Reduce Hospital Utilization Research Articles

Coaching People with Cardiovascular Disease to Close Their “Treatment Gaps” Reduces Hospital Utilization, Saves Lives, and Delivers Net Cost Savings Over 10 Years

BackgroundDisease management programs are an essential tool in the fight against rising prevalence and costs associated with cardiovascular disease (CVD). However, there is a lack of evidence on the long-term impact of these programs on clinical outcomes, healthcare utilization, and cost. This study presents a long-term follow up of clinical, healthcare utilization and cost, and mortality consequences of The COACH Program, a 6-month telephone delivered CVD prevention program. MethodsWe conducted 10-year retrospective propensity score matched cohort study of potentially eligible participants comparing individuals that participated to those that did not receive the Program. Primary outcomes of interest were differences in mortality, private healthcare utilization and cost of private healthcare utilization sourced from private health insurance claims data. ResultsOf the 24,932 potentially eligible participants, 11,988 were invited to participate in The COACH Program between July 1, 2010, and December 31, 2020. The COACH Program participants (n = 2,271) were 1:1 matched with individuals who did not participate in the Program. Participation in The COACH Program was associated with a 34% reduction in the risk of mortality (HR: 0.66, 95% CI: 0.54, 0.79), an 8% reduction in the number of hospitalizations (IRR: 0.92, 95% CI: 0.85, 0.98), and an annual reduction in healthcare costs of $1,499 (95% CI: $1,909, $1,087). Results were robust to sensitivity analyses. ConclusionsA structured 6-month telephone delivered coaching program focused on closing “treatment gaps” in people with a history of CVD saves lives and reduces hospital utilization, health care costs over 10-years follow-up.

Does home and community-based services use reduce hospital utilization and hospital expenditure among disabled elders? Evidence from China.

In the background of aging in place, home and community-based services (HCBS) have been playing an increasingly important role in long-term care (LTC) security systems. However, it is still uncertain whether and how HCBS use affects hospital utilization and the corresponding expenditures. Using data from the China Health and Retirement Longitudinal Survey (CHARLS) and the China City Statistical Yearbook, the instrumental variable (IV) approach is applied to identify the causal effects of HCBS use on hospital utilization and hospital expenditure among disabled elders. We find that HCBS use significantly reduces the probability of being hospitalized, the times of hospitalization, and the length of inpatient stay, as well as the total, out-of-pocket and reimbursement inpatient expenditures, demonstrating not only the substitution impact of HCBS for hospital care but also the effectiveness of medical expenditure control in LTC security systems. Heterogeneity analysis shows that the impacts of HCBS use on hospital utilization and hospital expenditure concentrate on disabled elders who are younger, male, living in urban areas, or from higher-income households; both healthcare and spiritual consolation services have significant negative effects, while the anticipated effects of daily care service use are not supported. The possible mechanisms are the substitution of HCBS for hospital care and the improvements in both the physical and psychological health of disabled elders. However, the mechanism of adverse events decrease is not verified, which needs to be investigated further with more proxy variables. This study provides empirical evidence that HCBS use can not only reduce hospital utilization and hospital expenditure among disabled elders but also improve their physical and psychological health. Policy designs should emphasize the orientation of HCBS, ensure the fundamental and central position of HCBS in the formal care service system, pay more attention to the accessibility and affordability of HCBS for fragile groups, and diversify and optimize the development of the health service and the spiritual consolation service.

Telemedicine vs Face-to-Face for Nursing Home Residents With Acute Presentations: A Noninferiority Study.

