Risk-adjusted Scores Research Articles

Quality of life outcomes for informal carers of long-term care service users in Austria, England and Finland

PurposeThe provision and funding of long-term care (LTC) for older people varies between European countries. Despite differences, there is limited information about the comparative performance of LTC systems in Europe. In this study, we compared quality of life (QoL) of informal carers of home care service users in Austria, England and Finland.MethodsInformal carers were surveyed in Austria, England and Finland. The study data (n = 835) contained information on social care-related quality of life (SCRQoL) associated with the ASCOT-Carer measure, and characteristics of carers and care recipients from each country. We applied risk-adjustment methods using a fractional regression model to produce risk-adjusted SCRQoL scores for the comparative analysis. In a sensitivity analysis, we applied multiple imputation to missing data to validate our findings.ResultsWe found that the mean values of the risk-adjusted SCRQoL of informal carers in England were 1.4–2.9% and 0.3–0.5% higher than in Finland and Austria, and the mean values of the risk-adjusted SCRQoL of carers in Austria were 0.8–2.7% higher than in Finland. Differences in the mean values of the country-specific risk-adjusted SCRQoL scores were small and statistically non-significant. English informal carers were less healthy and co-resided with care resipients more often than carers in Austria or Finland.ConclusionSmall differences between the risk-adjusted SCRQoL scores between Austria, England and Finland are consistent with the observation that the countries provide different types of support for informal carers. Our results help local and national decision-makers in these countries to benchmark their informal care support systems.

SmartCasaplus - risk-based geriatric health coaching for multimorbid insured persons

The geriatric coaching program Casaplus of Medical Contact AG offers health coaching for multimorbid geriatric patients since 2007. Since then, around 30,000 patients have benefited from individual coaching. The critical success factors for geriatric coaching are the risk-based identification of candidates with high and impactable escalation risk as well as the recruitment and coaching of participants by specifically trained specialists. Together with VIACTIV and DCC Risk Analytics, the smartCasaplus program has been improved to include AI-based models in the prediction of influenceable risks for identi-fication and risk-adjusted propensity scores matching during evaluation. Actual results of the VIACTIV program evaluation show a significant return on investment of 1.7 dur-ing the first 4 program years

Initial Investigation into the Key Differences for Achieving Patient-Reported Measure Outcome Goals in Concussion Rehabilitation

<h3>Research Objectives</h3> The purpose of this study was to examine differences in patient demographics, clinical, and organization characteristics between patients who achieved the FOTO-predicted Discharge Status Functional score in concussion rehabilitation. <h3>Design</h3> This retrospective study included all patients diagnosed with a concussion and admitted to an outpatient physical therapy network between September of 2021 to April 2022. Included data points consisted of sex, arrival rate, insurance provider, number of visits, and a functional outcome measure. <h3>Setting</h3> Commercial provider of physical therapy. <h3>Participants</h3> Participants with available data points who attended physical therapy (N=187) <h3>Interventions</h3> Outpatient physical therapy. <h3>Main Outcome Measures</h3> Patient reported outcomes were collected using Focus On Therapeutic Outcomes (FOTO), which is patient-self reported functional outcome measures that providers risk-adjusted scores. FOTO produces a "Discharge FS Score' which is a risk-adjusted predicated score the patient should achieve within the episode of care (Deutscher et al., 2018). <h3>Results</h3> Review of an outcome database identified 187 eligible participants with a mean age of 36.64 (SD = 17.33). Of these participants 78 (41.71%) were male,09 (58.29%) were female, 88 (47.06%) were commercial insurance, 18 (9.63%) were federal insurance, and 81 (43.32%) were classified as other. A majority of patients attended < 9 visits (n = 73; 39.04%) with a frequency of < 2 visits per week (n=137; 73.26%). There were no significant differences for any organization variables and FOTO scores. A majority of patients who successfully completed their course of care achieved the FOTO score (n=74; 77.89%; p < 0.001). In contrast, patients who were discharged secondary to a plateauing effect or insurance limitations were less likely to achieve the FOTO score (p < 0.001). <h3>Conclusions</h3> A majority of patients who attend physical therapy after a concussion successfully achieve patient-self reported functional outcomes. There were no significant differences in outcomes between sex, age, number of visits, frequency of visits, and number of rendering providers. Patients who were successfully discharged were more likely to achieve patient-reported functional outcomes compared to those discharged due to plateau or insurance limitations. <h3>Author(s) Disclosures</h3> None

Bank stock performance during the COVID-19 crisis: does efficiency explain why Islamic banks fared relatively better?

