American Hospital Association Data Research Articles

Increased health information technology investment decreases uncompensated care cost: A study of Texas hospitals.

Many previous research studies have demonstrated that investing in health information technology (IT) in a hospital setting has potential benefits, including eliminating duplicate or unnecessary tests and adverse drug events, conserving healthcare provider time and effort by making information more readily available, and reducing cost by increasing efficiency or productivity metrics. However, the effect of health IT on uncompensated care has not been reported yet. The objective of this study was to examine the effect of health IT investment on uncompensated care provided by hospitals. The general linear model (GLM) with log link and normal distribution was used to estimate the association between health IT spending and the provision of uncompensated care using Texas American Hospital Association (AHA) data from 2004 to 2010. The total health IT investment was significantly and negatively associated with the provision of uncompensated care. When health IT investment was increased by 10%, the provision of uncompensated care was reduced by 2.7%. Health IT investment was also significantly and negatively associated with bad debt. When health IT investment was increased by 10%, bad debt was decreased by 3.2%. Health IT investment was negatively associated with the provision of uncompensated care. This means that health IT could reduce administrative burden and improve efficiency of tracking patient insurance status and billings.

Comparison of Risk-Standardized Readmission Rates of Surgical Patients at Safety-Net and Non–Safety-Net Hospitals Using Agency for Healthcare Research and Quality and American Hospital Association Data

Medical patients discharged from safety-net hospitals (SNHs) experience higher readmission rates compared with those discharged from non-SNHs. However, little is known about whether this association persists for surgical patients. To examine differences in readmission rates between SNHs and non-SNHs among surgical patients after discharge and determine whether hospital characteristics might account for some of the variation. This observational retrospective study linked the Healthcare Cost and Utilization Project State Inpatient Databases of the Agency for Healthcare Research and Quality from January 1, 2011, through December 31, 2014, for 4 states (New York, Florida, Iowa, and Washington) with data from the 2014 American Hospital Association annual survey. After identifying surgical discharges, SNHs were defined as those with the top quartile of inpatient stays paid by Medicaid or self-paid. Hospital-level risk-standardized readmission rates (RSRRs) for surgical discharges were calculated. The association between hospital RSRRs and hospital characteristics was evaluated with bivariate analyses. An estimated multivariable hierarchical linear regression model was used to examine variation in hospital RSRRs, adjusting for hospital characteristics, state, year, and SNH status. Data were analyzed from June 1, 2017, through March 1, 2018. Surgical care at an SNH. Readmission after an index surgical admission. A total of 1 252 505 patients across all 4 years and states were included in the analysis (51.7% women; mean [SD] age, 52.7 [18.1] years). Bivariate analyses found that SNHs had higher mean (SD) surgical RSRRs compared with non-SNHs; significant differences were found for New York (9.6 [0.1] vs 10.9 [0.1]; P < .001) and Florida (11.6 [0.1] vs 12.1 [0.1]; P = .001). The SNHs also had higher RSRRs in these 2 states when stratified by hospital funding (nonfederal government SNHs in New York, 11.9 [0.2]; for-profit, private SNHs in Florida, 13.1 [0.2]; P < .001 for both); however, bed size was a significant factor for higher mean (SD) RSRRs only for New York (200 to 399 beds, 12.0 [0.4]; P = .006). Similar results were found for multivariable linear regression models; RSRRs were 1.02% higher for SNHs compared with non-SNHs (95% CI, 0.75%-1.29%; P < .001). Increased RSRRs were observed for hospitals in New York and Florida, teaching hospitals, and investor-owned hospitals. Factors associated with reduced RSRRs included presence of an ambulatory surgery center, cardiac catheterization capabilities, and high surgical volume. According to results of this study, surgical patients treated at SNHs experienced slightly higher RSRRs compared with those treated at non-SNHs. This association persisted after adjusting for year, state, and hospital factors, including teaching status, hospital bed size, and hospital volume.

Rural Hospital Nursing Skill Mix and Work Environment Associated with Frequency of Adverse Events.