Telemedicine and face-to-face outreach services to nursing homes (NHs) have been used to reduce hospital utilization rates for acute presentations. However, how these modalities compare against each other is unclear. This article examines if the management of acute presentations in NHs with care involving telemedicine is noninferior to care delivered face-to-face. A noninferiority study was conducted on a prospective cohort. Face-to-face intervention involved on-site assessment by a geriatrician and aged care clinical nurse specialist (CNS). Telemedicine intervention involved on-site assessment by an aged care CNS with telemedicine input by a geriatrician. A total of 438 NH residents with acute presentations from 17 NHs between November 2021 and June2022. Between-group differences in proportion of residents successfully managed on-site and mean number of encounters were evaluated using bootstrapped multiple linear regression; 95% CIs were compared against predefined noninferiority margins with noninferiority P values calculated. In the adjusted models, care involving telemedicine demonstrated noninferiority in the difference in proportion of residents successfully managed on-site (95% CI lower limit-6.2% to-1.4% vs-10% noninferiority margin; P < .001 for noninferiority) but not in the difference in mean number of encounters (95% CI upper limit 1.42 to 1.50 encounters vs 1 encounter noninferiority margin; P= .7 for noninferiority). In our model of care, care that involved telemedicine was noninferior to care delivered face-to-face in managing NH residents with acute presentations on-site. However, additional encounters may be required. Application of telemedicine ought to be tailored to fit the needs and preferences of stakeholders.

Mi Puente (My Bridge) Care Transitions Program for Hispanic/Latino Adults with Multimorbidity: Results of a Randomized Controlled Trial.

Multimorbidity frequently co-occurs with behavioral health concerns and leads to increased healthcare costs and reduced quality and quantity of life. Unplanned readmissions are a primary driver of high healthcare costs. We tested the effectiveness of a culturally appropriate care transitions program for Latino adults with multiple cardiometabolic conditions and behavioral health concerns in reducing hospital utilization and improving patient-reported outcomes. Randomized, controlled, single-blind parallel-groups. Hispanic/Latino adults (N=536; 75% of those screened and eligible; M=62.3 years (SD=13.9); 48% women; 73% born in Mexico) with multiple chronic cardiometabolic conditions and at least one behavioral health concern (e.g., depression symptoms, alcohol misuse) hospitalized at a hospital that serves a large, mostly Hispanic/Latino, low-income population. Usual care (UC) involved best-practice discharge processes (e.g., discharge instructions, assistance with appointments). Mi Puente ("My Bridge"; MP) was a culturally appropriate program of UC plus inpatient and telephone encounters with a behavioral health nurse and community mentor team who addressed participants' social, medical, and behavioral health needs. The primary outcome was 30- and 180-day readmissions (inpatient, emergency, and observation visits). Patient-reported outcomes (quality of life, patient activation) and healthcare use were also examined. In intention-to-treat models, the MP group evidenced a higher rate of recurrent hospitalization (15.9%) versus UC (9.4%) (OR=1.91 (95% CI 1.09, 3.33)), and a greater number of recurrent hospitalizations (M=0.20 (SD=0.49) MP versus 0.12 (SD=0.45) UC; P=0.02) at 30 days. Similar trends were observed at 180 days. Both groups showed improved patient-reported outcomes, with no advantage in the Mi Puente group. Results were similar in per protocol analyses. In this at-risk population, the MP group experienced increased hospital utilization and did not demonstrate an advantage in improved patient-reported outcomes, relative to UC. Possible reasons for these unexpected findings are discussed. ClinicalTrials.gov Identifier: NCT02723019. Registered on 30 March 2016.

Bendamustine is safe and effective for lymphodepletion before tisagenlecleucel in patients with refractory or relapsed large B-cell lymphomas

Anti-CD19 chimeric antigen receptor T-cell immunotherapy (CAR-T) is now a standard treatment of relapsed or refractory B-cell non-Hodgkin lymphomas; however, a significant portion of patients do not respond to CAR-T and/or experience toxicities. Lymphodepleting chemotherapy is a critical component of CAR-T that enhances CAR-T-cell engraftment, expansion, cytotoxicity, and persistence. We hypothesized that the lymphodepletion regimen might affect the safety and efficacy of CAR-T. We compared the safety and efficacy of lymphodepletion using either fludarabine/cyclophosphamide (n= 42) or bendamustine (n= 90) before tisagenlecleucel in two cohorts of patients with relapsed or refractory large B-cell lymphomas treated consecutively at three academic institutions in the United States (University of Pennsylvania, n= 90; Oregon Health & Science University, n= 35) and Europe (University of Vienna, n= 7). Response was assessed using the Lugano 2014 criteria and toxicities were assessed by the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 and, when possible, the American Society for Transplantation and Cellular Therapy (ASTCT) consensus grading. Fludarabine/cyclophosphamide led to more profound lymphocytopenia after tisagenlecleucel infusion compared with bendamustine, although the efficacy of tisagenlecleucel was similar between the two groups. We observed significant differences, however, in the frequency and severity of adverse events. In particular, patients treated with bendamustine had lower rates of cytokine release syndrome and neurotoxicity. In addition, higher rates of hematological toxicities were observed in patients receiving fludarabine/cyclophosphamide. Bendamustine-treated patients had higher nadir neutrophil counts, hemoglobin levels, and platelet counts, as well as a shorter time to blood count recovery, and received fewer platelet and red cell transfusions. Fewer episodes of infection, neutropenic fever, and post-infusion hospitalization were observed in the bendamustine cohort compared with patients receiving fludarabine/cyclophosphamide. Bendamustine for lymphodepletion before tisagenlecleucel has efficacy similar to fludarabine/cyclophosphamide with reduced toxicities, including cytokine release syndrome, neurotoxicity, infectious and hematological toxicities, as well as reduced hospital utilization.

