Short-term Acute Care Hospitals Research Articles

Organism-specific Trends in Carbapenem-resistant Enterobacterales Infections in a Cohort of Hospitalized Patients, 2012–2022

Background: Carbapenem-resistant Enterobacterales (CRE) infections are an urgent public health threat. An estimated 12,700 CRE (including E. coli, Klebsiella spp., and Enterobacter spp.) infections occurred in the United States in 2020. While the estimated incidence of CRE infections has been relatively stable between 2012 and 2020, organism-specific trends, including those for organisms not typically included in CRE surveillance definitions, have not been described. We estimated the annual rate of carbapenem-resistant Enterobacterales infections, disaggregated by organism, from 2012 to 2022. Methods: Data on inpatient hospitalizations from a dynamic cohort of short-term acute care hospitals reporting microbiology data between 2012 and 2022 were obtained from the PINC AI Database and the BD Insights Research Database. We included patients with clinical isolates of E. coli, Enterobacter spp., Klebsiella spp., Citrobacter spp., Serratia marcescens, Proteus mirabilis, and Morganella spp. and sufficient susceptibility results to identify carbapenem resistance. We limited our analysis to incident isolates, defined as a patient’s first isolate of a given organism and carbapenem resistance phenotype in a 14-day period. We calculated the annual rate of carbapenem-resistant infections per 10,000 hospitalizations for each organism. Results: There were 3,018,792 incident isolates from 55.8 million hospitalizations included in the analysis. Overall, 31,226 incident carbapenem-resistant isolates were identified. The rate of carbapenem-resistant infections varied by organism and over time (Table 1). The rate of carbapenem-resistant Klebsiella spp. infections appeared to decline from 3.94 in 2012 to 2.44 infections per 10,000 hospitalizations in 2022. The rate of carbapenem-resistant Enterobacter spp. infections appeared to increase from 1.05 in 2012 to 1.44 infections per 10,000 hospitalizations in 2022. The rate of carbapenem-resistant E. coli infections also appeared to increase, from 0.61 in 2012 to 0.85 infections per 10,000 hospitalizations in 2022. Rates of carbapenem-resistant Proteus mirabilis, Morganella spp., Citrobacter spp., or Serratia marcescens infections were similar in 2022 compared to 2012. Conclusions: Disaggregating data by organism revealed heterogeneous trends, with apparent increases in rates of carbapenem-resistant Enterobacter spp. and E. coli infections and apparent decreases in rates of carbapenem-resistant Klebsiella spp. infections. Organism-specific CRE analyses may provide additional insight into CRE epidemiology.

An Exploratory Analysis of the Association between Healthcare Associated Infections & Hospital Financial Performance.

Purpose: Healthcare-associated infections (HAIs) place a significant financial burden on United States hospitals. HAI treatments extend hospital lengths of stay and increase hospital operational costs while significantly reducing hospital profit margins. Given these challenges, the research aim of this study was to explore the association between HAIs and hospital financial performance. A better understanding of this relationship can assist hospital leaders in optimizing the use of scarce financial resources to reduce HAI prevalence. Methods: Data for calendar year 2022 for active short-term acute care hospitals (n = 1454) in the US were analyzed using multiple linear regression analysis. We explored two derived dependent variables, operating expense per staffed bed and operating expense per discharge. The independent variables included four healthcare-associated infection rates: methicillin-resistant Staphylococcus aureus (MRSA) infection rate, Clostridium difficile (C. diff) infection rate, Catheter-Associated Urinary Tract Infection (CAUTI) rate, and Central Line Associated Blood Stream Infections (CLABSI). Appropriate organizational and market-level variables that may independently influence hospital financial performance were included as control variables. Results: The results revealed that C. diff (β: 0.037, p < 0.05) and CAUTI (β: 0.031, p < 0.05) rates were positively associated with an increase in operating expense per staffed bed, while increases in MRSA (β: 0.042, p < 0.001), C. diff (β: 0.062, p < 0.001), and CAUTI rates (β: 0.039, p < 0.001) were correlated with increased operating expenses per discharge. Conclusions: This study demonstrates that specific HAIs may be associated with increased hospital expenses. Proactively targeting these infections through tailored interventions may lead to reduced hospital costs, improved financial performance, and economic stability.

