American Hospital Association Annual Survey Research Articles

Use of Pulmonary Rehabilitation after Chronic Obstructive Pulmonary Disease Hospitalization: An Analysis of Statewide Patient and Hospital Data.

Rationale: Pulmonary rehabilitation (PR) is a clinically effective and cost-effective outpatient treatment for chronic obstructive pulmonary disease (COPD) that remains highly underused. Existing analyses of PR use patterns have been focused largely on patient characteristics, but hospital-level analysis is lacking and is needed to inform interventions aimed at improving use after COPD hospitalization. Objectives: To evaluate PR use across hospitals after COPD hospitalization in the state of Michigan, with the goal of characterizing hospital-level variation and identifying the characteristics of high-performing hospitals. Methods: This is a retrospective study of patients with COPD hospitalizations between January 1, 2018, and December 31, 2021, using claims data from the Michigan Value Collaborative and hospital data from the American Hospital Association annual survey. Our primary outcome was the initiation of PR within 30 days of discharge. Chi-square tests and analysis of variance were used to test for differences in patient and hospital covariates. Multilevel logistic regression was used to analyze associations between patient covariates and the primary outcome and to characterize hospital-level variation. Results: A total of 36,389 patients and 99 hospitals were included in the analysis. The majority of patients were older than 65 years of age, female, White, and Medicare fee-for-service insured. The rate of PR initiation within 30 days after hospitalization was 0.8%. Adjusted rates of PR initiation by hospital ranged from 0.4% to 2.0%. Compared with the set reference groups, being female, in the fifth Distressed Community Index quintile, and older than 85 years of age independently decreased the odds of initiating PR. Some variation in initiation rate was attributed to the hospital level (7%; intraclass correlation coefficient = 0.07 [95% confidence interval, 0.03-0.15]). The median odds ratio was 1.6 for PR initiation by hospital. Conclusions: Rates of PR initiation after COPD hospitalization are universally low across all hospitals, though there is some variation. Interventions targeted at patients alone are not sufficient to improve use. Hospital-based strategies to improve PR use after discharge, adapted from those being successfully used with cardiac rehabilitation, should be further explored.

Psychometric development and validation of the Hospital Resilience Index

BackgroundThroughout the past decades, the United States healthcare system has seen increased efforts to promote continuity of operations in response to external or internal stressors. There is no marker to characterize this facet of health system resilience. The two databases which may contain the most relevant data are the American Hospital Association (AHA) annual survey, which gathers over 1000 data points from more than 6000 hospitals, and the RAND corporation, which provides information on the financial health and viability of hospitals and health care systems. In that sense, AHA focuses more on organizational and practice issues, while RAND will cover more economic factors. Our study aimed to develop and psychometrically validate a new Hospital Resilience Index (HRI).MethodsWe took the AHA and RAND databases as primary data sources, and defined hospital closure as the main negative outcome indicating failed resilience. We performed descriptive statistics, and regression analysis of the databases.ResultsOur findings show that a combination of eleven variables is strongly associated with the likelihood of hospital closure. These factors mirror smaller hospital size, lack of ancillary functions, staffing structure of the hospital, size of facilities, number of surgeries performed, Medicare discharges, operating expenses, and medical school affiliation as a teaching hospital. We further classified hospitals with a low HRI (< 25) or high HRI (> 25). In this setup, we found that both hospitals with a low HRI and hospitals that would subsequently close were characterized by smaller patient census, smaller numbers of surgeries, fewer beds, a smaller staff, and a lower operating margin.ConclusionsTogether, these factors would point to a higher resilience to external stressors in larger, more expanded hospitals and healthcare systems, offering a broad range of services, and having a higher operating margin. The higher tiers of the healthcare system therefore seem to have more resilience, but the recent Covid-19 pandemic exhibited how much all tiers in the system are needed to respond to extraordinary crises such as pandemics or large natural disasters. Future research should seek to determine whether tracking the HRI over time may be a tool to identify hospitals at risk of closure.

