicare Total Hip and Knee Arthroplasty

The Centers for Medicare and Medicaid Services has proposed bundling of payments for acute care episodes for certain procedures, including total joint arthroplasty. The purpose of this study is to quantify the readmission burden of TJA as a function of readmission rate and reimbursement for the bundled payment. Using the hospital’s administrative database, we identified all unplanned 30-day readmissions following index admissions for total hip and total knee arthroplasty, and revision hip and knee arthroplasty among Medicare beneficiaries from 2009 to 2012. For each group, we determined 30-day readmission rates and direct costs of each readmission. The hospital cost margins for Medicare TJAs are small and any decrease in these margins can potentially make performing these procedures economically unfeasible potentially decreasing Medicare patient access.

Older adults with acquired brain injury: a population based study

BackgroundAcquired brain injury (ABI), which includes traumatic (TBI) and non-traumatic brain injury (nTBI), is a leading cause of death and disability worldwide. The objective of this study was to examine the trends, characteristics, cause of brain injury, and discharge destination of hospitalized older adults aged 65 years and older with an ABI diagnosis in a population with universal access to hospital care. The profile of characteristics of patients with TBI and nTBI causes of injury was also compared.MethodsA population based retrospective cohort study design with healthcare administrative databases was used. Data on acute care admissions were obtained from the Discharge Database and patients were identified using the International Classification of Diseases – Version 10 codes for Ontario, Canada from April 1, 2003 to March 31, 2010. Older adults were examined in three age groups – 65 to 74, 75 to 84, and 85+ years.ResultsFrom 2003/04 to 2009/10, there were 14,518 episodes of acute care associated with a TBI code and 51, 233 episodes with a nTBI code. Overall, the rate of hospitalized TBI and nTBI episodes increased with older age groups. From 2007/08 to 2009/10, the percentage of patients that stayed in acute care for 12 days or more and the percentage of patients with delayed discharge from acute care increased with age. The most common cause of TBI was falls while the most common type of nTBI was brain tumours. The percentage of patients discharged to long term care and complex continuing care increased with age and the percentage discharged home decreased with age. In-hospital mortality also increased with age. Older adults with TBI and nTBI differed significantly in demographic and clinical characteristics and discharge destination from acute care.ConclusionsThis study showed an increased rate of acute care admissions for both TBI and nTBI with age. It also provided additional support for falls prevention strategies to prevent injury leading to cognitive disability with costly human and economic consequences. Implications for increased numbers of people with ABI are discussed.

Bundled Payments for Care Improvement Initiative: The Next Evolution of Payment Formulations

The Patient Protection and Affordable Care Act contains a number of provision for improving the delivery of healthcare in the United States, among the most impactful of which may be the call for modifications in the packaging of and payment for care that is bundled into episodes. The move away from fee for service payment models to payment for coordinated care delivered as comprehensive episodes is heralded as having great potential to enhance quality and reduce cost, thereby increasing the value of the care delivered. This effort builds on the prior experience around delivering care for arthroplasty under the Acute Care Episode Project and offers extensions and opportunities to modify the experience moving forward. Total hip and knee arthroplasties are viewed as ideal treatments to test the effectiveness of this payment model. Providers must learn the nuances of these modified care delivery concepts and evaluate whether their environment is conducive to success in this arena. This fundamental shift in payment for care offers both considerable risk and tremendous opportunity for physicians. Acquiring an understanding of the recent experience and the determinants of future success will best position orthopaedic surgeons to thrive in this new environment. Although this will remain a dynamic exercise for some time, early experience may enhance the chances for long term success, and physicians can rightfully lead the care delivery redesign process.

Characteristics of Acute Care Utilization of a Delaware Adult Sickle Cell Disease Patient Population

Sickle cell disease (SCD) is an inherited blood disorder that is chronic in nature and manifests itself through many facets of the patient's life. Comprehensive specialty centers have the potential to reduce health care costs and improve the quality of care for patients who have chronic medical conditions such as heart failure and SCD. The purpose of this practice inquiry was to analyze de-identified data for acute care episodes involving SCD in order to create a detailed picture of acute care utilization for adult patients in Delaware with SCD from 2007 to 2009. Gaining a better understanding of acute care utilization for adults with SCD may provide evidence to improve access to high-quality health care services for this vulnerable patient population in the state of Delaware.