Postacute Care for Medicare Advantage Enrollees Who Switched to Traditional Medicare Compared With Those Who Remained in Medicare Advantage

Medicare Advantage (MA) plans receive capitated per enrollee payments that create financial incentives to provide care more efficiently than traditional Medicare (TM); however, incentives could be associated with MA plans reducing use of beneficial services. Postacute care can improve functional status, but it is costly, and thus may be provided differently to Medicare beneficiaries by MA plans compared with TM. To estimate the association of MA compared with TM enrollment with postacute care use and postdischarge outcomes. This was a cohort study using Medicare data on 4613 hospitalizations among retired Ohio state employees and 2 comparison groups in 2015 and 2016. The study investigated the association of a policy change with use of postacute care and outcomes. The policy changed state retiree health benefits in Ohio from a mandatory MA plan to subsidies for either supplemental TM coverage or an MA plan. After policy implementation, approximately 75% of retired Ohio state employees switched to TM. Hospitalizations for 3 high-volume conditions that usually require postacute rehabilitation were assessed. Data from the Medicare Provider Analysis and Review files were used to identify all hospitalizations in short-term acute care hospitals. Difference-in-difference regressions were used to estimate changes for retired Ohio state employees compared with other 2015 MA enrollees in Ohio and with Kentucky public retirees who were continuously offered a mandatory MA plan. Data analyses were performed from September 1, 2019, to November 30, 2023. Enrollment in Ohio state retiree health benefits in 2015, after which most members shifted to TM. Received care in an inpatient rehabilitation facility, skilled nursing facility, or home health, or any postacute care; the occurrence of any hospital readmission; the number of days in the community during the 30 days after hospital discharge; and mortality. The study sample included 2373 hospitalizations for Ohio public retirees, 1651 hospitalizations for other Humana MA enrollees in Ohio, and 589 hospitalizations for public retirees in Kentucky. After the 2016 policy implementation, the percentage of hospitalizations covered by MA decreased by 70.1 (95% CI, -74.2 to -65.9) percentage points (pp), inpatient rehabilitation facility admissions increased by 9.7 (95% CI, 4.7 to 14.7) pp, use of only home health or skilled nursing facility care fell by 8.6 (95% CI, -14.6 to -2.6) pp, and days in the community fell by 1.6 (95% CI, -2.9 to -0.3) days for Ohio public retirees compared with other Humana MA enrollees in Ohio. There was no change in 30-day mortality or hospital readmissions; similar results were found by comparisons using Kentucky public retirees as a control group. The findings of this cohort study indicate that after a change in retiree health benefits, most Ohio public retirees shifted from MA to TM and received more intensive postacute care with no significant change in measured short-term postdischarge outcomes. Future work should consider additional measures of postacute functional status over a longer follow-up period.

Agency Staffing and Hospital Financial Performance: Insights and Implications.

Staffing is critical to hospital performance. However, in recent years, hospitals have struggled with severe staffing shortages, forcing them to rely on expensive agency staff to meet urgent patient care needs. This substitution of agency staff for permanent employees has raised concerns over its potential impact on financial stability. This study investigated the association of agency labor with hospital financial performance. Utilizing tenets from agency theory and transaction cost theory, data for the calendar year 2022 for active short-term acute care hospitals (n=2771) in the United States were analyzed using multivariable linear regression analysis. Hospital financial performance was assessed using three variables: net patient revenue, operating revenue per bed, and operating expense per bed. The independent variable was agency labor cost, representing the total expenditure on agency labor. Additionally, organizational and market-level control variables that may independently affect hospital financial performance were included. Our regression findings indicated that agency labor cost was significantly associated with all three dependent variables: net patient revenue (β = 0.224, p < 0.001), operating revenue per bed (β = 0.042, p < 0.001), and operating expense per bed (β = 0.032, p < 0.001). The results indicated that increased agency labor was associated with higher revenues, but it also corresponded with increased expenses. Therefore, hospitals should strategically use agency staffing to meet immediate operational needs while remaining cognizant of its financial implications. The judicious use of agency labor can help hospitals balance the benefits of increased revenue against higher costs, while ensuring that they still meet immediate patient needs.

Effects of Internal and External Factors on Hospital Data Breaches: Quantitative Study.

Health care data breaches are the most rapidly increasing type of cybercrime; however, the predictors of health care data breaches are uncertain. This quantitative study aims to develop a predictive model to explain the number of hospital data breaches at the county level. This study evaluated data consolidated at the county level from 1032 short-term acute care hospitals. We considered the association between data breach occurrence (a dichotomous variable), predictors based on county demographics, and socioeconomics, average hospital workload, facility type, and average performance on several hospital financial metrics using 3 model types: logistic regression, perceptron, and support vector machine. The model coefficient performance metrics indicated convergent validity across the 3 model types for all variables except bad debt and the factor level accounting for counties with >20% and up to 40% Hispanic populations, both of which had mixed coefficient directionality. The support vector machine model performed the classification task best based on all metrics (accuracy, precision, recall, F1-score). All the 3 models performed the classification task well with directional congruence of weights. From the logistic regression model, the top 5 odds ratios (indicating a higher risk of breach) included inpatient workload, medical center status, pediatric trauma center status, accounts receivable, and the number of outpatient visits, in high to low order. The bottom 5 odds ratios (indicating the lowest odds of experiencing a data breach) occurred for counties with Black populations of >20% and <40%, >80% and <100%, and >40% but <60%, as well as counties with ≤20% Asian or between 80% and 100% Hispanic individuals. Our results are in line with those of other studies that determined that patient workload, facility type, and financial outcomes were associated with the likelihood of health care data breach occurrence. The results of this study provide a predictive model for health care data breaches that may guide health care managers to reduce the risk of data breaches by raising awareness of the risk factors.