Trending in the right direction: critical access hospitals increased adoption of advanced electronic health record functions from 2018 to 2023.

We analyzed trends in adoption of advanced patient engagement and clinical data analytics functionalities among critical access hospitals (CAHs) and non-CAHs to assess how historical gaps have changed. We used 2014, 2018, and 2023 data from the American Hospital Association Annual Survey IT Supplement to measure differences in adoption rates (ie, the "adoption gap") of patient engagement and clinical data analytics functionalities across CAHs and non-CAHs. We measured changes over time in CAH and non-CAH adoption of 6 "core" clinical data analytics functionalities, 5 "core" patient engagement functionalities, 5 new patient engagement functionalities, and 3 bulk data export use cases. We constructed 2 composite measures for core functionalities and analyzed adoption for other functionalities individually. Core functionality adoption increased from 21% of CAHs in 2014 to 56% in 2023 for clinical data analytics and 18% to 49% for patient engagement. The CAH adoption gap in both domains narrowed from 2018 to 2023 (both P < .01). More than 90% of all hospitals had adopted viewing and downloading electronic data and clinical notes by 2023. The largest CAH adoption gaps in 2023 were for Fast Healthcare Interoperability Resources (FHIR) bulk export use cases (eg, analytics and reporting: 63% of CAHs, 81% of non-CAHs, P < .001). Adoption of advanced electronic health record functionalities has increased for CAHs and non-CAHs, and some adoption gaps have been closed since 2018. However, CAHs may continue to struggle with clinical data analytics and FHIR-based functionalities. Some crucial patient engagement functionalities have reached near-universal adoption; however, policymakers should consider programs to support CAHs in closing remaining adoption gaps.

Variation in organisational factors across high- and low-performing hospitals with regard to spontaneous vaginal birth for Black women in four states: a cross-sectional descriptive study

ObjectiveTo describe variation in hospital organisational factors across high- and low-performing hospitals with regard to spontaneous vaginal birth (SVB) for Black women.DesignCross-sectional descriptive.SettingWe conducted a cross-sectional study using three datasets...

The Evolution of Health Information Technology for Enhanced Patient-Centric Care in the United States: Data-Driven Descriptive Study.

Health information technology (health IT) has revolutionized health care in the United States through interoperable clinical care data exchange, e-prescribing, electronic public health reporting, and electronic patient access to health information. This study aims to examine progress in health IT adoption and its alignment with the Office of the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT (ASTP's) mission to enhance health care through data access and exchange. This study leverages data on end users of health IT to capture trends in engagement in interoperable clinical care data exchange (ability to find, send, receive, and integrate information from outside organizations), e-prescribing, electronic public health reporting, and capabilities to enable patient access to electronic health information. Data were primarily sourced from the American Hospital Association Annual Survey IT Supplement (2008 to 2023), Surescripts e-prescribing use data (2008 to 2023), the National Cancer Institute's Health Information National Trends Survey (2014 to 2022), and the National Center for Health Statistics' National Electronic Health Records Survey (2009 to 2023). Since 2009, there has been a 10-fold increase in electronic health record (EHR) use among hospitals and a 5-fold increase among physicians. This enabled the interoperable exchange of electronic health information, e- prescribing, electronic public health data exchange, and the means for patients and their caregivers to access crucial personal health information digitally. As of 2023, 70% of hospitals are interoperable, with many providers integrated within EHR systems. Nearly all pharmacies and 92% of prescribers possess e-prescribing capabilities, an 85%-point increase since 2008. In 2013, 40% of hospitals and one-third of physicians allowed patients to view their online medical records. Patient access has improved, with 97% of hospitals and 65% of physicians possessing EHRs that enable patients to access their online medical records. As of 2022, three-fourths of individuals report being offered access to patient portals, and over half (57%) report engaging with their health information through their patient portal. Electronic public health reporting has also seen an increase, with most hospitals and physicians actively engaged in key reporting types. Federal incentives have contributed to the widespread adoption of EHRs and broad digitization in health care, while efforts to promote interoperability have encouraged collaboration across health care entities. As a result, interoperable clinical care data exchange, e-prescribing, electronic public health reporting, and patient access to health information have grown substantially over the past quarter century and have been shown to improve health care outcomes. However, interoperability hurdles, usability issues, data security concerns, and inequitable patient access persist. Addressing these issues will require collaborative efforts among stakeholders to promote data standardization, implement governance structures, and establish robust health information exchange networks.