Introduction:Although rural hospitals serve about one fifth of the United States, few studies have investigated relationships among nursing resources and rural hospital adverse events.Objectives:The purpose was to determine relationships among nursing skill mix (proportion of registered nurses [RNs] to all nursing staff), the work environment, and adverse events (medication errors, patient falls with injury, pressure ulcers, and urinary tract infections) in rural hospitals.Methods:Using a cross-sectional design, nurse survey data from a large study examining nurse organizational factors, patient safety, and quality from four U.S. states were linked to the 2006 American Hospital Association data. The work environment was measured using the Practice Environment Scale of the Nursing Work Index (PES-NWI). Nurses reported adverse event frequency. Data analyses were descriptive and inferential.Results:On average, 72% of nursing staff were RNs (range = 45%–100%). Adverse event frequency ranged from 0% to 67%, across 76 hospitals. In regression models, a 10-point increase in the proportion of RNs among all nursing staff and a one standard deviation increase in the PES-NWI score were significantly associated with decreased odds of frequent adverse events.ConclusionRural hospitals that increase the nursing skill mix and improve the work environment may achieve reduced adverse event frequency.

The Methodology for the CLER National Report of Findings 2018.

The Methodology for the CLER National Report of Findings 2018.

Advanced Age and Post-Acute Care Outcomes After Subarachnoid Hemorrhage.

BackgroundOlder patients with aneurysmal subarachnoid hemorrhage (aSAH) are unique, and determinants of post–acute care outcomes are not well elucidated. The primary objective was to identify hospital characteristics associated with 30‐day readmission and mortality rates after hospital discharge among older patients with aSAH.Methods and ResultsThis cohort study used Medicare patients ≥65 years discharged from US hospitals from January 1, 2008, to November 30, 2010, after aSAH. Medicare data were linked to American Hospital Association data to describe characteristics of hospitals treating these patients. Using multivariable logistic regression to adjust for patient characteristics, hospital factors associated with (1) hospital readmission and (2) mortality within 30 days after discharge were identified. A total of 5515 patients ≥65 years underwent surgical repair for aSAH in 431 hospitals. Readmission rate was 17%, and 8.5% of patients died within 30 days of discharge. In multivariable analyses, patients treated in hospitals with lower annualized aSAH volumes were more likely to be readmitted 30 days after discharge (lowest versus highest quintile, 1–2 versus 16–30 cases; adjusted odds ratio, 2.10; 95% confidence interval, 1.56–2.84). Patients treated in hospitals with lower annualized aSAH volumes (lowest versus highest quintile: adjusted odds ratio, 1.52; 95% confidence interval, 1.05–2.19) had a greater likelihood of dying 30 days after discharge.ConclusionsOlder patients with aSAH discharged from hospitals treating lower volumes of such cases are at greater risk of readmission and dying within 30 days. These findings may guide clinician referrals, practice guidelines, and regulatory policies influencing which hospitals should care for older patients with aSAH.

Constructing a National Database to Perform a Modern Analysis of Radiation Therapy Facilities in the United States

Prior literature suggests that the geographic availability of radiation therapy (RT) has a significant effect on whether patients receive radiation and may be associated with better outcomes. However, these studies rely on imperfect proxies to determine the location of RT facilities. The American Medical Association (AMA) Masterfile relies on the location of radiation oncologists, and the American Hospital Association (AHA) relies on survey data from a subset of US hospitals. However, patients receive treatments where RT facilities are located, not just the primary hospitals from which physicians may bill. In this study, we attempted to compile and analyze a more comprehensive modern database of RT facilities in the United States and compared it to existing datasets. We contacted regulatory departments from all 50 states from March to June of 2015 to obtain data on RT facility locations across the US. We mapped the facilities by address and then aggregated the data to the county level to characterize the geographic distribution of RT and to compare this dataset with popular proxies. In our dataset, a county was flagged as providing RT if there was at least 1 RT facility in it. For the AMA data, a county was flagged as having RT if there was at least 1 radiation oncologist working there. For the AHA data, a county was flagged as having RT if there was at least one hospital that performed at least one of the RT modalities. We also performed a linear regression to determine which counties would be less likely to contain an RT facility based on county-level covariates in the Area Health Resources File. 2069 unique radiation treatment facilities in 41 states were included in our new database. 31.1% (815/2614) of total counties in the 41 states that reported data contained a radiation therapy site. Only 18.5% (483/2614) of counties in reporting states were flagged as having RT by all three data sources. 115 counties in reporting states were identified as having RT in the new database but not in AHA nor AMA. 169 counties were flagged in at least one other database but not in the new database. Counties with the most unique RT addresses included Chicago, Houston, and Phoenix. Counties that were urban, had a higher total population, higher income, and a lower median age were more likely to contain a RT facility (p<0.001). Our analysis suggests that existing data sources cataloguing RT availability are incomplete and can be improved by incorporating state-managed data. Our compiled dataset allows for a more comprehensive and detailed analysis of RT distribution in the US than prior studies relying on proxy measures. Future investigations improved by a more comprehensive dataset include specifying regions of greatest need for RT facility expansion and correlation with treatment or outcomes data.