Segregated Patterns of Hospital Care Delivery and Health Outcomes

Residential segregation has been shown to be a root cause of racial inequities in health outcomes, yet little is known about current patterns of racial segregation in where patients receive hospital care or whether hospital segregation is associated with health outcomes. Filling this knowledge gap is critical to implementing policies that improve racial equity in health care. To characterize contemporary patterns of racial segregation in hospital care delivery, identify market-level correlates, and determine the association between hospital segregation and health outcomes. This cross-sectional study of US hospital referral regions (HRRs) used 2018 Medicare claims, American Community Survey, and Agency for Healthcare Research and Quality Social Determinants of Health data. Hospitalization patterns for all non-Hispanic Black or non-Hispanic White Medicare fee-for-service beneficiaries with at least 1 inpatient hospitalization in an eligible hospital were evaluated for hospital segregation and associated health outcomes at the HRR level. The data analysis was performed between August 10, 2022, and September 6, 2023. Dissimilarity index and isolation index for HRRs. Health outcomes were measured using Prevention Quality Indicator (PQI) acute and chronic composites per 100 000 Medicare beneficiaries, and total deaths related to heart disease and stroke per 100 000 residents were calculated for individuals aged 74 years or younger. Correlation coefficients were used to compare residential and hospital dissimilarity and residential and hospital isolation. Linear regression was used to examine the association between hospital segregation and health outcomes. This study included 280 HRRs containing data for 4386 short-term acute care and critical access hospitals. Black and White patients tended to receive care at different hospitals, with a mean (SD) dissimilarity index of 23 (11) and mean (SD) isolation index of 13 (13), indicating substantial variation in segregation across HRRs. Hospital segregation was correlated with residential segregation (correlation coefficients, 0.58 and 0.90 for dissimilarity and isolation, respectively). For Black patients, a 1-SD increase in the hospital isolation index was associated with 204 (95% CI, 154-254) more acute PQI hospitalizations per 100 000 Medicare beneficiaries (28% increase from the median), 684 (95% CI, 488-880) more chronic PQI hospitalizations per 100 000 Medicare beneficiaries (15% increase), and 6 (95% CI, 2-9) additional deaths per 100 000 residents (6% increase) compared with 68 (95% CI, 24-113; 6% increase), 202 (95% CI, 131-274; 8% increase), and 2 (95% CI, 0 to 4; 3% increase), respectively, for White patients. This cross-sectional study found that higher segregation of hospital care was associated with poorer health outcomes for both Black and White Medicare beneficiaries, with significantly greater negative health outcomes for Black populations, supporting racial segregation as a root cause of health disparities. Policymakers and clinical leaders could address this important public health issue through payment reform efforts and expansion of health insurance coverage, in addition to supporting upstream efforts to reduce racial segregation in hospital care and residential settings.

Characteristics of short-term acute care hospitals that experienced a ransomware attack from 2016 to 2021.

As cybercrime increasingly targets the health care sector, hospitals face the growing threat of ransomware attacks. Ransomware is a type of malicious software that prevents users from accessing their electronic systems-demanding payment to restore access. In response, momentum is gathering to enact policy that will help hospitals strengthen their cybersecurity defenses. However, to design effective policy, it is crucial to understand the characteristics of hospitals associated with the risk of ransomware attack. In this paper, we compare the characteristics of ransomware-attacked and non-attacked short-term acute care hospitals in the United States. Using data from the American Hospital Association's Annual Survey and the Healthcare Cost Report Information System, we found that ransomware-attacked hospitals were larger, had higher net operating revenue, were more likely to be financially profitable, and more likely to provide trauma, emergency, and obstetric care than non-attacked hospitals. Measures of information technology sophistication did not vary between ransomware-attacked and non-attacked hospitals. These results can be used to tailor policy interventions in order to most effectively respond to and prevent cybercrime in health care.

