Hospital-acquired Conditions Research Articles

The Association of Hospital Magnet® Status and Pay-for-Performance Penalties.

The Centers for Medicare and Medicaid Services' Pay-for-Performance (P4P) programs aim to improve hospital care through financial incentives for care quality and patient outcomes. Magnet® recognition-a potential pathway for improving nurse work environments-is associated with better patient outcomes and P4P program scores, but whether these indicators of higher quality are substantial enough to avoid penalties and thereby impact hospital reimbursements is unknown. This cross-sectional study used a national sample of 2,860 hospitals to examine the relationship between hospital Magnet® status and P4P penalties under P4P programs: Hospital Readmission Reduction Program, Hospital-Acquired Conditions (HAC) Reduction Program, Hospital Value-Based Purchasing (VBP) Program. Magnet® hospitals were matched 1:1 with non-Magnet hospitals accounting for 13 organizational characteristics including hospital size and location. Post-match logistic regression models were used to compute a hospital's odds of penalties. In a national sample of hospitals, 77% of hospitals experienced P4P penalties. Magnet® hospitals were less likely to be penalized in the VBP program compared to their matched non-Magnet counterparts (40% vs. 48%). Magnet® status was associated with 30% lower odds of VBP penalties relative to non-Magnet hospitals. Lower P4P program penalties is one benefit associated with achieving Magnet® status or otherwise maintaining high-quality nurse work environments.

Patient Satisfaction is Equivalent for Inpatient and Outpatient Minimally-Invasive Adrenalectomy

IntroductionSame-day surgery in the carefully selected patient decreases costs, improves inpatient capacity, and decreases patient exposure to hospital-acquired conditions. Outpatient adrenalectomy has been shown to be safe and effective, but patients’ perspectives have yet to be addressed. This study compares patient satisfaction following inpatient and outpatient adrenalectomy. MethodsAn institutional database was queried for minimally-invasive adrenalectomies performed from 2017 to 2020. Patients were contacted up to two times to participate in a phone survey consisting of 25 questions modeled after the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS) assessing preparation for surgery, discharge experience, post-operative course, and overall satisfaction. Statistical analysis was performed using Kruskal Wallis, Wilcoxon-Mann Whitney, and Chi-square tests, as appropriate. ResultsOne hundred five adrenalectomy patients were identified, of which 98 were contacted and 58 responded (59%). Two surgeons contributed patients, with no difference in the percentage of patients in the outpatient group (51.7% versus 62.1%, P = 0.423). Outpatient adrenalectomy patients had slightly higher overall experience scores, but this difference was not statistically significant (9.12 ± 1.36 versus 8.93 ± 1.51, P = 0.367). Patients undergoing outpatient adrenalectomy were more likely to have their discharge plan discussed pre-operatively (94% versus 62%, P = 0.005), but no significant differences were noted between inpatient and outpatient groups regarding preparation for surgery, readiness for discharge, night of surgery experiences, or self-reported pain or complications (P > 0.05 for all). Significantly higher overall experience scores were reported by patients counseled about their discharge plan (9.27 versus 7.9, P = 0.036), felt prepared for recovery (9.39 versus 5.5, P < 0.001), received information about pain control (9.13 versus 7.00, P = 0.031), felt prepared at time of discharge (9.33 versus 5.80, P < 0.001), and received information about potential complications (9.29 versus 7.00, P = 0.001). Although not statistically significant, there was a trend towards outpatients being more likely to choose the same approach if they were to undergo surgery again (97% versus 84%, P = 0.081). ConclusionsPatient satisfaction following adrenalectomy is significantly associated with patients’ self-reported degree of preparation for surgery and discharge, with no significant difference in patient satisfaction between inpatient and outpatient groups. Patients undergoing outpatient adrenalectomy would be likely to choose the same approach compared to inpatients. Targeted pre-operative counseling can contribute to enhanced patient outcomes for all patients undergoing adrenalectomy.