Do Interventions Reducing Social Vulnerability Improve Health in Community Dwelling Older Adults? A Systematic Review.

BackgroundSocial vulnerability occurs when individuals have been relatively disadvantaged by the social determinants of health. Complex interventions that reduce social vulnerability have the potential to improve health in older adults but robust evidence is lacking.ObjectiveTo identify, appraise and synthesize evidence on the effectiveness of complex interventions targeting reduction in social vulnerability for improving health related outcomes (mortality, function, cognition, subjective health and healthcare use) in older adults living in the community.MethodsA mixed methods systematic review was conducted. Five databases and targeted grey literature were searched for primary studies of all study types according to predetermined criteria. Data were extracted from each distinct intervention and quality was assessed using the Mixed Methods Appraisal Tool. Effectiveness data were synthesized using vote counting by direction of effect, combining p values and Albatross plots.ResultsAcross 38 included studies, there were 34 distinct interventions categorized as strengthening social supports and communities, helping older adults and their caregivers navigate health and social services, enhancing neighbourhood and built environments, promoting education and providing economic stability. There was evidence to support positive influences on function, cognition, subjective health, and reduced hospital utilization. The evidence was mixed for non-hospital healthcare utilization and insufficient to determine effect on mortality.ConclusionDespite high heterogeneity and varying quality of studies, attention to reducing an older adult’s social vulnerability assists in improving older adults’ health.

Effectiveness of a telephone-based nursing intervention to reduce hospital utilization by COVID-19 patients.

ObjectiveDetermine the effectiveness of a COVID‐19 remote monitoring and management program in reducing preventable hospital utilization.DesignA retrospective cohort study utilizing data from electronic health records.SampleTwo hundred ninety‐three patients who tested positive for COVID‐19 at a drive‐through testing site in Michigan. [Correction added on 11 April 2022, after first online publication: In the preceding sentence, “Two hundred and ninety‐third” has been corrected to “Two hundred ninety‐three” in this version.] The intervention group, consisting of 139 patients, was compared to a control group of 154 patients.MeasurementsThe primary outcome was the 30‐day probability of hospital utilization. The covariates included in the analysis were age, gender, tobacco use, body mass index (BMI), race, and ethnicity.InterventionA nurse‐led, telephone‐based active management protocol for COVID‐19 patients who were isolating at home.ResultsThe intervention group had a non‐statistically significant 42% reduction in risk of hospital utilization within 30 days of a positive COVID‐19 test when compared to the control group (HR = 0.578, p‐value .111, HR 95% CI [0.29, 1.13]).ConclusionsA nurse‐led remote monitoring and management program for COVID‐19 reduced the probability of 30‐day hospital utilization. Although the findings were not statistically significant, the program yielded practical significance by reducing hospital utilization, in‐person interaction, and the risk of infection for healthcare workers.

Cost and Utilization Impacts of a Medicaid Managed Care Organization's Behavioral Health Wraparound Program.

