Medicare Hospital Research Articles

Hospital COVID-19 Burden and Adverse Event Rates

The COVID-19 pandemic introduced stresses on hospitals due to the surge in demand for care and to staffing shortages. The implications of these stresses for patient safety are not well understood. To assess whether hospital COVID-19 burden was associated with the rate of in-hospital adverse effects (AEs). This cohort study used data from the Agency for Healthcare Research and Quality's Quality and Safety Review System, a surveillance system that tracks the frequency of AEs among selected hospital admissions across the US. The study sample included randomly selected Medicare patient admissions to acute care hospitals in the US between September 1, 2020, and June 30, 2022. The main outcome was the association between frequency of AEs and hospital-specific weekly COVID-19 burden. Observed and risk-adjusted rates of AEs per 1000 admissions were stratified by the weekly hospital-specific COVID-19 burden (daily mean number of COVID-19 inpatients per 100 hospital beds each week), presented as less than the 25th percentile (lowest burden), 25th to 75th percentile (intermediate burden), and greater than the 75th percentile (highest burden). Risk adjustment variables included patient and hospital characteristics. The study included 40 737 Medicare hospital admissions (4114 patients [10.1%] with COVID-19 and 36 623 [89.9%] without); mean (SD) patient age was 73.8 (12.1) years, 53.8% were female, and the median number of Elixhauser comorbidities was 4 (IQR, 2-5). There were 59.1 (95% CI, 54.5-64.0) AEs per 1000 admissions during weeks with the lowest, 77.0 (95% CI, 73.3-80.9) AEs per 1000 admissions during weeks with intermediate, and 97.4 (95% CI, 91.6-103.7) AEs per 1000 admissions during weeks with the highest COVID-19 burden. Among patients without COVID-19, there were 55.7 (95% CI, 51.1-60.8) AEs per 1000 admissions during weeks with the lowest, 74.0 (95% CI, 70.2-78.1) AEs per 1000 admissions during weeks with intermediate, and 79.3 (95% CI, 73.7-85.3) AEs per 1000 admissions during weeks with the highest COVID-19 burden. A similar pattern was seen among patients with COVID-19. After risk adjustment, the relative risk (RR) for AEs among patients admitted during weeks with high compared with low COVID-19 burden for all patients was 1.23 (95% CI, 1.09-1.39; P < .001), with similar results seen in the cohorts with (RR, 1.33; 95% CI, 1.03-1.71; P = .03) and without (RR, 1.23; 95% CI, 1.08-1.39; P = .002) COVID-19 individually. In this cohort study of hospital admissions among Medicare patients during the COVID-19 pandemic, greater hospital COVID-19 burden was associated with an increased risk of in-hospital AEs among both patients with and without COVID-19. These results illustrate the need for greater hospital resilience and surge capacity to prevent declines in patient safety during surges in demand.

Market Factors, Not Quality, Influence Reimbursement for Pancreaticoduodenectomy in an Era of Price Transparency.

The Centers for Medicare and Medicaid Services (CMS) price transparency rule tries to facilitate cost-conscious decision-making. For surgical services, such as pancreaticoduodenectomy (PD), factors mediating transparency and real-world reimbursement are not well described. The Leapfrog Survey was used to identify United States hospitals performing PD. Financial and operational data were obtained from Turquoise Health and CMS Cost Reports. Chi-square tests and modified Poisson regression evaluated associations with reimbursement disclosure. Two-part logistic and gamma regression models estimated effects of hospital factors on commercial, Medicare, and self-pay reimbursements for PD. Of 452 Leapfrog hospitals, 295 (65%) disclosed PD hospital or procedure reimbursements. Disclosing hospitals were larger (beds >200: 81.0% vs. 71.3%, p = 0.04), reported higher net margins (0.7% vs. -2.1%, p = 0.04), more likely for-profit (26.1% vs. 6.4%, p < 0.001), and teaching-affiliated (82.0% vs. 65.6%, p < 0.001). Nonprofit status conferred hospitalization reimbursement increases of $8683-$12,329, while moderate market concentration predicted savings up to $5066. Teaching affiliation conferred reimbursement increases of $4589-$16,393 for hospitalizations and $644 for procedures. Top Leapfrog volume ratings predicted an increase of up to $7795 for only Medicare hospitalization reimbursement. Nondisclosure of hospital and procedural reimbursements for PD remains a major issue. Transparency was noted in hospitals with higher margins, size, and academic affiliation. Factors associated with higher reimbursement were non-profit status, academic affiliation, and more equitable market share. Reimbursement inconsistently tracked with PD quality or volume measures. Policy changes may be required to incentivize reimbursement disclosure and translate transparency into increased value for patients.