Regional Variation in Neonatal Intensive Care Admissions and the Relationship to Bed Supply

To characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates. This was a population-based, cross-sectional study. 2013 US birth certificate and 2012 American Hospital Association data were used to assign newborns and NICU beds to neonatal intensive care regions. Descriptive statistics of admission rates were calculated across neonatal intensive care regions. Multilevel logistic regression was used to examine the relationship between bed supply and individual odds of admission, with adjustment for maternal and newborn characteristics. Among 3 304 364 study newborns, the NICU admission rate was 7.2 per 100 births and varied across regions for all birth weight categories. IQRs in admission rates were 84.5-93.2 per 100 births for 500-1499 g, 35.3-46.1 for 1500-2499 g, and 3.5-5.5 for ≥2500 g. Adjusted odds of admission for newborns of very low birth weight were unrelated to regional bed supply; however, newborns ≥2500 g in regions with the highest NICU bed supply were significantly more likely to be admitted to a NICU than those in regions with the lowest (aOR 1.20 [1.03-1.40]). There is persistent underuse of NICU care for newborns of very low birth weight that is not associated with regional bed supply. Among larger newborns, we find evidence of supply-sensitive care, raising concerns about the potential overuse of expensive and unnecessary care. Rather than improving access to needed care, NICU expansion may instead further deregionalize neonatal care, exacerbating underuse.

Impact of Area Deprivation Index on Coronary Stent Utilization in a Medicare Nationwide Cohort.

Area Deprivation Index (ADI) is a marker of neighborhood deprivation. This study investigates utilization of coronary bare-metal stent (BMS) and drug-eluting stent (DES) in Medicare patients across hospitals with varying ADI. Data were abstracted using Diagnosis-Related Group (DRG) codes 249 (BMS without major complications or comorbidities [MCC]), 246, and 247 (DES with and without MCC, respectively) from the 2011-2012 Medicare Provider Utilization and Payment Data Inpatient File, which was linked to American Hospital Association data (to determine bed size, location, ownership, teaching status), and ADI for each hospital zip code was obtained. Hospitals were divided into quintiles using ADI values: Quintile 1 (privileged) to Quintile 5 (deprived). Logistic regression was conducted to determine odds ratios (ORs) for DES utilization across ADI quintiles. There were 313,739 discharges with DRG codes 246 (52,839), 247 (203,928), and 249 (56,972). DES utilization was lower in the deprived quintile, irrespective of teaching status. It was lower in larger hospitals and hospitals with more annual stent discharges, urban locations and nongovernment not-for-profit institutes. Lower odds of DES utilization were found in Quintile 2 (OR-0.9, 95% confidence interval [CI] 0.87-0.93, P < 0.001), Quintile 3 (OR-0.89, 95% CI 0.86-0.92, P < 0.001), and Quintile 4 (OR-0.95, 95% CI 0.92-0.98, P = 0.001) versus Quintile 1 and there was no difference in utilization of DES in Quintile 5 (OR-1.01, 95% CI 0.98-1.04, P = 0.6) versus Quintile 1. Significant differences exist in DES utilization in a large, uniformly insured cohort based on neighborhood deprivation.

