Determine Hospital Reimbursement Research Articles

1117: EVALUATION OF PREDICTIVE VALUE OF LACE SCORE FOR 30-DAY READMISSION FOR PNEUMONIA

Introduction: Patients hospitalized with community-acquired pneumonia (CAP) have a 30-day readmission rate of up to 25%, likely secondary to the high comorbidity burden in this patient population. Thirty-day hospital readmission rates are used by the Center for Medicare and Medicaid Services (CMS) as a performance measure to determine hospital reimbursement rates. The LACE score (length of stay, acuity of admission, comorbidities, and emergency department visits within the last six months) was designed to predict the risk of 30-day hospital readmissions to identify patients at risk for 30-day readmission. Herein, we assessed the predictive value of the LACE score, specifically in stratifying patients admitted to the hospital with a diagnosis of CAP for their risk of 30-day readmission. Methods: In this retrospective cohort study, all patients above 18 years of age admitted to our hospital during 2019 with a CAP diagnosis were included. Via chart review, the patient’s clinical characteristics, comorbidity burden, and hospital readmissions within 30-days of discharge were recorded. Logistic regression models were built to assess the predictive value of each variable for 30-day readmission after discharge. Results: A total of 128 patients (median age 65, IQR 54-78, 46.9% females) were included in the study. Fourteen (10.9%) patients required ICU stay, and 6(4.7%) patients died. Within 30 days of discharge from the hospital, 20 (15.6%) of patients were re-evaluated in the emergency department (ED), and 19 (14.8%) were re-admitted. Factors associated with readmission include LACE score on admission (OR 1.21 (1.02-1.47), p-value 0.02), length of stay (OR 1.10 (1.01-1.20), p-value 0.02), and number of ED visits within the last six months (OR 1.70 (1.22-2.49), p-value 0.003). Conclusions: A higher LACE score or behavior of frequent ED visits is associated with a higher chance of hospital readmission in patients with community-acquired pneumonia after discharge. LACE score can be used as a tool by physicians and case managers to identify patients at risk for 30-day readmission after discharge, and closer follow-ups may be arranged in this high-risk population.

National Incidence of Reportable Quality Metrics in the Knee Arthroplasty Population

BackgroundThe Centers for Medicare and Medicaid Services (CMS) characterizes adverse quality events in the inpatient setting as patient safety indicators (PSI). The incidence of PSI has not been quantified in the total knee arthroplasty (TKA) population. MethodsAll patients in the Nationwide Inpatient Sample who underwent primary TKA during an inpatient episode in 2013 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Disease, Ninth Revision diagnosis code algorithms used by CMS. Multivariable logistic regression was used to determine significant associations between patient level covariates (demographics, comorbidities, and hospital characteristics) and the risk of experiencing one or more PSI after TKA. ResultsWe identified 132,453 primary TKA patients in the Nationwide Inpatient Sample in 2013. We estimated the national incidence rate of experiencing one or more PSI as 0.98%. After adjusting for patient demographics and hospital characteristics, we found that relative to Medicaid/self-pay patients, neither Medicare nor privately insured patients faced significantly different risk of experiencing one or more PSI after TKA. However, alcohol abuse, deficiency anemia, congestive heart failure, coagulopathy, and electrolyte imbalance were associated with increased risk of experiencing one or more PSI after TKA. ConclusionThe national incidence of PSI among TKA patients was lower than has been reported in other surgical populations. CMS uses the incidence of adverse quality events (measured using PSI) in part to determine hospital reimbursement. As value-based payment becomes more widely adopted in the United States, initiatives designed to eliminate and reduce PSI incidence can benefit vulnerable patient populations, physicians, and hospital systems.

