Care Cost Containment Research Articles

Cost savings from an mHealth tool for improving medication adherence.

To determine the health care cost savings from the Wellth app, a mobile health intervention that uses financial incentives to increase medication adherence. An observational study of members in one of Arizona's Medicaid managed care plans, part of Arizona Health Care Cost Containment System (AHCCCS), using the Wellth app from March 28, 2020, to January 12, 2021. One-to-one matching was used to identify comparable nonparticipants, and a difference-in-differences approach was used to estimate the impact of the Wellth intervention on outcomes defined over the 9 months before and after using Wellth. An AHCCCS managed care health plan provided claims data that contained drug prescription, health care utilization, and health care cost information for all participants, and Wellth provided app usage data and contextual information about the Wellth intervention. On average, the Wellth intervention increased medication adherence by 5.0 percentage points (95% CI, 2.9-7.1; P = .008) and reduced emergency department (-0.02; 95% CI, -0.03 to -0.01; P = .002), inpatient (-0.04; 95% CI, -0.06 to -0.02; P = .001), and mental health clinic (-0.06; 95%CI, -0.10 to -0.01; P = .013) visits relative to nonparticipants over 9 months. Short-term reductions in utilization had an estimated mean cost savings over 9months of $88.15 (95% CI, $31.07-$136.40), with greater reductions for those with chronic obstructive pulmonary disease, schizophrenia, or major depression. Given the relatively low cost of the Wellth intervention, our findings provide preliminary evidence of cost savings from implementing Wellth among adults with several common chronicconditions.

“Factors influencing readmission patterns following radical cystectomy: An analysis of social determinants and discharge outcomes”

Introduction and objectivesRadical cystectomy readmission rates remain high, with around 25% of patients readmitted to index and nonindex hospitals in 30 days. Nonindex readmissions have been associated with poorer outcomes, including longer lengths of stay and higher mortality rates. This study aimed to examine the associations of social factors (e.g., sex, race, socioeconomic status, insurance type, and resident location) on readmission to index versus nonindex hospitals and discharge disposition. MethodsWe conducted a population-based retrospective study using the Pennsylvania Cancer Registry (PCR) to identify patients diagnosed with nonmetastatic muscle-invasive bladder cancer who underwent radical cystectomy in Pennsylvania between 2010 and 2018. Readmitted patients were identified using the Pennsylvania Health Care Cost Containment Council data (PHC4). The primary outcome was readmission location (i.e., index or nonindex hospital) following radical cystectomy. We used chi-square tests for categorical variables, Wilcoxon rank sum test for continuous variables, multivariable logistic regression model to assess predictors of being readmitted to an index hospital and calculating the predicted probability of being admitted to an index hospital depending on discharge disposition. ResultsA total of 517 patients were readmitted within 30-days after radical cystectomy. The majority of readmissions were index readmissions (83%). Median readmission hospital stay was 4 days (interquartile range [IQR] 4) for index and 5 days (IQR 7) for nonindex hospitals, P = 0.01. Patients readmitted to index hospitals had fewer comorbidities (median weighted Elixhauser Comorbidity Index 2 (IQR 2)) and lived in urban areas (89%). Discharge with home care was associated with a higher odds of index readmission (odds ratio, [OR] 2.40; 95% confidence interval, [CI] 1.25–4.52). ConclusionsPatients residing in urban areas and with fewer comorbidities were more likely to be readmitted to index hospitals than nonindex hospitals. Socioeconomic status and insurance type did not correlate with the type of readmission. Finally, being discharged with home health care was found to be a predictor of readmission to an index hospital.

Effects of Medicaid managed care on early detection of cancer: Evidence from mandatory Medicaid managed care program in Pennsylvania.

