Risk Adjustment Research Articles

Development and internal validation of El-Shazly-Buchholz's nomogram to predict postoperative complications after PCNL: A multicenter study.

A model to predict the risk of surgical complications following percutaneous nephrolithotomy (PCNL) could be a useful tool to guide clinical decision-making. The aim of this study was to develop a simple and widely applicable stratification tool to be used for patient counseling, surgical planning, evaluation of outcomes, and academic reporting. Data of patients who underwent PCNL were retrieved from the database of the collaborating centers including demographics of patients, characteristics of their stones and urinary tracts, and perioperative data. The primary outcome was the development of postoperative complications. Data were randomly split into a training dataset (85%) and a validation dataset (15%). A univariate and multivariate logistic regression analysis of the training dataset was performed to identify independent predictors of postoperative complications. Model variables were used to construct a nomogram that was internally validated on the testing dataset by measuring calibration, discrimination, and plotting the decision curve. Six hundred thirty one patients (245 Males) with a median (IQR) age of 49 (37-56) years were included. Post-operative complications occurred in 147 (23.3%) patients. Significant predictors of complications included preoperative urine culture (p < 0.001), largest stone diameter (p = 0.02), and intraoperative blood loss (p = 0.002). A nomogram was developed from the predictors and applied to the validation dataset showing an area under the curve (95%CI) of 66.4% (52.2;80.6). This new scoring system emphasized patient characteristics and operative details rather than stone characters to predict the morbidity of PCNL. Furthermore, it should facilitate risk adjustment, enabling physicians to better define the nephrolithiasis disease continuum and identify patients who should be referred to tertiary care centers.

Material economic hardship is associated with adverse 1-year outcomes after pediatric liver transplantation: Prospective cohort results from the multi-center SOCIAL-Tx study.

Pediatric liver transplant outcomes exhibit disparities, necessitating identification of modifiable risk factors to develop targeted interventions. We characterized associations between household material economic hardship (e.g., financial barriers to housing or food) and pediatric liver transplant outcomes. We recruited pediatric liver transplant recipients <18 years at the time of transplant across 8 U.S. centers. Our primary exposure was >/=1 household material economic hardship (i.e., food insecurity, housing instability, transportation challenges, or utility concerns), measured using the Accountable Healthcare Communities screening tool. Outcomes included 90-day and 1-year (1) total inpatient-bed days, and (2) episodes of T-cell mediated rejection (TCMR). Of the 77 participants (36% female), 34% reported household material economic hardship. Such hardship was associated with increased total inpatient bed-days within 90 days (ratio estimate: 1.45, 95%CI: 1.08, 1.96); the association persisted after adjusting for health literacy, insurance, and transplant center (ratio estimate: 1.37, 95%CI: 1.02, 1.84). Household material economic hardship was associated with total inpatient bed-days within 1-year post-transplant (ratio estimate: 3.2, 95%CI: 1.1, 10.1); associations diminished in multivariable analyses (ratio estimate: 2.2, 95%CI: 0.7, 6.9). Household material economic hardship was associated with increased risk of TCMR within 1 year of transplant (RR: 2.1, 95%CI: 1.1, 4.2); the association diminished in propensity-score matched analyses (RR: 1.4, 95%CI: 0.9, 2.3). Our findings highlight the adverse influence of household material economic hardship on pediatric liver transplant outcomes within the first year. Targeted social risk assistance and adjustment strategies offer actionable avenues to mitigate these challenges and enhance outcomes in pediatric liver transplant recipients.