Health Information Technology: Are We Aware and Engaged?

Health Information Technology: Are We Aware and Engaged?

Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care

Patients with low socioeconomic status (SES) use more acute hospital care and less primary care than patients with high socioeconomic status. This low-value pattern of care use is harmful to these patients' health and costly to the health care system. Many current policy initiatives, such as the creation of accountable care organizations, aim to improve both health outcomes and the cost-effectiveness of health services. Achieving those goals requires understanding what drives low-value health care use. We conducted qualitative interviews with forty urban low-SES patients to explore why they prefer to use hospital care. They perceive it as less expensive, more accessible, and of higher quality than ambulatory care. Efforts that focus solely on improving the quality of hospital care to reduce readmissions could, paradoxically, increase hospital use. Two different profile types emerged from our research. Patients in Profile A (five or more acute care episodes in six months) reported social dysfunction and disability. Those in Profile B (fewer than five acute care episodes in six months) reported social stability but found accessing ambulatory care to be difficult. Interventions to improve outcomes and values need to take these differences into account.

A Case and Care Management Program to Reduce Use of Acute Care by Clients With Substance Use Disorders

OBJECTIVE The authors describe outcomes of a targeted case and care management program for persons with addictions utilizing a high level of acute services in Connecticut's system of care. METHODS Administrative and cost data were analyzed from five consecutive years (2004-2008) (N=165,305 clients). RESULTS In the year after enrollment, acute care episodes fell by 56% compared with the year before enrollment, with a 19% increase in engagement in nonacute care services. Paid units of acute care fell by 62%; paid units of nonacute care increased by 63%. Costs of care were approximately 46% lower in the year after enrollment. CONCLUSIONS Findings suggest that outcomes can be improved while costs and acute care demands can be reduced through combined use of care management to identify high users and case management to engage them in lower levels of care. The system was able to reallocate acute care resources to nonacute services and serve additional clients.

A retrospective quasi-experimental study of a community crisis house for patients with severe and persistent mental illness

There is increasing international evidence that crisis houses can reduce the time spent in acute psychiatric inpatient units for patients with severe and persistent mental illness, at a lower cost and in an environment preferable to patients. We evaluated the Alternatives to Hospitalisation (AtH) program, a crisis house operating in outer suburban Brisbane. One hundred and ninety-three AtH patients were compared to 371 matched controls admitted to a peer hospital district acute psychiatric unit. Hospitalisations, demographics and illness acuity were compared one year before and after an acute index episode of residential care involving hospital and/or AtH. Hospital bed-days during the index episode were compared between AtH participants and controls. The cost of bed-days averted was compared to the cost of providing the AtH program. AtH participants spent 5.35 fewer days in hospital during the index episode than controls, after adjustment for illness acuity, living conditions, marital status and emergency department (ED) presentations. Per patient cost of averted psychiatric inpatient bed-days, $5948.22, was higher than the per patient cost of providing AtH, $3071.44. AtH participants had higher levels of illness acuity, ED presentations and acute psychiatric admissions than controls in the year after the index episode. For acutely unwell, stably housed patients, able to be managed outside of a secure facility, a crisis house program can reduce acute psychiatric bed-days, providing a cost saving for mental health services.