This paper evaluates the stock performance of Islamic banks relative to their conventional counterparts during the initial phase of the COVID-19 crisis (from December 31, 2019, to March 31, 2020). Using 426 banks from 48 countries, we find that stock returns of Islamic banks were about 10–13% higher than those of conventional banks after controlling for a host of the bank- and country-level variables. This study explains the Islamic banks’ superior crisis stock performance by exploring the potential role of pre-crisis bank efficiency. In a univariate analysis, we document higher non-parametric Data Envelopment Analysis (DEA) efficiency levels for Islamic banks than conventional banks in the year preceding the COVID-19 crisis. Our multivariate regressions show that the risk-adjusted DEA efficiency scores can explain crisis stock returns for Islamic banks but not conventional banks. The evidence is robust to alternative measures of stock returns, efficiency models, and other empirical strategies. Finally, we present insight on the importance of key bank characteristics in determining the stock returns of conventional banks during the crisis period.

Quality of life measurement in community-based aged care \u2013 understanding variation between clients and between care service providers

BackgroundMeasuring person-centred outcomes and using this information to improve service delivery is a challenge for many care providers. We aimed to identify predictors of QoL among older adults receiving community-based aged care services and examine variation across different community care service outlets.MethodsA retrospective sample of 1141 Australians aged ≥60 years receiving community-based care services from a large service provider within 19 service outlets. Clients’ QoL was captured using the ICEpop CAPability Index. QoL scores and predictors of QoL (i.e. sociodemographic, social participation and service use) were extracted from clients’ electronic records and examined using multivariable regression. Funnel plots were used to examine variation in risk-adjusted QoL scores across service outlets.ResultsMean age was 81.5 years (SD = 8) and 75.5% were women. Clients had a mean QoL score of 0.81 (range 0–1, SD = 0.15). After accounting for other factors, being older (p < 0.01), having lower-level care needs (p < 0.01), receiving services which met needs for assistance with activities of daily living (p < 0.01), and having higher levels of social participation (p < 0.001) were associated with higher QoL scores. Of the 19 service outlets, 21% (n = 4) had lower mean risk-adjusted QoL scores than expected (< 95% control limits) and 16% (n = 3) had higher mean scores than expected.ConclusionUsing QoL as an indicator to compare care quality may be feasible, with appropriate risk adjustment. Implementing QoL tools allows providers to measure and monitor their performance and service outcomes, as well as identify clients with poor quality of life who may need extra support.Trial registrationAustralian and New Zealand clinical trial registry number: ACTRN12617001212347. Registered 18/08/2017.

668 Utilizing Risk Score Assessment to Maximize Sleep Research Participant Safety During the COVID-19 Pandemic

IntroductionResearch study recruitment has been profoundly affected by the COVID-19 pandemic, demonstrated by significant delays or pauses. Various guidelines pertaining to in-person visits have applied to research. Some call for exclusion of participants that the CDC has labeled “at increased risk”.1 For obstructive sleep apnea (OSA) studies, these guidelines have caused a sharp decrease in the number of new participants. This decrease is due to high rates of OSA comorbidities including obesity and diabetes. New evidence-based risk scores have been developed using individual- and community-level factors. The use of more refined COVID-19 risk scores can help protect patient safety while allowing research to continue.MethodsThe risk score assessment used for this study (COVID-19 Mortality Risk Calculator; Johns Hopkins University, Baltimore, MD)2 is evidence-based and uses a set of risk factors and community-level pandemic dynamics in the state of residence.3,4 It was compared to the list of CDC medical conditions that are considered to put an individual “at increased risk.” Both measures were calculated retrospectively on current participants to determine how many could safely attend in-person visits based on each risk assessment method.ResultsSample characteristics of the 110 participants were: mean age: 49.5±13.7(24–76); mean BMI: 32.3±5.3(20.9–46.1); mean AHI: 24.3±21.4(5.1–110). Mortality Risk Calculator scores were: 91(82.7%) close to/lower than average [Level 1]; 12(10.9%) moderately elevated; 6(5.5%) substantially elevated; 1(0.9%) high; and 0(0%) very high [Level 5]. Using CDC guidance, 63 (57.3%) had at least one at-risk condition and 47 (42.7%) had 0. Using only Level 1 of the Risk Calculator would allow an additional 28 (25%) participants to attend in-person visits; using Levels 1 and 2 would allow an additional 40 (37%) participants.ConclusionPolicies based on CDC at-risk conditions resulted in higher levels of participant exclusion in research during the COVID-19 pandemic than use of an evidence-based Mortality Risk Calculator. This analysis shows that researchers can use risk-adjusted scores to make informed decisions about study participation that balances both participant safety and research study progress.Support (if any)This project was supported in part by Department of Veteran Affairs VA HSRD IIR 16–277, VA RRD D2651-R, and VA San Diego Healthcare System Research Service.