A retrospective multi-site examination of chronic kidney disease using longitudinal laboratory results and metadata to identify clinical and financial risk

BackgroundA retrospective observational study was conducted at 3 health care organizations to identify clinical gaps in care for patients with stage 3 or 4 chronic kidney disease (CKD), and financial opportunity from U.S. risk adjustment payment systems. Lack of evaluation for CKD in patients with diabetes was also assessed.MethodsOutpatient longitudinal laboratory results and patient metadata available in the electronic medical record, laboratory information system, and/or laboratory billing or facility claims data for the calendar year 2021 were evaluated. Laboratory results were compared to billing data (ICD-10 codes) and risk adjustment scores including Hierarchical Condition Categories (HCC) to determine if laboratory-identified CKD was coded as a disease condition in the electronic medical record. Adults 18 to 75 years of age were included; inpatient laboratory results and pregnant individuals were excluded.ResultsAt the 3 institutions, 12,478 of 16,063 (78%), 487 of 1511 (32%) and 19,433 of 29,277 (66%) of patients with laboratory evidence of stage 3 or 4 CKD did not have a corresponding ICD-10 or HCC code for CKD in the electronic medical record. For patients at the 3 institutions with diabetes on the basis of an HbA1c value of ≥ 6.5%, 34,384 of 58,278 (59%), 2274 of 2740 (83%) and 40,378 of 52,440 (77%) had not undergone guideline-recommended laboratory testing for CKD during the same 12 months. Using publicly available data for calendar year 2021, an estimated 3246 of 32,398 patients (9.9%) at the 3 institutions with undocumented CKD stages 3–4 would be enrolled in Medicare Advantage or Affordable Care Act Marketplace programs. The imputed lost reimbursement under risk-adjusted payment systems for under-documentation of CKD in this subset of patients was $2.85 M for the three institutions combined, representing lost opportunity for both identification and proactive clinical management of these patients, and financial recovery for the costs of providing that care.ConclusionsClinical laboratories can provide value beyond routine diagnostics, helping to close gaps in care for identification and management of CKD, stratifying subgroups of patients to identify risk, and capturing missed reimbursement through risk adjustment factors.

Incorporating clinical and demographic data into the Elixhauser Comorbidity Model: deriving and validating an enhanced model in a tertiary hospital’s internal medicine department

Background and objectivesThe Elixhauser Comorbidity Model is a prominent, freely-available risk adjustment model which performs well in predicting outcomes of inpatient care. However, because it relies solely on diagnosis codes, it may not capture the full extent of patient complexity. Our objective was to enhance and validatethe Elixhauser Model by incorporating additional clinical and demographic data to improve the accuracy of outcome prediction.MethodsThis retrospective observational cohort study included 55,945 admissions to the internal medicine service of a large tertiary care hospital in Jerusalem. A model was derived and validated to predict four primary outcomes. The four primary outcomes measured were length of stay (LOS), in-hospital mortality, readmission within 30 days, and increased care.ResultsInitially, the Elixhauser Model was applied using standard Elixhauser definitions based on diagnosis codes. Subsequently, clinical variables such as laboratory test results, vital signs, and demographic information were added to the model. The expanded models demonstrated improved prediction compared to the baseline model. For example, the R2 for log LOS improved from 0.101 to 0.281 and the c-statistic to predict in-hospital mortality improved from 0.711 to 0.879.ConclusionsAdding readily available clinical and demographic data to the base Elixhauser model improves outcome prediction by a considerable margin. This enhanced model provides a more comprehensive representation of patients’ health status. It could be utilized to support decisions regarding admission and to what setting, determine suitability for home hospitalization, and facilitate differential payment adjustments based on patient complexity.

Evaluation of early extubation in the operating room for paediatric patients after congenital open-heart surgery.