The Relationship between High-reliability practice and Hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

Introduction:Theoretically, the application of reliability principles in healthcare can improve patient safety outcomes by informing process design. As preventable harm continues to be a widespread concern in healthcare, evaluating the association between integrating high-reliability practices and patient harms will inform a patient safety strategy across the healthcare landscape. This study evaluated the association between high-reliability practices and hospital-acquired conditions.Methods:Twenty-five pediatric organizations participating in the Children’s Hospitals Solutions for patient safety collaborative participated in this nonexperimental design study. A survey utilizing the high-reliability healthcare maturity model assessed the extent of implementing high-reliability practices at each participating site. We analyzed responses for each component and a composite score of high reliability against an aggregate measure of hospital-acquired conditions.Results:Of the 95 invited sites, 49 responded and 25 were included in the final results. There was a significant inverse relationship between the culture of safety component score and the Serious Harm Index (odds ratio [OR] = 0.63, 95% confidence interval [CI] 0.42–0.95, P = 0.03). There was no association between the overall high-reliability score (OR = 0.91, 95% CI 0.78–1.05, P = 0.19), the Leadership component score (OR = 0.97, 95% CI 0.70–1.33, P = 0.84), or the robust process improvement (RPI) component score (OR = 0.75, 95% CI 0.41–1.28, P = 0.26) and the Serious Harm Index.Conclusion:The integration of high-reliability principles within healthcare may support improved patient safety in the hospital setting. Further research is needed to articulate the breadth and magnitude of the impact of integrating high-reliability principles into healthcare.

Racial Disparities in Hospital-acquired Conditions among Pediatric Patients

In Brief Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.

Evaluation of Clinical and Economic Outcomes Following Implementation of a Medicare Pay-for-Performance Program for Surgical Procedures

Surgical complications increase hospital costs by approximately $20 000 per admission and extend hospital stays by 9.7 days. Improving surgical care quality and reducing costs is needed for patients undergoing surgery, health care professionals, hospitals, and payers. To evaluate the association of the Hospital-Acquired Conditions Present on Admission (HAC-POA) program, a mandated national pay-for-performance program by the Centers for Medicare & Medicaid Services, with surgical care quality and costs. A cross-sectional study of Medicare inpatient surgical care stays from October 2004 through September 2017 in the US was conducted. The National Inpatient Sample and a propensity score-weighted difference-in-differences analysis of hospital stays with associated primary surgical procedures was used to compare changes in outcomes for the intervention and control procedures before and after HAC-POA program implementation. The sample consisted of 1 317 262 inpatient surgical episodes representing 1 198 665 stays for targeted procedures and 118 597 stays for nontargeted procedures. Analyses were performed between November 1, 2020, and May 7, 2021. Implementation of the HAC-POA program for the intervention procedures included in this study (fiscal year 2009). Incidence of surgical site infections and deep vein thrombosis, length of stay, in-hospital mortality, and hospital costs. Analyses were adjusted for patient and hospital characteristics and indicators for procedure type, hospital, and year. In our propensity score-weighted sample, the intervention procedures group comprised 1 047 351 (88.5%) individuals who were White and 742 734 (60.6%) women; mean (SD) age was 75 (6.9) years. The control procedures group included 94 715 (88.0%) individuals who were White, and 65 436 (60.6%) women; mean (SD) age was 75 (7.1) years. After HAC-POA implementation, the incidence of surgical site infections in targeted procedures decreased by 0.3 percentage points (95% CI, -0.5 to -0.1 percentage points; P = .02) compared with nontargeted procedures. The program was associated with a reduction in length of stay by 0.5 days (95% CI, -0.6 to -0.4 days; P < .001) and hospital costs by 8.1% (95% CI, -10.2% to -6.1%; P < .001). No significant changes in deep vein thrombosis incidence and mortality were noted. The findings of this study suggest that the HAC-POA program is associated with small decreases in surgical site infection and length of stay and moderate decreases in hospital costs for patients enrolled in Medicare. Policy makers may consider these findings when evaluating the continuation and expansion of this program for other surgical procedures, and payers may want to consider adopting a similar policy.

211. Patient, surgery, and hospital-related risk factors for hospital acquired conditions following common spinal procedures during inpatient stays

