Karen Joynt Maddox

BackgroundPatients hospitalized with heart failure (HF) and diabetes mellitus (DM) are at risk for worsening clinical status. Little is known about the frequency of therapeutic changes during hospitalization. We characterized the use of medical therapies before, during and after hospitalization in patients with HF and DM.MethodsWe identified Medicare beneficiaries in Get With The Guidelines-Heart Failure (GWTG-HF) hospitalized between July 2014 and September 2019 with Part D prescription coverage. We evaluated trends in the use of 7 classes of antihyperglycemic therapies (metformin, sulfonylureas, GLP-1RA, SGLT2-inhibitors, DPP-4 inhibitors, thiazolidinediones, and insulins) and 4 classes of HF therapies (evidence-based β-blockers, ACEi or ARB, MRA, and ARNI). Medication fills were assessed at 6 and 3 months before hospitalization, at hospital discharge and at 3 months post-discharge.ResultsAmong …

Background Little is known regarding differences in cause-specific costs between HF with EF≤ 40% versus> 40%, and potential cost implications of SGLT2i therapy. Objectives To compare cause-specific healthcare costs following hospitalization for heart failure (HF) with ejection fraction (EF)≤ 40% versus> 40%, and estimate the cost offset with implementation of SGLT2 inhibitor (SGLT2i) therapy. Methods We examined Medicare beneficiaries hospitalized for HF in the Get With The Guidelines-Heart Failure registry from 2016-2020. Mean per-patient total (excluding drug costs) and cause-specific costs from discharge through 1-year follow-up were calculated and compared between EF≤ 40% vs> 40%. We then estimated risk reductions on total all-cause and HF hospitalizations in a trial-level meta-analysis of 5 pivotal trials of SGLT2i in HF. Finally, we applied these relative treatment effects to Medicare …

Cardiovascular disease (CVD) is a major source of morbidity, mortality, and costs worldwide Approximately 523 million people worldwide were living with CVD in 2019, and in the same year CVD was associated with nearly 19 million deaths. 1 Costs in the USA alone were estimated at over US $200 billion in 2018. 2 The burden on the individual patient is similarly great—not only from direct healthcare spending, but also from hospitalizations, readmissions, decreased quality of life, and premature mortality. Moreover, both globally and in the USA in particular, this burden disproportionately impacts low-income individuals and people identifying as Black or Hispanic compared with patients identifying as White. 3In this issue of the European Heart Journal, a new study by Henry et al. analysed the National Inpatient Sample (NIS) for US hospitals to identify trends in cardiovascular hospitalizations and in-hospital mortality …

BackgroundSocioeconomic inequities in access to heart transplantation are well-documented, and may in part relate to insurance coverage. During the COVID pandemic, the federal government declared a Public Health Emergency (PHE), effective January 27, 2020, which prevented states from disenrolling people from Medicaid during this critical time period. We sought to determine whether the growth in Medicaid enrollment as a consequence of the PHE was associated with changes in the insurance composition of the heart transplant waiting list, the main insurance-dependent step in the transplant process.MethodsUsing the UNOS thoracic dataset, we analyzed weekly counts of adults (age> 17) added to the heart transplant waitlist on between January 1, 2018 and December 31, 2021 by primary payer, accounting for holiday effects and the acute dropoff in listing during the height of COVID-19 (March 14-June …

Looking AHEAD to State Global Budgets for Health Care In 2023, CMS announced a new model that moves toward population-based payment at the state level and aims to curb cost growth, improve population health, and advance health equity.

When President Obama came to office in 2008, his administration faced compounding health system challenges. Nearly 45 million Americans lacked health insurance coverage. Concerns that private plans were overtly prioritizing profits rather than patients had intensified. National health care costs had risen to 17% of the gross domestic product. At the same time, health outcomes in the United States were worse than comparable countries. In 2010, President Obama signed the Affordable Care Act (ACA) into law, which had 3 areas of focus: expanding coverage through public and private payers, reforming health insurance markets to be more patient-friendly, and improving quality of care and reducing spending through value-based payment programs.

BACKGROUND The objective of this study was to examine insurance-based disparities in mortality, non-home discharges, and ECMO utilization in patients hospitalized with COVID-19. METHODS Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, non-home discharge, and ECMO utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0-5.0%; 5.1-10%, 10.1-20%, 20.1-30%, 30.1%-) was evaluated. Modelling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased …

Background Improving quality of care provided to short‐stay patients with dementia in nursing homes is a policy priority. However, it is unknown whether dementia‐focused care strategies are associated with improved clinical outcomes or lower utilization and costs for short‐stay dementia patients. Methods We performed a national survey of nursing home administrators in 2020–2021, asking about the presence of three dementia‐focused care services used for their short‐stay patients: (1) a dementia care unit, (2) cognitive deficiency training for staff, and (3) dementia‐specific occupational therapy. Using Medicare claims, we identified short‐stay episodes for beneficiaries residing in surveyed skilled nursing facilities (SNFs) with and without dementia. We compared clinical, cost, and utilization outcomes for dementia patients in SNFs, which did and did not offer dementia‐focused care services. As a counterfactual …

Importance Medicare’s Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. Objective To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. Design, Setting, and Participants This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points …

The lack of equity in the US healthcare system is nothing short of a public health crisis. Between 1999 and 2020, Black individuals experienced approximately 1.6 million excess deaths and 80 million excess years of life lost compared to White individuals. 1 The magnitude of this inequity was laid bare during the recent pandemic; individuals from minoritized groups accounted for 36% of COVID-19 deaths and 70% of non–COVID-19 excess deaths. 2 These racial disparities in health outcomes are not rooted in biologic differences. Instead, they result from social determinants of health, such as lack of insurance coverage, and structural racism as manifested by unequal health care. inequities in anesthesia CareIn this issue, Guglielminotti et al. 3 aim to examine how a change to federal law impacts a racial and socioeconomic disparity that characterizes our care of pregnant women—namely, that Black and Hispanic …

ImportanceBlack adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown.ObjectiveTo compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals.Design, Setting, and ParticipantsPatients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022.ExposuresHospitals caring for high proportions of Black patients.Main Outcomes and MeasuresQuality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients.ResultsThis study included 422 483 patients (224 …

ImportancePayers are increasingly using approaches to risk adjustment that incorporate community-level measures of social risk with the goal of better aligning value-based payment models with improvements in health equity.ObjectiveTo examine the association between community-level social risk and health care spending and explore how incorporating community-level social risk influences risk adjustment for Medicare beneficiaries.Design, Setting, and ParticipantsUsing data from a Medicare Advantage plan linked with survey data on self-reported social needs, this cross-sectional study estimated health care spending health care spending was estimated as a function of demographics and clinical characteristics, with and without the inclusion of Area Deprivation Index (ADI), a measure of community-level social risk. The study period was January to December 2019. All analyses were conducted from …

OBJECTIVES/GOALS: Regionalized sepsis care could improve sepsis outcomes. There are no measures of sepsis capability to guide the identification of hospitals that can best serve sepsis patients. We derived Capability-Based (CB) scores from specific hospital characteristics and evaluated their performance as system predictors of mortality among adults with sepsis. METHODS/STUDY POPULATION: We used the 2018 State Inpatient Databases to identify 90051 adult sepsis encounters at 157 non-federal NY hospitals (derivation cohort), and 130,249 sepsis encounters at 220 hospitals in FL and MA (validation cohort). We used Principal Component Analysis to analyze to reduce 14 hospital-level resource use characteristics to 3 interpretable, linear data combinations (principal components (PC). We calculated CB scores for each hospital as a sum of standardized values for each component multiplied by the …