To examine changes in late- versus early-stage diagnosis of cancer associated with the introduction of mandatory Medicaid managed care (MMC) in Pennsylvania. We analyzed data from the Pennsylvania cancer registry (2010-2018) for adult Medicaid beneficiaries aged 21-64 newly diagnosed with a solid tumor. To ascertain Medicaid and managed care status around diagnosis, we linked the cancer registry to statewide hospital-based facility records collected by an independent state agency (Pennsylvania Health Care Cost Containment Council). We leveraged a natural experiment arising from county-level variation in mandatory MMC in Pennsylvania. Using a stacked difference-in-differences design, we compared changes in the probability of late-stage cancer diagnosis among those residing in counties that newly transitioned to mandatory managed care to contemporaneous changes among those in counties with mature MMC programs. N/A. Mandatory MMC was associated with a reduced probability of late-stage cancer diagnosis (-3.9 percentage points; 95% CI: -7.2, -0.5; p = 0.02), particularly for screening-amenable cancers (-5.5 percentage points; 95% CI: -10.4, -0.6; p = 0.03). We found no significant changes in late-stage diagnosis among non-screening amenable cancers. In Pennsylvania, the implementation of mandatory MMC for adult Medicaid beneficiaries was associated with earlier stage of diagnosis among newly diagnosed cancer patients with Medicaid, especially those diagnosed with screening-amenable cancers. Considering that over half of the sample was diagnosed with late-stage cancer even after the transition to mandatory MMC, Medicaid programs and managed care organizations should continue to carefully monitor receipt of cancer screening and design strategies to reduce barriers to guideline-concordant screening or diagnostic procedures.

Impact of the Affordable Care Act on access to accredited facilities for cancer treatment.

To examine differential changes in receipt of surgery at National Cancer Institute (NCI)-designated comprehensive cancer centers (NCI-CCC) and Commission on Cancer (CoC) accredited hospitals for patients with cancer more likely to be newly eligible for coverage under Affordable Care Act (ACA) insurance expansions, relative to those less likely to have been impacted by the ACA. Pennsylvania Cancer Registry (PCR) for 2010-2019 linked with discharge records from the Pennsylvania Health Care Cost Containment Council (PHC4). Outcomes include whether cancer surgery was performed at an NCI-CCC or a CoC-accredited hospital. We conducted a difference-in-differences analysis, estimating linear probability models for each outcome that control for residence in a county with above median county-level pre-ACA uninsurance and the interaction between county-level baseline uninsurance and cancer treatment post-ACA to capture differential changes in access between those more and less likely to become newly eligible for insurance coverage (based on area-level proxy). All models control for age, sex, race and ethnicity, cancer site and stage, census-tract level urban/rural residence, Area Deprivation Index, and year- and county-fixed effects. We identified adults aged 26-64 in PCR with prostate, lung, or colorectal cancer who received cancer-directed surgery and had a corresponding surgery discharge record in PHC4. We observe a differential increase in receiving care at an NCI-CCC of 6.2 percentage points (95% CI: 2.6-9.8; baseline mean = 9.8%) among patients in high baseline uninsurance areas (p = 0.001). Our estimate of the differential change in care at the larger set of CoC hospitals is positive (3.9 percentage points [95% CI: -0.5-8.2; baseline mean = 73.7%]) but not statistically significant (p = 0.079). Our findings suggest that insurance expansions under the ACA were associated with increased access to NCI-CCCs.

Patient Safety Trends in 2023: An Analysis of 287,997 Serious Events and Incidents From the Nation’s Largest Event Reporting Database

Background The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world, with over 4.7 million acute care event reports dating back to 2004. In this article, we analyze the patient safety event reports submitted to PA-PSRS in 2023. Methods We extracted data from PA-PSRS and obtained data from the Pennsylvania Health Care Cost Containment Council (PHC4). Report counts are based on report submission date, and rates are based on event occurrence date and calculated per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs). Results In 2023, 287,997 reports were submitted to PA-PSRS, which is a considerable increase from 2022 but very close to the 2021 total. Reports of serious and high harm events increased by 20.6% and 25.0%, respectively, representing the largest annual increases historically. Of the 287,997 reports, 96.0% were from hospitals, 3.8% were from ambulatory surgical facilities, and 0.2% were from birthing centers and abortion facilities. The vast majority (95.9%) of the 2023 reports were incidents, with the remaining 4.1% classified as serious events. The reporting rate based on event occurrence date for hospitals in the first half of 2023 was 30.0 reports per 1,000 patient days; for ASFs, the rate was 9.9 reports per 1,000 surgical encounters. For each of the past five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, which accounted for 33.1% of acute care event reports submitted in 2023. From a distribution perspective, the greatest increase in percent of total reports in 2023 occurred with event type Medication Error, and the greatest increase for serious events was with event type Complication of Procedure/Treatment/Test (P/T/T). Almost half of the increase in Complication of P/T/T was with subtype Complication following surgery or invasive procedure (48.2%; 968 of 2,009), and 54.6% (529 of 968) of reports in this subtype were due to unplanned returns to the operating room. Conclusion The number of total reports, serious events, and high harm events, as well as preliminary reporting rates for hospitals and ASFs, all increased in 2023. Patient Safety Authority will continue working with Pennsylvania healthcare facilities to support high-quality reporting and patient safety practices.