National Patterns of Remote Patient Monitoring Service Availability at US Hospitals and their Readmission Performance for Cardiovascular Conditions.

Digital remote patient monitoring (RPM) enables longitudinal care outside traditional healthcare settings, especially in the vulnerable period after hospitalizations, with broad coverage of the service by payers. We sought to evaluate patterns of RPM service availability at US hospitals and the association of these services with 30-day readmissions for two key cardiovascular conditions, heart failure (HF) and acute myocardial infarction (AMI). We used contemporary national data from the American Hospital Association (AHA) Annual Survey to ascertain US hospitals offering RPM services for post-discharge or chronic care and used census-based county-level data to define the characteristics of the communities they serve. We linked these with hospitals' benchmarked risk-standardized relative performance on readmissions (excess readmission ratio [ERR]) from CMS Hospital Quality Reports (2018-2022). We used mixed-effects multivariable regression to examine the association between RPM services at hospitals and hospital characteristics-adjusted ERR for HF and AMI. There were 2,754 hospitals with CMS quality report data. Over five years of the study, there was a 38.3% increase in the number of hospitals offering RPM services, rising from 952 (42.0%) hospitals in 2018 to 1,237 (58.1%) in 2022. However, the availability of RPM services varied across different hospital groups with smaller, non-teaching hospitals, particularly those serving rural, low-income communities, and those located in the South, were less likely to offer RPM services. There was a consistent association between the availability of RPM services and better risk-standardized readmission performance for HF, with lower ERR for hospitals offering RPM compared with those not offering RPM (absolute difference, -0.016 [-0.023, -0.009], standardized difference, 24.6%, p<0.001). However, no such association was observed for AMI (-0.007 [-0.016, 0.002], standardized difference, 10.3%, p=0.19). In this national study of US hospitals, there has been a large increase in the availability of RPM services but with large variation among hospitals, with lower availability in hospitals serving low-income and rural communities. RPM services were associated with lower hospital readmission rates for HF but not AMI.

Reducing readmissions: A business case for US hospitals

The 2010 Patient Protection and Affordable Care Act (ACA) linked acute care hospital reimbursements to quality-of-care measures. While the impact of healthcare quality on service provision is well-documented, the effects of 30-day readmissions on hospital financial performance are less understood. This study examines the relationship between 30-day readmission rates and financial performance in U.S. acute care hospitals from 2010 to 2018 using four financial metrics: operating margin, operating revenue, operating cost, and total margin. Data were sourced from the American Hospital Association (AHA) Annual Survey, Centers for Medicare and Medicaid Services (CMS), Area Health Resource Files (AHRF), and CMS cost reports. Univariate analysis of hospital characteristics was followed by an unbalanced panel regression with hospital and year-fixed effects. Inflation adjustments and controls for HRRP, CMI, managed care penetration, payer mix, physician supply, RN and MD staffing, occupancy, and mortality rates were applied. Increased readmission scores for AMI correlated with higher adjusted operating revenues per patient day (β = $26.86, p ≤ .001), but no significant changes in adjusted operating cost, operating margin, or total margin. Following HRRP implementation, adjusted operating revenue decreased for AMI (β = $425.21, p ≤ .019), HF (β = $229.41, p ≤ .023), and PN (β = $229.41, p ≤ .023). HF readmission scores marginally increased the adjusted operating margin (β = $0.0002, p ≤ .064) with no significant impact on other financial metrics. Pneumonia readmission rates marginally increased the adjusted operating margin (β = $0.0002, p ≤ .064) without significantly affecting other financial measures. The study’s findings highlight the potential financial benefits of reducing readmissions for hospitals. However, it also underscores the importance of developing and implementing broader quality metrics that can provide a more comprehensive evaluation of hospital performance, thereby enhancing the audience’s understanding of the need for a comprehensive evaluation of hospital performance.