L’index de comorbidité ajusté au risque de Charlson comme nouveau facteur prédictif de la mortalité à un an des patients chinois âgés après chirurgie de fracture du col du fémur

IntroductionRecently, many studies used the Charlson comorbidity index (CCI) to predict the postoperative mortality rate of elderly patients with hip fractures. However, as a predictor, CCI did not include other preoperative risk factors, resulting in decreasing its predictive value. Therefore, we performed a study to focus on two questions as follows: (1) What is the one-year mortality rate of elderly Chinese patients who underwent surgery for hip fracture? (2) Could risk-adjusted CCI act as a new predictor to predict the one-year mortality rate? HypothesisThe risk-adjusted CCI could exhibit a good predictive value for one-year mortality of elderly Chinese patients who underwent surgery for hip fracture. Material and methodsThis retrospective observational cohort study is based on data collected from July 2012 to April 2016. Patients aged 65 years and older who underwent hip fracture surgery were included. The clinical patient data were obtained, including gender, age, BMI, types of fracture, smoking, injury side, time from injury to surgery, and CCI. Stepwise multiple logistic regression analysis was used to identify risk factors contributed to the occurrence of postoperative death at one-year follow-up. The risk-adjusted CCI scores of patients were calculated by the formula based on the coefficient regression and independent variables. Receiver operating characteristic (ROC) curve analysis was used for determining the diagnostic value of different factors. ResultsA total of 445 elderly patients who underwent surgery for hip fracture, including 171 males and 274 females, were enrolled in the study cohort. The mean CCI scores of all enrolled patients were 1.20±1.62. Sixty-four patients died within one year, and the one-year mortality rate was 14.38 %. The multivariate logistic regression analysis reported that age, time from injury to surgery, and CCI were associated with death after surgical treatment within one year. The risk-adjusted CCI scores of patients=0.099×age (years)+0.355×time from injury to surgery (days)+0.434×CCI scores. The predictive value of the risk-adjusted CCI was highest among these risk predictors, whose AUC value was 0.816. DiscussionThe risk-adjusted Charlson comorbidity index could be used as a guide to predict one-year mortality rate in elderly Chinese patients after the surgical treatment of hip fractures. Level of evidenceIII; cohort comparative study.

The risk-adjusted Charlson comorbidity index as a new predictor of one-year mortality rate in elderly Chinese patients who underwent hip fracture surgery