Evaluating the network adequacy of vision care services for children in Arizona: A cross sectional study.

Vision challenges are among the most prevalent disabling conditions in childhood, affecting up to 28% of school-age children. These issues can impact the development, learning, and literacy skills of affected children. While vision problems are correctable with timely diagnosis and treatment, insufficient networks can impede children's access to comprehensive, and high-quality care. The study aims to determine where pediatric vision care network adequacy exists in the state of Arizona and where there are gaps in receiving vision care for children. This cross-sectional study assessed the adequacy of pediatric vision care networks in Arizona through a "secret shopper" phone survey. Calls were made to practices that accept Arizona's Medicaid program, Arizona Health Care Cost Containment System (AHCCCS) and/or commercial insurance. Providers were contacted following a standardized script to schedule routine appointments on behalf of 10 and 3-year-old patients enrolled in either Medicaid or commercial health insurance plans. The study examined various components of children's access to vision care services, including the reliability of provider directory information, time until the next available appointment, bilingual service offerings, ages served, region of practice and types of care available. A total of 556 practices in Arizona were evaluated through simulations as patients on AHCCCS, and 510 practices were assessed through simulations as patients with commercial health insurance plans. The average wait time for the next available appointment was 13 days for both insurance types. Alarmingly, up to 74% of vision care practices in Arizona do not serve children covered by AHCCCS. Furthermore, only 41% provide services to children 5 years and younger. Our findings underscore the need to improve access to vision care services for children in Arizona, especially racial/ethnic minorities, low-income groups, and rural residents.

Comparison of primary payer in cancer registry and discharge data.

To determine agreement between variables capturing the primary payer at cancer diagnosis across the Pennsylvania Cancer Registry (PCR) and statewide facility discharge records (Pennsylvania Health Care Cost Containment Council [PHC4]) for adults younger than 65 years, and to specifically examine factors associated with misclassification of Medicaid status in the registry given the role of managed care. Cross-sectional analysis of the primary cancer cases among adults aged 21 to 64 years in the PCR from 2010 to 2016 linked to the PHC4 facility visit records. We assessed agreement of payer at diagnosis (Medicare, Medicaid, private, other, uninsured, unknown) across data sources, including positive predictive value (PPV) and sensitivity, using the PHC4 records as the gold standard. The probability of misclassifying Medicaid in registry was estimated using multivariate logit models. Agreement of payers was high for private insurance (PPV, 89.7%; sensitivity, 83.6%), but there was misclassification and/or underreporting of Medicaid in the registry (PPV, 80%; sensitivity, 58%). Among cases with "other" and "unknown" insurance, 73.8% and 62.1%, respectively, had private insurance according to the PHC4 records. Medicaid managed care was associated with a statistically significant increase of 12.6 percentage points (95% CI, 9.4-15.8) in the probability of misclassifying Medicaid enrollment as private insurance in the registry. Findings suggest caution in conducting and interpreting research using insurance variables in cancer registries.

Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds.

Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.

Patient Safety Trends in 2022: An Analysis of 256,679 Serious Events and Incidents From the Nation’s Largest Event Reporting Database