The relationship between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services value-based purchasing metrics.

Despite the intense policy focus on reducing health-care-associated conditions, adverse events in health care settings persist. Therefore, evaluating patient safety efforts and related health policy initiatives remains critical. The aim of this study was to explore the relationship between hospital patient safety culture and hospital performance on Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) metrics. A pooled cross-sectional study design was used utilizing three secondary datasets from 2018 and 2021: the Hospital Survey on Patient Safety Culture, the American Hospital Association annual survey, and the Hospital Compare data from CMS. We used two multivariable linear regression models to examine the relationship between organizational patient safety culture and hospital performance. The dependent variables included the overall CMS total performance score (TPS) and the four individual TPS domain scores. Hospital patient safety culture, the independent variable, was operationalized using two measures from the Hospital Survey on Patient Safety Culture: (a) the domain score of overall perceptions of patient safety and (b) the patient safety grade. We observed positive and significant associations between hospital patient safety culture and a hospital's overall TPS and the "patient and community engagement" and "safety" domains. Findings suggest that building a strong patient safety culture has the potential to lead health care organizations to achieve high performance on HVBP metrics. Our findings have important policy implications for both the future of CMS HVBP as a motivator of patient safety and how health care managers integrate culture change into programs to meet external quality metrics.

Association of Hospital System Affiliation with Spending and Postoperative Outcomes: A Longitudinal Study of Hospital Mergers And Acquisitions From 2010 To 2018.

To determine whether hospital system affiliation was associated with changes in surgical episode spending or postoperative outcomes. Over 70% of US hospitals are now part of a hospital system. The presumed benefits of hospital consolidation include concentrating volume and expertise, care integration, and investment in quality improvement. However, there is conflicting evidence as to whether expanding hospital systems are actually reducing health spending or improving quality. These observations call into question whether systems are leveraging their collective volume and experience to standardize care and maximize efficiencies. The American Hospital Association Annual Survey was used to identify whether a hospital was part of a system and in which year a hospital joined the respective system. Using 100% Medicare claims data, we identified fee-for-service Medicare patients undergoing elective inpatient coronary artery bypass graft colon resection, lung resection, hip replacement, or knee replacement from 2010 to 2018. We used a difference-in-differences framework to evaluate hospital spending and outcomes before and after joining a system. The primary outcome was Medicare 30-day episode spending, with specific attention to the total episode payment, index hospitalization, and post-acute care components. Secondary outcomes included serious complications, 30-day mortality, and 30-day readmission. The cohort included 3,395,565 Medicare beneficiaries who underwent surgery between 2010 and 2018. Patients were treated at 3961 hospitals, of which 1097 (27.7%) were never in a system, 2262 (57.1%) were always in a system, and 602 (15.2%) joined a system during the study period. By 1 year after system affiliation, 30-day episode spending had decreased by $303 (95% CI: 63, 454, P=0.01), and after 5 years, 30-day episode spending decreased by $429 (95% CI: 5, 853, P=0.04). One year after system association, index hospitalization spending was not statistically different from before system affiliation ($-30, 95% CI: -160, 100, P=0.65). Conversely, 1 year after system association, postacute care spending decreased by $268 (95% CI: 107, 429, P<0.01) and remained lower for ≥5 years. There was no significant change in hospitals serious complications (-0.14, 95% CI: -0.40, 0.11, P=0.27), 30-day readmission (-0.14, 95% CI:-0.52, 0.25, P=0.48), or 30-day mortality (-0.08, 95% CI: -0.18, 0.03, P=0.17), 1 year after joining a system; similar patterns were observed at three and ≥5 years. system affiliation was associated with a small decrease in 30-day episode spending, driven by decreased spending in postacute care services. Notably, there was no difference in postoperative outcomes after system affiliation.

