Health Care Cost Containment Research Articles

Recent Debate over How to Tackle Rapid Increases in Pharmaceutical Expenditure in Japan.

Pharmaceutical expenditure has been rapidly increasing since 2000 in Japan mainly due to successive introduction and diffusion of high-priced new pharmaceuticals (thereafter, drugs). The share of drug expenditure in the national healthcare expenditure rose from 19.6% in 2000 to 22.3% in 2013, a 2.7% point rise in 13 years. In the same period, the share of healthcare personnel's income dropped 3.8% points from 50.2% to 46.4%. Further, in 2016 national healthcare expenditure rose for 3.8%, which is exceptionally high by Japanese standard (roughly 2%), and the main culprit was the rapid increase in drug expenditure due to successive introduction of extremely high-priced drugs. Due to these changes, drugs have become the main target in current healthcare cost containment policy.In this article, I briefly explain two debates relating to drug cost and cost control that occurred in 2016 and 2017, respectively, in Japan, based on my two articles that I wrote when I participated in these debates. Although two debates are independent, the first debate that was triggered by an introduction of extraordinary high-priced drug (Opdivo) substantially affected the second debate on how to introduce official cost-effectiveness appraisal of new drugs in Japan.

Association of Race/Ethnicity With Hospital Discharge Disposition After Elective Total Knee Arthroplasty

Total knee arthroplasty (TKA) is one of the most common elective procedures performed in adults with end-stage arthritis. Racial disparities in TKA outcomes have been described in the literature. To assess the association of race/ethnicity with discharge disposition and hospital readmission after elective primary TKA and to assess the association of nonhome discharge disposition with hospital readmission risk. This retrospective cohort study used data from the Pennsylvania Health Care Cost Containment Council Database, a large regional database that included demographic data from all discharges of patients who underwent elective primary TKA in 170 nongovernmental acute care hospitals in Pennsylvania from April 1, 2012, to September 30, 2015. Data analyses were conducted from September 29, 2017, to November 29, 2017. Patient race/ethnicity and discharge disposition. Discharge disposition and 90-day hospital readmission. Among 107 768 patients, 7287 (6.8%) were African American, 68 372 (63.4%) were women, 46 420 (43.1%) were younger than 65 years, and 60 636 (56.3%) were insured by Medicare. In multivariable logistic regression, among patients younger than 65 years, African American patients were more likely than white patients to be discharged to inpatient rehabilitation facility (IRF) (adjusted relative risk ratio [aRRR], 2.49 [95% CI, 1.42-4.36]; P = .001) or a skilled nursing facility (SNF) (aRRR, 3.91 [95% CI, 2.17-7.06]; P < .001) and had higher odds of 90-day hospital readmission (adjusted odds ratio [aOR], 1.30 [95% CI, 1.02-1.67]; P = .04). Compared with white patients 65 years or older, African American patients 65 years or older were more likely to be discharged to SNF (aRRR, 3.30 [95% CI, 1.81-6.02]; P < .001). In both age groups, discharge to an IRF (age <65 years: aOR, 3.62 [95% CI, 2.33-5.64]; P < .001; age ≥65 years: aOR, 2.85 [95% CI, 2.25-3.61]; P < .001) or SNF (age <65 years: aOR, 1.91 [95% CI, 1.37-2.65]; P < .001; age ≥65 years: aOR, 1.55 [95% CI, 1.27-1.89]; P < .001) was associated with higher odds of 90-day readmission. This cohort study found that race/ethnicity was associated with higher odds of discharge to an IRF or SNF for postoperative care after primary TKA. Among patients younger than 65 years, African American patients were more likely than white patients to be readmitted to the hospital within 90 days. Discharge to an IRF or SNF for postoperative care and rehabilitation was also associated with a higher risk of readmission to an acute care hospital.