<h3>BACKGROUND CONTEXT</h3> A total of 48,771 hospital-acquired conditions (HACs) have been reported in United States hospitals. These incidents resulted in excess costs of more than $2 billion, which translated to roughly $40,000 per patient per HAC. Along with this direct fiscal burden, enduring an HAC added on average 8.17 days to each patient's hospital stay, which can lead to indirect hidden costs. <h3>PURPOSE</h3> To critically analyze the classical and novel risk factors of HACs following the most prevalent inpatient spine procedures; spinal fusion (463,200 cases/year) and laminectomy (438,200 cases/year). <h3>STUDY DESIGN/SETTING</h3> Systematic review of observational cohort studies. <h3>PATIENT SAMPLE</h3> This study included 6,382 patients who underwent spine fusion or laminectomy. <h3>OUTCOME MEASURES</h3> Patient-, surgical-, hospital-, related risk factors and genetic associations. <h3>METHODS</h3> Several online databases were searched. Using illustrated figures and diagrams, we aim to provide spine surgeons with the knowledge and evidence about the economic impact, patient-, surgery-, and hospital-related risk factors of HACs. Additionally, we present the novel risk factors such as genetic biomarkers. <h3>RESULTS</h3> Patients undergoing fusion and laminectomy experience HACs at rates of 1.4% and 6.5%, respectively. The incidence of HACs most commonly comprises falls and trauma (87%) and SSIs (11%) for thoracolumbar fusion patients, while laminectomy patients experience venous thromboembolism (VTE) (1.4%) and surgical site infection (SSI) (0.2%) most frequently. Increased age is correlated with higher incidence of HACs. Complication rates in those over 65 are as high as 13.46% with wound complications (1.2%-1.69% of cases) and deep vein thrombosis (DVT) (2.1-2.2%) occurring at rates greater than that of those under 65. BMI less than 40 is associated with increased risk of VTE events and SSI, whereas those over 40 have higher risk of urinary tract infection (UTI). Patients who have had previous spinal surgery have a strong risk of developing wound complications (4.6% vs 1.0% among those without prior surgery). Insulin-dependent diabetes (OR=1.72) may increase the rate of complications and deep SSI following thoracolumbar spinal surgery (p=0.050). Steroid use (OR=1.55) may increase a patient's likelihood of complication. Patients with a preoperative psychiatric disorder are at greater risk of a surgical complication. Regarding hospital-related factors, increased operative time is associated with greater risk of HACs. In patients over the age of 75, the length of operation time (p=0.003) is a contributing factor to wound complications. Moreover, teaching hospitals and those with larger bed sizes may be associated with increased risk for HACs. Lastly, weekend admissions are associated with a 45.3% HAC incidence rate compared to a 4.59% rate in weekday admissions. However, higher surgeon volume is associated with lower complications. The pre-admission testing for novel genetic biomarkers of HACs could stratify the risk of HACs for patients. Patients with higher concentrations of miR-582, miR-195, miR- 532, nitric oxide synthase 3 polymorphism are at higher risk to develop VTE. <h3>CONCLUSIONS</h3> Identifying patient-, surgery-, and hospital- related risk factors in the setting of fusion and laminectomy is crucial to providing patients with optimal care and avoiding the penalties of HACs. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Assessing hospital electronic health record vendor performance across publicly reported quality measures.

Little is known regarding variation among electronic health record (EHR) vendors in quality performance. This issue is compounded by selection effects in which high-quality hospitals coalesce to a subset of market leading vendors. We measured hospital performance, stratified by EHR vendor, across 4 quality metrics. We used data on 1272 hospitals in 2018 across 4 quality measures: Leapfrog Computerized Provider Order Entry/EHR Evaluation, Centers for Medicare and Medicaid Services Hospital Compare Star Ratings, Hospital-Acquired Condition (HAC) score, and Hospital Readmission Reduction Program (HRRP) ratio. We examined score distributions and used multivariable regression to evaluate the association between vendor and score, recovering partial R2 to assess the proportion of quality variation explained by vendor. We found significant variation across and within EHR vendors. The largest vendor, vendor A, had the highest mean score on the Leapfrog Computerized Provider Order Entry/EHR Evaluation and HRRP ratio, vendor G had the highest Hospital Compare score, and vendor F had the highest HAC score. In adjusted models, no vendor was significantly associated with higher performance on more than 2 measures. EHR vendor explained between 1.2% (HAC) and 7.6 (HRRP) of the variation in quality performance. No EHR vendor was associated with higher quality across all measures, and the 2 largest vendors were not associated with the highest scores. Only a small fraction of quality variation was explained by EHR vendor choice. Top performance on quality measures can be achieved with any EHR vendor; much of quality performance is driven by the hospital and how it uses the EHR.

Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries

There has been insufficient research on the patient harms and costs associated with potential low-value procedures in the US Medicare population. To report the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. This is a retrospective cohort study using Medicare fee-for-service claims between January 2016 to December 2018. Participants were aged 65 years or older. Procedures were selected if they had previously published indicators of low-value care, including knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy, renal stenting, and hysterectomy for benign conditions. Analysis was conducted from July to December, 2020. For inpatient procedures, the number and rate of admissions with a hospital-acquired condition (HAC) or patient safety indicator event (PSIs), as well as the unadjusted and adjusted difference in mean LOS and Medicare costs between admissions with and without a HAC/PSI. For outpatient procedures, we report the number of claims where the beneficiary had an unplanned hospital admission within seven days and the number of these admissions with a HAC/PSI. There were 573 351 patients included in the study, with 617 264 procedures; the mean (SD) age was 74.2 (6.7) years, with 320 637 women (55.9%), and mostly White patients (520 735; 90.8%). Among the 197 755 claims for the inpatient procedures, 231 had an HAC and 1764 had a PSI. Spinal fusion was associated with the most HACs (123 admissions) and PSIs (1015 admissions). Overall, HACs during a PCI admission were associated with the highest adjusted additional mean LOS (17.5 days; 95% CI, 10.3-23.6), with also the highest adjusted additional mean cost ($22 000; 95% CI, $9100-$32 600). There were 419 509 included outpatient procedures, and 7514 (1.8%) had an unplanned admission within 7 days. A total of 17 HACs and PSIs occurred in these admissions. In this cross-sectional cohort study of Medicare fee-for-service claims, patients receiving potential low-value care were exposed to risk of unnecessary harm associated with higher cost and LOS.

Impact of a nutrition support therapy on hospital-acquired infections: A value analysis.

Hospital-acquired conditions (HACs) have a direct impact on value, as they decrease quality and increase costs. Numerous interventions have been tried, including nutrition support therapy, with unknown effect on value. Therefore, a value analysis of nutrition support therapy on HACs was performed. An extensive literature search was performed. Using the Medicare Parts A and B Claims 5% Sample data set, analytic claims modeling was conducted. The search identified 1099 studies, with eight meeting the inclusion criteria. All studies were performed on adult critically ill patients and focused on HA infections (HAIs) as the HAC. One study underwent Medicare claims modeling and revealed nutrition therapy has the potential of saving at least $104 million annually in Medicare patients with HAIs. Nutrition support therapy has the potential to reduce costs of Medicare spending in respect to HAIs.

Hospital-Acquired Conditions: A Review of Classical and Novel Risk Factors Following Total Hip and Knee Arthroplasties.

In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $41,000 per patient per HAC. In the settings of total hip arthroplasty (THA) and total knee arthroplasty (TKA), increased age, a body mass index of >35 kg/m2, male sex, diabetes mellitus, electrolyte disturbances, and a history of anemia increase the likelihood of surgical site infections. Institution-specific (surgical) risk factors such as increased tourniquet time, an operative time of >130 minutes, bilateral procedures, a femoral nerve block, and general anesthesia increase the risk of HACs in the settings of THA and TKA.

Early unplanned readmissions following same-admission cholecystectomy for acute biliary pancreatitis.

Same-admission cholecystectomy (CCY) is recommended for mild acute biliary pancreatitis (biliary-AP). However, there is a paucity of research investigating reasons for early (30-day) unplanned readmissions in patients who undergo CCY for biliary-AP. Hence, we sought to investigate this gap using a large population database. Using the Nationwide Readmission Database (2010-2014), we identified all adults (age ≥ 18years) with a principal diagnosis of biliary-AP who had undergone CCY during the index hospitalization. Multivariable logistic regression models were obtained to assess independent predictors for 30-day readmission. Principal diagnosis for all readmissions was collected to ascertain the indications for early readmission. During the study period, 118,224 patients underwent same-admission CCY for biliary-AP. Three-fourths of all patients underwent invasive cholangiography during the hospitalization (intraoperative cholangiogram (IOC) = 57,038, ERCP = 31,500). The rate of early (30-day) readmission was 7.25% (n = 8574). Exacerbation of prior medical conditions (42.2%), sequelae of biliary-AP (resolving and recurrent pancreatitis, pseudocysts) (27.6%), surgical site and other postoperative complications (16%), choledocholithiasis and/or bile leak (9.6%), and preventable hospital-acquired conditions (4.6%) accounted for early readmissions. On multivariable analysis, predictors for readmission included male sex (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.28), insurance type (Medicare insurance [OR 1.26, 95% CI 1.13-1.40]; Medicaid [OR 1.22, 95% CI 1.09-1.38]), outside-facility discharge (OR 1.35, 95% CI 1.16-1.57), severe AP (OR 1.35, 95% CI 1.21-1.50), and ≥ 3 Elixhauser comorbidities (OR 1.55, 95% CI 1.41-1.69). Performance of IOC (OR 0.90, 95% CI 0.82-0.97) and ERCP (OR 0.81, 95% CI 0.73-0.89) were associated with decreased risk of early readmission. In this study, using a national population database evaluating patients who underwent same-admission CCY after biliary-AP, we identified potentially modifiable risk factors and causes for early readmission as well as opportunities to improve clinical care.