Background Although cardiovascular mortality has increased among middle-aged U.S. adults since 2011, how the burden of cardiovascular risk factors has changed for this population by income level over the past 2 decades is unknown. Objective To evaluate trends in the prevalence, treatment, and control of cardiovascular risk factors among low-income and higher-income middle-aged adults and how social determinants contribute to recent associations between income and cardiovascular health. Design Serial cross-sectional study. Setting NHANES (National Health and Nutrition Examination Survey), 1999 to March 2020. Participants Middle-aged adults (aged 40 to 64 years). Measurements Age-standardized prevalence of hypertension …

Importance In response to the COVID-19 pandemic, Medicare introduced a public health emergency (PHE) waiver in March 2020, removing a 3-day hospitalization requirement before fee-for-service beneficiaries could receive skilled nursing facility (SNF) care benefits. Objective To assess whether there were changes in SNF episode volume and Medicare spending on SNF care before and during the PHE among long-term care (LTC) residents and other Medicare beneficiaries. Design, Setting, and Participants This retrospective cohort study used Medicare fee-for-service claims and the Minimum Data Set for Medicare beneficiaries who were reimbursed for SNF care episodes from January 2018 to September 2021 in US SNFs. Exposures The prepandemic period (January 2018-February 2020) vs the PHE period (March 2020-September 2021). Main Outcomes and Measures The main outcomes were SNF …

Background:Despite its approval for use in acute ischemic stroke (AIS)> 25 years ago, intravenous thrombolysis (IVT) remains underutilized, with inequities by age, sex, race/ethnicity, and geography. Little is known about IVT rates by insurance status. We aimed to assess temporal trends in the inequities in IVT use.Methods:We assessed trends from 2002 to 2015 in IVT for AIS in the Nationwide Inpatient Sample by sex, age, race/ethnicity, hospital location/teaching status, and insurance, using survey-weighted logistic regression, adjusting for sociodemographics, comorbidities, and hospital characteristics. We calculated odds ratios for IVT for each category in 2002–2008 (Period 1) and 2009–2015 (Period 2).Results:Among AIS patients (weighted N= 6,694,081), IVT increased from 1.0% in 2002 to 6.8% in 2015 (adjusted annual relative ratio (AARR) 1.15, 95% CI 1.14–1.16). Individuals≥ 85 years had the most …

Methods: We used the 2018 State Inpatient Databases to identify 90051 adult sepsis encounters at 157 non-federal New York hospitals (derivation cohort), and 130,249 sepsis encounters at 220 hospitals in Florida and Massachusetts (validation cohort). We evaluated the correlation of sepsis volume and each CB score with hospital mortality among non-transferred patients, and with outward sepsis transfer proportions. We fitted linear, nested, predictive models to compare the system predictive abilities of CB scores and sepsis volume in relation to hospital mortality.Results: In the derivation cohort, 83963 (93.2%) patients were non-transferred, of which 20230 (24.1%) died. The mean (range) score was 0 (-3-+ 5) with higher scores denoting more capable hospitals. Higher scores were weakly and inversely correlated (spearman’s coefficient [r]:-0.28) with outward sepsis transfer proportions. Higher scores had weak …

Targeted temperature management (TTM) is recommended for patients who do not respond after return of spontaneous circulation after cardiac arrest. However, the degree to which patients with cardiac arrest have access to this therapy on a national level is not known. Understanding hospital- and patient-level factors associated with receipt of TTM could inform interventions to improve access to this treatment among appropriate patients. Therefore, we performed a retrospective analysis using National Inpatient Sample data from 2016 to 2019. We used International Classification of Diseases, Tenth Edition diagnosis and procedure codes to identify adult patients with in-hospital and out-of-hospital cardiac arrest and receipt of TTM. We evaluated patient and hospital factors associated with receiving TTM. We identified 478,419 patients with cardiac arrest. Of those, 4,088 (0.85%) received TTM. Hospital use of TTM …

Objective To evaluate whether Medicare's Hospital Readmissions Reduction Program (HRRP) is associated with increased observation stay use. Data Sources and Study Setting A nationally representative sample of fee‐for‐service Medicare claims, January 2009–September 2016. Study Design Using a difference‐in‐difference (DID) design, we modeled changes in observation stays as a proportion of total hospitalizations, separately comparing the initial (acute myocardial infarction, pneumonia, heart failure) and subsequent (chronic obstructive pulmonary disease) target conditions with a control group of nontarget conditions. Each model used 3 time periods: baseline (15 months before program announcement), an intervening period between announcement and implementation, and a 2‐year post‐implementation period, with specific dates defined by HRRP policies. Data Collection/Extraction Methods We …

Background There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata. Methods Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income. Results The …

BackgroundThe COVID-19 pandemic caused massive disruption in usual care delivery patterns in hospitals across the USA, and highlighted long-standing inequities in health care delivery and outcomes. Its effect on hospital operations, and whether the magnitude of the effect differed for hospitals serving historically marginalized populations, is unknown.ObjectiveTo investigate the perspectives of hospital leaders on the effects of COVID-19 on their facilities’ operations and patient outcomes.MethodsA survey was administered via print and electronic means to hospital leaders at 588 randomly sampled acute-care hospitals participating in Medicare’s Inpatient Prospective Payment System, fielded from November 2020 to June 2021. Summary statistics were tabulated, and responses were adjusted for sampling strategy and non-response.ResultsThere were 203 responses to the survey (41.6%), with 20.7% of …

Background: Cardiovascular diseases, particularly heart failure (HF), are common reasons for interhospital transfer (IHT) in the United States. IHT targets patients requiring a higher level of care, and has been associated with increased cost, length of stay (LOS), and mortality. We aim to describe the characteristics and outcomes of patients undergoing IHT, as well as variation in the use of IHT across hospitals. Methods: Patients hospitalized for HF who were admitted from another hospital were compared to those who were not within the Get With The Guidelines-Heart Failure registry between January 2015 and June 2022. Hospital characteristics were obtained from the 2018 American Hospital Association Survey. Clinical data from the receiving hospital were analyzed. Results: Overall, 662,575 patients across 622 hospitals (156,263 patients at 127 transplant centers; 19,852 patients at 55 rural sites) were included …

PurposeTo investigate the real-world safety of paclitaxel (PTX)-coated devices for treating lower extremity peripheral artery disease using a commercial claims database.Materials and MethodsData from FAIR Health, the largest commercial claims data warehouse in the United States, were used for this study. The study consisted of patients who underwent femoropopliteal revascularization procedures between January 1, 2015, and December 31, 2019, with PTX and non-PTX devices. The primary outcome was 4-year survival following treatment. The secondary outcomes included 2-year survival, 2- and 4-year freedom from amputation, and repeat revascularization. Propensity score matching was used to minimize confounding, and the Kaplan-Meier methods were used to estimate survival.ResultsA total of 10,832 procedures were included in the analysis, including 4,962 involving PTX devices and 5,870 involving …