Risk for Financial Precarity From Hospitalization: Implications for Targeting Financial Assistance in Medicare.

High out-of-pocket costs in Medicare may leave many beneficiaries in financial precarity. Beneficiaries with modest incomes are often ineligible for Medicaid (which covers most out-of-pocket Medicare costs) and may have insufficient resources to pay an unexpected health care bill. This has prompted calls to improve financial protections, but the target population remains uncharacterized. To identify beneficiaries who would face financial precarity if exposed to the Medicare Part A hospital deductible ($1600). Cross-sectional study of the 2018 wave of the Health and Retirement Study. United States. Community-dwelling Medicare beneficiaries with incomes greater than 100% to 400% or less of the federal poverty level. Nationally representative estimates of financial precarity, defined as having insufficient funds to pay the deductible, examined across 4 scenarios that considered checking and savings account balances, total liquid assets (with a reserve for future living costs), and supplemental insurance. Among 4881 beneficiaries (population weighted n = 26 619 823), 45.0% had insufficient funds in checking and savings accounts to pay the Medicare hospital deductible. Financial precarity was more prevalent among Black and Hispanic versus White beneficiaries (73.5% and 76.2% vs. 36.2%), those with less versus more than high school education (70.0% vs. 37.1%), and those with 3 or more versus 2 or fewer chronic conditions (49.2% vs. 39.1%). In defining financial precarity to include beneficiaries with insufficient liquid assets to pay the deductible while maintaining a $5000 reserve for future living expenses, 50.7% were financially precarious. Building off this definition to assume supplemental insurance covered the deductible, 39.0% remained financially precarious. Cost-sharing exposure is limited to hospitalization. Many Medicare beneficiaries with modest incomes are at risk for financial hardship from costs of a single hospital stay. National Institute on Aging.

Inclusion of Veterans Health Administration hospitals in Centers for Medicare & Medicaid Services Overall Hospital Quality Star Ratings.

The Centers for Medicare & Medicaid Services (CMS) Overall Hospital Quality Star Rating, established in 2016, is a summary of publicly available quality information for acute care hospitals. In July 2023, Veterans Health Administration (VHA) hospitals became eligible to receive a CMS Overall Hospital Quality Star Rating for the first time. Our objective was to compare performance in quality ratings among VHA and non-VHA hospitals. We used the hospital quality measure scores posted to Care Compare on Medicare.gov as of January 2023 as our primary data set. We conducted a pair of analyses to characterize the performance of VHA hospitals compared to non-VHA hospitals: an overall analysis including all rated hospitals, and a matched analysis in which only a single nearby hospital was included for each VHA hospital. Of the 4518 non-VHA hospitals, 2962 (65.6%) received a Star Rating, compared to 114 (84%) of 136 VHA hospitals. VHA hospitals tended to receive higher ratings overall (one-star: 8%; two-star: 11%; three-star: 14%; four-star: 35%; five-star: 32%) than non-VHA (one-star: 8%; two-star: 22%; three-star: 29%; four-star: 26%; five-star: 15%). A similar pattern was observed in the matched analysis. VHA hospitals tended to perform better on the Overall Star Rating compared to non-VHA hospitals, as evidenced by being more likely to receive a four- or five-star rating. The eligibility of VHA hospitals to receive an Overall Star Rating signifies an important addition to the program that will allow Veterans to make more informed healthcare decisions.

Mapping Segregation Patterns of Hospital Care among Patients with Limited English Proficiency.

Individuals with limited English proficiency (LEP) are disproportionately more likely to experience suboptimal care outcomes compared to English-proficient individuals, attributed to multi-level social determinants of health, including the quality of the hospital where LEP patients are more likely to receive care. Evidence demonstrates that racial minority patients are more often admitted to lower-quality hospitals serving high proportions of minority patients, despite living closer to higher-quality hospitals. Less is known about where individuals with LEP reside, where they seek hospital care, and the quality of care in these hospitals. Using Geographic Information Systems (GIS) methods, we developed a density map characterizing residential patterns of the LEP population across zip code tabulation areas in New Jersey and designated hospitals as high, middle, or low-LEP volume. We described differences in 30-day hospital wide readmission rates for hospitals across varying LEP volume status using Centers for Medicare and Medicaid Services Hospital Care Compare Data. Most hospitals in ZCTAs with higher LEP populations serve a high proportion of LEP patients (i.e. their patients' demographics are reflective of the community in which they are located). However, our results also show instances in which LEP patients may be forgoing receiving care at closer hospitals to instead receive care at further-distanced, high-LEP volume hospitals. significant. High-LEP volume hospitals have higher 30-day hospital wide readmission rates (20.1%) compared to middle (15%) and low (11.3%)-LEP volume hospitals (p < .001), indicating lower quality of care within high-LEP volume hospitals.