IntroductionRecently, many studies used the Charlson comorbidity index (CCI) to predict the postoperative mortality rate of elderly patients with hip fractures. However, as a predictor, CCI did not include other preoperative risk factors, resulting in decreasing its predictive value. Therefore, we performed a study to focus on two questions as follows: (1) What is the one-year mortality rate of elderly Chinese patients who underwent surgery for hip fracture? (2) Could risk-adjusted CCI act as a new predictor to predict the one-year mortality rate? HypothesisThe risk-adjusted CCI could exhibit a good predictive value for one-year mortality of elderly Chinese patients who underwent surgery for hip fracture. Material and methodsThis retrospective observational cohort study is based on data collected from July 2012 to April 2016. Patients aged 65 years and older who underwent hip fracture surgery were included. The clinical patient data were obtained, including gender, age, BMI, types of fracture, smoking, injury side, time from injury to surgery, and CCI. Stepwise, multiple logistic regression analysis was used to identify risk factors contributed to the occurrence of postoperative death at one-year follow-up. The risk-adjusted CCI scores of patients were calculated by the formula based on the coefficient regression and independent variables. Receiver operating characteristic (ROC) curve analysis was used for determining the diagnostic value of different factors. ResultsA total of 445 elderly patients who underwent surgery for hip fracture, including 171 males and 274 females, were enrolled in the study cohort. The mean CCI scores of all enrolled patients were 1.20±1.62. Sixty-four patients died within one year, and the one-year mortality rate was 14.38%. The multivariate logistic regression analysis reported that age, time from injury to surgery, and CCI were associated with death after surgical treatment within one year. The risk-adjusted CCI scores of patients=0.099×age (years)+0.355×time from injury to surgery (days)+0.434×CCI scores. The predictive value of the risk-adjusted CCI was highest among these risk predictors, whose AUC value was 0.816. DiscussionThe risk-adjusted Charlson comorbidity index could be used as a guide to predict one-year mortality rate in elderly Chinese patients after the surgical treatment of hip fractures. Level of evidenceIII; cohort comparative study.

Development and Evaluation of a Risk-Adjusted Measure of Intraoperative Hypotension in Patients Having Nonemergent, Noncardiac Surgery.

BACKGROUND:Intraoperative hypotension is common and associated with organ injury and death, although randomized data showing a causal relationship remain sparse. A risk-adjusted measure of intraoperative hypotension may therefore contribute to quality improvement efforts.METHODS:The measure we developed defines hypotension as a mean arterial pressure <65 mm Hg sustained for at least 15 cumulative minutes. Comparisons are based on whether clinicians have more or fewer cases of hypotension than expected over 12 months, given their patient mix. The measure was developed and evaluated with data from 225,389 surgeries in 5 hospitals. We assessed discrimination and calibration of the risk adjustment model, then calculated the distribution of clinician-level measure scores, and finally estimated the signal-to-noise reliability and predictive validity of the measure.RESULTS:The risk adjustment model showed acceptable calibration and discrimination (area under the curve was 0.72 and 0.73 in different validation samples). Clinician-level, risk-adjusted scores varied widely, and 36% of clinicians had significantly more cases of intraoperative hypotension than predicted. Clinician-level score distributions differed across hospitals, indicating substantial hospital-level variation. The mean signal-to-noise reliability estimate was 0.87 among all clinicians and 0.94 among clinicians with >30 cases during the 12-month measurement period. Kidney injury and in-hospital mortality were most common in patients whose anesthesia providers had worse scores. However, a sensitivity analysis in 1 hospital showed that score distributions differed markedly between anesthesiology fellows and attending anesthesiologists or certified registered nurse anesthetists; score distributions also varied as a function of the fraction of cases that were inpatients.CONCLUSIONS:Intraoperative hypotension was common and was associated with acute kidney injury and in-hospital mortality. There were substantial variations in clinician-level scores, and the measure score distribution suggests that there may be opportunity to reduce hypotension which may improve patient safety and outcomes. However, sensitivity analyses suggest that some portion of the variation results from limitations of risk adjustment. Future versions of the measure should risk adjust for important patient and procedural factors including comorbidities and surgical complexity, although this will require more consistent structured data capture in anesthesia information management systems. Including structured data on additional risk factors may improve hypotension risk prediction which is integral to the measure’s validity.

PNS111 HEALTH PLAN PERFORMANCE ON HIGH-RISK MEDICATION USE AMONG MEDICARE PART D BENEFICIARIES: IMPACT OF RISK ADJUSTMENT