A directional distance function approach for identifying the input/output status of medical residents

ABSTRACTPrevious empirical studies examining the impact medical residents have on hospital productivity have made a priori assumptions about whether medical residents are inputs (labour providing patient care) or outputs (students receiving mandatory training under the supervision of an attending physician) when specifying their estimating equations. We shed light on the role medical residents play in hospital production by using a data-driven parametric approach based on the directional technology distance function. Our primary goal is to assess the extent to which one of the two roles of medical residents empirically dominates the other and to see whether the role varies across different types of hospital. Using the American Hospital Association data from 1994 to 2010, we find that residents are inputs in all rural and public non-teaching hospitals, but they are outputs in urban-area not-for-profit teaching hospitals. We also demonstrate that the status of residents is related to the case-mix index and can vary with hospital size.

Hospital and Health Insurance Markets Concentration and Inpatient Hospital Transaction Prices in the U.S. Health Care Market.

To examine the effects of hospital and insurer markets concentration on transaction prices for inpatient hospital services. Measures of hospital and insurer markets concentration derived from American Hospital Association and HealthLeaders-InterStudy data are linked to 2005-2008 inpatient administrative data from Truven Health MarketScan Databases. Uses a reduced-form price equation, controlling for cost and demand shifters and accounting for possible endogeneity of market concentration using instrumental variables (IV) technique. The findings suggest that greater hospital concentration raises prices, whereas greater insurer concentration depresses prices. A hypothetical merger between two of five equally sized hospitals is estimated to increase hospital prices by about 9 percent (p<.001). A similar merger of insurers would depress prices by about 15.3 percent (p<.001). Over the 2003-2008 periods, the estimates imply that hospital consolidation likely raised prices by about 2.6 percent, while insurer consolidation depressed prices by about 10.8 percent. Additional analysis using longer panel data and applying hospital fixed effects confirms the impact of hospital concentration on prices. The findings provide support for strong antitrust enforcement to curb rising hospital service prices and health care costs.

Abstract C14: Decomposing Racial Disparities in Breast Reconstruction Surgery

Abstract Background: Breast Reconstruction Surgery (BRS) is an important component of overall breast cancer treatment and is known to improve psychosocial and quality of life outcomes for patients who undergo mastectomy. Clinical guidelines recommend that BRS should be offered to all women who undergo mastectomy. However, significant racial disparities in receipt of BRS have been observed in literature. African Americans are known to be less likely to receive BRS as compared to Non-Hispanic Whites (NHWs) even after controlling for clinical characteristics. Not much is known about the factors that contribute to this disparity. Racial differences in barriers to receipt of BRS may explain the disparity. These barriers are grouped into patient, provider and area level factors. Objective: To determine the degree to which racial disparity in the receipt of BRS can be explained by observed factors at the patient, hospital and area level using Blinder-Oaxaca decomposition method. Data: State inpatient databases (SIDs) for 2010-2012 from seven diverse states were used to identify patients with breast cancer. Information on hospital-level characteristics was derived from the American Hospital Association (AHA) data and the area-level data was derived from the Area Health Resource File (AHRF) and the University of Michigan Racial Residential Segregation Measurement Project. Analyses: The primary outcome was receipt of BRS with mastectomy compared to mastectomy alone. The Fairlie modification to the Oaxaca-Blinder decomposition method was used to decompose the difference in likelihood of receiving BRS between Non-Hispanic Whites and Blacks into components that are explained by each observed characteristic. The observed characteristics included in the model are patient-level barriers: lack of insurance and higher comorbidities; hospital-level barriers: hospital-level factors that reduce the likelihood of offering culturally competent and appropriate care (racial mix catered to by the hospital, availability of knowledge and resources, market competition, etc.); and area-level barriers: racial residential segregation, socio-economic status of the area and availability of plastic surgeons. Findings: Racial differences in insurance status can explain 22% of the disparity and racial differences in socio-economic status of the county can explain 13% of the disparity in receipt of BRS between African American and NHW women. Other factors that contribute significantly to the racial disparity in BRS are higher rates of obesity, higher number and severity of comorbidities in African Americans and higher likelihood of seeking care at hospitals that cater to racial minorities. Lower likelihood of seeking care at an NCI designated Cancer Center by African American women also contributes significantly to the racial disparity in receipt of BRS for these women. On the other hand, African American patients are likely to be younger, reside in urban counties with high density of plastic surgeons and seek care at larger hospitals located in regions with high market competition. These factors contribute significantly to reducing disparities in receipt of BRS for African American women. Living in racially segregated neighborhoods reduces disparities in receipt of BRS for African American women. This could be explained by better psychosocial support in segregated neighborhoods. Conclusions: Known barriers to access significantly influence receipt of BRS for African American women. These findings help guide policy makers towards the barriers that have a high and significant impact on disparities. Selectively addressing these barriers may provide a focused approach to mitigating racial disparities in receipt of BRS. Citation Format: Jaya Shankar Khushalani. Decomposing Racial Disparities in Breast Reconstruction Surgery. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C14.