A health equity monitoring framework based on process mining.

In the United States, there is a proposal to link hospital Medicare payments with health equity measures, signaling a need to precisely measure equity in healthcare delivery. Despite significant research demonstrating disparities in health care outcomes and access, there is a noticeable gap in tools available to assess health equity across various health conditions and treatments. The available tools often focus on a single area of patient care, such as medication delivery, but fail to examine the entire health care process. The objective of this study is to propose a process mining framework to provide a comprehensive view of health equity. Using event logs which track all actions during patient care, this method allows us to look at disparities in single and multiple treatment steps, but also in the broader strategy of treatment delivery. We have applied this framework to the management of patients with sepsis in the Intensive Care Unit (ICU), focusing on sex and English language proficiency. We found no significant differences between treatments of male and female patients. However, for patients who don't speak English, there was a notable delay in starting their treatment, even though their illness was just as severe and subsequent treatments were similar. This framework subsumes existing individual approaches to measure health inequities and offers a comprehensive approach to pinpoint and delve into healthcare disparities, providing a valuable tool for research and policy-making aiming at more equitable healthcare.

The relationship between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services value-based purchasing metrics.

Despite the intense policy focus on reducing health-care-associated conditions, adverse events in health care settings persist. Therefore, evaluating patient safety efforts and related health policy initiatives remains critical. The aim of this study was to explore the relationship between hospital patient safety culture and hospital performance on Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) metrics. A pooled cross-sectional study design was used utilizing three secondary datasets from 2018 and 2021: the Hospital Survey on Patient Safety Culture, the American Hospital Association annual survey, and the Hospital Compare data from CMS. We used two multivariable linear regression models to examine the relationship between organizational patient safety culture and hospital performance. The dependent variables included the overall CMS total performance score (TPS) and the four individual TPS domain scores. Hospital patient safety culture, the independent variable, was operationalized using two measures from the Hospital Survey on Patient Safety Culture: (a) the domain score of overall perceptions of patient safety and (b) the patient safety grade. We observed positive and significant associations between hospital patient safety culture and a hospital's overall TPS and the "patient and community engagement" and "safety" domains. Findings suggest that building a strong patient safety culture has the potential to lead health care organizations to achieve high performance on HVBP metrics. Our findings have important policy implications for both the future of CMS HVBP as a motivator of patient safety and how health care managers integrate culture change into programs to meet external quality metrics.

Processing and validation of inpatient Medicare Advantage data for use in hospital outcome measures.

To determine the feasibility of integrating Medicare Advantage (MA) admissions into the Centers for Medicare & Medicaid Services (CMS) hospital outcome measures through combining Medicare Advantage Organization (MAO) encounter- and hospital-submitted inpatient claims. Beneficiary enrollment data and inpatient claims from the Integrated Data Repository for 2018 Medicare discharges. We examined timeliness of MA claims, compared diagnosis and procedure codes for admissions with claims submitted both by the hospital and the MAO (overlapping claims), and compared demographic characteristics and principal diagnosis codes for admissions with overlapping claims versus admissions with a single claim. We combined hospital- and MAO-submitted claims to capture MA admissions from all hospitals and identified overlapping claims. For admissions with only an MAO-submitted claim, we used provider history data to match the National Provider Identifier on the claim to the CMS Certification Number used for reporting purposes in CMS outcome measures. After removing void and duplicate claims, identifying overlapped claims between the hospital- and MAO-submitted datasets, restricting claims to acute care and critical access hospitals, and bundling same admission claims, we identified 5,078,611 MA admissions. Of these, 76.1% were submitted by both the hospital and MAO, 14.2% were submitted only by MAOs, and 9.7% were submitted only by hospitals. Nearly all (96.6%) hospital-submitted claims were submitted within 3 months after a one-year performance period, versus 85.2% of MAO-submitted claims. Among the 3,864,524 admissions with overlapping claims, 98.9% shared the same principal diagnosis code between the two datasets, and 97.5% shared the same first procedure code. Inpatient MA data are feasible for use in CMS claims-based hospital outcome measures. We recommend prioritizing hospital-submitted over MAO-submitted claims for analyses. Monitoring, data audits, and ongoing policies to improve the quality of MA data are important approaches to address potential missing data and errors.