113. Understanding the Changes in Infective Endocarditis Admission in Pennsylvania During the Opioid Crisis

BackgroundNationwide, there has been a rise in cases of infective endocarditis (IE) correlating with the rise of the opioid crisis. Pennsylvania (PA) has the third highest rate of drug overdose deaths in the country, with Allegheny and Philadelphia counties having the highest rates in the country. With this study, we evaluated how IE has changed in the face of the opioid crisis with respect to the population impacted and associated healthcare utilization in PA.MethodsWe performed a retrospective cohort study of all adults admitted to an acute care hospital in PA between January 2013 and March 2017 with a diagnosis of IE. Patients were identified through the Pennsylvania Health Care Cost Containment Council (PHC4) via billing codes. Exposed patients were those with drug use-associated IE (DU-IE); the unexposed group was those with non-DU-IE. We determined the number of admissions and geographical distribution of IE and DU-IE in the state. We then assessed for differences in hepatitis C (HCV) and HIV serostatus, length of stay (LOS), insurance status, total hospital charges, and rates of valve surgery between the two groups.ResultsThere were 17,224 admissions for IE in PA during the study period, of which 11.2% were DU-IE. In Allegheny and Philadelphia counties, 14.4% and 20.5% were from DU-IE, respectively. DU-IE cases increased from 6% in 2013 to 17% in 2017, P < 0.001. We found several significant differences between the DU-IE and non-DU-IE groups: DU-IE group was younger (median 33 vs. 69 years old, P < 0.001); the LOS was longer in the DU-IE group (10 vs. 7 days, P < 0.001); the percentage of patients leaving Against Medical Advice was higher in DU-IE group (15.7% vs. to 1.1%, P < 0.001); a higher proportion of the DU-IE group were HCV and HIV seropositive (27.1% vs. 3.3% for HCV, 2.4% vs. 0.74% for HIV, P < 0.001). See figures for complete results.ConclusionPennsylvania had an increase in the number of IE cases over the last 4 years, driven by the opioid crisis, with Philadelphia and Alleghany counties being the most impacted areas. While this study is limited by the use of claims data, it demonstrates the downstream effects of the opioid crisis on the patient population at risk and the healthcare system due to longer and costlier hospital stays. This study supports the need for innovative and integrative care models to support them. Disclosures All authors: No reported disclosures.

Changes in Infective Endocarditis Admissions in Pennsylvania During the Opioid Epidemic.

With the current opioid crisis in the United States, infectious complications related to injection drug use are increasingly reported. Pennsylvania is at the epicenter of the opioid crisis, with the third highest rate of drug overdose deaths in the United States. A retrospective cohort study was performed using the Pennsylvania Health Care Cost Containment Council database of all residents hospitalized for infective endocarditis (IE) in an acute care hospital from 1 January 2013 through 31 March 2017. Patients were separated into those with and those without substance use via diagnosis codes. The primary outcome was length of stay. Secondarily, we evaluated demographics, infection history, hospital charges, and insurance status. Of the 17 224 hospitalizations, 1921 (11.1%) were in patients with drug use-associated IE (DU-IE). Total quarterly IE admissions increased 20%, with a 6.5% increase in non-drug use-associated IE (non-DU-IE) admissions and a 238% increase in DU-IE admissions. In adjusted models, DU-IE was not associated with significant changes in length of stay (incidence rate ratio, 1.02; 95% confidence interval, .975-1.072; P = .36). Patients with DU-IE were predominantly insured by Medicaid (68.3% vs 13.4% for non-DU-IE), they had higher hospital charges ($86 622 vs $66 802), and they were more likely to leave against medical advice (15.7% vs 1.1%) (all P < .001). Our study demonstrates an increase in IE admissions, driven by an increase in admissions for DU-IE. The higher charges, proportion of patients on Medicaid, and rates of leaving against medical advice among the DU-IE group shows the downstream effects of the opioid crisis.

Readmissions After Lobectomy in an Era of Increasing Minimally Invasive Surgery: A Statewide Analysis.