Current Medicare health plan performance measures do not consider variations of patient characteristics within health plans, potentially leading to incorrect performance evaluations. This study examined the relationship between patient characteristics and high-risk medication (HRM) use and the impact of risk adjustment on HRM use measures among Medicare Advantage Prescription Drug Plan (MA-PD) and stand-alone Prescription Drug Plan (PDP) beneficiaries. This retrospective cross-sectional study used a 5% national sample of 2013 Medicare claims. Two groups of beneficiaries aged ≥65 years, continuously enrolled in MA-PD or PDP, and with ≥2 prescriptions for the same HRM (defined by Pharmacy Quality Alliance) were identified. First, we calculated unadjusted performance scores as a proportion of HRM users in each health plan. Second, we identified HRM use risk factors using multivariable logistic regression models for MA-PD and PDP. Third, we developed risk-adjustment scores using generalized linear mixed models to adjust for identified risk factors in specific plans within MA-PDs and PDPs. Agreement between unadjusted and adjusted scores was evaluated using Cohen’s kappa to demonstrate the effect of risk adjustment. This study included 520,019 MA-PD and 881,264 PDP beneficiaries (mean age=74.7±7.3 versus 75.6±7.8 years; females=61% versus 64%; white=81.7% versus 85.5%) enrolled in 474 MA-PD and 60 PDP contracts. In adjusted analyses, HRM users in MA-PDs were more likely to be younger (OR=0.981, 95%CI=0.980-0.983); women (OR=1.545, 95%CI=1.514-1.576); eligible for low-income subsidy (OR=1.086, 95%CI=1.057-1.115); disabled (OR=1.380, 95%CI=1.342-1.420); seeing multiple prescribers (OR=1.076, 95%CI=1.072-1.081); using multiple pharmacies (OR=1.092, 95%CI=1.083-1.102); and higher average modified RxRisk-V index (OR=1.176, 95%CI=1.171-1.181) than non-HRM users. PDP results were similar. Unadjusted scores had low levels of agreement (Cohen’s kappa <0.7) with risk-adjusted scores. This study suggests risk adjustment influences health plan performance evaluation. Thus, risk adjustment of HRM performance is recommended to ensure health plans are not penalized due to their beneficiaries’ characteristics.

Impact of intellectual capital on bank efficiency in emerging markets: evidence from Ghana

Various researchers have examined the relationship between intellectual capital (IC) and performance of banks. Yet, only few studies have examined the nexus between IC and bank efficiency especially in Africa. Using the VAIC™ model of Pulic (2000) [and its additive components human capital efficiency (HCE), structural capital efficiency (SCE) and capital employed efficiency (CEE)] to measure IC and data envelopment analysis to estimate efficiency scores, the current study used Ghanaian data of 32 banks from 2000 to 2015 to examine the nexus. The study found that risk-adjusted efficiency scores are higher than non-risk adjusted scores. There is evidence suggesting that IC instigates efficiency in banks. This is borne largely from HCE suggesting the prevalence of the human capital theory. The results of the impact of SCE and CEE are insignificant except for the significant positive impact of CEE on profit efficiency. Stock exchange listing increases efficiency scores especially risk-adjusted efficiency. Other exogenous variables such as size, leverage and concentration were controlled for with the results discussed into detail. The results have implications for bank regulation, bank management and future research.

Partnering for enhanced digital surveillance of influenza-like disease and the effect of antivirals and vaccines (PEDSIDEA).

BackgroundStandardised clinical outcome measures are urgently needed for the surveillance of influenza and influenza‐like illness (ILI) based on individual patient data (IPD).ObjectivesWe report a multicentre prospective cohort using a predefined disease severity score in routine care.Patients/MethodsThe Vienna Vaccine Safety initiative (ViVI) Disease Severity Score (“ViVI Score”) was made available as an android‐based mobile application to three paediatric hospitals in Berlin and Athens between 2013 and 2016. Healthcare professionals assessed ILI patients at the point of care including severity, risk factors and use of antibiotics/antivirals/vaccines. RT‐PCR for influenza A/B viruses was performed at the Hellenic Pasteur Institute and the Robert Koch Institute. PCR testing was blinded to severity scoring and vice versa.ResultsA total of 1615 children aged 0‐5 years (54.4% males) were assessed at the three sites. The mean age was 1.7 years (SD 1.5; range 0‐5.9). The success rate (completion of the scoring without disruption to the ER workflow) was 100%. ViVI Disease Severity Scores ranged from 0 to 35 (mean 13.72). Disease severity in the Berlin Cohort was slightly higher (mean 15.26) compared to the Athens Cohorts (mean 10.86 and 11.13). The administration of antibiotics was most prevalent in the Berlin Cohort, with 41.2% on antibiotics (predominantly cefuroxime) as opposed to only 0.5% on neuraminidase inhibitors. Overall, Risk‐adjusted ViVI Scores were significantly linked to the prescription of both, antibiotics and antivirals.ConclusionsThe Risk‐adjusted ViVI Score enables a precision medicine approach to managing ILI in multicentre settings. Using mobile applications, severity data will be obtained in real time with important implications for the evaluation of antiviral/vaccine use.