Budget Impact Analysis for the Spread and Financial Sustainability of Videoconference Antimicrobial Stewardship Programs

Background: In rural areas, antimicrobial stewardship programs often have limited access to infectious disease (ID) expertise. Videoconference Antimicrobial Stewardship Teams (VASTs) pair rural Veterans Affairs (VA) medical centers with an ID expert to discuss treatment of patients with concerns for infection. In a pilot study, VASTs were effective at improving antimicrobial use. Here, we evaluated 12-month operating costs for staffing for 3 VASTs. Methods: We used the following data to describe 12 months of clinical encounters for 3 VASTs operating from January 2022 – March 2023: the number of VAST sessions completed and clinical encounters; Current Procedural Terminology (CPT) codes associated with clinical encounters; session attendees (by role) and the time spent (percent effort) on VAST-related activities. The annual operating cost was based on the annual salaries and percent effort of VAST attendees. We used these characteristics combined with private-sector and Medicare reimbursements to evaluate the cost of implementation and number of clinical encounters needed to offset those costs (breakeven) for each site. Results: Three VASTs recorded 229 clinical encounters during 117 sessions (Table 1). Based on CPT codes, the approximate revenue per patient was $516.46. Site A, the only site to break even, had the most sessions and clinical encounters as well as the lowest operating costs. For Site B, a slight increase in the clinical encounters, which might be achieved by 3 additional VAST sessions, would help achieve breakeven. For Site C, increasing the number of clinical encounters to 3-4 per session would have helped their VAST break even without requiring a decrease in operating costs. Conclusions: The frequency of VAST sessions, volume of clinical encounters, and low operating costs all contributed the VAST at Site A achieving a financial break-even point within 12 months. Consideration of the potential number of clinical encounters and sessions will help other VASTs achieve financial sustainment, independent of cost-savings related to potential decreases in expenditures for antibiotics and antibiotic-related adverse events. These results also provide insight into possible adoption and diffusion of VAST-like programs in the Medicare hospital setting.

Emergency Department Visits And Hospital Capacity In The US: Trends In The Medicare Population During The COVID-19 Pandemic.

Although emergency department (ED) and hospital overcrowding were reported during the later parts of the COVID-19 pandemic, the true extent and potential causes of this overcrowding remain unclear. Using data on the traditional fee-for-service Medicare population, we examined patterns in ED and hospital use during the period 2019-22. We evaluated trends in ED visits, rates of admission from the ED, and thirty-day mortality, as well as measures suggestive of hospital capacity, including hospital Medicare census, length-of-stay, and discharge destination. We found that ED visits remained below baseline throughout the study period, with the standardized number of visits at the end of the study period being approximately 25percent lower than baseline. Longer length-of-stay persisted through 2022, whereas hospital census was considerably above baseline until stabilizing just above baseline in 2022. Rates of discharge to postacute facilities initially declined and then leveled off at 2percent below baseline in 2022. These results suggest that widespread reports of overcrowding were not driven by a resurgence in ED visits. Nonetheless, length-of-stay remains higher, presumably related to increased acuity and reduced available bed capacity in the postacute care system.

Hospital Patient Experience: Exploring Hospitals as Shifters and Sustainers Over Time.

Patient experience is a key factor in measuring hospital performance, and the Hospital Consumer Assessment of Healthcare Providers and Systems survey tool is used to assess patient perceptions. Hospitals with positive patient experience tend to have a better quality of clinical care, lower readmission and mortality rates, and an overall shorter inpatient length of stay. Studies have identified several organizational determinants of high- and low-rated patient experiences, including hospital size, type, staffing levels, and patient demographics.This study aims to explore the determinants of consistently high- and low-rated patient experience, as well as factors associated with positive and negative changes in patient experience over time. The 2014 to 2019 American Hospital Association annual survey and the Centers for Medicare and Medicaid Services Hospital Value-Based Purchasing database were used. A total of 2801 acute-care hospitals were included in this study. A series of multivariate logistic regressions were used to model the probability of "1" (being a superior hospital or an inferior hospital). In addition, a generalized linear mixed model for binary responses was used to analyze the change (probability of positive and negative change). The results showed that most hospitals did not sustain superior or inferior performance, and competition decreased the likelihood of a hospital consistently performing well in terms of patient experience. Superior performance was associated with hospital ownership (P <.001), size (P =.026), location (P =.002), teaching status (P =.009), average Herfindahl-Hirschman Index value (P =.005), and Medicaid and Medicare patient population. On the other hand, inferior performance was associated with hospital ownership (P =.003), size (P <.001), teaching status (P =.003), safety net status (P =.020), and Medicaid and Medicare patient population. This study aimed to examine the trends in hospital patient experience performance and the influence of hospital organizational characteristics on those trends. Our findings allow us to question the widely held belief that patient experience is a metric of differentiation and industry competition, suggesting that performance in this domain has not been utilized by most hospitals as a source of sustainable competitive advantage. The findings from this study highlight the importance of considering changes in performance over time and the need for significant organizational efforts to improve hospital performance in terms of patient experience.