Utilization of minimally invasive surgical modalities for lobectomy is increasing. Lobectomy can be associated with notable rates of readmission. As use of these modalities increases, evaluation of the impact on readmission is warranted. Data from the Pennsylvania Health Care Cost Containment Council were used to identify lobectomy operations performed in Pennsylvania from 2011 through 2014. Operations were stratified by approach: open, video-assisted thoracoscopic surgery (VATS) or robotic. Differences in patient characteristics were assessed with analysis of variance and chi-squared tests. Logistic regression modeled risk of 30-day readmission and linear regression modeled length of stay (LOS) after controlling for confounders. We evaluated 4,939 lobectomy operations (2,501 open, 1,944 VATS, 494 robotic) with 583 readmissions (11.8%). Robotic cases increased 333% over 4 years. VATS and open cases increased 38% and 22%, respectively. Surgical approach was not associated with hospital readmission (VATS odds ratio (OR) = 0.95; P = 0.632; and robotic OR = 1.02; P = 0.916). Longer LOS was associated with a greater likelihood of readmission (OR = 1.58; P = 0.002). LOS was 1 day less for VATS (P < 0.001) and 1.5 days less for robotic lobectomy (P < 0.001) when compared to an open approach. The most common reasons for readmission were respiratory complications and nonrespiratory infection. Surgical approach does not directly affect readmission. However, minimally invasive lobectomy appears to be associated with shorter LOS and results in more patients discharged home. Decreased LOS and discharge home are associated with fewer readmissions.

Inconsistent correlation between procedural volume and publicly reported outcomes in adult cardiac operations

Statewide public reporting provides transparent surgical outcomes. The objective of this study is to evaluate the correlation between procedural volume and publicly reported outcomes following adult cardiac surgery. The Pennsylvania Health Care Cost Containment Council (PHC4) statewide public reporting databases were analyzed. Isolated coronary artery bypass grafting (CABG), isolated valve surgery, and CABG plus valve surgery performed between 2014 and 2016 were included. The primary outcomes were operative mortality and 30-day readmission. Expected operative mortality and 30-day readmission were calculated using the risk models developed by PHC4. Observed-to-expected (OE) ratios were correlated with procedural volume using weighted linear regression analysis. The study included 29 578 operations (16 641 isolated CABGs, 8618 isolated valves, and 4319 CABG plus valves) performed by 182 surgeons at 60 hospitals. The expected risk of operative mortality for surgeons was 1.5%, 1.8%, and 4.3%, and for hospitals 1.5%, 1.7%, and 4.3% for isolated CABGs, isolated valves, and CABG plus valves, respectively. Expected 30-day readmission for surgeons and hospitals was 10.3%, 13.4%, and 14.4% and 10.2%, 13.2%, and 14.3% for the same operations, respectively. There was an inconsistent correlation between surgeon and hospital volume and OE operative mortality or 30-day readmission for any of the index operations. In this study of 29 578 index adult cardiac operations there is not a consistent association between surgeon or hospital volume and mortality or readmission for publicly reported outcomes. These data suggest that volume is not a reliable predictor of surgeon or hospital level OE outcomes in publicly reported data.

The Burden and Burnout in Documenting Patient Care: An Integrative Literature Review.

The implementation of the electronic health record (EHR) across the globe has increased significantly in the last decade. Motivations for this trend include patient safety, regulatory requirements, and healthcare cost containment. However, the impact of regulatory requirements and new EHRs on clinicians has increased the incidence of documentation burden and may lead to burnout syndrome. It is important to understand the extent of documentation burden and potential solutions such as EHR user-interface redesign and the use of scribes to assist healthcare providers across the world.