Hospitals' collection and use of data to address social needs and social determinants of health.

To assess differences in hospitals' collection and use of data on patients' health-related social needs (HRSN) by availability of programs or strategies in place to address patients' HRSN and social determinants of health (SDOH) of communities. The 2021 American Hospital Association Annual Survey and 2022 Information Technology (IT) Supplement. This cross-sectional study described hospitals' engagement in screening and the availability of programs or strategies to address nine different HRSN. We assessed differences in screening rates and uses of data collected through screening among hospitals with and without programs or strategies in place to address HRSN or SDOH using Chi-squared tests of independence. Analyses were restricted to IT Supplement respondents with complete data for social needs questions asked in the Annual Survey (N = 1997). In 2022, hospitals used social needs data collected through screening for various purposes including discharge planning and clinical decision-making at their hospital as well as to refer patients to needed resources and assess community-level needs. Hospitals with a program or strategy in place had higher rates of screening across all domains and higher rates of using of data collected through screening for uses involving exchange or coordination with external entities. Collection of social needs data may help inform the development of programs or strategies to address HRSN and SDOH, which in turn can enable providers to screen for these needs and use the data in the near term for care delivery and in the long term to address community and population needs.

Hospital Patient Experience: Exploring Hospitals as Shifters and Sustainers Over Time.

Patient experience is a key factor in measuring hospital performance, and the Hospital Consumer Assessment of Healthcare Providers and Systems survey tool is used to assess patient perceptions. Hospitals with positive patient experience tend to have a better quality of clinical care, lower readmission and mortality rates, and an overall shorter inpatient length of stay. Studies have identified several organizational determinants of high- and low-rated patient experiences, including hospital size, type, staffing levels, and patient demographics.This study aims to explore the determinants of consistently high- and low-rated patient experience, as well as factors associated with positive and negative changes in patient experience over time. The 2014 to 2019 American Hospital Association annual survey and the Centers for Medicare and Medicaid Services Hospital Value-Based Purchasing database were used. A total of 2801 acute-care hospitals were included in this study. A series of multivariate logistic regressions were used to model the probability of "1" (being a superior hospital or an inferior hospital). In addition, a generalized linear mixed model for binary responses was used to analyze the change (probability of positive and negative change). The results showed that most hospitals did not sustain superior or inferior performance, and competition decreased the likelihood of a hospital consistently performing well in terms of patient experience. Superior performance was associated with hospital ownership (P <.001), size (P =.026), location (P =.002), teaching status (P =.009), average Herfindahl-Hirschman Index value (P =.005), and Medicaid and Medicare patient population. On the other hand, inferior performance was associated with hospital ownership (P =.003), size (P <.001), teaching status (P =.003), safety net status (P =.020), and Medicaid and Medicare patient population. This study aimed to examine the trends in hospital patient experience performance and the influence of hospital organizational characteristics on those trends. Our findings allow us to question the widely held belief that patient experience is a metric of differentiation and industry competition, suggesting that performance in this domain has not been utilized by most hospitals as a source of sustainable competitive advantage. The findings from this study highlight the importance of considering changes in performance over time and the need for significant organizational efforts to improve hospital performance in terms of patient experience.

Where and what separates rural from urban hospital closures?