The association between the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and real-world clinical outcomes in lumbar spine surgery

Background ContextThe patient experience of care as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is currently used to determine hospital reimbursement. The current literature inconsistently demonstrates an association between patient satisfaction and surgical outcomes. PurposeTo determine whether patient satisfaction with hospital experience is associated with better clinical outcomes in lumbar spine surgery. Study DesignA retrospective cohort study conducted at a single institution. Patient SampleA total of 249 patients who underwent lumbar spine surgery between 2013 and 2015 and completed the HCAHPS survey. Outcome MeasuresSelf-reported health status measures, including the EuroQol 5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and visual analog score for back pain (VAS-BP). MethodsAll patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy, scoliosis, or had less than 1 year of follow-up. Patients who selected a 9 or 10 overall hospital rating (OHR) on HCAHPS were placed in the satisfied group, and the remaining patients comprised the unsatisfied group. The primary outcomes of this study include patient-reported health status measures such as EQ-5D, PDQ, and VAS-BP. No funds were received in support of this study, and the authors report no conflict of interest-associated biases. ResultsOur study population consisted of 249 patients undergoing lumbar spine surgery. Of these, 197 (79%) patients selected an OHR of 9 or 10 on the HCAHPS survey and were included in the satisfied group. The only preoperative characteristics that differed significantly between the twogroups were gender, a diagnosis of degenerative disc disease (DDD), heavy preoperative narcotic use, and a diagnosis of chronic renal failure. At 1 year follow-up, no statistically significant differences in EQ-5D, PDQ, or VAS-BP were observed. After using multivariable linear regression models to assess the association between patient satisfaction and pre- to 1-year postoperative changes in health status measures, selecting a top-box OHR was not found to be significantly associated with change in either EQ-5D (beta=0.055 [95% confidence interval {CI}: −0.035 to 0.145]), PDQ (beta=−9.013 [95% CI: −23.782 to 5.755]), or VAS-BP (beta=−0.849 [95% CI: −2.125 to 0.426]). These results suggest high satisfaction with the hospital experience may not necessarily correlate with favorable clinical outcomes. ConclusionsTop-box OHR was not associated with pre- to 1-year postoperative improvement in EQ-5D, PDQ, and VAS-BP. Although the associations between high satisfaction and improvement in health status did not reach statistical significance, the best estimates from our multivariable models reflect greater clinical improvement with top-box satisfaction. Future studies should seek to investigate whether HCAHPS are a reliable indicator of quality care in lumbar spine surgery.

Association between insurance status and patient safety in the lumbar spine fusion population

Background ContextLumbar fusion is a common and costly procedure in the United States. Reimbursement for surgical procedures is increasingly tied to care quality and patient safety as part of value-based reimbursement programs. The incidence of adverse quality events among lumbar fusion patients is unknown using the definition of care quality (patient safety indicators [PSI]) used by the Centers for Medicare and Medicaid Services (CMS). The association between insurance status and the incidence of PSI is similarly unknown in lumbar fusion patients. PurposeThis study sought to determine the incidence of PSI in patients undergoing inpatient lumbar fusion and to quantify the association between primary payer status and PSI in this population. Study DesignA retrospective cohort study was carried out. Patient SampleThe sample comprised all adult patients aged 18 years and older who were included in the Nationwide Inpatient Sample (NIS) that underwent lumbar fusion from 1998 to 2011. Outcome MeasureThe incidence of one or more PSI, a validated and widely used metric of inpatient health-care quality and patient safety, was the primary outcome variable. MethodsThe NIS data were examined for all cases of inpatient lumbar fusion from 1998 to 2011. The incidence of adverse patient safety events (PSI) was determined using publicly available lists of the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Logistic regression models were used to determine the association between primary payer status (Medicaid and self-pay relative to private insurance) and the incidence of PSI. ResultsA total of 539,172 adult lumbar fusion procedures were recorded in the NIS from 1998 to 2011. Patients were excluded from the secondary analysis if “other” or “missing” was listed for primary insurance status. The national incidence of PSI was calculated to be 2,445 per 100,000 patient years of observation, or approximately 2.5%. In a secondary analysis, after adjusting for patient demographics and hospital characteristics, Medicaid and self-pay patients had significantly greater odds of experiencing one or more PSI during the inpatient episode relative to privately insured patients (odds ratio 1.16, 95% confidence interval 1.07–1.27). ConclusionsAmong patients undergoing inpatient lumbar fusion, insurance status is associated with the adverse health-care quality events used to determine hospital reimbursement by the CMS. The source of this disparity must be studied to improve the quality of care delivered to vulnerable patient populations.