Frailty Severity Impacts Development of Hospital-acquired Conditions in Patients Undergoing Corrective Surgery for Adult Spinal Deformity.

This was a retrospective cohort study of a national dataset. The purpose of this study was to consider the influence of frailty on the development of hospital-acquired conditions (HACs) in adult spinal deformity (ASD). HACs frequently include reasonably preventable complications. Eleven events are identified as HACs by the Affordable Care Act. In the surgical ASD population, factors leading to HACs are important to identify to optimize health care. Patients 18 years and older undergoing corrective surgery for ASD identified in the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP). The relationship between HACs and frailty as defined by the NSQIP modified 5-factor frailty index (mFI-5) were assessed using χ2 and independent sample t tests. The mFI-5 is assessed on a scale 0-1 [not frail (NF): <0.3, mildly frail (MF): 0.3-0.5, and severely frail (SF): > 0.5]. Binary logistic regression measured the relationship between frailty throughout HACs. A total of 9143 ASD patients (59.1 y, 56% female, 29.3 kg/m2) were identified. Overall, 37.6% of procedures involved decompression and 100% fusion. Overall, 6.5% developed at least 1 HAC, the most common was urinary tract infection (2.62%), followed by venous thromboembolism (2.10%) and surgical site infection (1.88%). According to categorical mFI-5 frailty, 82.1% of patients were NF, 16% MF, and 1.9% SF. Invasiveness increased with mFI-5 severity groups but was not significant (NF: 3.98, MF: 4.14, SF: 4.45, P>0.05). Regression analysis of established factors including sex [odds ratio (OR): 1.22; 1.02-146; P=0.030], diabetes mellitus (OR: 0.70; 0.52-0.95; P=0.020), total operative time (OR: 1.01; 1.00-1.01; P<0.001), body mass index (OR: 1.02; 1.01-1.03; P=0.008), and frailty (OR: 8.44; 4.13-17.26; P<0.001), as significant predictors of HACs. Overall, increased categorical frailty severity individually predicted increased total length of stay (OR: 1.023; 1.015-1.030; P<0.001) and number of complications (OR: 1.201; 1.047-1.379; P=0.009). For patients undergoing correction surgery for ASD, the incidence of HACs increased with worsening frailty score. Such findings suggest the importance of medical optimization before surgery for ASD.

Predictors of serious, preventable, and costly medical complications in a population of adult spinal deformity patients