Potential of Telemedicine to Provide Acute Medical Care for Adults in Senior Living Communities

Older adults dwelling in senior living communities (SLCs) often experience barriers to medical care when they experience acute illness. The potential of telemedicine as a substitute for standard routes of evaluating and caring for individuals with acute illness (e.g., in-person or telephone-based interactions with primary care providers and emergency department [ED] visits) was explored in this study. In this cross-sectional, observational study, the authors conducted a 6-month retrospective review of the medical records of adults enrolled in a university-affiliated geriatrics practice that offers on-site primary medical care in SLCs. For each episode of acute care, patient demographics, medical history, and chief complaint were collected and presented to an expert panel of physicians, who determined whether telemedicine could have been used to provide acute evaluation and care. The care actually provided, including outcomes, was also noted. Descriptive statistics were used to characterize the population and potential for telemedicine care. The medical records of 646 patients were reviewed, accounting for 1,535 unique episodes of acute care. The expert panel identified 576 visits (38%) as potentially appropriate for telemedicine-based acute care, with 38, 47, and 27% of phone, in-home, and ED visits being eligible, respectively. Chief complaints most likely to be deemed potentially appropriate were falls and dermatologic, respiratory, and gastrointestinal illnesses, representing 58% of visits identified for telemedicine-based acute care. Telemedicine has a potentially significant role in the provision of acute care for older adults residing in SLCs. Studies are needed to evaluate the feasibility, acceptability, effectiveness, and efficiency of acute care telemedicine for this population.

Burden of Bloodstream Infection Caused by Extended-Spectrum β-Lactamase–Producing Enterobacteriaceae Determined Using Multistate Modeling at a Swiss University Hospital and a Nationwide Predictive Model

To obtain an unbiased estimate of the excess hospital length of stay (LOS) and cost attributable to extended-spectrum β-lactamase (ESBL) positivity in bloodstream infections (BSIs) due to Enterobacteriaceae. Retrospective cohort study. A 2,200-bed academic medical center in Geneva, Switzerland. Patients admitted during 2009. We used multistate modeling and Cox proportional hazards models to determine the excess LOS and adjusted end-of-LOS hazard ratio (HR) for ESBL-positive and ESBL-negative BSI. We estimated economic burden as the product of excess LOS and average bed-day cost. Patient-level accounting data provided a complementary analysis of economic burden. A predictive model was fitted to national surveillance data. Thirty ESBL-positive and 96 ESBL-negative BSI cases were included. The excess LOS attributable to ESBL-positive and ESBL-negative BSI was 9.4 (95% confidence interval [CI], 0.4-18.4) and 2.6 (95% CI, 0.7-5.9) days, respectively. ESBL positivity was therefore associated with 6.8 excess days and CHF 9,473 per BSI. The adjusted end-of-LOS HRs for ESBL-positive and ESBL-negative BSI were 0.62 (95% CI, 0.43-0.89) and 0.90 (95% CI, 0.74-1.10), respectively. After reimbursement, the average financial loss per acute care episode in ESBL-positive BSI, ESBL-negative BSI, and control cohorts was CHF 48,674, 48,131, and 13,532, respectively. Our predictive model estimated that the nationwide cost of third-generation cephalosporin resistance would increase from CHF 2,084,000 in 2010 to CHF 3,526,000 in 2015. This is the first hospital-wide analysis of excess LOS attributable to ESBL positivity determined using multistate modeling to avoid time-dependent bias. These results may inform health-economic evaluations of interventions targeting ESBL control.

'Online' geriatric assessment procedure for older adults referred for geriatric assessment during an acute care episode for consideration of reliability of triage decisions

BackgroundComprehensive geriatric assessment has been shown to improve patient outcomes, but the geriatricians who deliver it are in short-supply. A web-based method of comprehensive geriatric assessment has been developed with the potential to improve access to specialist geriatric expertise. The current study aims to test the reliability and safety of comprehensive geriatric assessment performed "online" in making geriatric triage decisions. It will also explore the accuracy of the procedure in identifying common geriatric syndromes, and its cost relative to conventional "live" consultations.Methods/DesignThe study population will consist of 270 acutely hospitalized patients referred for geriatric consultation at three sites. Paired assessments (live and online) will be conducted by independent, blinded geriatricians and the level of agreement examined. This will be compared with the level of agreement between two independent, blinded geriatricians each consulting with the patient in person (i.e. "live"). Agreement between the triage decision from live-live assessments and between the triage decision from live-online assessments will be calculated using kappa statistics. Agreement between the online and live detection of common geriatric syndromes will also be assessed using kappa statistics. Resource use data will be collected for online and live-live assessments to allow comparison between the two procedures.DiscussionIf the online approach is found to be less precise than live assessment, further analysis will seek to identify patient subgroups where disagreement is more likely. This may enable a protocol to be developed that avoids unsafe clinical decisions at a distance.Trial registrationTrial registration number: ACTRN12611000936921