Comparing strategies for prehospital transport to specialty care after cardiac arrest

Outcomes are better when patients resuscitated from out-of-hospital cardiac arrest (OHCA) are treated at specialty centers. The best strategy to transport patients from the scene of resuscitation to specialty care is unknown. MethodsWe performed a retrospective cohort study. We identified patients treated at a single specialty center after OHCA from 2010 to 2021 and used OHCA geolocations to develop a catchment area using a convex hull. Within this area, we identified short term acute care hospitals, OHCA receiving centers, adult population by census block group, and helicopter landing zones. We determined population-level times to specialty care via: (1) direct ground transport; (2) transport to the nearest hospital followed by air interfacility transfer; and (3) ground transport to air ambulance. We used an instrumental variable (IV) adjusted probit regression to estimate the causal effect of transport strategy on functionally favorable survival to hospital discharge. ResultsDirect transport to specialty care by ground to air ambulance had the shortest population-level times from OHCA to specialty care (median 56 [IQR 47–66] minutes). There were 1,861 patients included in IV regression of whom 395 (21%) had functionally favorable survival. Most (n = 1,221, 66%) were transported to the nearest hospital by ground EMS then to specialty care by air. Patient outcomes did not differ across transport strategies in our IV analysis. DiscussionWe did not find strong evidence in favor of a particular strategy for transport to specialty care after OHCA. Population level time to specialty care was shortest with ground ambulance transport to the nearest helicopter landing zone.

Changes in US Hospital Financial Performance During the COVID-19 Public Health Emergency

The COVID-19 public health emergency (PHE) caused substantial changes in hospital operations. The net effect of these changes on hospital financial performance is unclear. To evaluate changes in hospital financial performance before and during the COVID-19 PHE. This longitudinal within-hospital cohort analysis from 2017 to 2021 used national RAND hospital data merged with American Community Survey data. A total of 4223 short-term acute care or critical access hospitals in the US with financial data spanning 2017 to 2021 were evaluated. Financial performance during the first 2 years of the PHE. The main outcome was PHE financial distress calculated based on net operating income (operating revenue minus operating expenses). Within-hospital changes in net operating income over time were evaluated with and without COVID-19 relief funding. From henceforth, 2020/2021 means the weighted average financial performance for both calendar year 2020 and 2021. Hospitals were characterized as having new financial distress if (1) their average 2020/2021 net operating income was negative and (2) the average 2020/2021 net operating income was less than that hospital's pre-2020 net operating income. Predictors of new financial distress were evaluated using logistic regression and predictors of COVID-19 relief using 2-part models. In this sample of 4423 hospitals, 3529 (80.0%) received PHE funds during 2020/2021. A total of 846 (19.1%) were located in a census tract with more than 20% Hispanic residents. Of the total number of hospitals, 720 (16.3%) of hospitals had PHE financial distress, whereas 2047 (46.3%) had PHE financial distress after excluding COVID-19 relief funding from net operating income. The majority of hospitals (n = 3337; 74.8%) had a positive net operating income across 2020/2021, with 785 (17.8%) hospitals moving from a negative pre-2020 to a positive 2020/2021 net operating income. In adjusted analyses, hospitals treating a higher proportion of Hispanic populations were more likely to have PHE distress (adjusted odds ratio, 1.3; 95% CI, 1.1-1.6; P = .02). Median (IQR) operating margins from 2020/2021 were at an all-time high of 6.5% (0.2%-13.3%) compared with pre-2020 operating margins of 2.8% (-2.8% to 9.3%). In this cohort study of US hospitals, the large majority had positive financial performance during 2020/2021, partly due to COVID-19 relief funds. However, hospitals serving Hispanic populations had substantially worsened financial performance during 2020/2021, even after accounting for COVID-19 relief. That COVID-19 relief funding aided in operating margins reaching all-time highs indicates funding amounts may have been larger than was necessary for many hospitals. With COVID-19 relief funding ending yet COVID-19 related continuing to affect hospital expenses, ongoing monitoring of hospital financial performance is vital to ensure patients retain access to care.

Cardiovascular hospitalizations for Medicare advantage beneficiaries in the United States, 2009 to 2019

Federal programs measuring hospital quality of care for acute cardiovascular conditions are based solely on Medicare fee-for-service (FFS) beneficiaries, and exclude Medicare Advantage (MA) beneficiaries. In this study we characterize the proportion of Medicare beneficiaries enrolled in MA at the time of acute myocardial infarction (AMI), heart failure (HF), and ischemic stroke hospitalization. Retrospective cross-sectional study of short-term acute care hospitals using Medicare claims in 2009 and 2019. There were 2,653 hospitals in 2009 and 2,732 hospitals in 2019. Across hospitals, the proportion of Medicare beneficiaries hospitalized for AMI who were enrolled in MA increased between 2009 (hospital-level median 14.4% [IQR 5.1%-26.0%]) and 2019 (33.3% [IQR 20.6%-45.2%]), with substantial variation across hospitals. Similar patterns were observed for HF (13.0% [IQR 5.3%-24.3%] to 31.0% [IQR 20.2%-42.3%]) and ischemic stroke (14.6% [IQR 5.3%-26.7%] to 33.3% [IQR 20.9%-46.0%]). Within each hospital referral region, hospital size (large 36.3% vs small 24.5%; adjusted difference 6.7%, 95% CI, 4.5%-8.8%), teaching status (teaching 34.5% vs nonteaching 28.2%; 2.8%, 1.4%-4.1%), and ownership status (private nonprofit 32.3% vs public 24.5%; 5.2%, 3.5%-6.9%) were each associated with a higher hospital MA proportion. The proportion of Medicare beneficiaries hospitalized for AMI, HF, and ischemic stroke enrolled in MA doubled between 2009 and 2019, with substantial variation across hospitals. These findings have implications for federal efforts to measure and improve quality, which currently focus only on FFS beneficiaries.