Background ContextIn 2008, the Centers for Medicare and Medicaid Services (CMS) established a list of hospital-acquired conditions (HACs) with significant deleterious effects on both patients and providers. Adult spinal deformity (ASD) surgery is complex and highly invasive, and as such may result in significant morbidity including these HACs. PurposeIdentify predictors for developing the most common HACs among adult spinal deformity (ASD) patients undergoing corrective surgery. Study Design/SettingRetrospective analysis. Patient SampleOne thousand one hundred and seventy-one ASD patients. Outcome MeasuresHACs, Health-Related Quality of Life scores(HRQLs), Reoperation, Integrated Health State (IHS) MethodsASD pts undergoing surgery (>18 years, scoliosis ≥20°, SVA ≥5 cm, PT ≥25° and/or TK >60°) with complete data at BL and up to 2 years post-op were included. Patients were stratified by presence of >1 HAC, defined as at least one superficial/deep SSI, UTI, DVT, or PE within a 30-day post-op window. Random forest analysis generated 5,000 Conditional Inference Trees to compute a variable importance table for top predictors of HACs. An area-under-the-curve (AUC) methodology compared normalized HRQL scores between groups to determine an IHS with 2-year follow-up. ResultsTotal of 1,171 pts (59.8 years, 76.2%F, 28.1kg/m2) underwent corrective ASD surgery, with 1,053 pts in the non-HAC group and 118 in the HAC group. Of these pts, 25.4% had UTI, 15.4% DVT, 19.2% superficial SSI, 20.8% deep SSI, and 19.2% PE. HAC pts were on average older (63.5 vs 59.3, p=.004) and more often frail (51.3 vs 39.7%, p=.021) than non-HAC pts. Postop LOS and reoperation were most associated with HAC groups: [1] LOS >7 days [2] reoperation. Patient-related predictors of HACs were [3] age >50 yerr, [4] frailty, and [13] BMI >31. Procedure-related predictors of HACs were [5] operative-time >405 minutes, [6] levels fused >9, EBL >1450 mL, and [11] decompression. BL radiographic predictors were [7] PT >20°, [9] PI-LL>6°, [10] TL Cobb angle >15°, [12] SVA C7-S1 >29 mm. No differences were observed between groups with regards to IHS ODI (0.73 vs 0.74, p=.863), SRS (1.3 vs1.3, p=.374), NRS Back (0.6 vs 0.6, p=.158). HAC had higher rates of reoperation than non-HAC (0.08 vs 0.01, p=.066), and any HAC within 30-days of index was a significant predictor of reoperation (OR: 2.448 [1.94–3.09], p<.001). ConclusionsIn a population of ASD patients, HACs were associated with length of stay, reoperation, age, and frailty. Radiographic parameters such as pelvic tilt >20°, PI-LL >6°, & SVA >29 mm also increased odds of HACs, and should raise postoperative awareness for HAC development.

Association Between Treatment Progression, Disease Refractoriness, and Burden of Illness Among Hospitalized Patients With Status Epilepticus

Status epilepticus (SE) is associated with poor clinical outcomes and high cost. Increased levels of refractory SE require treatment with additional medications and carry increased morbidity and mortality, but the associations between SE refractoriness, clinical outcomes, and cost remain poorly characterized. To examine differences in clinical outcomes and costs associated with hospitalization for SE of varying refractoriness. A cross-sectional study of 43 988 US hospitalizations from January 1, 2016 to December 31, 2018, was conducted, including patients with primary or secondary International Statistical Classification of Diseases, Tenth Revision, diagnosis specifying "with status epilepticus." Patients were categorized by administration of antiseizure drugs given during hospitalization. Low refractoriness denoted treatment with none or 1 intravenous antiseizure drug. Moderate refractoriness denoted treatment with more than 1 intravenous antiseizure drug. High refractoriness denoted treatment with 1 or more intravenous antiseizure drug, more than 1 intravenous anesthetic, and intensive care unit admission. Outcomes included discharge disposition, hospital length of stay, intensive care unit length of stay, hospital-acquired conditions, and cost (total and per diem). Among 43 988 hospitalizations for SE, 22 851 patients (51.9%) were male; mean age was 49.9 years (95% CI, 49.7-50.1 years). There were 14 694 admissions (33.4%) for low refractory, 10 140 (23.1%) for moderate refractory, and 19 154 (43.5%) for highly refractory SE. In-hospital mortality was 11.2% overall, with the highest rates among patients with highly (18.9%) compared with moderate (6.3%) and low (4.6%) refractory SE (P < .001 for all comparisons). Median hospital length of stay was 5 days (interquartile range [IQR], 2-10 days) with greater length of stay in highly (8 days; IQR, 4-15 days) compared with moderate (4 days; IQR, 2-8 days) and low (3 days; IQR, 2-5 days) refractory SE (P < .001 for all comparisons). Patients with highly refractory SE also had greater hospital costs, with median costs of $25 105 (mean [SD], $41 858 [$59 063]) in the high, $10 592 (mean [SD], $18 328 [$30 776]) in the moderate, and $6812 (mean [SD], $11 532 [$17 228]) in the low refractory cohorts (P < .001 for all comparisons). Status epilepticus apparently continues to be associated with a large burden on patients and the US health system, with high mortality and costs that increase with disease refractoriness. Interventions that prevent SE from progressing to a more refractory state may have the potential to improve outcomes and lower costs associated with this neurologic condition.

A case-control study of length of stay outliers.