More Than Just Taking the Keys Away …

More Than Just Taking the Keys Away …

Transfer from residential aged care to emergency departments: an analysis of patient outcomes

In order to design optimal systems to meet the acute healthcare needs of the frail elderly living in residential care, good clinical information is essential. The aims of this study were to analyse the casemix and outcomes of patients transferred from residential aged care facilities to public hospital emergency departments in New South Wales. Individual patient data from six hospital emergency departments and inpatient wards were obtained from merged databases and analysed using descriptive and comparative statistics. Outcomes in 4680 patient transfers over a 12-month period in 2006-2007 were analysed. Transfers occur mostly in high-acuity patients, with approximately three of every four transfers admitted; one in every 12 dying; and admitted patients undergoing an average of 2.4 interventions or procedures during each hospital stay. Several variables are associated with prolonged length of emergency department stay including triage urgency, type of hospital and transfers occurring in winter or out of hours. Patients transferred from aged care facilities to emergency departments are predominantly high-acuity patients with a substantial likelihood of hospitalisation, intervention and death. Nevertheless, scope exists for some episodes of acute care, in both discharged and admitted patients, to be provided outside a hospital setting.

Bundled Medicare Pay Means Big Changes

Bundled Medicare Pay Means Big Changes

Medicare’s Bundled Payment Pilot For Acute And Postacute Care: Analysis And Recommendations On Where To Begin

In the National Pilot Program on Payment Bundling, a subset of Medicare providers will receive a single payment for an episode of acute care in a hospital, followed by postacute care in a skilled nursing or rehabilitation facility, the patient's home, or other appropriate setting. This article examines the promises and pitfalls of bundled payments and addresses two important design decisions for the pilot: which conditions to include, and how long an episode should be. Our analysis of Medicare data found that hip fracture and joint replacement are good conditions to include in the pilot because they exhibit strong potential for cost savings. In addition, these conditions pose less financial risk for providers than other common ones do, so including them would make participation in the program more appealing to providers. We also found that longer episode lengths captured a higher percentage of costs and hospital readmissions while adding little financial risk. We recommend that the Medicare pilot program test alternative design features to help foster payment innovation throughout the health system.

Community-Based Telemonitoring for Hypertension Management: Practical Challenges and Potential Solutions

Older adults residing in rural areas often lack convenient, patient-centered, community-based approaches to facilitate receipt of routine care to manage common chronic conditions. Without adequate access to appropriate disease management resources, the risk of seniors' experiencing acute events related to these common conditions increases substantially. Further, poorly managed chronic conditions are costly and place seniors at increased risk of institutionalization and permanent loss of independence. Novel, telehealth-based approaches to management of common chronic conditions like hypertension may not only improve the health of older adults, but may also lead to substantial cost savings associated with acute care episodes and institutionalization. The aim of this report is to summarize practical considerations related to operations and logistics of a unique community-based telemonitoring pilot study targeting rural seniors who utilize community-based senior centers. This article reviews the technological challenges encountered during the study and proposes solutions relevant to future research and implementation of telehealth in community-based, congregate settings.

Predisposing, Enabling, and Need Factors Associated with High Service Use in a Public Mental Health System