“Take the Volume Pledge” may result in disparity in access to care

"Take the Volume Pledge" proposes restricting pancreatectomies to hospitals that perform ≥20 per year. Our purpose was to identify those factors that characterize patients at risk for loss of access to pancreatic cancer care with enforcement of volume standards. Using the Healthcare Cost and Utilization Project State Inpatient Database from Florida, we identified patients who underwent pancreatectomy for pancreatic malignancy from 2007-2011. American Hospital Association and United States Census Bureau data were linked to patient-level data. High-volume hospitals were defined as performing ≥20 pancreatic resections per year. Univariable and multivariable statistics compared patient characteristics and utilization of high-volume hospitals. Classification and Regression Tree modeling was used to predict patients at risk for losing access to care. Our study included 1,663 patients. Five high-volume hospitals were identified, and they treated 1,056 (63.5%) patients. Patients residing far from high-volume hospitals, in areas with the highest population density, non-Caucasian ethnicity, and greater income had decreased odds of obtaining care at high-volume hospitals. Using these factors, we developed a Classification and Regression Tree-based predictive tool to identify these patients. Implementation of "Take the Volume Pledge" is an important step toward improving pancreatectomy outcomes; however, policymakers must consider the potential impact on limiting access and possible health disparities that may arise.

Opportunities to Create New General Surgery Residency Programs to Alleviate the Shortage of General Surgeons.

To estimate the capacity for supporting new general surgery residency programs among U.S. hospitals that currently do not have such programs. The authors compiled 2011 American Hospital Association data regarding the characteristics of hospitals with and without a general surgery residency program and 2012 Accreditation Council for Graduate Medical Education data regarding existing general surgery residencies. They performed an ordinary least squares regression to model the number of residents who could be trained at existing programs on the basis of residency program-level variables. They identified candidate hospitals on the basis of a priori defined criteria for new general surgery residency programs and an out-of-sample prediction of resident capacity among the candidate hospitals. The authors found that 153 hospitals in 39 states could support a general surgery residency program. The characteristics of these hospitals closely resembled the characteristics of hospitals with existing programs. They identified 435 new residency positions: 40 hospitals could support 2 residents per year, 99 hospitals could support 3 residents, 12 hospitals could support 4 residents, and 2 hospitals could support 5 residents. Accounting for progressive specialization, new residency programs could add 287 additional general surgeons to the workforce annually (after an initial five- to seven-year lead time). By creating new general surgery residency programs, hospitals could increase the number of general surgeons entering the workforce each year by 25%. A challenge to achieving this growth remains finding new funding mechanisms within and outside Medicare. Such changes are needed to mitigate projected workforce shortages.

The Effects of Hospital-Level Factors on Patientsʼ Ratings of Physician Communication

The quality of physician-patient communication influences patient health outcomes and satisfaction with healthcare delivery. Yet, little is known about contextual factors that influence physicians' communication with their patients. The main purpose of this article is to examine organizational-level factors that influence patient perceptions of physician communication in inpatient settings. We used the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and American Hospital Association data to determine patients' ratings of physician communication at the hospital level, and to collect information about hospital-level factors that can potentially influence physician communication. Our sample consisted of 2,756 hospitals. We ran a regression analysis to determine the predictors of poor physician communication, measured as the percentage of patients in a hospital who reported that physicians sometimes or never communicated well. In our sample of hospitals, this percentage ranged between 0% and 21%, with 25% of hospitals receiving poor ratings from more than 6% of patients. Three organizational factors had statistically significant negative associations with physician communication: for-profit ownership, hospital size, and hospitalists providing care in the hospital, On the other hand, the number of full-time-equivalent physicians and dentists per 10,000 inpatient days, physician ownership of the hospital, Medicare share of inpatient days, and public ownership were positively associated with patients' ratings of physician communication. Physician staffing levels are an understudied area in healthcare research. Our findings indicate that physician staffing levels affect the quality of physician communication with patients. Moreover, for-profit and larger hospitals should invest more in physician communication given the role that HCAHPS plays in value-based purchasing.