Advances in surgical and perioperative care have reduced the need for prolonged mechanical ventilation in children following cardiac surgery. To evaluate the feasibility and assess the clinical outcomes of an early extubation strategy in the operating room for children undergoing congenital heart surgery, including neonates (age < 28 days). This is a retrospective analysis including congenital open-heart surgery cases. We excluded patients who remained open chest postoperatively or patients with severe hemodynamic instability and high inotropic support from the study. Study variables include age, gender, weight, preoperative cardiac diagnosis, preoperative diagnosis of genetic or chromosomal abnormalities, prematurity, preoperative mechanical ventilation (invasive or non-invasive), cardiopulmonary bypass time, circulatory arrest time, postoperative use of inotropes, duration of mechanical ventilation, postoperative respiratory complication, sepsis, bleeding or other complications, paediatric cardiac ICU stay, total hospital stay, incidence of failed extubation, and operative or postoperative mortality. This study included 163 patients who underwent congenital open cardiac surgery, out of these studied patients, 118 (72.4%) were extubated in the operating room. In total, 19.6% of studied patients had Down syndrome. Other genetic or chromosomal disorders were present among 8.6% of studied patients. There was a statistically significant difference between operating room extubation group and non-operating room extubation group regarding Risk Adjustment for Congenital Heart Surgery Score classification, postoperative paediatric ICU duration, postoperative hospital length of stay, vasoactive-inotrope score, duration of inotrope, open chest, and mortality. Extubation in the operating room after congenital open-heart surgery was successful in most of our patients, even following complex procedures.

Multicenter Analysis of the Relationship Between Operative Team Familiarity and Safety and Efficiency Outcomes in Cardiac Surgery.

Safety in cardiac surgical procedures is predicated on effective team dynamics. This study associated operative team familiarity (ie, the extent of clinical collaboration among surgical team members) with procedural efficiency and Society of Thoracic Surgeons (STS) adjudicated patient outcomes. Institutional STS adult cardiac surgery registry and electronic health record data from 2014 to 2021 were evaluated across 3 quaternary hospitals. Team familiarity was defined as the mean number of cardiac operations performed by surgeon-anesthesiologist, surgeon-perfusionist, and anesthesiologist-perfusionist dyads within 1 year of the operation. The primary outcomes were (1) safety, measured by the STS' composite major morbidity and operative mortality measure, and (2) procedural efficiency, assessed by cardiopulmonary bypass duration. Team familiarity was stratified by terciles (low, moderate, and high) for crude analyses and analyzed continuously for adjusted analyses. Multivariable logistic and linear regression models were used to assess the association between team familiarity and outcomes. Team familiarity was calculated for 13 581 operations. The median (interquartile range) patient age was 64 (55-72) years, and 31.9% (4328/13 581) were women. Terciles of team familiarity were defined as low (<6.00 average shared operations), moderate (6.00-9.67), and high (>9.67). Teams in lower terciles had higher observed STS morbidity and mortality rates (low, 17.9%; moderate, 18.0%; high, 16.0%; P=0.02) and longer median cardiopulmonary bypass duration (low, 137 minutes; moderate, 131 minutes; high, 118 minutes; P<0.001). After risk adjustment, team familiarity was not significantly associated with STS morbidity and mortality (estimate, -0.001 [95% CI, -0.998 to 0.997]) but was inversely associated with cardiopulmonary bypass duration (estimate, -2.02 minutes per 1 unit increase in team familiarity [95% CI, -2.30 to -1.75]). Increased team familiarity was not associated with STS morbidity and mortality but was inversely correlated with cardiopulmonary bypass duration, demonstrating potential benefit. Interventions aimed at improving team familiarity among operative teams may increase procedural efficiency.

Short-term momentum and reversals, turnover, and a stock’s price-to-52-week-high ratio

We show that short-term reversal behavior declines with a stock’s turnover and the prior month’s price-to-52-week-high ratio (PTH), shifting to momentum for stocks with both a relatively high turnover and PTH. This behavior of consecutive one-month individual stock returns is robust to subperiod analysis, risk adjustments, and alternative methodologies. Our findings suggest opposing channels. First, promoting short-term momentum, our evidence implies a PTH-anchoring underreaction to recent news, consistent with the short-term contrarian price-dampening channel of Atmaz et al. (2024) with higher turnover implying a stronger contrarian-induced underreaction. Second, promoting short-term reversals, our evidence reinforces the importance of the well-known liquidity-provision-compensation channel. Reversals are especially strong for low-PTH, low-turnover stocks, where the lower PTH implies a generally smaller-cap, less-liquid stock and the lower turnover implies a weaker contrarian-induced underreaction. We also find that the return behaviors vary with dispersion in analysts’ earnings forecasts and with market-wide sentiment, in a manner consistent with these channels.