The purpose of this study was twofold: (1) To investigate the individual- and system-level characteristics associated with high utilization of acute mental health services according to a widely-used theory of service use—Andersen’s Behavioral Model of Health Service Use —in individuals enrolled in a large, public-funded mental health system; and (2) To document service utilization by high use consumers prior to a transformation of the service delivery system. We analyzed data from 10,128 individuals receiving care in a large public mental health system from fiscal years 2000–2004. Subjects with information in the database for the index year (fiscal year 2000–2001) and all of the following 3 years were included in this study. Using logistic regression, we identified predisposing, enabling, and need characteristics associated with being categorized as a single-year high use consumer (HU: >3 acute care episodes in a single year) or multiple-year HU (>3 acute care episodes in more than 1 year). Thirteen percent of the sample met the criteria for being a single-year HU and an additional 8% met the definition for multiple-year HU. Although some predisposing factors were significantly associated with an increased likelihood of being classified as a HU (younger age and female gender) relative to non-HUs, the characteristics with the strongest associations with the HU definition, when controlling for all other factors, were enabling and need factors. Homelessness was associated with 115% increase in the odds of ever being classified as a HU compared to those living independently or with family and others. Having insurance was associated with increased odds of being classified as a HU by about 19% relative to non-HUs. Attending four or more outpatient visits was an enabling factor that decreased the chances of being defined as a HU. Need factors, such as having a diagnosis of schizophrenia, bipolar disorder or other psychotic disorder or having a substance use disorder increased the likelihood of being categorized as a HU. Characteristics with the strongest association with heavy use of a public mental health system were enabling and need factors. Therefore, optimal use of public mental services may be achieved by developing and implementing interventions that address the issues of homelessness, insurance coverage, and substance use. This may be best achieved by the integration of mental health, intensive case management, and supportive housing, as well as other social services.

Novel approaches to incorporating pharmacoeconomic studies into phase III clinical trials for Alzheimer's disease.

The societal and individual costs of Alzheimer's disease are significant, worldwide. As the world ages, these costs are increasing rapidly, while health systems face finite budgets. As a result, many regulators and payers will require or at least consider phase III cost-effectiveness data (in addition to safety and efficacy data) for drug approval and reimbursement, increasing the risks and costs of drug development. Incorporating pharmacoeconomic studies in phase III clinical trials for Alzheimer's disease presents a number of challenges. We propose several specific suggestions to improve the design of pharmacoeconomic studies in phase III clinical trials. We propose that acute episodes of care are key outcome measures for pharmacoeconomic studies. To improve the possibility of detecting a pharmacoeconomic impact in phase III, we suggest several strategies including; study designs for enrichment of pharmacoeconomic outcomes that include co-morbidity of patients; reducing variability of care that can affect pharmacoeconomic outcomes through standardized care management; employing administrative claims data to better capture meaningful pharmacoeconomic data; and extending clinical trials in open label follow-up periods in which pharmacoeconomic data are captured electronically by administrative claims. Specific aspects of power analysis for pharmacoeconomic studies are presented. The particular pharmacoeconomic challenges caused by the use of biomarkers in clinical trials, the increasing use of multinational studies, and the pharmacoeconomic challenges presented by biologicals in development for Alzheimer's disease are discussed. In summary, since we are entering an era in which pharmacoeconomic studies will be essential in drug development for supporting regulatory approval, payor reimbursement and integration of new therapies into clinical care, we must consider the design and incorporation of pharmacoeconomic studies in phase III clinical trials more seriously and more creatively.

Access-Related Measures and Out-of-System Utilization Among Veterans With Bipolar Disorder

This study examined associations between access-related measures and out-of-system health services utilization (general medicine and mental health services) among patients with bipolar disorder at a U.S. Department of Veterans Affairs (VA) medical center. VA patients (N=391) with bipolar disorder answered questions about health services access (non-VA insurance coverage, travel distance to their VA facility, service-connected disability status, and difficulty receiving needed mental health care) and out-of-system services utilization. Multivariable Tobit regression was used to evaluate associations between access measures and propensity to receive out-of-system services. More than half the veterans (56%) reported some non-VA utilization. Out-of-system utilization was more likely among patients who were married, younger, homeless, with private insurance, without service-connected disabilities, and who reported access difficulties. Out-of-system utilization was associated with multiple measures of access and indicators specific to VA and non-VA providers. Enhancing health system access for patients with bipolar disorder may reduce out-of-system utilization, potentially enhancing continuity of care.

Health Care Reform and Speech-Language Pathology Practice

Health Care Reform and Speech-Language Pathology Practice