Impact of insurance plan design on bariatric surgery utilization

BackgroundBariatric surgery is underused in the United States. ObjectivesThis study examined whether utilization of bariatric surgery is associated with payor and insurance plan type, after removing potential sociodemographic confounders. SettingThe study used Pennsylvania Health Care Cost Containment Council’s data in 5 counties of Pennsylvania from 2014 to 2016. MethodsBariatric surgery patients and eligible patients who did not undergo surgery were identified and 1:1 matched by age, sex, race, and zip code (n = 5114). A logistic regression was performed to investigate the association of payor type and insurance plan within payor type with odds of undergoing bariatric surgery. ResultsThe odds of undergoing bariatric surgery were not statistically different based on payor type. Medicare preferred provider organization plan was associated with greater odds of undergoing surgery (odds ratio [OR] = 2.49, 95% confidence interval [CI] 1.23–5.04, P = .01) compared with Medicare health maintenance organization (HMO). Medicaid fee for service plan was associated with smaller odds of undergoing surgery (OR = .04, 95% CI .005–.27, P = .001) compared with Medicaid HMO. Individuals with Blue Cross preferred provider organization (OR = 2.43, 95% CI 1.83–3.24, P < .001), Blue Cross fee for service (OR = 1.79, 95% CI 1.32–2.43, P < .001), and Blue Cross HMO (OR = 1.85, 95% CI 1.39–2.46, P < .001) had greater odds of undergoing surgery compared with those with other commercial HMO plans. ConclusionsSpecific aspects of insurance plan design, rather than more general payor type, is more strongly associated with the utilization of bariatric surgery. Further investigations could identify which components of insurance plan design have the greatest influence on the utilization of bariatric surgery.

Quality of Life and Value Assessment in Health Care.

Proposals for health care cost containment emphasize high-value care as a way to control spending without compromising quality. When used in this context, 'value' refers to outcomes in relation to cost. To determine where health spending yields the most value, it is necessary to compare the benefits provided by different treatments. While many studies focus narrowly on health gains in assessing value, the notion of benefit is sometimes broadened to include overall quality of life. This paper explores the implications of using subjective quality of life measures for value assessment. This approach is claimed to be more respectful of patients and better capture the perspectival nature of quality of life. Even if this is correct, though, subjective measurement also raises challenging issues of interpersonal comparability when used to study health outcomes. Because such measures do not readily distinguish benefits due to medical interventions from benefits due to personal or other factors, they are not easily applied to the assessment of treatment value. I argue that when the outcome of interest in value assessment is broadened to include quality of life, the cost side of these measures should also be broadened. I show how one philosophical theory of well-being, Jason Raibley's "agential flourishing" theory, can be adapted for use in quality of life research to better fit the needs and aims of value assessment in health care. Finally, I briefly note some implications of this argument for debates about fairness in health care allocations.

Opioid-related hospitalizations in Pennsylvania: A latent class analysis

BackgroundOpioid abuse is associated with substantial morbidity and often results in hospitalization. Despite this, patient-level factors associated with opioid-related hospitalizations are not well understood. MethodsWe used the Pennsylvania Health Care Cost Containment Council dataset (2000–2014) to identify opioid-related hospitalizations using primary and/or secondary ICD-9-CM hospital discharge codes for opioid use disorder (OUD), opioid poisoning, and heroin poisoning. Latent class analyses (LCA) of patient-level factors including sociodemographic characteristics, pregnancy, alcohol, tobacco, other substance use, and psychiatric disorders were used to identify common patterns within hospitalizations. ResultsAmong 28,538,499 hospitalizations, 430,569 (1.5%) were opioid-related. LCA identified five latent class (LC) patient groups associated with opioid-related hospitalizations: pregnant women with OUD (LC1); women over 65 with opioid overdose (LC2); OUD, polysubstance use and co-occurring psychiatric disorders (LC3); patients with opioid overdose without co-occurring polysubstance use (LC4); and African American patients with OUD and co-occurring cocaine use (LC5). LC3 was the largest latent class (58.2%) with annual hospitalizations doubling over time. DiscussionAmong patients with opioid-related discharges, we identified five subpopulations among this sample. These findings suggest increased outpatient OUD treatment, mental health service support for patients with co-occurring psychiatric disorders and polysubstance use to prevent overdose and hospitalization.

Predictors of increased costs following index adult cardiac operations: Insights from a statewide publicly reported registry.