An Exploratory Analysis of the Association Between Hospital Labor Costs and the Quality of Care.

The competent healing touch of a caregiver is a critical component to the care patients receive. The more skilled the provider, the higher the likelihood outcomes will be delivered in a safe and effective manner. Unfortunately, in recent years, hospitals in the United States have faced immense financial pressures that are threatening their economic sustainability and patients' access to care in the future. Through the recent COVID-19 pandemic, the cost of delivering healthcare has continued to escalate, while the demand for patient care has exceeded many hospitals' capacity. Most troubling is the impact that the pandemic has had on the healthcare workforce, which has resulted in many hospitals struggling to fill vacancies at ever-increasing cost - all while under immense pressure to deliver quality patient care. What remains uncertain is whether the increase in labor costs has been matched with a commensurate rise in the quality of care or if quality has deteriorated as the labor force mix has changed to include more contract and temporary staff. Thus, in the enclosed study, we sought to determine what association, if any, exists between hospitals' cost of labor and the quality of care delivered. Drawing from a representative national sample of nearly 3214 short-term acute care hospitals' common quality measures from the year 2021, we examined the labor cost-quality relationship via multivariate linear and logistic regression and found there is a persistent negative association across all quality outcome variables studied. These findings lead us to believe simply paying more for hospital labor does not, by itself, ensure a positive patient outcome. We contend cautious use of temporary staff, measured adoption of short-term financial incentives, and robust staff development all should be considered as features of future workforce planning.

Geographic Disparities in Re-triage Destinations Among Seriously Injured Californians.

To quantify geographic disparities in sub-optimal re-triage of seriously injured patients in California. Re-triage is the emergent transfer of seriously injured patients from the emergency departments of non-trauma and low-level trauma centers to, ideally, high-level trauma centers. Some patients are re-triaged to a second non-trauma or low-level trauma center (sub-optimal) instead of a high-level trauma center (optimal). This was a retrospective observational cohort study of seriously injured patients, defined by an Injury Severity Score > 15, re-triaged in California (2009-2018). Re-triages within one day of presentation to the sending center were considered. The sub-optimal re-triage rate was quantified at the state, regional trauma coordinating committees (RTCC), local emergency medical service agencies, and sending center level. A generalized linear mixed-effects regression quantified the association of sub-optimality with the RTCC of the sending center. Geospatial analyses demonstrated geographic variations in sub-optimal re-triage rates and calculated alternative re-triage destinations. There were 8,882 re-triages of seriously injured patients and 2,680 (30.2 %) were sub-optimal. Sub-optimally re-triaged patients had 1.5 higher odds of transfer to a third short-term acute care hospital and 1.25 increased odds of re-admission within 60 days from discharge. The sub-optimal re-triage rates increased from 29.3 % in 2009 to 38.6 % in 2018. 56.0 % of non-trauma and low-level trauma centers had at least one sub-optimal re-triage. The Southwest RTCC accounted for the largest proportion (39.8 %) of all sub-optimal re-triages in California. High population density geographic areas experienced higher sub-optimal re-triage rates.

Improving Health and Addressing Social Determinants of Health Through Hospital Partnerships.

Hospitals and health systems are forming partnerships to develop an integrated social network of services that better address the needs of their surrounding communities and their social determinants of health (SDOH). There is little research on the association of these partnered services with hospital outcomes. This study examined the association between hospital social need partnerships and activities to improve hospital and community outcomes. A secondary cross-sectional design to analyze 2021 census data of nonfederal short-term acute care hospitals in the United States was utilized. Data were obtained from the American Hospital Association. Four multilevel logistic regression models were used to analyze data from 1005 hospitals. The authors found that hospital partnership type differed in association to social need outcomes. They found that hospitals with a partnership with health insurance providers were more likely to have better health outcomes. Hospitals partnered with health insurance providers, local organizations addressing housing insecurity, local businesses, or chambers of commerce were more likely to have decreased health care costs. Hospitals partnered with health care providers, health insurance providers, local organizations providing legal assistance, or law enforcement/safety forces were more likely to have decreased utilization of hospital services. However, hospitals partnered with other local or state government or social service organizations were less likely to indicate decreased utilization of services. Many hospitals and health systems across the United States are screening for SDOH and are advancing health care delivery and improving the community's overall health and well-being by identifying unmet social needs and partnering with the community to address them.