Despite the recent closure of several high-profile metropolitan hospitals, investigations into risk factors for metropolitan hospital closures have been limited. The goal of this study wasto describe metropolitan hospitals that closed and compare them to metropolitan hospitals that remain open and micropolitan and rural hospitals that closed using American Hospital Association Annual Survey Data from 2010 to 2021. We independently verified hospitals reported as closed in the Annual Survey and examined the hospital characteristics associated with closure using bivariate statistics and logistic regression. We found that metropolitan hospitals that closed (n = 142) were more likely to be for-profit (66.9% vs. 29.7%, p < .0001;adjusted odds ratio [AOR]:3.05, 95% confidence interval [CI]: 1.93, 4.81) and to come from a state that did not expand Medicaid (45.1% vs. 29.4%, p < .0001; AOR: 1.66, 95% CI: 1.16, 2.38). Policies tailored to metropolitan hospitals should be developed to identify at-risk hospitals and mitigate the effect of closures on patients, clinicians, and other stakeholders.

Systematic Screening and Assessment of Hospital-Based Youth Violence Prevention Programs.

Youth violence is a preventable public health issue. Few hospital-based programs intentionally focus on youth violence prevention. This project aimed to describe the Systematic Screening and Assessment (SSA) methodology used to identify existing hospital-based youth violence prevention (HBYVP) programs ready for future rigorous evaluation. To identify promising HBYVP programs currently in use and assess readiness for evaluation, data from the 2017 American Hospital Association (AHA) Annual Survey of Hospitals was used to identify hospitals with Level I-III trauma centers with reported HBYVP programs. Information for each program was gathered via environmental scan and key informant interviews. A total of 383 hospital-based violence prevention programs were identified. Two review panels were conducted with violence prevention experts to identify characteristics of programs suitable for an evaluability assessment (EA). Fifteen programs focused on youth (10-24 years old) and were identified to be promising and evaluable. Three of the 15 programs were determined to have the infrastructure and readiness necessary for rigorous evaluation. Lessons learned and best practices for SSA project success included use of streamlined outreach efforts that provide program staff with informative and culturally tailored project materials outlining information about the problem, project goals, proposed SSA activities, and altruistic benefit to the community at the initial point of contact. In addition, success of review panels was attributed to use of software to streamline panelist review processes and use of evaluation and data analysis subject matter experts to serve as panel facilitators. Communities experiencing high youth violence burden and hospitals serving these communities can improve health outcomes among youth by implementing and evaluating tailored HBYVP programs.

When Agency Fails: An Analysis of the Association Between Hospital Agency Staffing and Quality Outcomes.

Staffing is critical to hospital quality, but recent years have seen hospitals grappling with severe shortages, forcing them to rely on contract or agency staff for urgent patient care needs. This shift in staffing mix has raised questions about its impact on quality. Consequently, this study investigated whether the increased use of agency staff has affected healthcare quality in hospitals. Given the limited recent research on this topic, practitioners remain uncertain about the effectiveness of their staffing strategies and their potential impact on quality. Drawing from agency theory, data were obtained from Definitive Healthcare which consolidates information from numerous public access databases pertaining to hospitals such as the American Hospital Association Annual Survey (hospital profile) and the Hospital Value-Based Purchasing Program (quality data). We conducted a cross-sectional study using a multivariable linear regression model (2021-2022) with appropriate organizational and market- level control variables. Quality was measured across eight variables while the independent variable of interest was agency labor cost ratio operationalized as the percentage of net patient revenue consumed by agency labor expense. Our results suggested that the employment of agency staff was significantly and negatively associated with six of eight quality measures tested, including the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) star rating, Hospital Compare rating, the hospital Total Performance Score (TPS), and three of the four sub-domains that comprise the TPS: clinical domain score, person and community engagement domain score, and the efficiency and cost reduction score. Our results indicated that the increased use of agency labor may have a significant negative influence on quality outcomes at the hospital level. Our findings support the premise that interventions that promote full-time staffing may be more supportive of the quality of care delivered as well as patients' perceptions of care.