Background COVID‐19 stressed hospitals and may have disproportionately affected the stroke outcomes and treatment of Black and Hispanic individuals. Methods and Results This retrospective study used 100% Medicare Provider Analysis and Review file data from between 2016 and 2020. We used interrupted time series analyses to examine whether the COVID‐19 pandemic exacerbated disparities in stroke outcomes and reperfusion therapy. Among 1 142 560 hospitalizations for acute ischemic strokes, 90 912 (8.0%) were Hispanic individuals; 162 752 (14.2%) were non‐Hispanic Black individuals; and 888 896 (77.8%) were non‐Hispanic White individuals. The adjusted odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51 [95% CI, 1.34–1.69]; P<0.001), whereas the rates of nonhome discharges decreased by 11% (aOR, 0.89 [95% CI, 0.82–0.96]; P=0.003) for patients hospitalized …

Methods: We used the New York State Inpatient Database to analyze 90,051 adult sepsis encounters in 2018 at 157 non-federal hospitals. We used patient-level data to construct 14 a priori identified, hospital-level resource use characteristics and classified them into distinct capability constructs: clinical volume (4 measures: bed size, annual volumes of sepsis, emergency department [ED] visits, ICU admissions); diagnostic (3 measures: annual volumes of magnetic resonance imaging [MRI], CT scans, ultrasound); therapeutic capacity (7 measures: renal replacement therapy, mechanical ventilation [MV], ECMO, central venous catheterization, percutaneous nephrostomy [PN] and cholecystostomy, and major surgical procedures). Using Principal Component Analysis with varimax rotation, we analyzed the dimensionality of, and reduced the 14 characteristics to 3 interpretable, linear data combinations (principal …

Clinician payment is transitioning from fee-for-service to value-based payment, with reimbursement tied to health care quality and cost. However, the overarching goals of value-based payment—to improve health care quality, lower costs, or both—have been largely unmet. This policy statement reviews the current state of value-based payment and provides recommended best practices for future design and implementation. The policy statement is divided into sections that detail different aspects of value-based payment: (1) key program design features (patient population, quality measurement, cost measurement, and risk adjustment), (2) the role of equity during design and evaluation, (3) adjustment of payment, and (4) program implementation and evaluation. Each section introduces the topic, describes important considerations, and lists examples from existing programs. Each section includes recommended best …

Medicare implemented Bundled Payments for Care Improvement (BPCI) Model 3 in 2013, in which participating skilled nursing facilities (SNFs) were accountable for episode costs. We performed comparative interrupted time series analyses to evaluate associations between SNF BPCI participation and nurse staffing levels, using Medicare claims, resident assessments, and facility-level and market-level files of 2010–2017. For persistent-participating SNFs, BPCI was associated with improved certified nursing assistant (CNA) staffing levels (differential change = .03 hours, p = .025). However, BPCI was not related to changes in registered nurse (RN) and all licensed nurse hours, and nurse skill mix. Among drop-out SNFs, BPCI was associated with increased RN staffing levels (differential change = .02 hours, p = .009), leading to a higher nurse skill ratio (0.51 percentage points, p = .016) than control SNFs. Bundled …

with IBS also attending their first gastroenterology consult. Retrospective chart review deter-mined patient demographics, income, and presenting symptoms, as well as provider manage-ment recommendations including pharmacologic therapies, non-pharmacologic treatment, and lifestyle interventions. Results Among 602 IBS patients (301 Black/AA), Black/AA patients had a lower mean income (by zip code) and were significantly more likely to have a history of asthma, diabetes, obesity, hypertension, and chronic pain. Black/AA patients were significantly more likely to present with abdominal pain and less likely to have imple-mented dietary changes for symptoms prior to receiving a diagnosis of IBS (p< 0.001). During their initial gastroenterology consultation for IBS, Black/AA patients were less likely to receive dietary guidance (p= 0.03) and/or a referral to a dietician within one year following their diagnosis of IBS …

ImportanceClinical guidelines for patients with heart failure with reduced ejection fraction (HFrEF) strongly recommend treatment with a sodium-glucose cotransporter-2 inhibitor (SGLT2i) to reduce cardiovascular mortality or HF hospitalization. Nationwide adoption of SGLT2i for HFrEF in the US is unknown.ObjectiveTo characterize patterns of SGLT2i use among eligible US patients hospitalized for HFrEF.Design, Setting, and ParticipantsThis retrospective cohort study analyzed 49 399 patients hospitalized for HFrEF across 489 sites in the Get With The Guidelines–Heart Failure (GWTG-HF) registry between July 1, 2021, and June 30, 2022. Patients with an estimated glomerular filtration rate less than 20 mL/min/1.73 m2, type 1 diabetes, and previous intolerance to SGLT2i were excluded.Main Outcomes and MeasuresPatient-level and hospital-level prescription of SGLT2i at hospital discharge.ResultsOf 49 399 …

ImportanceResidential 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.ObjectiveTo characterize contemporary patterns of racial segregation in hospital care delivery, identify market-level correlates, and determine the association between hospital segregation and health outcomes.Design, Setting, and ParticipantsThis 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 …

It seems unlikely that a significant proportion of individuals, who paid for a long-acting levonorgestrel IUS and had the device inserted, would deliberately pursue removal within the first year of use with the intent of conceiving. In fact, a study cited by Jugl and Winterstein concluded that the main reason for levonorgestrel IUS discontinuation within the first year of insertion is adverse effects from the IUS, such as pain and abnormal bleeding, not the desire to conceive. 2 Individuals choosing to remove a recently inserted IUS due to adverse effects would likely switch to another hormonal contraceptive method, which was accounted for in our Research Letter. 1 Jugl and Winterstein request an analysis on all pregnancy outcomes. Using the same cohort and the same statistical model to calculate the incidence of conceiving (instead of incidence of ectopic pregnancy) within the first year of a filled levonorgestrel IUS …

BACKGROUND Bundled Payments for Care Improvement–Advanced (BPCI-A) is a Medicare initiative that aims to incentivize reductions in spending for episodes of care that start with a hospitalization and end 90 days after discharge. Cardiovascular disease, an important driver of Medicare spending, is one of the areas of focus BPCI-A. It is unknown whether BPCI-A is associated with spending reductions or quality improvements for the 3 cardiovascular medical events or 5 cardiovascular procedures in the model. METHODS In this retrospective cohort study, we conducted difference-in-differences analyses using Medicare claims for patients discharged between January 1, 2017, and September 30, 2019, to assess differences between BPCI-A hospitals and matched nonparticipating control hospitals. Our primary outcomes were the differential changes in spending, before versus after implementation of BPCI-A, for …

ImportanceThe COVID-19 pandemic disrupted usual care for emergent conditions, such as acute myocardial infarction (AMI). Understanding whether Black and Hispanic individuals experiencing AMI had greater increases in poor outcomes compared with White individuals during the pandemic has important equity implications.ObjectiveTo investigate whether the COVID-19 pandemic was associated with increased disparities in treatment and outcomes among Medicare patients hospitalized with AMI.Design, Setting, and ParticipantsThis cross-sectional study used Medicare data for patients hospitalized with AMI between January 2016 and November 2020. Patients were categorized as Hispanic, non-Hispanic Black, and non-Hispanic White. The association between race and ethnicity and outcomes as a function of the proportion of hospitalized patients with COVID-19 was evaluated using interrupted time series …