The Predictive Factors of Hospital Bankruptcy-An Exploratory Study.

The United States healthcare industry has witnessed a number of hospitals declare bankruptcy. This has a meaningful impact on local communities with vast implications on access, cost, and quality of care available. In our research, we seek to determine what contemporary structural and operational factors influence a bankruptcy outcome, and craft predictive models to guide healthcare leaders on how to best avoid bankruptcy in the future. In this exploratory study we performed, a single-year cross-sectional analysis of short-term acute care hospitals in the United States and subsequently developed three predictive models: logistic regression, a linear support vector machine (SVM) model with hinge function, and a perceptron neural network. Data sources include Definitive Healthcare and Becker's Hospital Review 2019 report with 3121 observations of 32 variables with 27 observed bankruptcies. The three models consistently indicate that 18 variables have a significant impact on predicting hospital bankruptcy. Currently, there is limited literature concerning financial forecasting models and knowledge detailing the factors associated with hospital bankruptcy. By having tailored knowledge of predictive factors to establish a sound financial structure, healthcare institutions at large can be empowered to take proactive steps to avoid financial distress at the organizational level and ensure long-term financial viability.

Financial impact of telehealth: rural chief financial officer perspectives.

To explore the perceived impacts of a variety of telehealth services on hospital finances and assess how hospital administrators make decisions about adopting telehealth programs. From October 2021 to January 2022, we conducted semistructured interviews with chief financial officers (CFOs) of rural hospitals. Recruitment occurred in collaboration with 6 rural health collaboratives and hospital associations that facilitated CFO peer-learning groups. We used inductive and deductive approaches informed by a health care innovation adoption model to identify themes in the qualitative data. Twenty rural hospital CFOs and other hospital administrators from 10 states participated in interviews. Seventeen (85%) represented critical access hospitals and 3 (15%) represented short-term acute care hospitals. Although CFOs believed telehealth has some financial advantages (eg, can help to avoid patient transfers), they did not believe that telehealth improved their hospitals' financial situations. CFOs, rather, seem motivated to implement telehealth services to improve quality of care and address patients' needs. CFOs reported that limited reimbursement, low volumes, preference for in-person care, and insufficient broadband were key challenges to telehealth's financial viability. Understanding how CFOs think about the return on investment of telehealth can inform efforts to promote telehealth utilization in rural communities and to develop policy solutions to make telehealth more sustainable. CFOs may benefit from guidance on promising practices and cost-effective implementation strategies. Policy makers could take steps to improve telehealth's financial attractiveness (eg, through payment parity, subsidies to improve technology infrastructure).

Examining sources of post-acute care inequities with layered target matching.

To examine factors associated with racial inequities in discharge location, skilled nursing facility (SNF) utilization, and readmissions. A 20% sample of longitudinal Medicare claims from 2016 to 2018. We present layered target matching, a method for studying sources of inequities. Layered target matching examines a fixed target population profile representing any race, ethnicity, or vulnerable population, sequentially adjusting for sets of characteristics that may contribute to inequities these groups endure. We use the method to study racial inequities in post-acute care use and readmissions. We studied Black and non-Hispanic White fee-for-service Medicare beneficiaries aged 66+ admitted to short-term acute-care hospitals for qualifying diagnoses or procedures between January 1, 2016 and November 30, 2018. Admitted Black patients tended to be younger, had significantly higher rates of risk factors such as diabetes, stroke, or renal disease, and were much more frequently admitted to large or academic hospitals. Relative to demographically similar White patients, Black patients were significantly more likely to be discharged to SNFs (21.8% vs. 19.3%, difference=2.5%, p < 0.0001) and to receive any SNF care within 30 days of discharge (25.3% vs. 22.4%, difference=2.9%, p < 0.0001). Black patients were also significantly more likely to experience 30-day readmission (18.7% vs. 14.5%, difference=4.2%, p < 0.0001). Differences in reasons for hospitalization and risk factors explained most of the differences in discharge location, post-acute care use, and readmission rates, while additional adjustment for differences in hospital characteristics and complications made little difference for any of the measures studied. We found significant Black-White differences in discharge to SNFs, SNF utilization, and readmission rates. Using layered target matching, we found that differences in risk factors and reasons for hospitalization explained most of these differences, while differences in hospitals did not materially impact the differences.