Inpatients with extended length of stay (LOS), referred to as LOS outliers, pose a challenge to health systems by contributing to high costs while assuming all the risks associated with hospital-acquired conditions. Limited research has been conducted within the US health system to better define LOS outliers and the risk factors for becoming an outlier in the setting of inpatient medicine stays. This was a retrospective study on adult inpatient admissions to the general medicine service of a university hospital from September 2015 to August 2016. Cases were defined as patients with observed LOS 3 SD above predicted. Controls were defined as those who stayed within 3 SD of predicted LOS. A total of 108 LOS outliers were identified through the University Health System Consortium, and 72 were matched with inlier controls by principal diagnosis and disease severity. Compared with their inlier controls, outliers stayed 32.41 days longer and cost $77,228 more per stay. There were higher odds of being an outlier observed for patients with a history of smoking (odds ratio [OR], 29.5; 95% CI, 2.9-301.3), in-hospital complications (OR, 17.6; 95% CI, 3.5-88.6), hospital-acquired infections (OR, 7.2; 95% CI, 1.7-31.4), and discharge to a facility (OR, 11.5; 95% CI, 2.6-50.0). In-hospital complications, hospital-acquired infections, and discharge to a facility are all predictors of not only increasing hospital days for patients but also increasing the risk of becoming LOS outliers, who stay disproportionately longer and use disproportionately more resources than predicted.

Specialty Certification: A Path To Improving Outcomes.

Specialty Certification: A Path To Improving Outcomes.

Length of Stay Beyond Medical Readiness in a Neurosurgical Patient Population and Associated Healthcare Costs.

Length of stay beyond medical readiness (LOS-BMR) leads to increased expenses and higher morbidity related to hospital-acquired conditions. To determine the proportion of admitted neurosurgical patients who have LOS-BMR and associated risk factors and costs. We performed a prospective, cohort analysis of all neurosurgical patients admitted to our institution over 5 mo. LOS-BMR was assessed daily by the attending neurosurgeon and neuro-intensivist with a standardized criterion. Univariate and multivariate logistic regressions were performed. Of the 884 patients admitted, 229 (25.9%) had a LOS-BMR. The average LOS-BMR was 2.7± 3.1 d at an average daily cost of $9 148.28 ± $12 983.10, which resulted in a total cost of $2 076 659.32 over the 5-mo period. Patients with LOS-BMR were significantly more likely to be older and to have hemiplegia, dementia, liver disease, renal disease, and diabetes mellitus. Patients with a LOS-BMR were significantly more likely to be discharged to a subacute rehabilitation/skilled nursing facility (40.2%vs 4.1%) or an acute/inpatient rehabilitation facility (22.7%vs 1.7%, P<.0001). Patients with Medicare insurance were more likely to have a LOS-BMR, whereas patients with private insurance were less likely (P=.048). The most common reason for LOS-BMR was inefficient discharge of patients to rehabilitation and nursing facilities secondary to unavailability of beds at discharge locations, insurance clearance delays, and family-related issues.

Measurement matters: changing penalty calculations under the hospital acquired condition reduction program (HACRP) cost hospitals millions

BackgroundSince October 2014, the Centers for Medicare and Medicaid Services has penalized 25% of U.S. hospitals with the highest rates of hospital-acquired conditions under the Hospital Acquired Conditions Reduction Program (HACRP). While early evaluations of the HACRP program reported cumulative reductions in hospital-acquired conditions, more recent studies have not found a clear association between receipt of the HACRP penalty and hospital quality of care. We posit that some of this disconnect may be driven by frequent scoring updates. The sensitivity of the HACRP penalties to updates in the program’s scoring methodology has not been independently evaluated.MethodsWe used hospital discharge records from 14 states to evaluate the association between changes in HACRP scoring methodology and corresponding shifts in penalty status. To isolate the impact of changes in scoring methods over time, we used FY2018 hospital performance data to calculate total HAC scores using FY2015 through FY2018 CMS scoring methodologies.ResultsComparing hospital penalty status based on various HACRP scoring methodologies over time, we found a significant overlap between penalized hospitals when using FY 2015 and 2016 scoring methodologies (95%) and between FY 2017 and 2018 methodologies (46%), but substantial differences across early vs later years. Only 15% of hospitals were eligible for penalties across all four years. We also found significant changes in a hospital’s (relative) ranking across the various years, indicating that shifts in penalty status were not driven by small changes in HAC scores clustered around the penalty threshold.ConclusionsHACRP penalties have been highly sensitive to program updates, which are generally announced after performance periods are concluded. This disconnect between performance and penalties calls into question the ability of the HACRP to improve patient safety as intended.