Variation in Postoperative Outcomes Across Federally Designated Hospital Star Ratings

Despite widespread use to guide patients to hospitals providing the best care, it remains unknown whether Centers for Medicare & Medicaid Services (CMS) hospital star ratings are a reliable measure of hospital surgical quality. To examine the CMS hospital star ratings and hospital surgical quality measured by 30-day postoperative mortality, serious complications, and readmission rates for Medicare beneficiaries undergoing colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, and incisional hernia repair. This cohort study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals with a CMS hospital star rating for calendar years 2014-2018. Data analysis was performed from January 15, 2022, to April 30, 2023. Participants included fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair with continuous Medicare coverage for 3 months before and 6 months after surgery. Centers for Medicare & Medicaid Services hospital star rating. Risk- and reliability-adjusted hospital rates of 30-day postoperative mortality, serious complications, and 30-day readmissions were measured and compared across hospitals and star ratings. A total of 1 898 829 patients underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair at 3240 hospitals with a CMS hospital star rating. Mean (SD) age was 74.8 (7.0) years, 50.6% of the patients were male, and 86.5% identified as White. Risk- and reliability-adjusted 30-day mortality rate decreased in a stepwise fashion from 6.80% (95% CI, 6.79%-6.81%) in 1-star hospitals to 4.93% (95% CI, 4.93%-4.94%) in 5-star hospitals (adjusted odds ratio, 1.86; 95% CI, 1.73-2.00). There was wide variation in the rates of hospital mortality (variation, 1.89%; range, 2.4%-16.2%), serious complications (variation, 1.97%; range, 5.5%-45.1%), and readmission (variation, 1.27%; range, 9.1%-22.5%) across all hospitals. After stratifying hospitals by their star rating, similar patterns of variation were observed within star rating groups for 30-day mortality: 1 star (variation, 1.91%; range, 3.6%-12.0%), 2 star (variation, 1.86%; range, 2.8%-16.2%), 3 star (variation, 1.84%; range, 2.9%-12.3%), 4 star (variation, 1.76%; range, 2.9%-11.5%), and 5 star (variation, 1.79%; range, 2.4%-9.1%). Similar patterns were observed for serious complications and readmissions. Although CMS hospital star rating was associated with postoperative mortality, serious complications, and readmissions, there was wide variation in surgical outcomes within each star rating group. These findings highlight the limitations of the CMS hospital star rating system as a measure of surgical quality and should be a call for continued improvement of publicly reported hospital grade measures.

Incorporating Medicare Advantage Admissions Into the CMS Hospital-Wide Readmission Measure

Medicare Advantage (MA) enrollment is rapidly expanding, yet Centers for Medicare & Medicaid Services (CMS) claims-based hospital outcome measures, including readmission rates, have historically included only fee-for-service (FFS) beneficiaries. To assess the outcomes of incorporating MA data into the CMS claims-based FFS Hospital-Wide All-Cause Unplanned Readmission (HWR) measure. This cohort study assessed differences in 30-day unadjusted readmission rates and demographic and risk adjustment variables for MA vs FFS admissions. Inpatient FFS and MA administrative claims data were extracted from the Integrated Data Repository for all admissions for Medicare beneficiaries from July 1, 2018, to June 30, 2019. Measure reliability and risk-standardized readmission rates were calculated for the FFS and MA cohort vs the FFS-only cohort, overall and within specialty subgroups (cardiorespiratory, cardiovascular, medicine, surgery, neurology), then changes in hospital performance quintiles were assessed after adding MA admissions. Risk-standardized readmission rates. The cohort included 11 029 470 admissions (4 077 633 [37.0%] MA; 6 044 060 [54.8%] female; mean [SD] age, 77.7 [8.2] years). Unadjusted readmission rates were slightly higher for MA vs FFS admissions (15.7% vs 15.4%), yet comorbidities were generally lower among MA beneficiaries. Test-retest reliability for the FFS and MA cohort was higher than for the FFS-only cohort (0.78 vs 0.73) and signal-to-noise reliability increased in each specialty subgroup. Mean hospital risk-standardized readmission rates were similar for the FFS and MA cohort and FFS-only cohorts (15.5% vs 15.3%); this trend was consistent across the 5 specialty subgroups. After adding MA admissions to the FFS-only HWR measure, 1489 hospitals (33.1%) had their performance quintile ranking changed. As their proportion of MA admissions increased, more hospitals experienced a change in their performance quintile ranking (147 hospitals [16.3%] in the lowest quintile of percentage MA admissions; 408 [45.3%] in the highest). The combined cohort added 63 hospitals eligible for public reporting and more than 4 million admissions to the measure. In this cohort study, adding MA admissions to the HWR measure was associated with improved measure reliability and precision and enabled the inclusion of more hospitals and beneficiaries. After MA admissions were included, 1 in 3 hospitals had their performance quintile changed, with the greatest shifts among hospitals with a high percentage of MA admissions.