Is the Hospital Value-Based Purchasing Program Associated with Reduced Hospital Readmissions?

IntroductionHospital readmissions have been associated with adverse outcomes and elevated financial costs to patients, families, and hospitals across the United States. Historically, nearly 20% of all Medicare discharges had a readmission within 30 days. In an effort to address this issue, the Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012 to positively influence readmissions associated with acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and total hip and/or knee arthroplasty. However, as recently as 2018, there were still 3.8 million 30-day all-cause adult hospital readmissions, with a 14% readmission rate and an average readmission cost of $15,200. The ACA also produced the Hospital Value-Based Purchasing (HVBP) program with the stated intent to (1) reduce mortality and complications, (2) reduce healthcare-associated infections, (3) increase patient safety, (4) improve the patient experience, and (5) increase efficiency and reduce costs. Given the costs and quality implications of an average readmission, it is logical to believe that HVBP eligible hospitals are simultaneously seeking to meet the goals of both programs. However, to date, no studies have examined if that is the case. Thus, in this study, we seek to determine if HVBP eligible hospitals are associated with a reduction in the core set of HRRP readmission rates better than the facilities that are not eligible for the HVBP program.MethodsHospital-level data from calendar year 2019 for 3,276 short-term acute care hospitals in the United States were evaluated using multivariate regression analysis to examine the readmission rate performance between 2,719 HVBP eligible hospitals and 557 ineligible hospitals.ResultsOur six separate multivariable linear regressions revealed a statistically significant and positive association between HVBP participation and readmission rates after controlling for numerous organizational, clinical complexity, and environmental factors. In each case, the magnitude of the positive directional association is moderate, ranging from and increase of +0.19% (pneumonia readmissions) to as high as +0.37% (all cause readmissions) for HVBP eligible hospitals. When considered in the context of the average number of discharges in our data set (x- = 9570), a third of a percent increase from the average 15.56% all cause readmissions to 16.08% in HVBP eligible hospitals equates to 50 additional readmissions annually (9570 × 15.56% = 1,489 vs 9570 × 16.08% = 1,539). At an average cost of $15,200 per readmission, which equates to an average additional cost to the average HVBP eligible hospital in excess of $760,000.DiscussionThe fact that there is a positive association between HVBP participating hospitals and readmissions at all, and that the same effect appears to be persistent across all dependent measures is concerning. One would logically expect hospitals that are focused on quality-based care to thoroughly care for individuals in order for them to not be readmitted to the hospital. The results provided do not necessarily prove that either program is not working. But they also do not confirm that the HVBP and HRRP programs are working together and accomplishing what they were originally designed to do: improve patient care and lower health-care costs.

Association Between Hospital Private Equity Acquisition and Outcomes of Acute Medical Conditions Among Medicare Beneficiaries

As private equity (PE) acquisitions of short-term acute care hospitals (ACHs) continue, their impact on the care of medically vulnerable older adults remains largely unexplored. To investigate the association between PE acquisition of ACHs and access to care, patient outcomes, and spending among Medicare beneficiaries hospitalized with acute medical conditions. This cross-sectional study used a generalized difference-in-differences approach to compare 21 091 222 patients admitted to PE-acquired vs non-PE-acquired short-term ACHs between January 1, 2001, and December 31, 2018, at least 3 years before to 3 years after PE acquisition. The analysis was conducted between December 28, 2020, and February 1, 2022. Differences were estimated using both facility and hospital service area fixed effects. To assess the robustness of findings, regressions were reestimated after including fixed effects of patient county of origin to account for geographic differences in underlying health risks. Two subset analyses were also conducted: (1) an analysis including only hospitals in hospital referral regions with at least 1 PE acquisition and (2) an analysis stratified by participation in the Hospital Corporation of America 2006 acquisition. The study included Medicare beneficiaries 66 years and older who were hospitalized with 1 of 5 acute medical conditions: acute myocardial infarction (AMI), acute stroke, chronic obstructive pulmonary disease exacerbation, congestive heart failure exacerbation, and pneumonia. Acquisition of hospitals by PE firms. Comorbidity burden (measured by Elixhauser comorbidity score), hospital length of stay, in-hospital mortality, 30-day mortality, 30-day readmission, and 30-day episode payments. Among 21 091 222 total Medicare beneficiaries admitted to ACHs between 2001 and 2018, 20 431 486 patients received care at non-PE-acquired hospitals, and 659 736 received care at PE-acquired hospitals. Across all admissions, the mean (SD) age was 79.45 (7.95) years; 11 727 439 patients (55.6%) were male, and 4 550 012 patients (21.6%) had dual insurance; 2 996 560 (14.2%) patients were members of racial or ethnic minority groups, including 2 085 128 [9.9%] Black and 371 648 [1.8%] Hispanic; 18 094 662 patients (85.8%) were White. Overall, 3 083 760 patients (14.6%) were hospitalized with AMI, 2 835 777 (13.4%) with acute stroke, 3 674 477 (17.4%) with chronic obstructive pulmonary disease exacerbation, 5 868 034 (27.8%) with congestive heart failure exacerbation, and 5 629 174 (26.7%) with pneumonia. Comorbidity burden decreased slightly among patients admitted with acute stroke (difference, -0.04 SDs; 95% CI, -0.004 to -0.07 SDs) at acquired hospitals compared with nonacquired hospitals but was unchanged across the other 4 conditions. Among patients with AMI, a greater decrease in in-hospital mortality was observed in PE-acquired hospitals compared with non-PE-acquired hospitals (difference, -1.14 percentage points, 95% CI, -1.86 to -0.42 percentage points). In addition, a greater decrease in 30-day mortality (difference, -1.41 percentage points; 95% CI, -2.26 to -0.56 percentage points) was found at acquired vs nonacquired hospitals. However, 30-day spending and readmission rates remained unchanged across all conditions. The extent and directionality of estimates were preserved across all robustness assessments and subset analyses. In this cross-sectional study using a difference-in-differences approach, PE acquisition had no substantial association with the patient-level outcomes examined, although it was associated with a moderate improvement in mortality among Medicare beneficiaries hospitalized with AMI.