Disparities in reportable quality metrics by insurance status in the primary spine neoplasm population

Background ContextThe Centers for Medicare and Medicaid Services (CMS) defines “adverse quality events” as the incidence of certain complications such as postsurgical hematoma or iatrogenic pneumothorax during an inpatient stay. Patient safety indicators (PSI) are a means to measure the incidence of these adverse events. When adverse events occur, reimbursement to the hospital decreases. The incidence of adverse quality events among patients hospitalized for primary spinal neoplasms is unknown. Similarly, it is unclear what the impact of insurance status is on adverse care quality among this patient population. PurposeWe aimed to determine the incidence of PSI among patients admitted with primary spinal neoplasms, and to determine the association between insurance status and the incidence of PSI in this population. Study DesignThis is a retrospective cohort study. Patient SampleWe included all patients, 18 years and older, in the Nationwide Inpatient Sample (NIS) who were hospitalized for primary spine neoplasms from 1998 to 2011. Outcome MeasuresIncidence of PSI from 1998 to 2011 served as outcome variable. MethodsThe NIS was queried for all hospitalizations with a diagnosis of primary spinal neoplasm during the inpatient episode from 1998 to 2011. Incidence of PSI was determined using publicly available lists of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Logistic regression models were used to determine the effect of primary payer status on PSI incidence. All comparisons were made between privately insured patients and Medicaid or self-pay patients. ResultsWe identified 6,095 hospitalizations in which a primary spinal neoplasm was recorded during the inpatient episode. We excluded patients younger than 18 years and those with “other” or “missing” primary insurance status, leaving 5,880 patients for analysis. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more PSI (odds ratio [OR] 1.81 95% confidence interval [CI] 1.11–2.95) relative to privately insured patients. ConclusionsAmong patients hospitalized for primary spinal neoplasms, primary payer status predicts the incidence of PSI, an indicator of adverse health-care quality used to determine hospital reimbursement by the CMS. As reimbursement continues to be intertwined with reportable quality metrics, identifying vulnerable populations is critical to improving patient care.

Insurance status and reportable quality metrics in the cervical spine fusion population

Background ContextThe incidence of adverse care quality events among patients undergoing cervical fusion surgery is unknown using the definition of care quality employed by the Centers for Medicare and Medicaid Services (CMS). The effect of insurance status on the incidence of these adverse quality events is also unknown. PurposeThis study determined the incidence of hospital-acquired conditions (HAC) and patient safety indicators (PSI) in patients with cervical spine fusion and analyzed the association between primary payer status and these adverse events. Study DesignThis is a retrospective cohort design. Patient SampleAll patients in the Nationwide Inpatient Sample (NIS) aged 18 and older who underwent cervical spine fusion from 1998 to 2011 were included. Outcome MeasuresIncidence of HAC and PSI from 1998 to 2011 served as outcome variables. MethodsWe queried the NIS for all hospitalizations that included a cervical fusion during the inpatient episode from 1998 to 2011. All comparisons were made between privately insured patients and Medicaid or self-pay patients because Medicare enrollment is confounded with age. Incidence of nontraumatic HAC and PSI was determined using publicly available lists of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. We built logistic regression models to determine the effect of primary payer status on PSI and nontraumatic HAC. ResultsWe identified 419,424 hospitalizations with cervical fusion performed during an inpatient episode. The estimated national incidences of nontraumatic HAC and PSI were 0.35% and 1.6%, respectively. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more HAC (odds ratio [OR] 1.51 95% conflict of interest [CI] 1.23–1.84) or PSI (OR 1.52 95% CI 1.37–1.70) than the privately insured cohort. ConclusionsAmong patients undergoing inpatient cervical fusion, primary payer status predicts PSI and HAC (both indicators of adverse health-care quality used to determine hospital reimbursement by CMS). As the US health-care system transitions to a value-based payment model, the cause of these disparities must be studied to improve the quality of care delivered to vulnerable patient populations.

How Well Do All Patient Refined-Diagnosis-Related Groups Explain Costs of Pediatric Cancer Chemotherapy Admissions in the United States?