Excess Diagnosis Coding In Medicare Advantage: Evidence From Skilled Nursing Facility Clinical Assessments.

Some research suggests that risk adjustment plays a substantial role in explaining the high levels of government spending on Medicare Advantage (MA). We studied whether the reliance on diagnosis codes to risk-adjust payments to MA plans leads to the inflation of submitted diagnoses. Our approach relied on a comparison among diagnoses included in hospital claims, health status measures from similarly timed health assessments completed by skilled nursing facility (SNF) clinicians, and short-term mortality data. SNF assessments are completed for both MA and traditional Medicare enrollees and, in contrast to diagnoses in claims, cannot be directly manipulated by MA plans or inform their payments. We found that among patients with the same assessment-based health status discharged to the same SNF, claims-based disease scores were 4.1percent higher for MA enrollees, on average, relative to traditional Medicare enrollees. However, short-term mortality risk was, on average, 8.8percent lower for MA enrollees. About 60percent of the payer-based difference in disease scores was attributable to MA chart review updates to diagnoses, and additional codes from chart reviews were unrelated to assessment-based health status. Given the growth of MA and current spending on the program, which reached $321billion in 2021, this evidence of potential coding inflation may have large fiscal implications.

Incidence and risk factors for complications following cervical epidural steroid injections.

Cervical epidural steroid injections (CESIs) are commonly used in management of cervical pathology. While severe complications have been reported, they are rare, and thus their incidence and risk factors have not been well characterized. To determine the incidence of complications 7, 30, and 90 days after CESI and to identify associated risk factors. Retrospective cohort study of a large, national administrative claims database (MeritiveTM Marketscan®). The study included 229,412 patients (mean age 52.2 ± 11.3 years, 57.1% female) undergoing 448,209 CESIs from 2008-2015. Complication rates following CESI, and risk factors for complication. Adults undergoing a CESI with active enrollment for one year prior to and 90 days after CESI were included. Patients with neoplasm, fracture, infection, inflammatory spondyloarthropathy or prior cervical surgery within one year preceding CESI were excluded. Multivariable repeated measures logistic regression models were used to identify risk factors for complications at 7, 30, and 90 days. Complications were stratified into procedural and medical complications. Each time point was modeled separately with Bonferroni adjustment for the multiple time points. Complications increased from 1.7% to 4.1%, to 8.0% within 7, 30, and 90 days, respectively. Procedural complications occurred in 0.6% of cases within 7 days, with neurologic complications occurring in 0.5% of cases. Medical complications occurred in 1.1%, 3.6%, and 7.2% within 7, 30 and 90 days, respectively. After multivariable risk adjustment, a transforaminal approach was associated with greater odd for procedural complications within 7 days relative to an interlaminar approach (p<0.001), with an odds ratio (95% confidence interval) of 1.55 (1.35, 1.77). The transforaminal approach also was associated with greater odds of neurologic complications at 7 days [1.69 (1.45, 1.95); p<0.001]. A myelopathy diagnosis was not associated with risk of overall, procedural, medical, or neurological complications. The most influential factors independently associated with greater odds of any complication within 30 days included anticoagulant prescription [5.40 (4.55, 6.41); p<0.001] and history of venous thromboembolism [3.01 (2.40, 3.77); p<0.001]. The factors most strongly associated with procedural complications at 7 days included history of neurologic deficit [3.04 (2.65, 3.50); p<0.001] and antiplatelet medication prescription [2.21 (1.49, 3.27); p=0.003]. Complications following CESIs are infrequent. Neurologic complications were most common among procedural complications at 0.5% at 7 days. The transforaminal approach was associated with higher procedural complication rate compared to the interlaminar approach. Procedural and neurological complications were also associated with multiple factors including obesity, existing neurologic deficit, anxiety, and antiplatelet medication prescription. Attention should be given to these factors to mitigate procedural complications.