BACKGROUNDHousing insecurity is increasingly being recognized as an important social determinant of health. Pregnant individuals experiencing housing insecurity may represent a particularly vulnerable subset of this population, but few studies have examined this population nationally. In particular, racial and ethnic minority individuals may be at risk for poor outcomes within this group because of structural racism and discrimination. The introduction of the International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes related to social determinants of health represent a new opportunity to identify patients with housing insecurity nationally.OBJECTIVEThis study aimed to evaluate the prevalence of and delivery outcomes for pregnant people experiencing housing insecurity, both nationally and by race and ethnicity.STUDY DESIGNThis was a retrospective cohort study using data …

OBJECTIVES:Regionalized sepsis care could improve sepsis outcomes by facilitating the interhospital transfer of patients to higher-capability hospitals. There are no measures of sepsis capability to guide the identification of such hospitals, although hospital case volume of sepsis has been used as a proxy. We evaluated the performance of a novel hospital sepsis-related capability (SRC) index as compared with sepsis case volume.DESIGN:Principal component analysis (PCA) and retrospective cohort study.SETTING:A total of 182 New York (derivation) and 274 Florida and Massachusetts (validation) nonfederal hospitals, 2018.PATIENTS:A total of 89,069 and 139,977 adult patients (≥ 18 yr) with sepsis were directly admitted into the derivation and validation cohort hospitals, respectively.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:We derived SRC scores by PCA of six hospital resource use …

Background Nursing home quality of care is a persistent challenge, with recent reports calling for increased reforms to improve quality and safety. Less is known about the clinical approaches currently used and the barriers perceived by skilled nursing facilities (SNFs) to provide care for their short‐stay residents. Methods We conducted a nationally representative survey of SNFs from October 2020 to May 2021 to understand their care delivery approaches and perceived barriers. Our primary outcomes were the reported number of 23 separate care delivery approaches and the reported number of 12 separate barriers to reduce spending or improve care for SNF short‐stay residents. We also performed stratified analyses by facility participation in bundled payments and other SNF characteristics. Results We received 377 responses from 693 SNFs contacted (response rate = 54%). SNFs reported an average of 16.8 …

BackgroundDeclines in CV mortality have stagnated, and there is concern that these population-level trends may reflect increases in CV risk factor burden among younger adults.MethodsUsing NHANES (N= 55,999) 2009-2020, we identified adults ages 20-44 years (N= 12,924). Among these adults, we determined nationally representative biannual age-adjusted rates of diabetes, hypertension, hyperlipidemia, obesity, and smoking, and evaluated changes over time using linear regression. Secondary outcomes included control of these risk factors.ResultsAmong a weighted 106,440,191 adults age 20-44 years, mean HbA1c, BP, total cholesterol, and BMI are shown (Table). Prevalence of diabetes increased from 3.0%(95% CI: 2.2%, 3.7%) in 2007-2008 to 4.1%(95% CI: 3.3%, 4.8%) in 2017-2018 (P for Trend= 0.03). Similarly, the prevalence of obesity increased from 32.7%(95% CI: 30.0%, 35.5%) to 40.8%(95 …

Methods| Data on target prices, case volume, and reconciliation payments for hospitals and physician groups participating in the BPCI-A for performance periods 1 (beginning October 1, 2018) through 4 (ending December 31, 2020) were acquired through a Freedom of Information Act request. Adjustments to reconciliation payments based on quality performance and accountable care organization participation were incorporated in performance periods 1, 2, and 3. While these adjustments were not available for performance period 4, this should have had no material effect on results (ρ=. 99 between adjusted and unadjusted reconciliation in performance period 1). To capture CMS spending expectations if the BPCI-A had not been implemented, mean target prices were inflated by the 3% discount rate embedded in program rules and weighted by bundle episode volume. To estimate the reduction in clinical …

In October 2018, the allocation policy for adult orthotopic heart transplant (OHTx) in the United States was changed, with the goal of reducing waitlist mortality and providing broader sharing of donor organs within the United States. This study aimed to assess the association of this policy change with changes in access to OHTx versus left ventricular assist devices (LVADs), overall and in key sociodemographic subgroups, in the United States from 2016 to 2019. We identified all patients receiving OHTx or LVAD between 2016 and 2019 using the National Inpatient Sample. Controlling for medical co-morbidities, prepolicy trends, and within-hospital-year effects, we fit a dynamic logistic regression model to evaluate patient and hospital factors associated with receiving OHTx versus LVAD before versus after policy change. We also examined the frequency of temporary mechanical circulatory support in the same fashion …

ObjectiveTo examine the influence of socioeconomic, clinical, and hospital characteristics on the risk of severe maternal morbidity among postpartum readmissions.Study DesignA cross-sectional analysis was conducted using the National Inpatient Sample 2006–2012 to estimate the risk of severe maternal morbidity and identify potential risk factors. Odds ratios were calculated using multivariate logistic regression.ResultsWomen aged ≥35 years (ages 35–39: OR 1.12 [CI 1.06, 1.19]; ages 40+: OR 1.27 [CI 1.17, 1.39]), non-Hispanic blacks (OR 1.16 [CI 1.10, 1.22]), and women with pre-existing medical conditions (OR 1.62 [CI 1.56, 1.68]) were at greater risk of severe maternal morbidity during postpartum readmissions. Women hospitalized outside the Northeast region (Midwest: OR 1.20 [CI 1.10, 1.30]; South: OR 1.29 [CI 1.20, 1.38]; West: OR 1.33 [CI 1.22, 1.44]) were also at increased risk.ConclusionThe risk of …

Background:Patients with dementia are a growing and vulnerable population within Medicare. Accountable care organizations (ACOs) are becoming Medicare’s dominant care model, but ACO enrollment and care patterns for patients with dementia are unknown.Objective:The aim of this study was to compare differences in ACO enrollment for patients with versus without dementia, and in risk profiles and ambulatory care among patients with dementia by ACO enrollment status.Research Design:Cohort study assessing the relationships between patient dementia, following-year ACO enrollment, and ambulatory care patterns.Subjects:A total of 13,362 (weighted: 45, 499,049) person-years for patients [2761 (weighted: 6,312,304) for dementia patients] ages 65 years and above in the 2015–2019 Medicare Current Beneficiary Survey.Measures:We assessed differences in ACO enrollment rates for patients with versus …

Objective:To determine the extent to which counting observation stays changes hospital performance on 30-day readmission measures.Methods:This was a retrospective study of inpatient admissions and observation stays among fee-for-service Medicare enrollees in 2017. We generated 3 specifications of 30-day risk-standardized readmissions measures: the hospital-wide readmission (HWR) measure utilized by the Centers for Medicare and Medicaid Services, which captures inpatient readmissions within 30 days of inpatient discharge; an expanded HWR measure, which captures any unplanned hospitalization (inpatient admission or observation stay) within 30 days of inpatient discharge; an all-hospitalization readmission (AHR) measure, which captures any unplanned hospitalization following any hospital discharge (observation stays are included in both the numerator and denominator of the measure …

Objective:To examine the association between SNF BPCI participation and patient outcomes and across-facility differences in these outcomes among Medicare beneficiaries undergoing lower extremity joint replacement (LEJR).