Purpose:State-based Medicaid programs have begun using All Patient Refined–Diagnosis-Related Groups (APR-DRGs) to determine hospital reimbursement rates. Medicaid provides coverage for 45% of childhood cancer admissions. This study aimed to examine how well APR-DRGs reflect admission costs for childhood cancer chemotherapy to inform clinicians, hospitals, and policymakers in the wake of policy changes.Methods:We identified 25,613 chemotherapy admissions in the 2009 Kids’ Inpatient Database. To determine how well APR-DRGs explain costs, we applied a hierarchic linear regression model of hospital costs, allowing for a variety of patient, hospital, and geographic confounders.Results:APR-DRGs proved to be the most important predictors of admission costs (P < .001), with costs increasing by DRG severity code. Diagnosis, age, and hospital characteristics also predicted costs above and beyond those explained by APR-DRGs. Compared with admissions for patients with acute lymphoblastic leukemia, costs of admissions for patients with acute myelomonocytic leukemia were 82% higher; non-Hodgkin lymphoma, 20% higher; Hodgkin lymphoma, 25% lower; and CNS tumors, 27% lower. Admissions for children who were 10 years of age or older cost 26% to 35% more than admissions for infants. Admissions to children’s hospitals cost 46% more than admissions to other hospital types.Conclusion:APR-DRGs developed for adults are applicable to childhood cancer chemotherapy but should be refined to account for cancer diagnosis and patient age. Possible policy and clinical management changes merit further study to address factors not captured by APR-DRGs.

How to identify and control noise that could cost your hospital money

Noise levels in hospitals are problematic. Today, patient opinions on noise, because of HCAHPS, determine hospital reimbursement. It's critical for hospitals to reduce noise levels in their facilities or face reductions in reimbursement. Patient perceptions of noise in hospitals is difficult to accurately measure and determine root cause. Many hospitals are implementing programs to address noise, but very few are making these decisions based on systematic sound monitoring data within their facility. Sound monitoring equipment installed in hospitals can accurately measure and identify both sources and patterns of noise in hospital. Real-time and historical sound data can help inform changes needed. We compare historic sound data from our experience monitoring sound levels in NICU’s and compare findings to improving sound levels throughout hospital. We discuss how visual alarming alone is insufficient to maintain long term improvements. We also discuss the use of measuring “sound events” to idenitfy ture source of noise disturbances. We argue that hospitals that measure “sound events” can systematically improve their HCAHPS scores. In conclusion, sound recording equipment within hospitals will provide actionable data. This data can be used to implement structural and procedural improvements allowing hospitals to maximize reimbursement and improve outcomes.

Development of a risk‐adjusted blood utilization metric

Blood utilization has become an important outcome measure for surgical patients because of the recognized risks and costs associated with transfusion. However, comparisons of blood utilization between providers or institutions are difficult, because there is no standard method for risk adjustment when assessing surgical blood requirements. We examined whether accepted diagnosis-related group (DRG) case mix indexes can be used for this purpose. We retrospectively analyzed electronic medical record data from 37,403 surgical inpatients to assess the relationship between intraoperative blood component transfusion requirements and the case mix indexes: weighted Medicare severity DRG and weighted all-patient refined DRG. Thirty-one surgeons from the general surgery service were compared to determine correlations between blood component utilization and case mix index in both a risk unadjusted and an adjusted fashion. Case mix indexes and transfusion requirements were directly correlated for red blood cells (RBCs), plasma, and platelet (PLT) transfusions (p < 0.0001 for all three blood components, for both indexes). Surgeons with greater case mix index values had greater transfusion requirements, and adjustment for case mix index resulted in less variation among surgeons (p < 0.0001, p = 0.0003, and p < 0.0001 for unadjusted vs. adjusted utilization of RBCs, plasma, and PLTs, respectively). The standard DRG-based case mix indexes used to determine hospital reimbursement were strongly correlated with intraoperative transfusion requirements. We propose that these methods can be used as a risk-adjusted blood utilization metric for surgical patients.

Circulation Editors’ Picks

<i>Circulation</i> Editors’ Picks

Congenital Heart Surgery: Applicability of Hospital Reimbursement According to German Diagnosis-Related Groups System in Conformity with the Aristotle Complexity Score