Supplementing risk adjustment with high‐risk pooling using historical data for identifying the high risks

AbstractMany regulated health insurance markets with community‐rated premiums rely on risk adjustment (RA) to mitigate insurer‐incentives to risk select. However, insurers remain typically undercompensated for chronically ill enrollees. We use historical data on health spending and risk adjuster information to identify individuals undercompensated by the Dutch RA model of 2021 and find a selective group (1% of the population) with an average annual undercompensation of €6,050. We supplement the RA model with a risk sharing modality called high‐risk pooling (HRP) to organize residual‐based compensations towards insurers for the identified group to reduce the mean undercompensation to zero. The effects are evaluated on subgroups defined by chronic disease, finding a 42% reduction of their average undercompensation. Therefore, through compensating 1% of the population, the insurer‐incentives to select against chronically ill individuals substantially diminish. These results are compared to outlier‐risk sharing (reinsurance), proving HRP to be more effective at reducing selection incentives.

Insurability and government-funded mitigation: safer but costlier

AbstractHurricanes significantly harm homeowners through physical damage and long-term financial strain due to rising insurance costs, property value loss, and repair expenses. This paper focuses on the interrelated decisions of the government mitigation funding of residential acquisitions and retrofit subsidies and of price restrictions on the insurance market in eastern North Carolina to determine the financial effects on stakeholders. The introduction of these policy interventions have impacts that propagate through the system due to risk adjustments, homeowner take-up behaviour, and insurer profit-maximising behaviour. This study uses an integrated game theoretic model to demonstrate that there are cost-effective government spending levels that reduce residential loss from hurricane damage. When insurance prices are capped at preintervention levels, the number of households and their distribution of losses, which has been altered through mitigation, leads to increased insurer insolvency. When insurance prices are allowed to adjust after mitigation, some homeowners find insurance is no longer affordable. This highlights the tradeoff between ensuring insurer stability and expanding homeowner insurance accessibility.

Optimized Profit Allocation Model for Service Alliance Transactions Considering Risk

In service alliances, where multiple service providers collaborate to complete service transactions, the equitable allocation of profits based on their respective contributions and risk-bearing capacities is paramount. This paper introduces an optimized profit allocation game model that integrates risk considerations into the Nash bargaining framework. Initially, the study established a service alliance transaction model that considered the interactions among multiple participants, providing a robust theoretical foundation for cooperation. Subsequently, the concept of marginal risk was introduced, and a unique calculation method based on the Shapley value was devised to quantify risk contributions. Finally, an improved Nash bargaining model was proposed, which introduced a risk adjustment factor, explicitly addressing the impact of each participant’s risk on profit allocation. Through computational cases and result analyses, this model demonstrated its ability to balance profit and risk and to optimize outcomes for all participants, and it validated the fairness and rationality of the proposed allocation method.

How stressful is firm insolvency? Self-reported, biological, and physiological indicators of entrepreneurs’ well-being

This study advances research on the nexus of business insolvency and entrepreneurs’ well-being. We broadly build upon the Conservation of Resources Theory (COR) and explore the severity of the impact of firm insolvency on subjective well-being, stress hormones, and physiological recovery. To test our hypotheses, we compared entrepreneurs operating in 51 businesses affected by insolvency with 51 entrepreneurs in a control group. We conducted our study in Germany, where legal regulations surrounding insolvency are relatively unfavorable for those affected. Our findings indicate that entrepreneurs facing insolvency experience lower psychological well-being, greater vital exhaustion, higher stress hormone levels, and, as revealed by supplementary analyses, poorer risk adjustment. Our study complemented entrepreneurs’ self-reports with objective methods to examine entrepreneurial well-being in times of hardship from three perspectives: psychological, biological, and physiological. Although exploratory, our study provides relevant insights into potential repercussions of business failure. JEL CLASSIFICATION: I10; L26; G01

Perception of and adjustment to adverse weather events among smallholder coffee farmers in Rwanda

AbstractChanging temperature and precipitation patterns threaten smallholder farmers producing coffee. Adaptation is crucial, and perceiving adverse weather events as a risk is the first step towards it. The study, therefore, investigated the link between smallholder coffee farmers' perception of adverse weather events and their adjustments to them. First, four distinct groups of farmers can be distinguished based on their risk perception of adverse weather events. Results show that farmers' risk perception is connected to changes in the timing of the seasons and the expected amount of precipitation. Most farmers in the sample adjust to the adverse weather events they experience. Results also found that farmers’ risk perception and adjustment decisions are closely linked.