Financial Impacts And Operational Implications Of Private Equity Acquisition Of US Hospitals.

Although private equity acquisition of short-term acute care hospitals purportedly improves efficiency and cost-effectiveness, financial performance after acquisition remains unexamined. We compared changes in the financial performance of 176 hospitals acquired during 2005-14 versus changes in matched control hospitals. Acquisition was associated with a $432 decrease in cost per adjusted discharge and a 1.78-percentage-point increase in operating margin. The majority of acquisitions-134 members of the Hospital Corporation of America, acquired in 2006-were associated with a $559 decrease in cost per adjusted discharge but no change in operating margin. Conversely, non-HCA hospitals exhibited a 3.27-percentage-point increase in operating margin without a concomitant change in cost per adjusted discharge. When we examined markers of hospital capacity, operational efficiency, and costs, we found that private equity acquisition was associated with decreases in total beds, ratio of outpatient to inpatient charges, and staffing (total personnel and nursing full-time equivalents and total full-time equivalents per occupied bed). Therefore, financial performance improved after acquisition, whereas patient throughput and inpatient utilization increased and staffing metrics decreased. Future research is needed to identify any unintended trade-offs with safety and quality.

Mechanical Ventilator Liberation of Patients With COVID-19 in Long-term Acute Care Hospital

BackgroundMechanical ventilation (MV) via tracheostomy is performed commonly for patients who are in long-term acute care hospitals (LTACHs) after respiratory failure. However, the outcome of MV in COVID-19-associated respiratory failure in LTACHs is not known.Research QuestionWhat is the ventilator liberation rate of patients who have received tracheostomy with COVID-19-associated respiratory failure compared with those with respiratory failure unrelated to COVID-19 in LTACHs?Study Design and MethodsIn this retrospective cohort study, we examined mechanically ventilated patients discharged between June 2020 and March 2021. Of 242 discharges, 165 patients who had undergone tracheostomy arrived and were considered for ventilator liberation. One hundred twenty-eight patients did not have COVID-19 and 37 patients were admitted for COVID-19.ResultsThe primary outcome of the study was ventilator liberation; secondary outcomes were functional recovery, length of stay (LOS) at the LTACH, and discharge disposition. After controlling for demographics, the number of comorbidities, hemodialysis, vasopressor need, thrombocytopenia, and the LOS at the short-term acute care hospital, our results indicated that patients with COVID-19 showed a higher adjusted ventilator liberation rate of 91.4% vs 56.0% in those without COVID-19. Functional ability was assessed with the change of Functional Status Score for the Intensive Care Unit (FSS-ICU) between admission and discharge. The adjusted mean change in FSS-ICU was significantly higher in the COVID-19 group than in the non-COVID-19 group: 9.49 (95% CI, 7.38-11.6) vs 2.08 (95% CI, 1.05-3.11), respectively (P < .001). Patients with COVID-19 experienced a shorter adjusted LOS at the LTACH with an adjusted hazard ratio of 1.57 (95% CI, 1.0-2.46; P = .05) compared with patients without COVID-19. We did not observe significant differences between the two groups regarding discharge location, but a trend toward need for lower level of care was found in patients with COVID-19.InterpretationOur study suggests that patients with COVID-19 requiring MV and tracheostomy have a higher chance for recovery than those without COVID-19.