Telemedicine critical care availability and outcomes among mechanically ventilated patients

PurposeTelemedicine Critical Care (TCC) improves adherence to evidence based protocols associated with improved mortality among patients receiving invasive mechanical ventilation (IMV). We sought to evaluate the relationship between hospital availability of TCC and outcomes among patients receiving IMV. Materials and methodsWe performed a cross-sectional study of 66,522 adults who received IMV for non-postoperative acute respiratory failure at 318 non-federal hospitals in New York, Massachusetts, Maryland, and Florida in 2018. Hospital-level TCC availability was ascertained from the 2018 American Hospital Association Annual Survey. The primary outcome was in-hospital mortality. Secondary outcomes included the composite of tracheostomy or reintubation and duration of IMV. We used two-level hierarchical multivariable regression models to investigate the association between TCC availability and outcomes. Results20,270 (30.5%) patients were admitted into 89 TCC-available hospitals. There was no difference between TCC and non-TCC-available hospitals in mortality (odds ratio [OR] 0.94, 99% confidence interval [CI] 0.84–1.05), composite of tracheostomy or reintubation (OR 0.95 [0.82–1.11], or duration of IMV (OR 0.95 [0.83–1.09]). There was no difference in outcomes among the subgroup of patients with acute respiratory distress syndrome. ConclusionsHospital TCC availability was not associated with improved outcomes among patients receiving IMV.

The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort.

There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes. This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality. Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services. Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.

Validation of a measure of hospital maternal level of care for the United States

BackgroundLack of a validated assessment of maternal risk-appropriate care for use in population data has prevented the existing literature from quantifying the benefit of maternal risk-appropriate care. The objective of this study was to develop a measure of hospital maternal levels of care based on the resources available at the hospital, using existing data available to researchers.MethodsThis was a secondary data analysis. The sample was abstracted from the American Hospital Association Annual Survey Database for 2018. Eligibility was limited to short-term acute general hospitals that reported providing maternity services as measured by hospital reporting of an obstetric service level, obstetric services, or birthing rooms. We aligned variables in the database with the ACOG criteria for each maternal level of care, then built models that used the variables to measure the maternal level of care. In each iteration, the distribution of hospitals was compared to the distribution in the CDC Levels of Care Assessment Tool Validation Pilot, assessing agreement with the Wilson Score for proportions for each level of care. Results were compared to hospital self-report in the database and measurement reported with another published method.ResultsThe sample included 2,351 hospitals. AHA variables were available to measure resources that align with ACOG Levels 1, 2, and 3. Overall, 1219 (51.9%) of hospitals reported resources aligned with Maternal Level One, 816 (34.7%) aligned with maternal level two, and 202 (8.6%) aligned with maternal level Three. This method overestimates the prevalence of hospitals with maternal level one compared to the CDC measurement of 36.1% (Mean 52.9%; 95% CI47.2%—58.7%), and likely includes hospitals that would not qualify as level one if all resources required by the ACOG guidelines could be assessed. This method underestimates the prevalence of hospitals with maternal critical care services (Level 3 or 4) compared to CDC measure of 12.1% (Mean 8.1%; 95%CI 6.2% – 10.0%) but is an improvement over hospital self-report (24.7%) and a prior published method (32.3%).ConclusionsThis method of measuring maternal level of care allows researchers to investigate the value of perinatal regionalization, risk-appropriate care, and hospital differences among the three levels of care. This study identified potential changes to the American Hospital Association Annual Survey that would improve identification of maternal levels of care for research.