Modest Associations Between Electronic Health Record Use and Acute Myocardial Infarction Quality of Care and Outcomes: Results From the National Cardiovascular Data Registry.

In 2009, national legislation promoted wide-spread adoption of electronic health records (EHRs) across US hospitals; however, the association of EHR use with quality of care and outcomes after acute myocardial infarction (AMI) remains unclear. Data on EHR use were collected from the American Hospital Association Annual Surveys (2007-2010) and data on AMI care and outcomes from the National Cardiovascular Data Registry Acute Coronary Treatment and Interventions Outcomes Network Registry-Get With The Guidelines. Comparisons were made between patients treated at hospitals with fully implemented EHR (n=43 527), partially implemented EHR (n=72 029), and no EHR (n=9270). Overall EHR use increased from 82.1% (183/223) hospitals in 2007 to 99.3% (275/277) hospitals in 2010. Patients treated at hospitals with fully implemented EHRs had fewer heparin overdosing errors (45.7% versus 72.8%; P<0.01) and a higher likelihood of guideline-recommended care (adjusted odds ratio, 1.40 [confidence interval, 1.07-1.84]) compared with patients treated at hospitals with no EHR. In non-ST-segment-elevation AMI, fully implemented EHR use was associated with lower risk of major bleeding (adjusted odds ratio, 0.78 [confidence interval, 0.67-0.91]) and mortality (adjusted odds ratio, 0.82 [confidence interval, 0.69-0.97]) compared with no EHR. In ST-segment-elevation MI, outcomes did not significantly differ by EHR status. EHR use has risen to high levels among hospitals in the National Cardiovascular Data Registry. EHR use was associated with less frequent heparin overdosing and modestly greater adherence to acute MI guideline-recommended therapies. In non-ST-segment-elevation MI, slightly lower adjusted risk of major bleeding and mortality were seen in hospitals implemented with full EHRs; however, in ST-segment-elevation MI, differences in outcomes were not seen.

Abstract 208: Association of Hospital Prices for Coronary Artery Bypass Graft Surgery with Hospital Quality and Reimbursement

Background: Although prices for medical services are known to vary markedly between hospitals especially for patients without medical insurance, it remains unknown whether this large variation in price is explained by differences in hospital quality or reimbursement from major insurers. Methods: We obtained an “out-of-pocket” hospital and physician price estimate for a coronary artery bypass graft (CABG) surgery for a hypothetical patient without medical insurance via telephone call from a random sample of U.S. hospitals during January 2014. We examined whether the price provided by a hospital was associated with its 1) structural characteristics obtained from the American Hospital Association data, 2010 2) risk-standardized CABG mortality obtained from the Society of Thoracic Surgeons data, 2013 and 3) “fair price” estimate for CABG base don reimbursement data from major insurers in the zip code of the hospital location (Healthcare Bluebook, www.healthcarebluebook.com). Results: We contacted a total of 111 U.S. hospitals, of which 56 (50.5%) were able to provide a price estimate for CABG. The mean price for CABG obtained from the hospitals was $151,784.64, and ranged from $44,824 - $448,039. Except geographic location (p=0.03), which was weakly associated, hospital prices for a CABG surgery were not associated with teaching status, for-profit/not-for-profit/government classification, urban/rural location, or CABG volume (p &gt;0.10 for all). Likewise, we found no association between a hospital’s quoted price for CABG and its risk-standardized CABG mortality (r= -0.03 p=0.89), or its average reimbursement for CABG surgery from major insurers within the same zip code (r= 0.07, p=0.6). Conclusion: We found a 10-fold variation in the prices obtained from U.S. hospitals for CABG surgery for an uninsured patient. Although there was slight variation in CABG surgery prices based on geographic region, we found no evidence to suggest that hospitals with higher prices have lower mortality or receive higher reimbursement from insured patients.