Administrativeriskadjustmentmodelsarewidelyused in health care and substantially affect spending, allocation of resources, and health equity. In the Medicare program, quality reporting, value-based and alternative payment models, and Medicare Advantage payments all rely on the same underlying model. However, despite advances in machine learning methods, here referring both to complex modeling approaches and to rigorous statistical practices developed by computer scientists and biostatisticians, the risk adjustment models used in Medicare have not been meaningfully updated. This Viewpoint reviews the current state of these models in the Medicare program and makes concrete suggestions for their modernization.Historical Perspective The Centers for Medicare & Medicaid Services Hierarchical Condition Categories (CMS-HCC) model is a paradigmatic administrative risk model first developed in 2004 …

Background Hypertrophic cardiomyopathy (HCM) is the most common heritable cardiac disease. In small studies, sociodemographic factors have been associated with disparities in septal reduction therapy, but little is known about the association of sociodemographic factors with HCM treatments and outcomes more broadly. Methods and Results Using the National Inpatient Survey from 2012 to 2018, HCM diagnoses and procedures were identified by International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification (ICD‐9‐CM and ICD‐10‐CM) codes. Logistic regression was used to determine the association of sociodemographic risk factors with HCM procedures and in‐hospital death, adjusting for clinical comorbidities and hospital characteristics. Of 53 117 patients hospitalized with HCM, 57.7% were women, 20.5% were Black individuals, 27.7% lived in the lowest zip income quartile, and …

OBJECTIVES: We aimed to describe the experience of a state Medicaid agency incentivizing reduction of racial and ethnic disparities in a hospital quality incentive program (QIP). STUDY DESIGN: Retrospective review of a decade of experience implementing a hospital health disparity (HD) composite measure. METHODS: Observational analysis of programwide trends in missed opportunity rates and between-group variance (BGV) for the HD composite from 2011 to 2020 and subanalysis of 16 metrics included in the HD composite for at least 4 years over the decade. RESULTS: Programwide missed opportunity rates and BGV fluctuated widely from 2011 to 2020, likely due to variation in measures included in the HD composite. When the 16 measures that were included in the HD composite for at least 4 years were collapsed into a hypothetical 4-year period, missed opportunity rates decreased across the 4 …

Over the past 2 decades, the US government has steadily shifted care for Medicare beneficiaries into value-based payment models. Central to their success is the ability to measure and pay fairly for performance on quality measures, including clinical outcome measures. While there is broad consensus that outcome measures, such as age and comorbidities, should be adjusted for clinical risk, there is considerable controversy regarding whether they should be adjusted for social risk. Proponents of social risk adjustment argue that failure to account for social factors that are independently associated with health outcomes leads to fundamentally inaccurate characterization of clinicians’ performance and inappropriately penalizes those caring for historically marginalized patients. 1 Opponents of social risk adjustment argue that it obscures disparities, reduces incentives to invest in efforts that improve equity, and …

BACKGROUND Traditional cardiac rehabilitation (CR) improves cardiovascular outcomes and reduces mortality, but less is known about the relative benefit of intensive CR (ICR) which incorporates greater lifestyle education through 72 sessions (versus 36 in CR). Our objective was to determine whether ICR is associated with a mortality and cardiovascular benefit compared with CR. METHODS Retrospective cohort study of Medicare Fee-For-Service beneficiaries in a 100% sample, claims data set. Qualifying events were captured from May 1, 2016 to December 31, 2019 and ICR/CR utilization captured from May 1, 2016 to December 31, 2020. Among patients attending at least 1 day of either CR or ICR, Cox proportional hazards models using a 1 to 5 propensity score match were used to compare utilization and the association of ICR versus CR participation with (1) all-cause mortality and (2) cardiovascular …

Heart failure (HF) is a common and highly morbid condition that impacts more than 65 million patients worldwide, including more than 6 million patients in the United States, and it leads to more than $30 billion in annual health care spending. 1 One of the most important tools we have as clinicians to improve outcomes in this disease is the use of highly effective guideline-directed medical therapy (GDMT) using clinical trial–proven medications. However, several prior studies have shown that use of GDMT is suboptimal; the CHAMP-HF (Change the Management of Patients with Heart Failure) registry showed that< 1% of patients at 12 months of followup were on target doses of all 3 medication classes. 2 One facet of GDMT delivery that has been less well understood is where and when these medications should be initiated and titrated. In this issue of JACC: Heart Failure, Swat et al 3 examine this important question …

Cardiovascular disease (CVD) is the leading cause of death in the US1, 2 and is responsible for extensive costs to the health care system. 2 Although CVD mortality rates declined over the past several decades in the US, this decline has recently stagnated. 1, 3 Additionally, population-level increases in CVD risk factors and aging of the population threaten to further undermine progress. 1, 2 Key clinical guideline recommendation changes to chronic CVD treatment have been implemented over the past 10 years aiming to lower atherosclerotic CVD (ASCVD) risk in the US. 4, 5 In 2013, the American College of Cardiology/American Heart Association recommended statin use for primary prevention of CVD among adults with a 10-year predicted ASCVD risk greater than or equal to 7.5% calculated using the pooled cohort equations. 4, 6 In 2017, the American College of Cardiology/American Heart Association …

The global COVID-19 pandemic has generated enormous morbidity and mortality, as well as large health system disruptions including changes in use of prescription medications, outpatient encounters, emergency department admissions, and hospitalizations. These pandemic-related disruptions are reflected in real-world data derived from electronic medical records, administrative claims, disease or medication registries, and mobile devices. We discuss how pandemic-related disruptions in healthcare utilization may impact the conduct of noninterventional studies designed to characterize the utilization and estimate the effects of medical interventions on health-related outcomes. Using hypothetical studies, we highlight consequences that the pandemic may have on study design elements including participant selection and ascertainment of exposures, outcomes, and covariates. We discuss the implications of these …

BackgroundThe sodium-glucose cotransporter-2 (SGLT-2) inhibitors form the latest pillar in the management of heart failure with reduced ejection fraction (HFrEF) and appear to be effective across a range of patient profiles. There is increasing interest in initiating SGLT-2 inhibitors during hospitalization, yet little is known about the putative benefits of this implementation strategy.MethodsWe evaluated Medicare beneficiaries with HFrEF (≤ 40%) hospitalized at 228 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry in 2016 who had linked claims data for ≥ 1 year postdischarge. We identified those eligible for dapagliflozin under the latest U.S. Food and Drug Administration label (excluding estimated glomerular filtration rates < 25 mL/min per 1.73 m2, dialysis and type 1 diabetes). We evaluated 1-year outcomes overall and among key subgroups (age ≥ 75 years, gender, race, hospital region …

Objective To assess recent trends in age adjusted mortality rates (AAMRs) in the United States based on county level presidential voting patterns.Design Cross sectional study.Setting USA, 2001-19.Participants 99.8% of the US population.Main outcome measures AAMR per 100 000 population and average annual percentage change (APC).Methods The Centers for Disease Control and Prevention WONDER database was linked to county level data on US presidential elections. County political environment was classified as either Democratic or Republican for the four years that followed a November presidential election. Additional sensitivity analyses analyzed AAMR trends for counties that voted only for one party throughout the study, and county level gubernatorial election results and state level AAMR trends. Joinpoint analysis was used to assess for an inflection point in APC trends.Results The study period …