Wraparound programs that provide comprehensive evidence-based outpatient treatment, transportation, social services, and housing supports have shown promise for improving clinical behavioral health-related outcomes to reduce the need for institutionalized care; however, the majority of evidence is based on wraparound programs for children. This study examined the impact of a wraparound program for adult Medicaid managed care organization members with serious mental health or substance use disorders on health care costs and utilization. This retrospective observational study used 2013-2018 claims data collected from a large Medicaid managed care organization operating in multiple states. We used an intention-to-treat difference-in-difference study design to examine the association of the wraparound with costs and utilization. Adult Medicaid members with an emergency department (ED) or inpatient visit for a behavioral health condition (index visit) were eligible for the study. Outcomes included all-cause and behavioral health-related costs and utilization during follow-up after the index visit's admission date. Outcomes were calculated overall, as well as separately by inpatient, ED, and outpatient/wraparound settings. We found that during the first post-admission month, the wraparound program was associated with 27.6 percentage points (PP) and 27.2 PP reductions in the number of behavioral health-related inpatient nights and costs, respectively. However, during subsequent months (median follow-up ranging from 7 to 10months) there were no associations with per-member-per-month total all-cause or behavioral health-related costs. Nonetheless, the wraparound program was associated with 12.3 PP reduction in all-cause cost during the entire study period among a subset of members who were high cost at the baseline. Reduced hospital utilization and costs during the first month of wraparound services were fully counteracted by outpatient, housing, and other wraparound services costs during the following months. This indicates the importance of proper payment arrangements with value-based contracting or performance targets with wraparound services providers to align the objective of reducing inpatient use. Future wraparound programs may consider a more focused recruitment from high-cost members with complex care needs. However, our estimates were conservative given that it's from a single Medicaid managed care organization's perspective and some benefit from investing in addressing social needs may be realized in longer term (beyond our study period). States' Medicaid programs may consider the longer-term cost and broader, societal benefit of wraparound investment.

Interventions to Reduce Hospital and Emergency Department Utilization Among People With Alcohol and Substance Use Disorders: A Scoping Review.

Substance use disorders (SUDs), prevalent worldwide, are associated with significant morbidity and health care utilization. To identify interventions addressing hospital and emergency department utilization among people with substance use, to summarize findings for those seeking to implement such interventions, and to articulate gaps that can be addressed by future research. A scoping review of the literature. We searched PubMed, PsycInfo, and Google Scholar for any articles published from January 2010 to June 2020. The main search terms included the target population of adults with substance use or SUDs, the outcomes of hospital and emergency department utilization, and interventions aimed at improving these outcomes in the target population. Adults with substance use or SUDs, including alcohol use. Hospital and emergency department utilization. Our initial search identified 1807 titles, from which 44 articles were included in the review. Most interventions were implemented in the United States (n=35). Half focused on people using any substance (n=22) and a quarter on opioids (n=12). The tested approaches varied and included postdischarge services, medications, legislation, and counseling, among others. The majority of study designs were retrospective cohort studies (n=31). Overall, we found few studies assessing interventions to reduce health care utilization among people with SUDs. The studies that we did identify differed across multiple domains and included few randomized trials. Study heterogeneity limits our ability to compare interventions or to recommend one specific approach to reducing health care utilization among this high-risk population.

Palliative Care Teams Reduce Hospital Mortality and Utilization: Causal Evidence from a Quasi‐Experimental, Nationwide Evaluation in Ireland