Scores of Aristotle comprehensive complexity (ACC) levels have been demonstrated to correlate with the case-mix index (CMI) (cost-weights) generated by the German Diagnosis-Related Groups (DRG) 2009 version (G-DRG 2009). The equation used was "y = 0.5591 + 0.939 x" whereby y stands for cost-weight and x for ACC score. We hypothesised that each ACC level could be assigned a DRG (ACC DRG) and be used to determine hospital reimbursement. 185 patients underwent cardiac surgery between January and June 2009. The ACC scores of these 185 patients were grouped in ACC levels, based on the basic cost-weight value of their DRG. One ACC DRG was assigned to each group and a corresponding cost-weight calculated based on the aforementioned equation. The resulting ACC CMI was compared with the CMI generated by the G-DRG 2009 (G-DRG 2009 CMI). Finally, the ACC surgical performance (complexity x hospital survival) was used to calculate the cost-weight; the obtained CMI was called "effective ACC CMI". Mean ACC score was 9.515 +/- 3.611 points. Derived ACC CMI and related G-DRG 2009 CMI were 9.494 and 8.438, respectively. Hospital survival was 97.8 % (181/184). Therefore ACC surgical performance and "effective ACC CMI" were 9.306 and 9.297, respectively. For each ACC level, the number of patients (n), mean ACC score, ACC CMI and related G-DRG 2009 CMI were as follows: Level 1: n = 25, 4.024 +/- 0.879, 4.338 and 5.911; Level 2: n = 30, 6.563 +/- 0.574, 6.722 and 6.602; Level 3: n = 43, 8.665 +/- 0.540, 8.695 and 8.088; Level 4: n = 73, 11.730 +/- 1.690, 11.574 and 9.612; Level 5: n = 14, 16.710 +/- 1.380, 16.249 and 11.843, respectively. The Aristotle score can be used to adjust hospital reimbursement by assigning a DRG and cost-weight value to each ACC level. Missing figures for level 6 can be obtained from a previous study which showed a mean score of 22.11 +/- 1.24: the ACC CMI would be 21.320. The 6 ACC DRGs indicate the correct compensation based on the complexity of the procedure. Reimbursement using the German DRG 2009 appears to favour less complex cases, while procedures with a higher complexity are penalised. Reimbursement according to "effective ACC CMIs" would have a strong impact by supporting units providing high-quality care.

Congenital heart disease: hospital reimbursement according to Aristotle complexity score in the German Disease Related Groups (DRG) system

Background: Aristotle complexity score accurately measures complexity of procedures involved in congenital heart disease. Can it be also applied to determine hospital reimbursement?

DRG 272: Does it Provide Adequate Burn Center Reimbursement for the Care of Patients With Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis?

Patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TENS) often are referred to burn centers for wound and intensive care management. Unless they undergo a surgical procedure, patients with this diagnosis are assigned to DRG 272 to determine hospital reimbursement. In 2002, this DRG had an average length of stay of 5.2 days and an average national Medicare reimbursement of $4,416. The purpose of this study was to compare demographics, resource utilization, and hospital charges and reimbursement for all patients assigned to this DRG and to evaluate the effect of the extent of surface area involvement on resource utilization, hospital costs, and reimbursement. We reviewed the records of all patients admitted to our burn centers who were assigned to DRG 272 from January 1998 through December 2002. Patients with dermatologic diagnoses assigned to this DRG were compared with patients with SJS and TENS from our institutions and the American Burn Association National Burn Repository for calendar years 2000 and 2001. Patients assigned to DRG 272 with TENS involving >or=20% TBSA had significantly greater mortality, ventilator days, intensive care unit days, and length of hospital stay than patients with dermatologic conditions or SJS who were assigned to this DRG. In addition, patients with TENS had significantly greater hospital charges and costs than patients with dermatologic diagnoses and SJS. This study supports the need for a reassessment of the adequacy of DRG 272 for the reimbursement of burn center hospitals caring for patients with TENS. This would likely require modification of the current ICD-9-CM diagnosis codes to better quantify the extent of cutaneous involvement and the frequently associated comorbid conditions that accompany the cutaneous manifestations.

Understanding Diagnostic Related Groups (DRGs) and Inpatient Hospital Reimbursement

Knowing insurance plan regulations and complying precisely with requirements is critical for hospital reimbursement of care provided. Diagnostic related groups provide guidelines widely used in the United States to determine hospital reimbursement by Medicare, Medicaid, and many insurance providers. Because hospitals are the largest employers of nurses, nurses have a responsibility and interest in contributing to the stability of their hospital's financial status to protect incomes and job security. This article provides an overview of diagnostic related groups and demonstrates how nurses can contribute to more accurate documentation outcomes that determine hospital reimbursement.