The aim of this study was to identify hospital-level predictors of increased cost following index adult cardiac operations in a statewide registry. The Pennsylvania Health Care Cost Containment Council (PHC4) database was queried for isolated coronary artery bypass grafting (CABG), isolated valve surgery, or CABG plus valve surgery performed between 2014 and 2016. Charge-to-cost ratios for each individual hospital were used to estimate cost. Expected (predicted) operative mortality and 30-day readmission were evaluated using multivariable risk models and linear regression analysis was utilized to evaluate the risk-adjusted impact of multiple hospital-level characteristics on costs. During the study period, 29 578 patients underwent isolated CABG (n = 16,641), isolated valve surgery (n = 8618), or CABG plus valve surgery (n = 4319) at 60 hospitals. The median cost of CABG was $61 573 (interquartile range [IQR] $50 780 to $77 482). The median cost of isolated valve surgery was $68,835 (IQR $56 039 to $89 465) and CABG plus valve surgery $83 574 (IQR $69 806 to $114 407). Hospital-level predictors of increasing costs in isolated CABG included higher predicted mortality rates, higher observed-to-expected (OE) mortality ratios, and nonteaching status. No hospital-level independent predictors of increased costs were identified for isolated valve or CABG plus valve surgery. Hospitals that performed higher risk cases and had higher OE ratios for operative mortality in isolated CABG were found to have increased costs. These data collectively suggest that attention to risk assessment and outcome optimization efforts in isolated CABG would likely result in programmatic advantages not only from a clinical standpoint but also economic.

PDB25 THE EFFECT OF MEDICATION NON-ADHERENCE ON HOSPITALIZATION COSTS AMONG MEDICARE ENROLLEES WITH DRUG COVERAGE THROUGH A PHARMACY ASSISTANCE PROGRAM

To examine the association between medication nonadherence and hospitalization costs among Medicare enrollees who received medications through a pharmacy assistance program. This study included Medicare enrollees (≥ 65 years) who received oral antidiabetic medications (OAMs) through Pharmaceutical Assistance Contract for Elderly (PACE) program of Pennsylvania in 2015 and had at least one inpatient hospital admission during 12-months from the index date (when first prescription for OAM was filled). Medication adherence was estimated as proportion of days covered (PDC) [adherent: PDC ≥ 80%, nonadherent: PDC < 80%]. The hospitalization costs (2015 USD) were calculated by applying hospital-level Medicare-specific cost-to-charge ratios (CCRs) to hospital inpatient charges obtained from Pennsylvania Health Care Cost Containment Council’s (PHC4), which included only direct charges for hospital services. General linear model with a gamma distribution and log link function was used to examine the association between medication nonadherence and hospitalization costs (all-cause and diabetes-related), while controlling for covariates such as sociodemographic characteristics, lived in a pharmacy desert or not, number of unique medications received and out-of-pocket drug costs. Among 1,907 Medicare enrollees included in the study, 1,447 (73.5%) patients were adherent. Total study population cost the Medicare program $35.5 million for all-cause and $9.1 million for diabetes-related inpatient hospital admissions. The annual mean healthcare cost per patient was $18,066 and $4,416 for all-cause and diabetes-related hospitalizations respectively. All-cause hospitalization cost was significantly higher for nonadherent than adherent patients (mean $23,059 vs $16,266; p < 0.0001). GLM models showed that medication nonadherence was associated with significant increase in all-cause hospitalization costs ($22,670 vs $16,383; p < 0.0001) and diabetes-related hospitalization costs ($13,518 vs $12,634; p= 0.0003). Medicare enrollees who were nonadherent to OAMs received through prescription assistance program had more hospitalization costs as compared to adherent patients.

Readmissions attributable to skilled nursing facility use after a colectomy: Evidence using propensity scores matching.

BackgroundPostacute care (PAC) is a major driver of the rising health care costs in the United States (US). There is limited evidence on the causal effect of skilled nursing facility (SNF) use on readmission after an inpatient colectomy.Study designWe performed a retrospective analysis of data from the Pennsylvania Health Care Cost Containment Council (PHC4) on 38,635 patients who underwent an inpatient colectomy between 2011 and 2014 in a Pennsylvania hospital. Using propensity scores, we matched patients who were discharged to a SNF to those who were discharged elsewhere. We compared the probability of readmissions within 30 days for the two groups of matched patients in a regression framework. For the subset of patients who were readmitted within 30 days, we assessed whether patients discharged to SNF were readmitted earlier than those discharged to other entities.ResultsThe use of a SNF after a colectomy significantly raises the patients’ chance of readmissions within 30 days, even after controlling for their demographic characteristics and illness severity. Based on our estimates, being discharged to a SNF raises the chance of a readmission by 7.7 percentage points. For patients who were admitted within 30 days, we find no association between discharge to a SNF and the timing of readmission.ConclusionSending less severe patients to facilities other than a SNF following inpatient colectomy may help hospitals reduce 30-day readmission rates.