A two-decade trend analysis of in-hospital outcomes and racial/ethnic disparities among hospitalized patients with lung cancer in the United States.

11035 Background: Previous research has focused largely on the disease and healthcare cost burden of lung cancer (LC),however, long-term trends of hospitalizations among LC patients (pts) in the US are limited. We aimed to describe longitudinal trends in in-hospital outcomes among hospitalized LC pts, overall and by race/ethnicity. Methods: We analyzed data from the National Inpatient Sample database, spanning 1998 to 2020. The study cohort included pts aged ≥18 years with a principal LC diagnosis. We assessed four in-hospital outcomes: 1) hospitalization, 2) mortality, 3) length of stay (LOS), and 4) total hospitalization charges (THCs). THCs were adjusted for inflation using the Medicare Hospital Care Consumer Price Index.To quantify trends, we performed weighted analyses (weighted means or proportions) and calculated P-trend using Cochran-Armitage or Jonckheere-Terpstra tests. Results: Of 791,100 pts (mean age 68.2 years), 80.4% were White, followed by 11.9% Black, 4.7% Hispanic, and 3.0% Asian or Pacific Islander (API). Among US hospitalized pts in 1998, 0.54% had a principal LC diagnosis, with hospitalization rates having decreased to 0.37% in 2020 ( P-trend&lt;.001). By race/ethnicity, the LC hospitalization rate for White pts declined from 0.53% in 1998 to 0.39% in 2020; for Black pts, it declined from 0.35% to 0.26%; and for Hispanic pts, it declined from 0.18% to 0.12% (all P-trend&lt;.001). In contrast, the hospitalization rate for API pts increased from 0.30% in 1998 to 0.38% in 2020 ( P-trend&lt;.001). The overall LC-specific in-hospital mortality rate declined drastically from 15.9% in 1998 to 6.2% in 2020 ( P-trend&lt;.001); a similar pattern was observed across racial/ethnic groups. The LOS reduced from an average of 7.9 days in 1998 to 5.9 days in 2020 ( P-trend&lt;.001). By race/ethnicity, the LOS for White pts decreased from 7.8 days in 1998 to 5.2 days in 2020; for Black pts, it decreased from 9.0 to 7.0 days; for Hispanic pts, it decreased from 8.8 to 6.7 days; and it declined from 8.7 to 5.9 days in API pts (all P-trend&lt;.001). THCs rose significantly from $39,706 in 1998 to $92,734 in 2020 ( P-trend&lt;.001). In White pts, THCs rose from $39782 to $89,681; from $41,235 to $91,792 in Black pts; from $49,444 to $119,386 in Hispanic pts; and from $52,779 to $112,365 in API pts (all P-trend&lt;.001). Moreover, the odds of female pts hospitalized with LC was higher (AOR=1.47, 95% CI=1.40-1.54, P&lt;.001) in 2020 compared to 1998. Conclusions: In this racially diverse hospitalized LC cohort, LOS, rates of hospitalizations, and mortality rates have declined, while THCs have risen significantly, over the last 20 years. API and female pts bore a heavier burden of hospitalizations. Our findings suggest the need for targeted healthcare interventions or policies to reduce THCs and hospitalization disparities in LC pts.

Comorbid opioid use disorder and resource utilization outcomes in patients with neoplasm-related pain: A population analysis.