Disparities in the receipt of robot-assisted radical prostatectomy: between-hospital and within-hospital analysis using 2009–2011 California inpatient data

ObjectivesDespite the rapid proliferation of robot-assisted radical prostatectomy (RARP), little attention has been paid to patient utilisation of this newest surgical innovation and barriers that may result in disparities in...

Hospital employment of supplemental registered nurses and patients' satisfaction with care.

The aim of this study is to determine whether use of supplemental registered nurses (SRNs) from agencies is associated with patients' satisfaction. Employment of SRNs is common, but little is known about whether their use is associated with patients' satisfaction with hospital care. Cross-sectional survey data from nurses in 427 hospitals were linked to American Hospital Association data and patient data from the Hospital Consumer Assessment of Healthcare Providers and Systems survey. We found little evidence that patients' satisfaction with care is related to the use of SRNs. After other hospital and nursing characteristics were controlled, greater use of SRNs was not associated with patients' global satisfaction, including whether they would rank their hospital highly or recommend their hospital, nor was it associated with nurse communication, medication explanation, or pain control. Employment of SRNs does not detract from patients' overall satisfaction or satisfaction with nurses specifically.

Public health insurance expansions and hospital technology adoption

This paper explores the effects of public health insurance expansions on hospitals' decisions to adopt medical technology. Specifically, we test whether the expansion of Medicaid eligibility for pregnant women during the 1980s and 1990s affects hospitals' decisions to adopt neonatal intensive care units (NICUs). While Medicaid expansion provided new insurance to a substantial number of pregnant women, prior literature also finds that some newly insured women would otherwise have been covered by more generously reimbursed private sources. Such crowd-out, combined with Medicaid's low reimbursement rats, leads to a theoretically ambiguous net effect of Medicaid expansion on a hospital's incentive to invest in technology. Using American Hospital Association data, we find that on average, Medicaid expansion has no statistically significant effect on NICU adoption. However, we also find that in geographic areas where more of the newly Medicaid-insured may have come from the privately insured population, Medicaid expansion slows NICU adoption. This holds true particularly when Medicaid payment rates are very low relative to private payment rates. Our findings are consistent with prior evidence on reduced NICU adoption from increased managed-care penetration. We conclude by discussing the policy implications of our work for insurance expansions associated with the Affordable Care Act.

Performance of racial and ethnic minority-serving hospitals on delivery-related indicators

We sought to explore how racial/ethnic minority-serving hospitals perform on 15 delivery-related indicators, and examine whether indicators vary by race/ethnicity within the same type of hospitals. We used 2008 through 2011 linked State Inpatient Database and American Hospital Association data from 7 states, and designated hospitals with >50% of deliveries to non-Hispanic white, non-Hispanic black, and Hispanic women as white-, black-, and Hispanic-serving, respectively. We calculated indicator rates per 1000 deliveries by hospital type and, separately, for non-Hispanic white, non-Hispanic black, and Hispanic women within each hospital type. We fitted multivariate Poisson regression models to examine associations between delivery-related indicators and patient and hospital characteristics by hospital type. White-serving hospitals offer obstetric care to an older and wealthier population than black- or Hispanic-serving hospitals. Rates of the most prevalent indicators examined (complicated vaginal delivery, complicated cesarean delivery, obstetric trauma) were lowest in Hispanic-serving hospitals. Generally, indicator rates were similar in Hispanic- and white-serving hospitals. Black-serving hospitals performed worse than other hospitals on 12 of 15 indicators. Indicator rates varied greatly by race/ethnicity in white- and Hispanic-serving hospitals, with non-Hispanic blacks having 1.19-3.27 and 1.15-2.68 times higher rates than non-Hispanic whites, respectively, for 11 of 15 indicators. Conversely, there were few indicator rate differences by race/ethnicity in black-serving hospitals, suggesting an overall lower performance of these hospitals compared to white- and Hispanic-serving hospitals. We found considerable differences in delivery-related indicators by hospital type and patients' race/ethnicity. Obstetric care quality measures are needed to track racial/ethnic disparities at the facility and population levels.