Abstract Su601: Missed Hypoxia in the Prehospital Care of Major Traumatic Brain Injury: Discrepancies Between Continuous Monitor Data and Clinical Documentation

Background: It is well established that prehospital hypoxia dramatically increases mortality in Traumatic Brain Injury (TBI). Thus, in EMS TBI research, case ascertainment and risk adjustment are highly dependent upon documentation of in-field O 2 saturation (SpO 2 ). Objective: To compare the rate of hypoxia identified by EMS personnel and documented in EMS patient care records (PCR) versus the actual rate of hypoxia recorded by continuous, non-invasive monitoring in TBI. Methods: A subset of major TBI cases (moderate/severe) from 5 EMS agencies reporting monitor data (Philips MRx™) in the EPIC EMS TBI Study (NIH 1R01NS071049) were evaluated (02/13-02/18). All monitor data available for post-hoc review were displayed and accessible to the providers during EMS care. We compared PCR documentation of hypoxia (SpO 2 &lt;90%) to continuous monitor data in TBI patients (nasal canula O 2 , mask, basic or advanced airway). Statistic: exact McNemar’s test, α=0.05. Results: 120 cases were included [med. age 50; IQR (23.8, 68); 65% male. Monitors recorded 44 hypoxic cases (36.7%; 95%CI 28.1, 45.9%). Only 8 (6.7%; 2.9, 12.7%) were documented in the PCR (p&lt;0.0001; Figure). Three machine-detected hypoxia cases had no PCR-documented SpO 2 at all. Conclusions: The difference in PCR-documented and monitor-identified hypoxia was dramatic. The monitor data revealed a five-fold greater incidence of hypoxia than that documented by EMS providers. This may be partially explained by the continuous nature of pulse oximetry in the face of ongoing care responsibilities and scene distractions. The field environment may cause providers to miss low readings as they fluctuate moment-by-moment. These findings have major clinical implications. While some of the discrepancy between PCR reporting and monitor data might simply be failure to document hypoxia, the much more concerning implication is that many cases might be unrecognized and untreated. Furthermore, these findings have important implications for case ascertainment, confounding, and risk-adjustment in EMS TBI research. Whenever possible, quality improvement and research projects should utilize continuous non-invasive monitor data to identify and evaluate hypoxic patients in the setting of TBI. These findings may also have implications for identifying hypoxia in EMS patients with other critical conditions.

A post-pandemic new normal for interest rates in emerging bond markets? Evidence from Chile

Before the COVID-19 pandemic, researchers intensely debated the extent of the decline in the so-called equilibrium or natural rate of interest. Given the recent sharp increase in interest rates, we revisit this question in an emerging bond market context and offer a Chilean perspective using a dynamic term structure finance model estimated directly on the prices of individual Chilean inflation-indexed bonds with adjustments for bond-specific liquidity risk and real term premia. Beyond documenting the existence of large and time-varying liquidity risk premia in the bond prices, we estimate that the equilibrium real rate in Chile fell about 2 and a half percentage points in the 2003-2022 period and has remained low since then with model projections only suggesting a gradual reversal in coming years. Instead, recent increases in real interest rates in Chile are driven by spikes in the liquidity and term premia of inflation-indexed bond prices.

Differences in the Relationship Between Educational Attainment and Health Status Across Racial and Ethnic Groups in a Multi-ethnic United States Older Adult Population: A Cross-Sectional Electronic Health Record-Based Study.