11040 Background: Neoplasm-related pain (NRP) is one of the most debilitating sequalae of cancer, affecting patients’ (pts) quality of life. Its intersection with opioid use disorder (OUD) adds a layer of complexity to patient care in the United States (US). As the prevalence of both conditions continues to increase, understanding the association between OUD and NRP becomes important. This study aimed to shed light on this intricate relationship by examining outcomes in resource utilization among OUD pts with NRP. Methods: We analyzed weighted data from the 2016-2020 iterations of the National Inpatient Sample database. We included pts 18 years or older with a principal discharge diagnosis of NRP with or without a secondary diagnosis of OUD. The main outcomes for the study were length of stay (LOS) and total hospitalization charges (THC) adjusted for inflation using the Medicare Hospital Consumer Price Index. Baseline sociodemographic and hospital characteristics as well as comorbidities of patients with and without OUD were compared using χ2 for categorical variables and Student’s t-test for continuous variables. Multivariable Linear regression was used to assess the relationship between comorbid OUD and resource utilization among NRP hospitalizations. Statistical significance was set at p&lt;0.05. Results: There were 120,359 hospitalizations for NRP between 2016 and 2020. Among patients hospitalized for NRP, 3335 (2.78%) had a secondary diagnosis of OUD. The mean age of NRP pts was 60 years. Compared to patients without OUD, OUD pts were male (50.67% vs 45.47%; p = 0.0086), younger (mean age 56 vs 60 years; p&lt;0.0001), more likely to be on Medicaid (37.48% vs 21.00%; p &lt;0.0001) and hospitalized in urban hospitals (94.6% vs 91.37%; p = 0.0040). On multivariable linear regression, OUD was associated with an increased LOS by 0.93 days compared to non-OUD patients (95% CI: 0.265 – 1.600; p = 0.006), as well as increased THC by $9248 (95% CI: 1676.00 – 16820.41; p = 0.017) after adjusting for sociodemographic and hospital covariates. Conclusions: Our study highlights an increased resource utilization among pts with NRP and comorbid OUD. We surmise this could be due to increased tolerance to and dependence on the effects of opioids requiring more intricate multidisciplinary care in managing their pain. Recognizing this association is important for medical oncologists and other health care providers when managing NRP pts with OUD. Incorporating multimodality pain management early on admission could improve patient outcomes while optimizing healthcare resources.

Utilization and Outcomes in U.S. ICU Hospitalizations.

Despite its importance, detailed national estimates of ICU utilization and outcomes remain lacking. We aimed to characterize trends in ICU utilization and outcomes over a recent 12-year period in the United States. In this longitudinal study, we examined hospitalizations involving ICU care ("ICU hospitalizations") alongside hospitalizations not involving ICU care ("non-ICU hospitalizations") among traditional Medicare beneficiaries using 100% Medicare part A claims data and commercial claims data for the under 65 adult population from 2008 to 2019. There were 18,313,637 ICU hospitalizations and 78,501,532 non-ICU hospitalizations in Medicare, and 1,989,222 ICU hospitalizations and 16,732,960 non-ICU hospitalizations in the commercially insured population. From 2008 to 2019, about 20% of Medicare hospitalizations and 10% of commercial hospitalizations involved ICU care. Among these ICU hospitalizations, length of stay and ICU length of stay decreased on average. Mortality and hospital readmissions on average also decreased, and they decreased more among ICU hospitalizations than among non-ICU hospitalizations, for both Medicare and commercially insured patients. Both Medicare and commercial populations experienced a growth in shorter ICU hospitalizations (between 2 and 7 d in length), which were characterized by shorter ICU stays and lower mortality. Among these short hospitalizations in the Medicare population, for common clinical diagnoses cared for in both ICU and non-ICU settings, patients were increasingly triaged into an ICU during the study period, despite being younger and having shorter hospital stays. ICUs are used in a sizeable share of hospitalizations. From 2008 to 2019, ICU length of stay and mortality have declined, while short ICU hospitalizations have increased. In particular, for clinical conditions often managed both within and outside of an ICU, shorter ICU hospitalizations involving younger patients have increased. Our findings motivate opportunities to better understand ICU utilization and to improve the value of ICU care for patients and payers.

Statewide Hospital Admissions for Adult Survivors of Infant Surgical Diseases Over a 10-Year Period

IntroductionThe number of patients with congenital disease living to adulthood continues to grow. Often undergoing surgical correction in infancy, they continue to require lifelong care. Their numbers are largely unknown. We sought to evaluate hospital admissions of adult patients with esophageal atresia with tracheoesophageal fistula (EA/TEF), congenital diaphragmatic hernia (CDH), and Hirschsprung disease (HD). MethodsThe Florida Agency for Healthcare Administration inpatient database was merged with the Distressed Communities Index and Centers for Medicare and Medicaid Services Hospital and Physician Compare datasets. The dataset was queried for adult patients (≥18 y, born after 1970) with EA/TEF, CDH, and HD in their problem list from 2010 to 2020. Patient demographics, hospitalization characteristics, and discharge information were obtained. ResultsIn total, 1140 admissions were identified (266 EA/TEF, 135 CDH, 739 HD). Patients were mostly female (53%), had a mean age of 31.6 y, and often admitted to an adult internist in a general hospital under emergency. Principal diagnoses and procedures (when performed) varied with diagnosis and age at admission. EA patients were admitted with dysphagia and foregut symptoms and often underwent upper endoscopy with dilation. CDH patients were often admitted for diaphragmatic hernias and underwent adult diaphragm repair. Hirschsprung patients were often admitted for intestinal obstructive issues and frequently underwent colonoscopy but trended toward operative intervention with increasing age. ConclusionsAdults with congenital disease continue to require hospital admission and invasive procedures. As age increases, diagnoses and performed procedures for each diagnoses evolve. These data could guide the formulation of multispecialty disease-specific follow-up programs for these patients.