An analysis of pediatric trauma center undertriage in a mature trauma system.

Improved mortality as a result of appropriate triage has been well established in adult trauma and may be generalizable to the pediatric trauma population as well. We sought to determine the overall undertriage rate (UTR) in the pediatric trauma population within Pennsylvania (PA). We hypothesized that a significant portion of pediatric trauma population would be undertriaged. All pediatric (age younger than 15) admissions meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800-959) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database and the Pennsylvania Trauma Systems Foundation (PTSF) registry. Undertriage was defined as patients not admitted to PTSF-verified pediatric trauma centers (n = 6). The PHC4 contains inpatient admissions within PA, while PTSF only reports admissions to PA trauma centers. ArcGIS Desktop was used for geospatial mapping of undertriage. A total of 37,607 cases in PTSF and 63,954 cases in PHC4 met criteria, suggesting UTR of 45.8% across PA. Geospatial mapping reveals significant clusters of undertriage regions with high UTR in the eastern half of the state compared to low UTR in the western half. High UTR seems to be centered around nonpediatric facilities. The UTR for patients with a probability of death 1% or less was 39.2%. Undertriage is clustered in eastern PA, with most areas of high undertriage located around existing trauma centers in high-density population areas. This pattern may suggest pediatric undertriage is related to a system issue as opposed to inadequate access. Retrospective study, without negative criteria, Level III.

The study on the influential factors on cost containment in health care

In response to the economic crisis, the worldwide economic recession and its consequences have become a challenge to various healthcare organizations to control their health expenditures. The mainly affected areas are the cost containment and cost-effective practices by administrative staff and health economists. The purpose of this review literature study was embarked to identify evidence-based solutions to control the health expenditures. The current study had analyzed reviewed 30 articles using electronic databases from year 2006 to 2018. The reviewed articles were regarding quality of health services, health information technology, and organization empowerment. Getting insight and having a better understanding of these areas is beneficial to the decision makers to hold cost-effective practices in healthcare organizations. Significance of this study is to benefit from the in depth analysis drawn from literature review of the affected areas that had clogged of economic recession such as cost containment and cost-effective practices, thus an implication of this knowledge on the hospital administrative services are extremely valuable. Containing healthcare expenditure is achievable target despite of all currently compressing financial challenges, and radical solutions could be accomplished through visionary leaders.

Race, Discharge Disposition, and Readmissions After Elective Hip Replacement: Analysis of a Large Regional Dataset

Purpose: Total hip arthroplasty (THA) is one of the fastest growing procedures. There is increasing evidence that social determinants of health influence health care utilization and outcomes after THA, including postoperative care. We sought to examine how race impacts discharge destination after elective THA, and we assessed the impact of discharge destination on 90-day readmission to an acute care hospital.Methods: We conducted a retrospective study using data from the Pennsylvania Health Care Cost Containment Council Database. We included patients of African American (AA) or white race undergoing THA, discharge disposition (inpatient rehabilitation facility [IRF], skilled nursing facility [SNF], home health care (HHC), home), and 90-day readmission rates.Results: Our study included 93,493 primary elective THAs. Compared with whites, AAs were more likely to be discharged to an IRF or SNF or HHC than home after THA. In all age groups, discharge to an IRF, SNF, or HHC for postop care/rehab was associated with higher odds of 90-day readmission as compared with home.Conclusion: AA race was associated with higher odds of discharge to an institution (IRF/SNF) or HHC for post-THA care. Disposition to these were associated with significantly higher risk of 90-day readmission to acute care hospital compared with home.