Introduction We aimed to describe the relationship of educational attainment with the prevalence of six health outcomes (ever and current smoking, diabetes, hypertension, coronary artery disease, and chronic obstructive pulmonary disease) in an older adult population, including whether education-health relationships differed by health outcome, by racialand ethnic (racial/ethnic) group, and byracial/ethnic groupwithinthe same level of education. Methods This cross-sectional study used 2015-2016 electronic health record data for 149,417 non-Hispanic White (White), 15,398 African-American or other Black (Black), 15,319 Hispanic or Latino (Latino), 10,133 Filipino, and 8810 Chinese Northern California health plan members aged 65-79 years whose preferred language was English. For each racial/ethnic group, sex-specific age-standardized prevalence of the six health outcomes was estimated for four levels of education (non-high school graduate, high school graduate, some college, college graduate). Age-adjusted prevalence ratios were used to compare the prevalence between adjacent levels of education and at lower versus college graduate levels within racial/ethnic groups, and the prevalence between White adults and adults in the other racial/ethnic groups, within each level of education and overall. Results The education-health relationship varied across racial/ethnic groups and health outcomes, with gradient relationships more consistently seen for White, Black, and Latino older adults than Filipino and Chinese older adults. Even when a gradient relationship was not observed, the prevalence at the college graduate level was usually significantly lower than the prevalence at the three lower levels of education. The prevalence of current smoking, diabetes, and hypertension was higher among Black than White adults at most levels of education. Controlling for education level minimally affected comparisons of overall prevalence of health outcomes between adults in the White and the other racial/ethnic groups, with the broadest impact seen for Latino-White comparisons. Conclusions The relationship of level of education and health outcomes differs acrossracial/ethnic groupsand by health outcome. This should be taken into consideration when using education as a risk adjustment factor or predictor of health outcomes in multi-ethnic older adult populations.

Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods.

Centers for Medicare & Medicaid Services provides reimbursement through Hierarchical Condition Category (HCC) coding. Medical systems strive toward risk adjustment optimization, often implementing costly chart review processes. Previously, our organization implementing countermeasures through workflows was complex and performed in silos. Our goal was to put in place HCC-Risk Adjustment Factor (RAF) improvement tools to optimize HCC-RAF management in Population Health using rapid process improvement methods. In this quality improvement analysis (IRB#806198), we used Lean methodology to develop tools and implement streamlined processes for providers to manage, document, and code high-risk HCC conditions. Rather than applying costly countermeasures, Transformational Healthcare conducted a Rapid Process Improvement Workshop (RPIW), with workgroups implementing proposed changes, to improve processes. Each of these tools was embedded in standard work, for teams to use in practice. Tools included the development of RPIW-inspired work groups, a Provider Education website, tip sheets, clinical champions, trainings, audits, practice alerts, smart phrases, schedule view tools, severity scores, reports, dashboards, on-screen decision-support tools, coding expertise, and HCC standard work. Quantitatively, Year 1 showed enterprise HCC-RAF scores improved by 4.1%. We were able to develop tools for providers and team members to allow for more optimized pathways. Although quantitatively we realized an improvement in enterprise HCC-RAF score, our overall aim was to improve process flow and limit waste. Leveraging Lean improvement methods for the collective design of tools has supported culture change. In the end, we found that providers are indeed willing to adopt these newly built tools. These tools have optimized operations, allowing providers to work smarter, not harder.