Background Pennsylvania is the only state that requires acute care facilities to report all events of harm or potential for harm. The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world, with over 4.5 million acute care event reports dating back to 2004. Herein, we examine patient safety event reports submitted to the PA-PSRS acute care database in 2022 and compare them to prior years. Methods We extracted data from PA-PSRS and obtained data from the Pennsylvania Health Care Cost Containment Council (PHC4). Counts of reports were calculated based on report submission date, and rates were calculated based on event occurrence date and calculated per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs). Results A total of 256,679 reports were submitted to PA-PSRS in 2022, representing an 11.1% decrease from 2021. Three facilities collectively submitted 18,601 fewer reports in 2022 compared to 2021, which accounted for 57.8% of the overall decrease. Reports of serious and high harm events increased by 7.7% and 11.1%, respectively. Of the 256,679 reports submitted, 95.9% were from hospitals, 3.9% were from ambulatory surgical facilities, and 0.2% were from birthing centers and abortion facilities. The vast majority of the 2022 reports were incidents (96.2%) as opposed to serious events (3.8%). For each of the past five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, accounting for 32.8% of all submitted acute care event reports in 2022. The second, third, and fourth most frequently reported event types in 2022 were Complication of Procedure/Treatment/Test, Medication Error, and Fall, accounting for 15.6%, 13.2%, and 12.8% of submitted reports, respectively. The reported event rate based on occurrence date for hospitals in the first half of 2022 was 27.5 reports per 1,000 patient days. For ASFs, the reported event rate for the first half of 2022 was 9.4 reports per 1,000 surgical encounters. Conclusions There was a decrease in the number of incident reports submitted to PA-PSRS in 2022 and an increase in serious and high harm event reports. PSA will continue to work with facilities, monitor reporting, and take further action as needed.

Changes in Urologic Cancer Surgical Volume and Length of Stay During the COVID-19 Pandemic in Pennsylvania

Disruptions in cancer surgery during the COVID-19 pandemic led to widespread deferrals and cancellations, creating a surgical backlog that presents a challenge for health care institutions moving into the recovery phase of the pandemic. To describe patterns in surgical volume and postoperative length of stay for major urologic cancer surgery during the COVID-19 pandemic. This cohort study identified 24 001 patients 18 years or older from the Pennsylvania Health Care Cost Containment Council database with kidney cancer, prostate cancer, or bladder cancer who received a radical nephrectomy, partial nephrectomy, radical prostatectomy, or radical cystectomy between the first quarter (Q1) of 2016 and Q2 of 2021. Postoperative length of stay and adjusted surgical volumes were compared before and during the COVID-19 pandemic. The primary outcome was adjusted surgical volume for radical and partial nephrectomy, radical prostatectomy, and radical cystectomy during the COVID-19 pandemic. The secondary outcome was postoperative length of stay. A total of 24 001 patients (mean [SD] age, 63.1 [9.4] years; 3522 women [15%], 19 845 White patients [83%], 17 896 living in urban areas [75%]) received major urologic cancer surgery between Q1 of 2016 and Q2 of 2021. Of these, 4896 radical nephrectomy, 3508 partial nephrectomy, 13 327 radical prostatectomy, and 2270 radical cystectomy surgical procedures were performed. There were no statistically significant differences in patient age, sex, race, ethnicity, insurance status, urban or rural status, or Elixhauser Comorbidity Index scores between patients who received surgery before and patients who received surgery during the pandemic. For partial nephrectomy, a baseline of 168 surgeries per quarter decreased to 137 surgeries per quarter in Q2 and Q3 of 2020. For radical prostatectomy, a baseline of 644 surgeries per quarter decreased to 527 surgeries per quarter in Q2 and Q3 of 2020. However, the likelihood of receiving radical nephrectomy (odds ratio [OR], 1.00; 95% CI, 0.78-1.28), partial nephrectomy (OR, 0.99; 95% CI, 0.77-1.27), radical prostatectomy (OR, 0.85; 95% CI, 0.22-3.22), or radical cystectomy (OR, 0.69; 95% CI, 0.31-1.53) was unchanged. Length of stay for partial nephrectomy decreased from baseline by a mean of 0.7 days (95% CI, -1.2 to -0.2 days) during the pandemic. This cohort study suggests that partial nephrectomy and radical prostatectomy surgical volume decreased during the peak waves of COVID-19, as did postoperative length of stay for partial nephrectomy.

Impact of the COVID-19 pandemic on pediatric Medicaid dental claims in Arizona.