Teaching and Safety-Net Hospital Penalization in the Hospital-Acquired Condition Reduction Program

The Hospital-Acquired Condition Reduction Program (HACRP) evaluates acute care hospitals on the occurrence of patient safety events and health care-associated infections. Since its implementation, several studies have raised concerns about the overpenalization of teaching and safety-net hospitals, and although several changes in the program's methodology have been applied in the last few years, whether these changes reversed the overpenalization of teaching and safety-net hospitals is unknown. To determine hospital characteristics associated with HACRP penalization and penalization reversal. This retrospective cross-sectional study assessed data from 3117 acute care hospitals participating in the HACRP. The HACRP penalization and hospital characteristics were obtained from Hospital Compare (2020 and 2021), the Inpatient Prospective Payment System impact file (2020), and the American Hospital Association annual survey (2018). Hospital characteristics, including safety-net status and teaching intensity (no teaching and very minor, minor, major, and very major teaching levels). The primary outcome was HACRP penalization (ie, hospitals that fell within the worst quartile of the program's performance). Multivariable models initially included all covariates, and then backward stepwise variable selection was used. Of 3117 hospitals that participated in HACRP in 2020, 779 (25.0%) were safety-net hospitals and 1090 (35.0%) were teaching institutions. In total, 771 hospitals (24.7%) were penalized. The HACRP penalization was associated with safety-net status (odds ratio [OR], 1.41 [95% CI, 1.16-1.71]) and very major teaching intensity (OR, 1.94 [95% CI, 1.15-3.28]). In addition, non-federal government hospitals were more likely to be penalized than for-profit hospitals (OR, 1.62 [95% CI, 1.23-2.14]), as were level I trauma centers (OR, 2.05 [95% CI, 1.43-2.96]) and hospitals located in the New England region (OR, 1.65 [95% CI, 1.12-2.43]). Safety-net hospitals with major teaching levels were twice as likely to be penalized as non-safety-net nonteaching hospitals (OR, 2.15 [95% CI, 1.14-4.03]). Furthermore, safety-net hospitals penalized in 2020 were less likely (OR, 0.64 [95% CI, 0.43-0.96]) to revert their HACRP penalization status in 2021. Findings from this cross-sectional study indicated that teaching and safety-net hospital status continued to be associated with overpenalization in the HACRP despite recent changes in its methodology. Most of these hospitals were also less likely to revert their penalization status. A reevaluation of the program methodology is needed to avoid depleting resources of hospitals caring for underserved populations.

Hospital Capabilities Associated With Behavioral Health Integration Within Emergency Departments.

To identify hospital capabilities associated with behavioral health (BH) processes in emergency departments (EDs). Six hundred two hospital responses to the 2017/2018 National Survey of Healthcare Organizations and Systems were linked to 2017 American Hospital Association Annual Survey data. Separate multivariable regressions estimated how hospital capabilities (the use of quality improvement methods, approaches to disseminate best patient-care practices, barriers to using care delivery innovations, and inpatient beds for psychiatric or substance use) were associated with each of 4 ED-based BH processes: mental health and substance use disorder screening, team-based approaches to BH, telepsychiatry, and direct referrals to community-based BH clinicians. Models controlled for hospital structural characteristics and area-level socioeconomic factors. Most hospitals screened for BH conditions and provided direct referrals to community-based BH clinicians. Approximately half of the hospitals used a team approach to BH. A minority had implemented telepsychiatry. Each additional process used to disseminate best patient-care practices was associated with more screening for BH conditions (an increase of 4.07 points on the screening index, P <0.01) and greater likelihood of using a team approach to BH [4.41 percentage point ( P <0.01) increase]. Hospitals reporting more barriers to the use of care delivery innovations reported less screening and use of a team approach [a decrease of 0.15 points on the screening index ( P <0.01) and 0.28 percentage points reduction in likelihood of team approach use ( P <0.001) for 1-point increase in the barrier index]. Research and interventions focused on removing innovation barriers or adding processes to disseminate best practices offer a path to accelerate BH integration in hospital EDs.

Racial and ethnic disparities in emergency department transfers to public hospitals.

To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences. ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018). Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means. We examined 1,265,588 adult ED patients transferred from 187 hospitals. Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer. Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.