Comparison of Surgeon Performance of Rotator Cuff Repair: Risk Adjustment Toward a More Accurate Performance Measure.

Movement toward a value-based health-care system necessitates the development of performance measures to compare physicians, hospitals, and health-care systems. Patient-reported outcomes (PROs) are a potential metric. However, valid use of PROs hinges on the ability to risk-adjust for baseline patient differences across a surgeon's panel of patients. The purpose of this study was to propose an approach for baseline risk adjustment and evaluate the importance of risk adjustment when comparing surgeons' performance of rotator cuff repair. Patients (n = 995) treated with arthroscopic rotator cuff repair by 34 surgeons from 2010 to 2017 were identified from a large sports medicine clinical data registry. A linear regression model was used to adjust for baseline PROs, patient demographics, and clinical characteristics to predict American Shoulder and Elbow Surgeons (ASES) change scores for each surgeon. A risk-adjusted performance measure was calculated as the difference between the average unadjusted ASES change scores and the risk-adjusted predicted ASES change scores across all patients treated by a surgeon. The differences between unadjusted and risk-adjusted performance scores varied widely across surgeons (range, -13.8 to 10.3 ASES points). Use of the risk-adjusted performance scores resulted in a dramatic change in the relative ranking of surgeons, compared with the ranking based on the observed ASES change scores, with 31 of the 34 surgeons' rank changing following risk adjustment. On average, the observed ASES scores improved from 49.5 ± 17.5 at baseline to 78.0 ± 22.5 at 6 months across all surgeons. In the risk-adjustment model (R = 0.44), male sex, Workers' Compensation status, higher scores on the Veterans RAND 12-item Health Survey (VR-12), lower baseline ASES scores, fair and poor tendon quality, and night pain all had a significant effect on the predicted ASES change scores (p < 0.05). Our results show wide variation of nearly 25 points in the risk-adjusted 6-month ASES performance difference from the highest to the lowest-performing surgeons. Additionally, 91% of surgeons' rank changed following risk adjustment. This suggests that performance measurement that does not account for baseline patient characteristics would likely result in incorrect conclusions about a surgeon's relative performance based on PROs. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Order of operations in using expanded measurement to promote treatment quality improvement.

Order of operations in using expanded measurement to promote treatment quality improvement.

Reconsidering the Affordable Care Act's Restrictions on Physician-Owned Hospitals: Analysis of CMS Data on Total Hip and Knee Arthroplasty.

Concerns about financial incentives and increased costs prompted legislation limiting the expansion of physician-owned hospitals in 2010. Supporters of physician-owned hospitals argue that they improve the value of care by improving quality and reducing costs. The purpose of the present study was to determine whether physician-owned and non-physician-owned hospitals differ in terms of costs, outcomes, and patient satisfaction in the setting of total hip arthroplasty (THA) and total knee arthroplasty (TKA). With use of the U.S. Centers for Medicare & Medicaid Services (CMS) Inpatient Charge Data, we identified 45 physician-owned and 2,657 non-physician-owned hospitals that performed ≥11 primary TKA and THA procedures in 2014. Cost data, patient-satisfaction scores, and risk-adjusted complication and 30-day readmission scores for knee and hip arthroplasty patients were obtained from the multiyear CMS Hospital Compare database. Physician-owned hospitals received lower mean Medicare payments than did non-physician-owned hospitals for THA and TKA procedures ($11,106 compared with $12,699; p = 0.002). While the 30-day readmission score did not differ significantly between the 2 types of hospitals (4.48 compared with 4.62 for physician-owned and non-physician-owned, respectively; p = 0.104), physician-owned hospitals had a lower risk-adjusted complication score (2.83 compared with 3.04; p = 0.015). Physician-owned hospitals outperformed non-physician-owned hospitals in all patient-satisfaction categories, including mean linear scores for recommending the hospital (93.9 compared with 87.9; p < 0.001) and overall hospital rating (93.4 compared with 88.4; p < 0.001). When controlling for hospital demographic variables, status as a non-physician-owned hospital was an independent risk factor for being in the upper quartile of all inpatient payments for Medicare Severity-Diagnosis Related Group (MS-DRG) 470 (odds ratio, 3.317; 95% confidence interval, 1.174 to 9.371; p = 0.024), which may be because of a difference in CMS payment methodology. Our findings suggest that physician-owned hospitals are associated with lower mean Medicare costs, fewer complications, and higher patient satisfaction following THA and TKA than non-physician-owned hospitals. Policymakers should consider these data when debating the current moratorium on physician-owned hospital expansion. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improving Value in Total Hip and Knee Arthroplasty: The Role of High Volume Hospitals