To examine the role COVID-19 had on access to dental services among children in Arizona by comparing paid pediatric dental claims made before and during the pandemic. In a retrospective descriptive study, we examined Medicaid paid claims for dental services among pediatric patients from March through December 2019 and during the outbreak in 2020. Using dental claims data obtained from the Centers for Health Information and Research at Arizona State University (ASU), we analyzed Medicaid (Arizona Health Care Cost Containment System [AHCCCS]) reimbursed dental services. During the COVID-19 pandemic, paid preventive dental claims for children aged birth to 21 years decreased in 2020 compared to the same time period in 2019. Pediatric patients in Arizona utilized fewer dental services and had less access to credentialed Medicaid dental providers during the pandemic. Further, rural counties had statistically significant fewer preventive, minor restorative, major restorative, and endodontic claims compared to urban counties. Arizona rural counties also had fewer providers who were paid $10,000 or more per year during 2020 than in 2019. COVID-19 has had a detrimental impact on pediatric dental service utilization. While dental services were provided during the COVID-19 pandemic, preventive and restorative dental claims dropped for rural Arizona children aged birth to 21 years. This reveals potential negative impacts on oral health. Further research should examine the direct and indirect impact the COVID-19 pandemic has had on dental service utilization and oral health for the general pediatric population.

Abstract PR004: Urban/rural differences in receiving cancer surgery at high-volume hospitals and sensitivity to hospital volume thresholds

Abstract Research Objective: There is strong evidence that hospital volume is associated with improved outcomes for patients undergoing surgery for cancer across a number of common cancers, yet there is no consensus on how to classify hospitals as high-volume. Further, lack of access to high-volume hospitals (HVHs) may contribute to rural-urban disparities in cancer outcomes. This study examines urban/rural differences in receipt of cancer surgery at HVHs and sensitivity to volume thresholds used. Study Design: We used logistic regression models to examine the association between cancer surgery at a HVH and individual and area factors using different volume thresholds that are commonly used in the literature: top 10%, 20%, 25%, and 30%. Population Studied: Using 2017-2020 statewide Pennsylvania Health Care Cost Containment Council (PHC4) inpatient data, we identified patients ages 18+ with a diagnosis of 10 cancers (lung, pancreas, breast, brain, rectum, bladder, colon, esophagus, prostate, stomach) who underwent a cancer-related surgery. Principal Findings: We found variability in the number of hospitals classified as high-volume as well as the percentage of surgeries performed at HVH. Across the 10 cancers examined, the relationship between rural residence and treatment in a HVH varied by cancer type, and for some cancers, varied depending on the volume threshold used. There was a consistent negative relationship between rural residence and surgery at a high-volume hospital for breast and lung cancer; for colon and prostate cancers the association was generally negative but only significant using certain high-volume thresholds. For esophageal and pancreatic cancer, there was a positive relationship between rural residence and surgery at a HVH and therefore, compared to urban counties, patients with esophageal and pancreatic cancer in rural counties were more likely to be treated at a HVH. Among less prevalent cancers (bladder, stomach, rectum and brain) there was less consistency in the relationship between rural residence and treatment at a HVH across different thresholds. Conclusions: For many cancers, rural patients are less likely to receive care at HVHs, though the relationship differs across cancers and depending on volume threshold examined. Findings highlight the complexity of examining patterns of cancer care at HVHs, and the importance of protocols outlining minimum procedural volume thresholds. Positive relationships between rural residence and treatment at a HVH may result from selection effects if rural patients are less likely to receive surgery overall. Implications for Policy or Practice: There has been interest in using treatment at HVHs as a quality metric for determining reimbursement, including for breast cancer in the New York Medicaid program in recent years. Our findings highlight the complexity of developing such programs for other cancers. This study informs protocols focusing on high-volume thresholds and have implications for surgical education and training. Citation Format: Haleh Ramian, Lindsay Sabik, Zhaojun Sun, Jonathan Yabes, Bruce Jacobs. Urban/rural differences in receiving cancer surgery at high-volume hospitals and sensitivity to hospital volume thresholds [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PR004.

Wellness Program Participation and its Association With Reduction in Health Risks and Health Care Costs: One University's Story.