Research ObjectiveTo evaluate the causal effect of palliative care consultation teams (PCCTs) on in‐hospital mortality and health care utilization in public hospitals in Ireland for the period 2005–2018 using a quasi‐experimental research design.Study Design Setting: Ireland is a country in north‐western Europe with a population of approximately 4.6million. The health system has both public and private provision, but the 40 acute public hospitals account for 95% &lt; of inpatient admissions and 90% &lt; of hospital deaths nationally. Population: All adults admitted to a public hospital with a primary diagnosis of advanced cancer, organ (heart, liver, kidney, lung) failure, or Alzheimer's disease. Analysis: We applied decomposed difference‐in‐differences (Goodman‐Bacon method) to exploit the implementation of PCCTs by different hospitals at different times across the study period. For each hospital we identified the year that a PCCT was founded, and so for each year allocated each hospital a treatment variable value of 1 (had a PCCT for the entirety of that year) or 0 (did not). The method then calculates a weighted average of all possible two‐group/two‐period difference‐in‐difference estimators in the data. We controlled for hospital size, type, location and socioeconomic catchment as additional predictors. Sources: We collected PCCT data by hand from each individual hospital service. Outcome data and other predictors were routinely collected administrative data from a national database.Population StudiedAll adults admitted to a public hospital with a primary diagnosis of advanced cancer, organ (heart, liver, kidney, lung) failure, or Alzheimer's disease.Principal FindingsWe had sufficient data for 34 hospitals (85% of sites, 90% &lt; relevant admissions to public hospitals in the study period). There were 600,306 eligible admissions in the data, with an overall mortality rate of 6% (N = 38,595) and a mean LOS of 10.0 days. Sixteen hospitals (47%) had a PCCT at the start of the study period and 34 hospitals (100%) had a PCCT at the end of the study period. Implementation of a PCCT was associated with a mean absolute reduction in in‐hospital mortality of 0.9% (95% CI: −1.6% to −0.2%), a proportional reduction of 10%. Implementation of a PCCT resulted in an absolute reduction in LOS of 0.86 days (95% CI: −1.3 days to −0.4 days), a proportional reduction of 8.6%. Secondary analysis of these data using validated unit costs for acute inpatient stays in Ireland suggests a mean estimated saving per admission of €1500 (~$1250) per admission.ConclusionsPCCTs improve the value of hospital care for people admitted with serious medical illness. These results were derived using quasi‐experimental methods, an important advance in a field where observational studies are at high risk of selection bias and high‐quality trials are rare. The magnitude of effect estimates is lower than reported by most previous studies. We consider the implications for future research.Implications for Policy or PracticePCCTs both reduce costs and improve outcomes for people admitted with serious illness. Services should be expanded to meet current and future needs. The optimal level of this expansion is unknown and requires further development of appropriate methods.Primary Funding SourceHealth Research Board (Ireland).

The cost of business restrictions during the COVID-19 pandemic

Background: In addition to reducing mortality and morbidity, COVID-19 therapies confer societal benefits by reducing the disease’s economic impact. Therapies that address COVID hospitalizations mitigate the need for government-imposed economic restrictions to reduce disease spread and hence the risk that hospitals become overwhelmed. We investigated the potential value of such therapies by estimating the cost of government restrictions imposed during late 2020, costs that COVID therapies might make less necessary. Methods: We combined high frequency consumer spending and initial unemployment claims data (outcomes), information about when state governments restricted business activities (explanatory variable of interest), and case incidence and mortality data (proxies for the potential confounding effect of pandemic severity on voluntary economic activity reductions). We developed linear mixed models that account for nesting within US state and correlation across observations close in time. Sensitivity analyses explored the impact of: (1) limiting attention to the 10 U.S. states that “mostly closed” at some point during late 2020; (2) excluding subsets of potential confounding variables; (3) altering our outcome variable definition (i.e., for designating a state as “mostly closed”); and (4) considering alternative model correlation structures. Results: Government-imposed restrictions reduced total consumer spending by 2% and spending on restaurants and accommodations by 5%. They increased weekly initial unemployment claims by 0.21% of the 2019 US workforce. We estimate that restrictions in the U.S. during late 2020 reduced consumer spending by $12 billion and increased initial weekly unemployment claims by 114,000. Sensitivity analyses indicated that our findings are robust. Conclusions: Assuming that late 2020 is representative of tendencies for the government to restrict economic activity in response to high hospital utilization, therapies reducing hospital utilization have the potential to confer substantial societal value. Recognizing societal benefits in health technology assessment will help allocate resources to address the most important risks society faces.

The Impact of Comorbidities on Calgary Hospital Utilization in Patients With Chronic Obstructive Pulmonary Disease and Heart Failure.