BackgroundRecent healthcare reform efforts have focused on improving the quality of total joint replacement care while reducing overall costs. The purpose of this study is to determine if higher volume centers have lower costs and better outcomes than lower volume hospitals. MethodsWe queried the Centers for Medicare and Medicaid Services (CMS) Inpatient Charge Data and identified 2702 hospitals that performed a total of 458,259 primary arthroplasty procedures in 2014. Centers were defined as low (performing <100 total joint arthroplasty [TJA] per year) or high volume and mean total hospital-specific charges and inpatient payments were obtained. Patient satisfaction scores as well 30-day risk-adjusted complication and readmission scores were obtained from the multiyear CMS Hospital Compare database. ResultsOf all the hospitals, 1263 (47%) hospitals were classified as low volume and performed 60,895 (12%) TJA cases. Higher volume hospitals had lower mean total hospital-specific charges ($56,323 vs $60,950, P < .001) and mean Medicare inpatient payments ($12,131 vs $13,289, P < .001). Higher volume facilities had a lower complication score (2.96 vs 3.16, P = .015), and a better CMS hospital star rating (3.14 vs 2.89, P < .001). When controlling for hospital geographic and demographic factors, lower volume hospitals are more likely to be in the upper quartile of inpatient Medicare costs (odds ratio 2.127, 95% confidence interval 1.726-2.621, P < .001). ConclusionHospitals that perform <100 TJA cases per year may benefit from adopting the practices of higher volume centers in order to improve quality and reduce costs.

Total and free cortisol responses and their relation to outcomes after cardiopulmonary bypass in infants

BackgroundHypothalamic-pituitary-adrenal (HPA) axis dysfunction may be partially responsible for the hemodynamic instability experienced by infants after cardiopulmonary bypass (CPB). We report the full spectrum of the HPA response surrounding CPB for infant congenital cardiac surgery. MethodsWe enrolled 84 infants who received 1 mg/kg of dexamethasone before initiation of CPB. Total cortisol (TC), free cortisol (FC), adrenocorticotropic hormone (ACTH), and corticosteroid-binding globulin (CBG) were measured at 3 time points: immediately before CPB (TP1), on intensive care unit arrival (TP2), and at 24 hours after surgery (TP3). A 1-μg ACTH stimulation test was performed at each time point to evaluate adrenal responsiveness. ResultsSixty-eight infants completed all study procedures. Levels of TC, FC, CBG, and ACTH decreased significantly between the preoperative and 24-hour postoperative measurements. There were no significant associations between preoperative FC responses and clinical outcomes after adjusting for weight and Risk-Adjusted Scores for Congenital Heart Surgery. Infants with subnormal TC responses to ACTH stimulation (<9 μg/dL) at TP2 had greater fluid requirements (P < .001) and greater chest tube output (P < .001) during the first 24 hours, as well as longer length of stay (LOS) (P = .007). Except for LOS, these differences persisted for infants with subnormal stimulation tests at TP3. ConclusionsWe observed a significant decline in all aspects of the HPA axis throughout the first 24 hours after infant CPB. TC and FC levels were not associated with clinical outcomes. Subnormal (Δ <9 μg/dL) TC response to cosyntropin stimulation during the postoperative period was associated with increased fluid resuscitation and greater LOS.