Evaluate if there is a(n): 1) reduction in health risk behaviors and 2) association between health and wellness initiative participation and claims costs decreases overtime. Health risk behavior change consisted of the analysis of pre (2009) - post (2019) measures of health questionnaire participants. The medical and pharmaceutical claims costs evaluation consisted of a time-series (2016-2019) design with a comparison group. A large mid-western university with a health system. The health risk behavior sample ranged from 5215-5399, depending on the variable of interest. The medical and pharmaceutical costs sample used a cohort of participants (participating all 4 years, n=11114) and non-participants (not participating all 4 years, n=4776). Comprehensive employee health and well-being initiative. McNemar's tests were used to identify bivariate associations between 2009 and 2019 health risks. The claims cost analysis used propensity score matching based on select demographics and linear mixed-effects regression modeling. Results show statistically significant (P > .001) improvements (ranging from -2.1% to -12.5%) in 7 of 8 health risk behaviors. 2016 and 2019 claims costs have a lower statistically significant (P > .001) percent increase for participants (32.6%) compared to non-participants (47.5%). Employers, may consider implementing a comprehensive health and wellness program as part of their strategy to assist in health behavior risk reduction and health care cost containment.

Discharge destination and readmissions among patients with head and neck cancer.

ObjectiveLowering hospital readmission rates is a national goal, and presents an opportunity to lower health care costs, improve quality, and increase patient satisfaction. We aim to assess whether discharge disposition is associated with readmission.MethodsA retrospective cohort study using logistic regression to quantify risk factors of hospital readmission in patients with confirmed head and neck cancer (HNC) who underwent surgery from 2010 to 2018 contained in the Pennsylvania Health Care Cost Containment Council database, which includes patients treated in Pennsylvania hospitals.ResultsThe readmission rate in this study was 18.1%. Cancers of the hypopharynx had the highest rates of readmission (29.2%). Male sex (odds ratio [OR]: 0.87, 95% CI: 0.75–1.00), emergent admission (vs. elective admission: OR = 1.33, 95% CI: 1.02–1.74), discharge to home health (vs. home: OR = 1.85, 95% CI: 1.59–2.16), discharge to skilled nursing facility (SNF) (vs. home: OR = 2.21, 95% CI: 1.80–2.72), and having 4+ comorbidities (vs. 0–1: OR = 1.39, 95% CI: 1.09–1.76) were significant risk factors for hospital readmission.ConclusionIt is necessary to consider the readmission risk associated with HNC patients. Reasons for readmission are multifactorial and can be related to demographics, hospital course, comorbidities, or discharge disposition–this requires further assessment. There is importance in increasing HNC awareness and staff education about the unique needs of this population.Level of Evidence4.

Risk factors for 30-day readmission following liver transplantation in Pennsylvania

BackgroundReadmissions after liver transplantation (LT) are common given the complexity of the procedure, the severity of illness of patients, and complications related to immunosuppression. The objectives of this research were to identify risk factors for 30-day readmission and length of stay (LOS) for patients undergoing LT in Pennsylvania (PA). MethodsData from the Pennsylvania Health Care Cost Containment Council (PHC4) were used to identify 1,163 patients admitted to 10 liver transplant centers in Pennsylvania for liver transplantation between 2010 and 2018. Logistic and generalized linear regression models were used to estimate risk factors for 30-day readmission and LOS, respectively, adjusting for patient, disease, and hospital characteristics. ResultsOf the 1,163 patients receiving LT, 361 (31.1%) required readmission within 30 days, most frequently for surgical complication (23.5%). Both 30-day readmission rates and LOS showed a decreasing trend from 2010 to 2018. Readmitted patients were more likely to be younger than 60, female, have had a longer LOS, have been discharged to a skilled nursing facility, and have concomitant comorbid renal disease. Longer LOS was associated with patients who had an emergent admission, were transferred from another acute care institution, had surgical complications, and were discharged to a skilled nursing facility. We also found that age, hospital volume, and comorbidities were associated with longer LOS. ConclusionsPatient demographics, including age, sex, and race/ethnicity are associated with readmission and LOS following LT in PA. These results may be useful in guiding efforts to prevent readmissions.

Impact of Expanding Telephonic Codes in a State Medicaid Program During COVID-19.