Association of Stratification by Proportion of Patients Dually Enrolled in Medicare and Medicaid With Financial Penalties in the Hospital-Acquired Condition Reduction Program

The Hospital-Acquired Condition Reduction Program (HACRP) is a value-based payment program focused on safety events. Prior studies have found that the program disproportionately penalizes safety-net hospitals, which may perform more poorly because of unmeasured severity of illness rather than lower quality. A similar program, the Hospital Readmissions Reduction Program, stratifies hospitals into 5 peer groups for evaluation based on the proportion of their patients dually enrolled in Medicare and Medicaid, but the effect of stratification on the HACRP is unknown. To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification. This economic evaluation used publicly available data on HACRP performance and penalties merged with hospital characteristics and cost reports. A total of 3102 hospitals participating in the HACRP in fiscal year 2020 (covering data from July 1, 2016, to December 31, 2018) were studied. Hospitals were divided into 5 groups based on the proportion of patients dually enrolled, and penalties were assigned to the lowest-performing quartile of hospitals in each group rather than the lowest-performing quartile overall. Penalties in the prestratification vs poststratification schemes. The study identified 3102 hospitals evaluated by the HACRP. Safety-net hospitals received $111 333 384 in penalties before stratification compared with an estimated $79 087 744 after stratification-a savings of $32 245 640. Hospitals less likely to receive penalties after stratification included safety-net hospitals (33.6% penalized before stratification vs 24.8% after stratification, Δ = -8.8 percentage points [pp], P < .001), public hospitals (34.1% vs 30.5%, Δ = -3.6 pp, P = .003), hospitals in the West (26.8% vs 23.2%, Δ = -3.6 pp, P < .001), hospitals in Medicaid expansion states (27.3% vs 25.6%, Δ = -1.7 pp, P = .003), and hospitals caring for the most patients with disabilities (32.2% vs 28.3%, Δ = -3.9 pp, P < .001) and from racial/ethnic minority backgrounds (35.1% vs 31.5%, Δ = -3.6 pp, P < .001). In multivariate analyses, safety-net status and treating patients with highly medically complex conditions were associated with higher odds of moving from penalized to nonpenalized status. This economic evaluation suggests that stratification of hospitals would be associated with a narrowing of disparities in penalties and a marked reduction in penalties for safety-net hospitals. Policy makers should consider adopting stratification for the HACRP.

The impact of hospital safety-net status on inpatient outcomes for brain tumor craniotomy: a 10-year nationwide analysis.

BackgroundOutcome disparities have been documented at safety-net hospitals (SNHs), which disproportionately serve vulnerable patient populations. Using a nationwide retrospective cohort, we assessed inpatient outcomes following brain tumor craniotomy at SNHs in the United States.MethodsWe identified all craniotomy procedures in the National Inpatient Sample from 2002–2011 for brain tumors: glioma, metastasis, meningioma, and vestibular schwannoma. Safety-net burden was calculated as the number of Medicaid plus uninsured admissions divided by total admissions. Hospitals in the top quartile of burden were defined as SNHs. The association between SNH status and in-hospital mortality, discharge disposition, complications, hospital-acquired conditions (HACs), length of stay (LOS), and costs were assessed. Multivariate regression adjusted for patient, hospital, and severity characteristics.Results304,719 admissions were analyzed. The most common subtype was glioma (43.8%). Of 1,206 unique hospitals, 242 were SNHs. SNH admissions were more likely to be non-white (P < .001), low income (P < .001), and have higher severity scores (P = .034). Mortality rates were higher at SNHs for metastasis admissions (odds ratio [OR] = 1.48, P = .025), and SNHs had higher complication rates for meningioma (OR = 1.34, P = .003) and all tumor types combined (OR = 1.17, P = .034). However, there were no differences at SNHs for discharge disposition or HACs. LOS and hospital costs were elevated at SNHs for all subtypes, culminating in a 10% and 9% increase in LOS and costs for the overall population, respectively (all P < .001).ConclusionsSNHs demonstrated poorer inpatient outcomes for brain tumor craniotomy. Further analyses of the differences observed and potential interventions to ameliorate interhospital disparities are warranted.