BackgroundChronic obstructive pulmonary disease (COPD) and heart failure (HF) are chronic conditions with high acute care utilization. Disease-specific order sets were developed for patients with COPD or HF in Calgary to reduce total days in hospital for this population of patients. However, many patients have comorbidities which may contribute to hospital utilization; thus, disease-specific order sets may not be an optimal solution to reduce overall acute care utilization.MethodsInpatient data on Calgary hospitalizations for COPD or HF between April 1, 2017 - March 31, 2019 and associated diagnoses were identified. Outcomes included total days in hospital and length of stay for COPD and HF patients stratified by number of comorbidities.ResultsTotal days in hospital increased with the number of comorbidities for both conditions. During the study period, 131 patients with COPD and no comorbidities had a median length of stay of three days (IQR: 3) compared to 3,911 COPD patients with one to five comorbidities with a median length of stay of seven days (IQR: 9). There were 47 patients with HF and no comorbidities with a median length of stay of four days (IQR: 5) compared to 6,273 HF patients with one to five comorbidities with a median length of stay of nine days (IQR: 12). Common comorbidities included hypertension, type 2 diabetes, and acute renal failure. COPD and HF are frequently comorbid. ConclusionsTotal days in hospital for patients with COPD or HF is positively correlated with the number of comorbidities. COPD or HF patients with between one to five comorbidities (compared to those with no comorbidities, and those with more than five comorbidities) represent the majority of total days in hospital, and the majority of patients. This highlights the importance of focusing on patients with comorbidities in efforts to reduce hospital utilization, and suggests that concurrent management of commonly occurring comorbidities for HF and COPD patients may be necessary to achieve this goal.

Neutralizing Monoclonal Antibody Treatment Reduces Hospitalization for Mild and Moderate Coronavirus Disease 2019 (COVID-19): A Real-World Experience.

BackgroundNeutralizing monoclonal antibody (NmAb) treatments have received emergency use authorization to treat patients with mild or moderate COVID-19 infection. To date, no real- world data about the efficacy of NmAb has been reported from clinical practice. We assessed the impact of NmAb treatment given in the outpatient clinical practice setting on hospital utilization.MethodsElectronic medical records were used to identify adult COVID-19 patients who received NmAbs [bamlanivimab (BAM) or casirivimab and imdevimab (REGN-COV2)] and historic COVID-19 controls. Post-index hospitalization rates were compared.Results707 confirmed COVID-19 patients received NmAb and 1709 historic COVID-19 controls were included; 553 (78%) received BAM, 154 (22%) received REGN-COV2. Patients receiving NmAb infusion had significantly lower hospitalization rate (5.8% vs. 11.4%, p<0.0001); a shorter length of stay if hospitalized (mean 5.2 days vs. 7.4 days, p=0.02), and fewer ED visits within 30 days post-index (8.1% vs 12.3%, p=0.003) than controls. Hospitalization-free survival was significantly longer in NmAb patients compared to controls (p<0.0001). There was a trend towards a lower hospitalization rate among patients who received NmAb within 2-4 days after symptom onset. In multivariate analysis, having received a NmAb transfusion was independently associated with a lower risk of hospitalization after adjustment for age, sex, race, BMI and referral source: adjusted hazard ratio (95% CI) = 0.54 (0.38 – 0.79), p=0.0012. Overall mortality was not different between the two groups.Conclusions and RelevanceNmAb treatment reduced hospital utilization especially when received within a few days of symptom onset. Further study is needed to validate these findings.

Practical alternative to hospitalization for emergency department patients (PATH): A feasibility study

We sought to determine the feasibility of the Practical Alternative to Hospitalization (PATH) program, an intervention that offers ED clinicians an outpatient care pathway for patients initially designated for inpatient admission or observation. We evaluated a novel care delivery model that was piloted at a tertiary academic medical center in December 2019. An advanced practice provider screened patients designated for inpatient admission or observation and identified eligible participants. Outpatient services were customized for each patient but primarily included care coordination and monitoring through telemedicine and home health services. The primary feasibility outcome was the proportion of eligible patients who were enrolled in the program, as well as patient outcomes after discharge including return ED visits and averted ED boarding time. A total of 199 patients were designated for inpatient admission or observation during PATH program hours. Of 52 eligible patients, 30 (58%) were enrolled. The mean participant age was 62.5 years (SD 17.5), and 25 (83%) had non-Hispanic Black race/ethnicity. The most common disease conditions were chest pain, heart failure, and hyperglycemia. 4 (13%) enrolled patients returned to an ED within 30 days. We estimate that ED boarding time was reduced by 8.2h (SD 8.1) per patient. Emergency physicians and patients were willing to use a novel service that provided an alternative disposition to hospitalization. alternative payment models that seek to reduce hospital utilization and cost may consider strengthening systems to monitor and coordinate care for patients after ED discharge.