Cost Containment in Healthcare

Cost Containment in Healthcare

Investigating the Social Ecological Contexts of Opioid Use Disorder and Poisoning Hospitalizations in Pennsylvania

Opioid use disorder (OUD) and overdose rates have been sharply on the rise in the United States. Although systematic patterns of geographic variation in OUD and opioid overdose have been identified, the factors that explain why opioid-related hospitalizations increase in certain areas are not well understood. We examined Pennsylvania Health Care Cost Containment Council (PHC4) hospital inpatient discharge data at the ZIP code level to measure the geographic growth and spread of OUD as measured by 44 quarters of inpatient hospitalization data (from 2004 through 2014) for the entire state of Pennsylvania (n = 16,275 ZIP codes). We assessed the relative contribution of specific attributes of areas (e.g., population density) to patterns of OUD, heroin poisonings, and non-heroin opioid poisonings. Unit misalignment and spatial autocorrelation were corrected for using Bayesian space-time conditional autoregressive models. The associations between a greater density of manual labor establishments and all opioid-related hospitalizations were well supported and positive. A dose-response relationship between population density and opioid-related hospitalizations existed, with a stronger association for heroin poisonings (relative rate, densest quintile vs. least dense: 3.40 [95% credible interval 2.68, 4.39]). Posterior distributions from these models enabled the identification of locations most vulnerable to problems related to the opioid epidemic in Pennsylvania. Understanding spatial patterns of OUD and poisonings can enhance the development and implementation of effective prevention programs.

Thirty-day Readmission Rates for Carotid Endarterectomy Versus Carotid Artery Stenting

BackgroundBecause of the emergence of readmission-related Medicare penalties, efforts are being made to identify and reduce patient readmissions. The purpose of this study was to compare rates and risk factors for 30-d readmission and hospital length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) among patients treated for carotid artery stenosis in Pennsylvania. Materials and methodsData were from the Pennsylvania Health Care Cost Containment Council (PHC4). We identified 15,966 patients who underwent CEA (n = 13,557) or CAS (n = 2409) in Pennsylvania between 2011 and 2014. Logistic regression was used to determine risk factors for 30-d readmission, whereas linear regression was used to model factors influencing LOS. Propensity score analysis was used to control for imbalanced covariates between procedures. ResultsThirty-day readmission rates in Pennsylvania after CEA and CAS for carotid artery stenosis were similar (9.8% and 9.6%, respectively; P = 0.794). Not home discharge destination, Charlson comorbidity index ≥2, and LOS >1 d were all significantly associated with readmission risk. Procedure type (CEA or CAS) did not significantly influence risk. A significant difference in LOS was found between CEA and CAS, but the magnitude of the difference was small (2.38 for CAS versus 2.59 for CEA; P = 0.007). Black race, urgent and emergent cases, and not home discharges significantly increased LOS by notable amounts (1, 1.5, 3.9, and 1.9 d, respectively). ConclusionsCarotid artery stenosis patients in Pennsylvania undergoing CEA or CAS had similar 30-d readmission rates. Although LOS was significantly different, the magnitude of the difference was not large.

Quality Through Coopetition: An Empiric Approach to Measure Population Outcomes for Emergency Care–Sensitive Conditions

We develop a novel approach for measuring regional outcomes for emergency care-sensitive conditions. We used statewide inpatient hospital discharge data from the Pennsylvania Healthcare Cost Containment Council. This cross-sectional, retrospective, population-based analysis used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes to identify admissions for emergency care-sensitive conditions (ischemic stroke, ST-segment elevation myocardial infarction, out-of-hospital cardiac arrest, severe sepsis, and trauma). We analyzed the origin and destination patterns of patients, grouped hospitals with a hierarchical cluster analysis, and defined boundary shapefiles for emergency care service regions. Optimal clustering configurations determined 10 emergency care service regions for Pennsylvania. We used cluster analysis to empirically identify regional use patterns for emergency conditions requiring a communitywide system response. This method of attribution allows regional performance to be benchmarked and could be used to develop population-based outcome measures after life-threatening illness and injury.