BackgroundSurvival rates following in-hospital cardiac arrest (IHCA) are lower during nights and weekends (off-hours), as compared to daytime on weekdays (on-hours). Telemedicine Critical Care (TCC) may provide clinical support to improve IHCA outcomes, particularly during off-hours.ObjectiveTo evaluate the association between hospital availability of TCC and IHCA survival.MethodsWe identified 44,585 adults at 280 U.S. hospitals in the Get With The Guidelines® - Resuscitation registry who suffered IHCA in an Intensive Care Unit (ICU) or hospital ward between July 2017 and December 2019. We used 2-level hierarchical multivariable logistic regression to investigate whether TCC availability was associated with better survival, overall, and during on-hours (Monday–Friday 7:00 a.m.-10:59p.m.) vs. off-hours (Monday–Friday 11:00p.m.-6:59 a.m., and Saturday-Sunday, all day, and US national holidays …

Within the United States, rural-urban disparities in cardiovascular disease and resulting mortality have widened over time. 1 When compared with their urban counterparts, rural residents experience higher rates of cardiovascular disease and mortality for acute cardiovascular conditions such as myocardial infarction, heart failure, and stroke. 1, 2 These inequities are partly driven by hospital-level differences in quality of care, worse access to emergency services, and barriers to accessing posthospitalization medical services in rural areas. 1, 2 Delays in medical care can be particularly devastating, especially for rural residents experiencing ST-segment elevation myocardial infarction (STEMI), which relies on swift detection and timely intervention to improve survival. 3 While patients typically receive greater benefit from rapid reperfusion by primary percutaneous coronary intervention (PCI), rural hospitals often lack …

Introduction: Cardiac rehabilitation (CR) improves outcomes after acute myocardial infarction (AMI). The Bundled Payments for Care Improvement Advanced (BPCI-A) program holds participating hospitals accountable for all costs incurred within 90 days of discharge. There is concern that this financial incentive will lead participants to cut back on high-value care, including CR, in order to meet cost targets. We examined whether patients discharged from BPCI-A participating hospitals after an AMI had lower CR utilization compared to non-participating hospitals. Methods: We included patients from a 100% sample of fee-for-service Medicare beneficiaries discharged home after a hospitalization for AMI during a baseline period (January 1, 2016 to December 31, 2017) or an intervention period (October 1, 2018 to September 30, 2019). Our exposure was discharge from a hospital participating in BPCI-A. Our outcomes …

There are profound and widening racial disparities in maternal morbidity and mortality in the United States, including a 4-to 5-fold increased risk of poor maternal outcomes in Black women compared to White women. 1–3 A substantial proportion of adverse maternal outcomes are believed to be cardiovascular in nature; data from 13 Maternal Mortality Review Committees (MMRC) across the United States indicate that more than a third of maternal deaths are cardiovascular-related. 4 However, less is known about the frequency of nonfatal cardiovascular events, nor regarding which specific types of cardiovascular disease are the primary drivers of racial inequities, which has implications for designing interventions to address them.Therefore, the goal of this study was to fill these important knowledge gaps by answering 3 research questions:(1) What are the rates of total cardiovascular hospitalizations in the first year …

Background Excess mortality from cardiovascular disease during the COVID‐19 pandemic has been reported. The mechanism is unclear but may include delay or deferral of care, or differential treatment during hospitalization because of strains on hospital capacity. Methods and Results We used emergency department and inpatient data from a 12‐hospital health system to examine changes in volume, patient age and comorbidities, treatment (right‐ and left‐heart catheterization), and outcomes for patients with acute myocardial infarction (AMI) and heart failure (HF) during the COVID‐19 pandemic compared with pre‐COVID‐19 (2018 and 2019), controlling for seasonal variation. We analyzed 27 427 emergency department visits or hospitalizations. Patient volume decreased during COVID‐19 for both HF and AMI, but age, race, sex, and medical comorbidities were similar before and during COVID‐19 for both …

The Centers for Medicare & Medicaid Services (CMS) is moving increasingly toward alternative payment models that incentivize high-quality, low-cost care. Bundled payments, for example, now cover medical, procedural, and therapeutic episodes, from a broad range of medical and surgical conditions in Bundled Payments for Care Improvement Advanced (BPCI-A); to hip and knee replacements in the Comprehensive Care for Joint Replacement Model (CJR); to chemotherapy administration in the Oncology Care Model (OCM). Bundled payments encourage cost efficiency by setting a total spending benchmark for all services associated with a clinical “episode.” In the full riskbearing phase of these and other similar programs, if model participants reduce average costs below their benchmark, CMS rewards them with a financial bonus; if their costs exceed the benchmark, they owe CMS a penalty payment.Many feel …

Background Black adults experience a disproportionately higher burden of cardiovascular risk factors and disease in comparison with White adults in the United States. Less is known about how sex-based disparities in cardiovascular mortality between these groups have changed on a national scale over the past 20 years, particularly across geographic determinants of health and residential racial segregation. Methods We used CDC WONDER (Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research) to identify Black and White adults age ≥25 years in the United States from 1999 to 2019. We calculated annual age-adjusted cardiovascular mortality rates (per 100 000) for Black and White women and men, as well as absolute rate differences and rate ratios to compare the mortality gap between these groups. We also examined patterns by US census region, rural …

Accountable Care's Reach in Medicare. Reply. - Abstract - Europe PMC Sign in | Create an account https://orcid.org Europe PMC Menu About Tools Developers Help Contact us Helpdesk Feedback Twitter Blog Tech blog Developer Forum Europe PMC plus Search life-sciences literature (41,208,796 articles, preprints and more) Search Advanced search Feedback This website requires cookies, and the limited processing of your personal data in order to function. By using the site you are agreeing to this as outlined in our privacy notice and cookie policy. Abstract Full text Citations & impact Accountable Care's Reach in Medicare. Reply. Gondi S 1 , Joynt Maddox K 2 , Wadhera RK 3 Author information Affiliations 1 author 1. Brigham and Women's Hospital, Boston, MA. 1 author 2. Washington University School of Medicine, St. Louis, MO. 1 author 3. Beth Israel Deaconess Medical Center, Boston, MA. The New England …

ImportanceDecreases in 30-day readmissions following the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP) have occurred against the backdrop of increasing hospital observation stay use, yet observation stays are not captured in readmission measures.ObjectiveTo examine whether the HRRP was associated with decreases in 30-day readmissions after accounting for observation stays.Design, Setting, and ParticipantsThis retrospective cohort study included a 20% sample of inpatient admissions and observation stays among Medicare fee-for-service beneficiaries from January 1, 2009, to December 31, 2015. Data analysis was performed from November 2021 to June 2022. A differences-in-differences analysis assessed changes in 30-day readmissions after the announcement of the HRRP and implementation of penalties for target conditions (heart failure, acute myocardial …