The impact of Dual Eligible Special Need Plan regulations on healthcare utilization

BackgroundTo determine if requiring Dual Eligible Special Need Plans (D-SNPs) to receive approval from the National Committee of Quality Assurance and contract with state Medicaid agencies impacts healthcare utilization.MethodsWe use a Multiple Interrupted Time Series to examine the association of D-SNP regulations with dichotomized measures of emergency room (ER) and hospital utilization. Our treatment group is elderly D-SNP enrollees. Our comparison group is near-elderly (ages 60–64) beneficiaries enrolled in Medicaid Managed Care plans (N = 360,405). We use segmented regression models to estimate changes in the time-trend and slope of the outcomes associated with D-SNP regulations, during the post-implementation (2012–2015) period, relative to the pre-implementation (2010–2011) period. Models include a treatment-status indicator, a monthly time-trend, indicators and splines for the post-period and the interactions between these variables. We conduct the following sensitivity analyses: (1) Re-estimating models stratified by state (2) Estimating models including interactions of D-SNP implementation variables with comorbidity count to assess for differential D-SNP regulation effects across comorbidity level. (3) Re-estimating the models stratifying by race/ethnicity and (4) Including a transition period (2012–2013) in the model.ResultsWe do not find any statistically significant changes in ER or hospital utilization associated with D-SNP regulation implementation in the broad D-SNP population or among specific racial/ethnic groups; however, we do find a reduction in hospitalizations associated with D-SNP regulations in New Jersey (DD level = − 3.37%; p = 0.02)/(DD slope = − 0.23%; p = 0.01) and among individuals with higher, relative to lower levels of co-morbidity (DDD slope = − 0.06%; p = 0.01).ConclusionsThese findings suggest that the impact of D-SNP regulations varies by state. Additionally, D-SNP regulations may be particularly effective in reducing hospital utilization among beneficiaries with high levels of co-morbidity.

A Review of Peripheral Nerve Blocks for Cesarean Delivery Analgesia

(Reg Anesth Pain Med. 2020;45:52–62) Peripheral nerve blocks are used in nonobstetrical surgery as part of a multimodal analgesic strategy. These blocks have been associated with reduced opioid requirements, better quality of recovery, and reduced hospital utilization. Yet, peripheral nerve blocks are not routinely performed for cesarean delivery. This review article discussed several peripheral nerve block options for cesarean delivery, including lumbar sympathetic paravertebral (PVB), transversus abdominis plane (TAP), quadratus lumborum (QL), ilioinguinal-iliohypogastric (II-IH), continuous wound infiltration (CWI), and erector spinae plane blocks.

Remote Patient Monitoring Program for Hospital Discharged COVID-19 Patients.

We deployed a Remote Patient Monitoring (RPM) program to monitor patients with coronavirus disease 2019 (COVID-19) upon hospital discharge. We describe the patient characteristics, program characteristics, and clinical outcomes of patients in our RPM program. We enrolled COVID-19 patients being discharged home from the hospital. Enrolled patients had an app, and were provided with a pulse oximeter and thermometer. Patients self-reported symptoms, O2 saturation, and temperature daily. Abnormal symptoms or vital signs were flagged and assessed by a pool of nurses. Descriptive statistics were used to describe patient and program characteristics. A mixed-effects logistic regression model was used to determine the odds of a combined endpoint of emergency department (ED) or hospital readmission. A total of 295 patients were referred for RPM from five participating hospitals, and 225 patients were enrolled. A majority of enrolled patients (66%) completed the monitoring period without triggering an abnormal alert. Enrollment was associated with a decreased odds of ED or hospital readmission (adjusted odds ratio: 0.54; 95% confidence interval: 0.3-0.97; p = 0.039). Referral without enrollment was not associated with a reduced odds of ED or hospital readmission. RPM for COVID-19 provides a mechanism to monitor patients in their home environment and reduce hospital utilization. Our work suggests that RPM reduces readmissions for patients with COVID-19 and provides scalable remote monitoring capabilities upon hospital discharge. RPM for postdischarge patients with COVID-19 was associated with a decreased risk of readmission to the ED or hospital, and provided a scalable mechanism to monitor patients in their home environment.