Background: The recent pandemic caused by the 2019 novel coronavirus (COVID-19) resulted in declaration of a national emergency (NE) in March 2020. The Centers for Medicare and Medicaid Services quickly responded with temporary expansion of telehealth coverage policies. Aim: To determine the impact of implementing a temporary telephonic code set in a state Medicaid population by comparing the utilization patterns of telehealth claims before and after a NE announcement. Methods: This was a retrospective cohort study conducted with the Arizona Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS). Data include telehealth claims submitted to AHCCCS between January and May 2020 by contracted managed care organizations. Results: Approximately 2.3 million telehealth claims were analyzed in this study. Utilization of the audio-visual (A/V) modality increased 1,610% and telephonic visits increased 408% compared with pre-NE. Compared with pre-NE, three provider type groups increased their utilization of telephonic visits from 1.8% to 50.8% as a result of the temporary telephonic set post-NE. Rural counties had higher rates of telephonic modality adoption, whereas urban counties adopted the A/V modality more readily. Ten telephonic codes constituted 87% of all telehealth claims, with the majority of those codes used for behavioral health and established office visit types. Conclusion: The telephonic modality was adopted more frequently in rural areas and the A/V modality in urban areas. There were several new provider types utilizing telehealth as a result of the temporary telephonic code set implementation.

Intensive care unit versus floor admission following lower extremity free flap surgery: Is there a difference in outcomes?

Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted toward admitting FTT patients to the floor postoperatively instead of the ICU. The purpose of this study is to compare surgical outcomes in patients admitted to the floor versus ICU immediately following LE free flap reconstruction. We retrospectively reviewed patients undergoing LE FTT reconstruction from 2011 to 2021. Flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or floor postoperatively. To ensure proper comparability between cohorts, we corrected for age, BMI and Charlson Comorbidity Index (CCI) using 1:2 propensity score matching (floor: ICU). Primary outcomes included early postoperative complications, flap takeback and salvage, flap success, and postoperative length of stay (LOS). A total of 252 patients were identified. Forty-five patients (17.9%) were admitted to the floor postoperatively and 207 patients (82.1%) to the ICU. Overall, microsurgical success rate was 97.2%, which was similar for floor and ICU patients. Flap takeback and salvage were similar between cohorts. Average postoperative LOS was significantly shorter in floor patients (15.7 vs. 19.1 days, p= 0.043). Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. In the ongoing era of health care cost containment, microsurgery centers should consider appropriate floor training to allow medically stable free flap patients to avoid an ICU stay.

Cost-consciousness among Chinese medical staff: a cross-sectional survey

BackgroundRapidly increasing health care costs are a widespread problem in the world. The cost-consciousness among Chinese medical staff is an important topic that needs further investigation. Our study aimed to focus on the cost-consciousness of Chinese medical staff and explore the factors related to their cost-consciousness. Differences regarding cost-consciousness between doctors and nurses were also reported.MethodsEight hospitals in Liaoning Province, China, were surveyed using a self-reporting questionnaire. A total of 1043 respondents, including 635 doctors and 408 nurses, participated in the study. A revised Chinese Cost-consciousness Scale was used to estimate cost-consciousness.ResultsThe mean score of the Cost-consciousness Scale was 27.60 and 28.18 among doctors and nurses, respectively, and there were no significant differences in any personal characteristics. Most Chinese medical staff were aware of the treatment costs and considered cost control as their responsibility. Chinese doctors disliked adhering to guidelines more and preferred to remain independent in making or denying a treatment decision; thus, they like autonomously balancing the treatment and cost. Chinese nurses have similar attitudes, but nurses tended to deny costly services and interventions and were more sensitive to the health care costs by rationing decisions and uncertainty in their medical practice.ConclusionWe reveal the attitudes regarding cost-consciousness among Chinese medical staff. Chinese medical staff was aware of their responsibility in health cost control. Chinese doctors and nurses had different tendencies with regard to health care cost containment. Our study highlights the importance of education and professional training on cost-consciousness.

Are Income-based Differences in TKA Use and Outcomes Reduced in a Single-payer System? A Large-database Comparison of the United States and Canada.