Hospital COVID-19 Burden and Adverse Event Rates

The COVID-19 pandemic introduced stresses on hospitals due to the surge in demand for care and to staffing shortages. The implications of these stresses for patient safety are not well understood. To assess whether hospital COVID-19 burden was associated with the rate of in-hospital adverse effects (AEs). This cohort study used data from the Agency for Healthcare Research and Quality's Quality and Safety Review System, a surveillance system that tracks the frequency of AEs among selected hospital admissions across the US. The study sample included randomly selected Medicare patient admissions to acute care hospitals in the US between September 1, 2020, and June 30, 2022. The main outcome was the association between frequency of AEs and hospital-specific weekly COVID-19 burden. Observed and risk-adjusted rates of AEs per 1000 admissions were stratified by the weekly hospital-specific COVID-19 burden (daily mean number of COVID-19 inpatients per 100 hospital beds each week), presented as less than the 25th percentile (lowest burden), 25th to 75th percentile (intermediate burden), and greater than the 75th percentile (highest burden). Risk adjustment variables included patient and hospital characteristics. The study included 40 737 Medicare hospital admissions (4114 patients [10.1%] with COVID-19 and 36 623 [89.9%] without); mean (SD) patient age was 73.8 (12.1) years, 53.8% were female, and the median number of Elixhauser comorbidities was 4 (IQR, 2-5). There were 59.1 (95% CI, 54.5-64.0) AEs per 1000 admissions during weeks with the lowest, 77.0 (95% CI, 73.3-80.9) AEs per 1000 admissions during weeks with intermediate, and 97.4 (95% CI, 91.6-103.7) AEs per 1000 admissions during weeks with the highest COVID-19 burden. Among patients without COVID-19, there were 55.7 (95% CI, 51.1-60.8) AEs per 1000 admissions during weeks with the lowest, 74.0 (95% CI, 70.2-78.1) AEs per 1000 admissions during weeks with intermediate, and 79.3 (95% CI, 73.7-85.3) AEs per 1000 admissions during weeks with the highest COVID-19 burden. A similar pattern was seen among patients with COVID-19. After risk adjustment, the relative risk (RR) for AEs among patients admitted during weeks with high compared with low COVID-19 burden for all patients was 1.23 (95% CI, 1.09-1.39; P < .001), with similar results seen in the cohorts with (RR, 1.33; 95% CI, 1.03-1.71; P = .03) and without (RR, 1.23; 95% CI, 1.08-1.39; P = .002) COVID-19 individually. In this cohort study of hospital admissions among Medicare patients during the COVID-19 pandemic, greater hospital COVID-19 burden was associated with an increased risk of in-hospital AEs among both patients with and without COVID-19. These results illustrate the need for greater hospital resilience and surge capacity to prevent declines in patient safety during surges in demand.

Risk of Financial Toxicity Among Adults Undergoing Lung and Esophageal Resections for Cancer

BackgroundAlthough financial toxicity, defined as the harmful financial burden experienced by patients undergoing cancer treatment, has been of growing interest, data in thoracic oncology are lacking. This study aimed to examine the risk of financial toxicity among patients undergoing surgical resection of thoracic malignant diseases. MethodsAdults undergoing lobectomy, pneumonectomy, or esophagectomy for cancer were identified in the 2012 to 2021 National Inpatient Sample. Risk of financial toxicity was defined as health expenditure (total hospitalization costs for the uninsured and maximum out-of-pocket costs for the insured) exceeding 40% of postsubsistence income. Multivariable logistic regressions were used to identify factors associated with financial toxicity risk. ResultsOf 384,340 patients, 69.5% had government-funded insurance, 27.2% had private insurance, and 1.0% were uninsured. Compared with patients with insurance, uninsured patients were more commonly Black and Hispanic and less commonly electively admitted. Mortality, complications, length of stay, and costs were comparable regardless of insurance status. Approximately 68.9% of uninsured and 17.3% of insured patients were at risk of financial toxicity, and the incidence of financial toxicity remained stable over time. After risk adjustment, complications were associated with a greater than 2-fold increased risk of financial toxicity among uninsured patients (adjusted odds ratio, 2.21; 95% CI, 1.38-3.55). Among the insured patients, Black, Hispanic, and publicly insured patients demonstrated a greater risk of financial toxicity, while patients undergoing minimally invasive operations and receiving care at metropolitan hospitals exhibited a lower risk of financial toxicity. ConclusionsConcordant with previous work examining financial toxicity in abdominal oncologic surgery, thoracic surgery demonstrates a comparable burden of financial toxicity. Referral policies and care subsidization may be considered in patients at risk for financial toxicity who are undergoing resections for thoracic malignant diseases.