A-01 Dementia Care Ecosystem: Health Care Utilization at Six Months

Abstract Objective This study implemented the University of California, San Francisco (UCSF) Care Ecosystem Program, a Persons with Dementia (PWD)- and Caregiver (CG)-centered model of dementia care designed to improve quality of life and reduce the cost of care associated with emergency department (ED) visits and hospitalizations. Method Community-dwelling PWD and CGs at a southern regional medical system who had a diagnosis of dementia and at least one hospitalization or ED visit in the previous 12 months were prospectively enrolled in a mixed method study. These dyads (N = 54) completed monthly visits for six months, including behavior management, financial and advanced care planning, caregiver well-being, and navigating community and healthcare resources. PWD were predominantly Caucasian (70.4%; 30% African American) and female (53.7%), with an average age of 80.26 (SD = 6.99). CGs were demographically similar, but younger [M(SD) = 66.18(12.89)]. Results ED utilization decreased by 41% (51 visits in 6 months prior to enrollment vs. 30 visits post enrollment); [pre-M(SD) = 0.94(1.57); post-M(SD) = 0.56(1.11); 95% Confidence Interval − 0.09—0.86; t = 1.64, p &amp;gt; .05; Cohen’s d = 0.28]. On a paired samples t-test, there was a small effect despite not reaching statistical significance. Hospitalizations decreased by 43% (30 in 6 months prior to enrollment, 17 post enrollment); [pre-M(SD) = 0.56(1.09); post-M(SD) = 0.31(0.77); 95% Confidence Interval − 0.03—0.51; t = 1.79, p &amp;gt; .05; Cohen’s d = .26]. Again, there was a small effect despite not reaching statistical significance. Conclusions Preliminary results suggested a trend toward reduced hospital utilization. Future analysis on cost savings and other benefits of this type of program will be crucial to sustainability.

Hospital markets in the United States, 2007–2017

BackgroundU.S. hospital markets have undergone consolidation in recent decades with the growth of large “health systems,” but little is known about the characteristics of systems, and whether certain geographic areas or service types (e.g. intensive care, obstetrics) have been differentially impacted by consolidation. MethodsUsing 2007–2017 American Hospital Association data, we characterized health systems and their growth, and determined how changes in hospital market structure have differentially affected specific service types and geographic areas. ResultsDespite a national trend of reduced hospital utilization, health systems grew larger during our study period. Hospital markets were already highly concentrated in 2007 and became even more concentrated between 2007 and 2017, across all service types that we measured. The least concentrated service was emergency department care, while intensive care and obstetrics were the most concentrated. As of 2017, 19.0% of markets – representing 11.2 million Americans – are served by only one hospital system. Concentrated markets are less populous, poorer areas and have lower physician supply than less concentrated markets. ConclusionsHospital markets were highly concentrated in 2007 and have since become more concentrated in the subsequent decade. Hospital consolidation is a nationwide phenomenon, and is occurring across hospital service types. ImplicationsAntitrust alone may be insufficient to address high and increasing hospital market power. Decreasing barriers to entry may allow for more competition.

Mobile Technology Care Coordination of Long-Term Services and Support: Cluster Randomized Clinical Trial.

The purpose of the study was to assess whether the effects of a mobile predictive intervention used by Service Coordinators (SCs) reduce hospital utilization in a Medicaid Long-Term Services and Supports (LTSS) population in Baltimore city during a 5-month intervention. SC participants (n = 11) were recruited to treatment or control groups. LTSS clients (n = 420) followed their SC randomization assignment. Utilization data were obtained from the Maryland Chesapeake Regional Information System for our Patients (CRISP) Health Information Exchange (HIE) system and linked to service coordination records. Study groups were similar in age, gender, race, and years receiving LTSS. SCs' satisfaction with use of the mobile tool was surveyed. SC perceptions were neutral (mean scores ranged from 2.3 to 3.3 on a 5-point scale). No significant differences between groups were observed for all utilization metrics. The mobile technology software system used in this study did not improve health care utilization for a LTSS population needing ongoing clinical and social services coordinated care.