Measuring Local-Area Racial Segregation for Medicare Hospital Admissions

Considerable racial segregation exists in US hospitals that cannot be explained by where patients live. Approaches to measuring such segregation are limited. To measure how and where sorting of older Black patients to different hospitals occurs within the same health care market. This retrospective cross-sectional study used 2019 Medicare claims data linked to geographic data. Hospital zip code markets were based on driving time. The local hospital segregation (LHS) index was defined as the difference between the racial composition of a hospital's admissions and the racial composition of the hospital's market. Assessed admissions were among US Medicare fee-for-service enrollees aged 65 or older living in the 48 contiguous states with at least 1 hospitalization in 2019 at a hospital with at least 200 hospitalizations. Data were analyzed from November 2022 to January 2024. Degree of residential segregation, ownership status, region, teaching hospital designation, and disproportionate share hospital status. The LHS index by hospital and a regional LHS index by hospital referral region. In the sample of 1991 acute care hospitals, 4 870 252 patients (mean [SD] age, 77.7 [8.3] years; 2 822 006 [56.0%] female) were treated, including 11 435 American Indian or Alaska Native patients (0.2%), 129 376 Asian patients (2.6%), 597 564 Black patients (11.9%), 395 397 Hispanic patients (7.8), and 3 818 371 White patients (75.8%). In the sample, half of hospitalizations among Black patients occurred at 235 hospitals (11.8% of all hospitals); 878 hospitals (34.4%) exhibited a negative LHS score (ie, admitted fewer Black patients relative to their market area) while 1113 hospitals (45.0%) exhibited a positive LHS (ie, admitted more Black patients relative to their market area); of all hospitals, 79.4% exhibited racial admission patterns significantly different from their market. Hospital-level LHS was positively associated with government hospital status (coefficient, 0.24; 95% CI, 0.10 to 0.38), while New York, New York; Chicago, Illinois; and Detroit, Michigan, hospital referral regions exhibited the highest regional LHS measures, with hospital referral region LHS scores of 0.12, 0.16, and 0.21, respectively. In this cross-sectional study, a novel measure of LHS was developed to quantify the extent to which hospitals were admitting a representative proportion of Black patients relative to their market areas. A better understanding of hospital choice within neighborhoods would help to reduce racial inequities in health outcomes.

Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program

Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Hospital Value-Based Purchasing program HEA. Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

Abstract P245: Association Between Individual Socioeconomic Status and Discharge Dispositions to Home or Rehabilitation Following Incident Stroke Hospitalization: The Atherosclerosis Risk in Communities (ARIC) Study

Background: The contribution of socioeconomic status (SES) to discharge destination in stroke survivors is not known. Hypothesis: Discharge to home, as compared to inpatient rehabilitation, will be greater among stroke survivors with low, as compared to high SES. Methods: The study population included ARIC Study participants, enrolled in fee-for-service Medicare, aged 66 years or older, with incident ischemic or hemorrhagic stroke (1992-2017). Black participants from the Minneapolis and Washington County study centers were excluded due to low numbers. Individual SES was estimated from median household income and education. Discharge disposition was ascertained from CMS Medicare inpatient records. Logistic regression models with inverse probability of treatment weighting were used to estimate the effect of exposures, accounting for age, sex, race, study center, comorbidity, and stroke severity. The Elixhauser Comorbidity Index was used to as a measure of comorbidity burden. Stroke severity was estimated from discharge diagnosis and procedure codes obtained from Medicare hospitalization records. Results: Of a total 710 ARIC stroke survivors (mean age at discharge 76 (SD: 6.2) years, 30.1% (214 of 710) Black, 57.5% (408 of 710) women), 50.7% (360 of 710) were discharged home. Compared to high income, low and moderate income was associated with lower adjusted odds of discharge to home among White participants (AOR:0.8, 95% CI: 0.68-0.93) and AOR: 0.63, 95% CI: 0.57-0.69), respectively) and higher odds discharge to home among Black participants (AOR: 1.36, 95% CI: 1.07-1.73 and AOR: 1.43, 95% CI: 1.11-1.83, respectively). Low income was also associated with higher odds of discharge home among women. Adjustment for stroke severity and comorbidity did not attenuate estimates. No significant association between education and discharge disposition was observed. Conclusions: Low and moderate median household income is statistically significantly associated with discharge home among Black and female stroke survivors.