Introduction: The gold standard risk prediction tool for atherosclerotic cardiovascular disease (ASCVD), the Pooled Cohort Equations (PCE) underestimates risk among the socially disadvantaged, yet social determinants of health are absent from the PCE. This may be contributing to racial inequities in CVD since due to systemic and structural racism, socioeconomic disadvantage is disproportionately concentrated in African American (AA) communities. This analysis aimed to determine whether SDOH variables were important for the prediction of 10-year ASCVD risk in a large cohort of AA and to test whether the addition of these variables improved PCE model performance. Methods: Retrospective observational study of 3,470 Jackson Heart Study (JHS) participants aged 40-79 years old without prior ASCVD at baseline study visit. 10-year ASCVD event was defined as stroke, MI, or death from MI. First, we used …

odds of undergoing EGD. On weighted multivariable analysis, Black (OR 0.82; CI 0.78-0.87), Native American (OR 0.60; CI 0.47-0.76), and Medicaid (OR 0.74; CI 0.70-0.79) patients had lower odds of undergoing EGD (Table 2). In comparison, increasing age and median income by zip code, Asian race (OR 1.69; CI 1.48-1.92), and receiving care in an urban teaching-hospital (OR 1.05; CI 1.00-1.10) were independent predictors for undergoing EGD. On stratified analysis Black race was associated with lower odds of undergoing EGD in urban-teaching hospitals (OR 0.79; CI 0.75-0.85) and urban non-teaching hospitals (OR 0.87; CI 0.77-0.98), while Hispanic ethnicity is associated with lower odds of undergoing EGD in rural hospitals (OR 0.49; CI 0.34-0.72). Conclusions: Vulnerable patient populations including Black, Native American, Medicaid and those receiving care in a rural hospital are independently …

Methods| We used a 100% sample of outpatient, emergency department, and laboratory claims for fee-for-service Medicare beneficiaries with a new COVID-19 diagnosis or confirmed exposure between November 2020 (first month of mAb availability) and August 2021. Beneficiaries hospitalized or deceased within 7 days of COVID-19 diagnosis, who were less likely to have mild to moderate disease and be eligible for mAb therapy, were excluded. We identified mAb infusions with Current Procedural Terminology codes (Q0239, Q0243-7, M0239, M0243-8) and classified COVID-19 diagnosis using International Classification of Diseases, Ninth Revision codesU07. 1, B97. 29, and Z20. 828 (exposure to confirmed COVID-19). Among nonhospitalized patients with a COVID-19 diagnosis, we compared rates of mAb receipt by age, sex, race and ethnicity, Medicaid eligibility, region, number of chronic conditions, reason …

“REACHing” for Equity Recent value-based payment models have often moved dollars away from patients and providers with fewer resources and toward those with more. A new model names promoting equity as a central goal.

ImportanceDuring the COVID-19 pandemic, the US federal government required that skilled nursing facilities (SNFs) close to visitors and eliminate communal activities. Although these policies were intended to protect residents, they may have had unintended negative effects.ObjectiveTo assess health outcomes among SNFs with and without known COVID-19 cases.Design, Setting, and ParticipantsThis retrospective observational study used US Medicare claims and Minimum Data Set 3.0 for January through November in each year beginning in 2018 and ending in 2020 including 15 477 US SNFs with 2 985 864 resident-years.ExposuresJanuary through November of calendar years 2018, 2019, and 2020. COVID-19 diagnoses were used to assign SNFs into 2 mutually exclusive groups with varying membership by month in 2020: active COVID-19 (≥1 COVID-19 diagnosis in the current or past month) or no …

Medicare’s Bundled Payments for Care Improvement Advanced Model (BPCI-A) is a voluntary Alternative Payment Model in which participating hospitals are held accountable for ninety-day episodes of care. To meet spending targets, hospitals must either decrease utilization or attract a less sick patient population; this could lead to the elimination of necessary care or avoidance of patients with medical or social vulnerability. We used publicly available data on BPCI-A participation, along with Medicare claims from the period 2017–19, to examine patient selection, changes in Medicare payment, and key clinical outcomes among three groups: patients with frailty, patients with multimorbidity, and patients with dual enrollment (both Medicare and Medicaid). We found no consistent change in patient selection associated with BPCI-A participation. Patients with frailty, multimorbidity, or dual enrollment were more …

Introduction: In October 2018, the heart allocation policy for adult heart transplant (OHTx) in the United States was changed, with the goal of reducing waitlist mortality and providing broader sharing of donor organs within the United States. The aim of this study was to assess the effect of this policy change on access to OHTx vs LVAD, overall and among key sociodemographic subgroups, in the US from 2016 to 2019. Hypothesis: We hypothesized that the UNOS heart allocation policy would increase OHTx volume overall as well as use of temporary mechanical circulatory support. Methods: We identified all patients receiving OHTx or LVAD between 2016-2019 using the National Inpatient Sample. Controlling for medical comorbidities, trends over time, and within hospital-year effects, we fit a dynamic logistic regression model to evaluate patient and hospital factors associated with receiving OHTx vs LVAD pre- versus …

Equity Implications of Hospital Penalties During 4 Years of the Comprehensive Care for Joint Replacement Model, 2016 to 2019 | Health Policy | JAMA Health Forum | JAMA Network [Skip to Navigation] Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Network Home JAMA Health Forum HomeNew OnlineIssuesFor Authors Podcast Journals JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American …

Purpose:Intensive cardiac rehabilitation (ICR) was developed to enhance traditional cardiac rehabilitation (CR) by adding sessions focused on nutrition, lifestyle behaviors, and stress management. Intensive CR has been Medicare-approved since 2010, yet little is known about national utilization rates of ICR in the Medicare population or characteristics associated with its use.Methods:A 5% sample of Medicare claims data from 2012 to 2016 was used to identify beneficiaries with a qualifying indication for ICR/CR and to quantify utilization of ICR or CR within 1 yr of the qualifying diagnosis.Results:From 2012 to 2015, there were 107 246 patients with a qualifying indication. Overall, only 0.1% of qualifying patients participated in ICR and 16.2% in CR from 2012 to 2016, though utilization rates of both ICR and CR increased during this period (ICR 0.06 to 0.17%, CR 14.3 to 18.2%). The number of ICR centers …

ImportanceMedicare’s Merit-Based Incentive Payment System (MIPS) is a new, mandatory, outpatient value-based payment program that ties reimbursement to performance on cost and quality measures for many US clinicians. However, it is currently unknown how the program measures the performance of psychiatrists, who often treat a different patient case mix with different clinical considerations than do other outpatient clinicians.ObjectiveTo compare performance scores and value-based reimbursement for psychiatrists vs other outpatient physicians in the 2020 MIPS.Design, Setting, and ParticipantsIn this cross-sectional study, the Centers for Medicare & Medicaid Services Provider Data Catalog was used to identify outpatient Medicare physicians listed in the National Downloadable File between January 1, 2018, and December 31, 2020, who participated in the 2020 MIPS and received a publicly reported final …

Health care disparities occur across a broad range of dimensions but are often viewed through the lens of race, ethnicity, sex, and socioeconomic status. Equally important but less well recognized are disparities related to geographic location. Across many health conditions, including acute cardiovascular diseases, there is a health disadvantage in rural areas compared with urban and suburban locations. 1 In the US, cardiovascular mortality rates are higher in rural communities compared with urban areas owing to a greater burden of traditional and socioeconomic risk factors, poorer access to health care, and lower quality of care. 2 ST-segment elevation myocardial infarction (STEMI), one of the most common cardiac emergencies, clearly illustrates this dilemma. 3 Like other emergencies, STEMI outcomes depend critically on early recognition and timely treatment, which in most rural hospitals involves primary …

Excludes participants who reported not needing accommodations (ie, those who replied “I did not request accommodations because I feel I do not need accommodations” to the survey question “Which of the following best describes why your medical school did not or has not provided accommodations?”). a Statistically significantly lower proportion of students who requested accommodations than the other groups (χ2 2= 13.7; P=. 001).