Do Hospital-Acquired Condition Scores Correlate With Patients' Perspectives of Care?

Beginning in fiscal year 2015, the federal Hospital-Acquired Condition (HAC) Reduction Program requires the Centers for Medicare & Medicaid Services to reduce payments by 1% for hospitals in the top quartile of risk-adjusted national HAC scores. The HAC penalty underscores the need for hospitals to become increasingly quality- and safety-focused, which could negatively affect their performance on patient satisfaction with care, another key performance metric tied to reimbursement. Using publicly available data through the Centers for Medicare & Medicaid Services Hospital Compare program, we assessed the correlation between preliminary HAC scores and patients' perspectives of care, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Higher quality of care (lower HAC score) was modestly associated with a better patient experience (r = -0.090, P < .001). Additional research is needed to ensure that national policy efforts are not working at cross purposes and there need not be a trade-off between delivering high quality of care and patient satisfaction.

Measuring pharmacy performance in the area of medication adherence: addressing the issue of risk adjustment.

Pharmacies and pharmacists play an important role in the health care system, improving health outcomes and enhancing quality through better pharmaceutical care. Yet, little information is available to accurately evaluate pharmacy store quality and thereby encourage quality improvement at the pharmacy store level. To (a) assess pharmacy performance in the area of medication adherence and (b) examine the impact of risk adjustment of performance scores on pharmacy rankings. We used proportion of days covered (PDC) to compute pharmacy performance scores using the 2007 Mississippi Medicare administrative claims dataset. We calculated unadjusted and adjusted quality scores for 685 pharmacies serving 137,497 eligible Medicare beneficiaries. Risk-adjusted quality scores were computed using a hierarchical logistic regression model (Method 1) and the shrinkage estimators of the model (Method 2). Patient demographics, income subsidy status, and comorbidity burden were used as variables for risk adjustment. Unadjusted scores showed low levels of agreement (Cohen's kappa less than 0.45) with risk-adjusted scores in identifying statistical outliers based on 95% CIs. Unadjusted scores also failed to identify 39%-43% of the top 20% and bottom 20% of pharmacies and displayed moderate agreement (0.4 less than kappa less than 0.5) with risk-adjusted scores. Pharmacy classifications based on risk-adjusted scores obtained from different statistical methods showed high levels of agreement (0.79 less than kappa less than 0.98). In the risk-adjustment methods presented here, we account for many patient characteristics previously reported to be associated with medication adherence and available in our dataset. Risk-adjusted scores produced more robust indicators of pharmacy quality than unadjusted scores. Depending on the availability of important variables in the source data, the use of risk-adjusted quality indicators may lead to better evaluation of pharmacy quality and should be considered when providing public reports on pharmacy quality.

Baby-MONITOR: a composite indicator of NICU quality.

NICUs vary in the quality of care delivered to very low birth weight (VLBW) infants. NICU performance on 1 measure of quality only modestly predicts performance on others. Composite measurement of quality of care delivery may provide a more comprehensive assessment of quality. The objective of our study was to develop a robust composite indicator of quality of NICU care provided to VLBW infants that accurately discriminates performance among NICUs. We developed a composite indicator, Baby-MONITOR, based on 9 measures of quality chosen by a panel of experts. Measures were standardized, equally weighted, and averaged. We used the California Perinatal Quality Care Collaborative database to perform across-sectional analysis of care given to VLBW infants between 2004 and 2010. Performance on the Baby-MONITOR is not an absolute marker of quality but indicates overall performance relative to that of the other NICUs. We used sensitivity analyses to assess the robustness of the composite indicator, by varying assumptions and methods. Our sample included 9023 VLBW infants in 22 California regional NICUs. We found significant variations within and between NICUs on measured components of the Baby-MONITOR. Risk-adjusted composite scores discriminated performance among this sample of NICUs. Sensitivity analysis that included different approaches to normalization, weighting, and aggregation of individual measures showed the Baby-MONITOR to be robust (r = 0.89-0.99). The Baby-MONITOR may be a useful tool to comprehensively assess the quality of care delivered by NICUs.