Income-based differences in the use of and outcomes in TKA have been studied; however, it is not known if different healthcare systems affect this relationship. Although Canada's single-payer healthcare system is assumed to attenuate the wealth-based differences in TKA use observed in the United States, empirical cross-border comparisons are lacking. (1) Does TKA use differ between Pennsylvania, USA, and Ontario, Canada? (2) Are income-based disparities in TKA use larger in Pennsylvania or Ontario? (3) Are TKA outcomes (90-day mortality, 90-day readmission, and 1-year revision rates) different between Pennsylvania and Ontario? (4) Are income-based disparities in TKA outcomes larger in Pennsylvania or Ontario? We identified all patients hospitalized for primary TKA in this cross-border retrospective analysis, using administrative data for 2012 to 2018, and we found a total of 161,244 primary TKAs in Ontario and 208,016 TKAs in Pennsylvania. We used data from the Pennsylvania Health Care Cost Containment Council, Harrisburg, PA, USA, and the ICES (formally the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada. We linked patient-level data to the respective census data to determine community-level income using ZIP Code or postal code of residence and stratified patients into neighborhood income quintiles. We compared TKA use (age and gender, standardized per 10,000 population per year) for patients residing in the highest-income versus the lowest-income quintile neighborhoods. Similarly secondary outcomes 90-day mortality, 90-day readmission, and 1-year revision rates were compared between the two regions and analyzed by income groups. TKA use was higher in Pennsylvania than in Ontario overall and for all income quintiles (lowest income quartile: 31 versus 18 procedures per 10,000 population per year; p < 0.001; highest income quartile: 38 versus 23 procedures per 10,000 population per year; p < 0.001). The relative difference in use between the highest-income and lowest-income quintile was larger in Ontario (28% higher) than in Pennsylvania (23% higher); p < 0.001. Patients receiving TKA in Pennsylvania were more likely to be readmitted within 90 days and were more likely to undergo revision within the first year than patients in Ontario, but there was no difference in mortality at 1 year. When comparing income groups, there were no differences between the countries in 90-day mortality, readmission, or 1-year revision rates (p > 0.05). These results suggest that universal health insurance through a single-payer may not reduce the income-based differences in TKA access that are known to exist in the United States. Future studies are needed determine if our results are consistent across other geographic regions and other surgical procedures. Level III, therapeutic study.

Patient Safety Trends in 2021: An Analysis of 288,882 Serious Events and Incidents From the Nation’s Largest Event Reporting Database

Background: Pennsylvania is the only state that requires acute care facilities to report all events of harm or potential for harm. With over 4.2 million acute care event reports, the Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world. This study examines patient safety event reports submitted to the PA-PSRS acute care database in 2021. Methods: We queried PA-PSRS for all event reports submitted by Pennsylvania acute care facilities during calendar year 2021. We also obtained the most current data from the Pennsylvania Health Care Cost Containment Council (PHC4) to calculate rates based on patient days for hospitals and surgical encounters for ambulatory surgical facilities (ASFs). For the Other (specify) subtype within the Other/Miscellaneous event type, we identified the words occurring most frequently in the required free-text response field and calculated the increase in associated reports for each of the words from 2020 to 2021. Results: Of the 288,882 patient safety event reports submitted by Pennsylvania’s acute care facilities in 2021, 96.8% were from hospitals and 3.1% were from ASFs. The remaining 0.1% were from birthing centers and abortion facilities. The vast majority of the 2021 reports were Incidents (96.9%) rather than Serious Events (3.1%). For each of the past five years, the most frequently reported event type was Error Related to Procedure/Treatment/Test, accounting for 31.3% of all submitted acute care event reports in 2021. The second, third, and fourth most frequently reported event types were Medication Error, Complication of Procedure/Treatment/Test, and Fall, accounting for 16.9%, 15.3%, and 12.3% of submitted reports in 2021, respectively. The reporting rate for hospitals in 2021 (Q1 and Q2) was 30.9 reports per 1,000 patient days. For ASFs, the reporting rate in 2021 (Q1 and Q2) was 8.6 reports per 1,000 surgical encounters. Conclusions: There was an increase in the total number of patient safety event reports submitted in 2021, yet the percentage of high harm reports remained steady. Four event types—Error Related to Procedure/Treatment/Test, Medication Error, Complication of Procedure/Treatment/ Test, and Fall—accounted for more than three-quarters of all reports submitted to PA-PSRS in 2021. Readers can use the longitudinal and categorical insights shared in this article to focus patient safety improvement efforts.