Importance Bundled Payments for Care Improvement Advanced (BPCI-A) is a Centers for Medicare & Medicaid Services (CMS) initiative that aims to produce financial savings by incentivizing decreases in clinical spending. Incentives consist of financial bonuses from CMS to hospitals or penalties paid by hospitals to CMS. Objective To investigate the association of hospital participation in BPCI-A with spending, and to characterize hospitals receiving financial bonuses vs penalties. Design, Setting, and Participants Difference-in-differences and cross-sectional analyses of 4 754 139 patient episodes using 2013-2019 US Medicare claims at 694 participating and 2852 nonparticipating hospitals merged with hospital and market characteristics. Exposures BPCI-A model years 1 and 2 (October 1, 2018, through December 31, 2019). Main Outcomes and Measures Hospitals’ per-episode spending, CMS gross and net …

Introduction: Black individuals have higher hospitalization and mortality rates from heart failure (HF). Black adults receive care at a limited set of US hospitals (minority-serving hospitals [MSH]) and understanding quality of care at these sites could inform efforts to improve health equity. Using the Get With The Guidelines (GWTG) - HF Registry, we compared HF care quality and clinical outcomes at MSH vs. non-MSH. Methods: We identified adults ≥18 years hospitalized for HF at GWTG-HF sites. MSH were defined as the top quintile of proportion of hospitalizations for Black adults. We compared performance on GWTG-HF quality measures at MSH vs. non-MSH, adjusting for age, sex, comorbidities, and hospital characteristics, using GEE to account for clustering within sites. After restricting to adults ≥65 years and linking to Medicare FFS claims, we used multivariable Cox proportional hazard models to compare post …

ImportanceWhether people from racial and ethnic minority groups experience disparities in access to minimally invasive mitral valve surgery (MIMVS) is not known.ObjectiveTo investigate racial and ethnic disparities in the utilization of MIMVS.Design, Setting, and ParticipantsThis cross-sectional study used data from the Society of Thoracic Surgeons Database for patients who underwent mitral valve surgery between 2014 and 2019. Statistical analysis was performed from January 24 to August 11, 2022.ExposuresPatients were categorized as non-Hispanic White, non-Hispanic Black, and Hispanic individuals.Main Outcomes and MeasuresThe association between MIMVS (vs full sternotomy) and race and ethnicity were evaluated using logistic regression.ResultsAmong the 103 753 patients undergoing mitral valve surgery (mean [SD] age, 62 [13] years; 47 886 female individuals [46.2%]), 10 404 (10.0%) were …

ImportanceAs 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.ObjectiveTo investigate the association between PE acquisition of ACHs and access to care, patient outcomes, and spending among Medicare beneficiaries hospitalized with acute medical conditions.Design, Setting, and ParticipantsThis 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 …

The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with high readmission rates. In fiscal year 2019 the program was changed to account for the association between social risk and high readmission rates. The new approach stratifies hospitals into five groups by hospitals’ proportion of patients dually enrolled in Medicare and Medicaid, and it evaluates performance within each stratum instead of within the national cohort. Its impact on hospitals caring for vulnerable populations has not been studied. We calculated the change in average annual penalty percentage, before and after stratification, for safety-net hospitals, rural hospitals, and hospitals caring for a high share of Black and Hispanic or Latino patients. We found that stratification by proportion of dual enrollees was associated with a decrease in penalties by −0.09 percentage points at hospitals with the highest …

ImportanceThe COVID-19 pandemic caused significant disruptions in surgical care. Whether these disruptions disproportionately impacted economically disadvantaged individuals is unknown.ObjectiveTo evaluate the association between the COVID-19 pandemic and mortality after major surgery among patients with Medicaid insurance or without insurance compared with patients with commercial insurance.Design, Setting, and ParticipantsThis cross-sectional study used data from the Vizient Clinical Database for patients who underwent major surgery at hospitals in the US between January 1, 2018, and May 31, 2020.ExposuresThe hospital proportion of patients with COVID-19 during the first wave of COVID-19 cases between March 1 and May 31, 2020, stratified as low (≤5.0%), medium (5.1%-10.0%), high (10.1%-25.0%), and very high (>25.0%).Main Outcomes and MeasuresThe main outcome was inpatient …

ImportanceThe Medicare Shared Savings Program provides financial incentives for accountable care organizations (ACOs) to reduce costs of care. The structure of the shared savings program may not adequately adjust for challenges associated with caring for patients with high medical complexity and social needs, a population disproportionately made up of racial and ethnic minority groups. If so, ACOs serving racial and ethnic minority groups may be more likely to exit the program, raising concerns about the equitable distribution of potential benefits from health care delivery reform efforts.ObjectiveTo evaluate whether ACOs with a high proportion of beneficaries of racial and ethnic minority groups are more likely to exit the Medicare Shared Savings Program and identify characteristics associated with this disparity.Design, Setting, and ParticipantsThis retrospective observational cohort study used secondary data …

In 2012, the Centers for Medicare and Medicaid Services launched the End-Stage Renal Disease Quality Incentive Program (ESRD QIP), a value-based payment program in which dialysis facilities were held accountable for quality measures and outcomes for patients attributed to their care. 1 The focus on ESRD patients was intentional; patients receiving dialysis in the United States have high costs, estimated at $90,602 annually in 2017, and high rates of morbidity and mortality. This group of patients is also important from a racial health equity standpoint, as US Medicare dialysis patients are 36% Black and 16% Hispanic compared with 10% and 9% in the general Medicare population, respectively. 2, 3 Furthermore, this population is important from a socioeconomic-based health equity standpoint; Medicare patients receiving dialysis have high rates of poverty, as reflected in the rates of dual enrollment in …

Introduction: Therapeutic hypothermia is a guideline-recommended treatment for certain unresponsive patients after a cardiac arrest. However, the degree to which patients with cardiac arrest have access to this therapy on a national level is unknown. Understanding hospital- and patient-level factors associated with receipt of hypothermia could inform interventions to improve access to this treatment among appropriate patients. Methods: This was a retrospective analysis using National Inpatient Sample data from 2016-2019. We used ICD10 diagnosis and procedure codes to identify adult patients with in-hospital and out-of-hospital cardiac arrest and receipt of therapeutic hypothermia. We used logistic regression with GEE clustering on hospital-year, and controlling for medical comorbidities, to evaluate patient and hospital factors associated with receiving therapeutic hypothermia. Results: We identified 478,419 …

ImportanceThe Medicare alternative payment models are designed to incentivize cost reduction and quality improvement, but there are no requirements established for evaluating the outcomes of the Medicare populations.ObjectiveTo examine whether participation in the Medicare Bundled Payments for Care Improvement Advanced (BPCI-A) program was associated with narrowing or widening of Black and White racial inequities in outcomes and access.Design, Setting, and ParticipantsRetrospective cohort alternative payment models on equity and quality for disadvantaged populations were studied between April 6, 2021, and August 28, 2022, in US hospitals. Black and White Medicare beneficiaries admitted for any of the 29 inpatient conditions in the BPCI-A program between January 1, 2017, and September 31, 2019, were included.ExposuresBPCI-A participation implemented in 2018.Main Outcomes and …