What Causes Failures in Personal Protective Equipment Use in Hospitals?

MedicalResearch.com Interview with:

Sarah L. Krein, PhD, RN Research Career Scientist VA Ann Arbor Healthcare System Ann Arbor, MI 

Sarah L. Krein, PhD, RN
Research Career Scientist
VA Ann Arbor Healthcare System
Ann Arbor, MI

MedicalResearch.com: What is the background for this study?

Response: We conducted this study to better understand the challenges faced by health care personnel when trying to follow transmission based precaution practices while providing care for hospitalized patients.  We already know from other studies that there are breaches in practice but our team was interested in better understanding why and how those breaches (or failures) occur so we can develop better strategies to ensure the safety of patients and health care personnel.

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Maryland’s Global Budget Plan Did Not Change Hospital or Primary Care Usage

MedicalResearch.com Interview with:

Eric T. Roberts, PhD Assistant Professor of Health Policy & Management University of Pittsburgh Graduate School of Public Health Pittsburgh, PA 15261

Dr. Roberts

Eric T. Roberts, PhD
Assistant Professor of Health Policy & Management
University of Pittsburgh Graduate School of Public Health
Pittsburgh, PA 15261

MedicalResearch.com: What is the background for this study?

Response: There is considerable interest nationally in reforming how we pay health care providers and in shifting from fee-for-service to value-based payment models, in which providers assume some economic risk for their patients’ costs and outcomes of care.  One new payment model that has garnered interest among policy makers is the global budget, which in 2010 Maryland adopted for rural hospitals.  Maryland subsequently expanded the model to urban and suburban hospitals in 2014.  Maryland’s global budget model encompasses payments to hospitals for inpatient, emergency department, and hospital outpatient department services from all payers, including Medicare, Medicaid, and commercial insurers.  The intuition behind this payment model is that, when a hospital is given a fixed budget to care for the entire population it serves, it will have an incentive to avoid costly admissions and focus on treating patients outside of the hospital (e.g., in primary care practices).  Until recently, there has been little rigorous evidence about whether Maryland’s hospital global budget model met policy makers’ goals of reducing hospital use and strengthening primary care.

Our Health Affairs study evaluated how the 2010 implementation of global budgets in rural Maryland hospitals affected hospital utilization among Medicare beneficiaries.  This study complements work our research group published in JAMA Internal Medicine (January 16, 2018) that examined the impact of the statewide program on hospital and primary care use, also among Medicare beneficiaries.

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Substituting Less Well Trained Assistants For Nurses Increased Hospital Mortality

MedicalResearch.com Interview with:

Dr Linda H Aiken PhD, FAAN, FRCN, RN Claire M. Fagin Leadership Professor in Nursing Professor of Sociology, School of Arts & Sciences Director, Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing Center for Health Outcomes and Policy Research Philadelphia, PA 19104

Dr Linda H Aiken

Dr Linda H Aiken PhD, FAAN, FRCN, RN
Claire M. Fagin Leadership Professor in Nursing
Professor of Sociology, School of Arts & Sciences
Director, Center for Health Outcomes and Policy Research
University of Pennsylvania School of Nursing
Center for Health Outcomes and Policy Research
Philadelphia, PA 19104

MedicalResearch.com: What is the background for this study?

Response: The idea that adding lower skilled and lower wage caregivers to hospitals instead of increasing the number of professional nurses could save money without adversely affecting care outcomes is intuitively appealing to mangers and policymakers but evidence is lacking on whether this strategy is safe or saves money.
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Safety-Net Hospitals Show Improvement in Hospital Readmissions, Modifications To Penalty Formula Still Needed

MedicalResearch.com Interview with:

Kathleen Carey, Ph.D. Professor, Department of Health Law, Policy and Management School of Public Health Boston University Boston MA  02118

Dr. Kathleen Carey

Kathleen Carey, Ph.D.
Professor, Department of Health Law, Policy and Management
School of Public Health
Boston University
Boston MA

MedicalResearch.com: What is the background for this study? What are the main findings?
Response: The ACA’s Hospital Readmissions Reduction Program (HRRP) imposes Medicare reimbursement penalties on hospitals with readmission rates for certain conditions if they exceed national averages. A number of observers have expressed serious concern over the program’s impact on safety-net hospitals, which serve a high proportion of low income patients who are more likely to be readmitted – often for reasons outside hospital control. Many have argued that the HRRP should adjust for socio-economic status. However, Medicare does not want to lower the standard of quality for these hospitals.

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Many Seniors Carry Superbugs Home From the Hospital

MedicalResearch.com Interview with:
Lona Mody, MD, MS
Veterans Affairs Healthcare System, Geriatric Research, Education, and Clinical Center
Division of Geriatric and Palliative Medicine, University of Michigan Medical School,
School of Public Health
University of Michigan, Ann Arbor

MedicalResearch.com: What is the background for this study?

Dr. Mody: Hand hygiene is considered to be the most important strategy to prevent infections and spread of drug resistant organisms. Surprisingly, all strategies and efforts have predominantly involved healthcare workers and that too mainly in acute care hospitals.  We are now facing a tsunami of an aging population in our hospitals, post-acute care facilities and long-term care facilities.  Hand hygiene falls off when patients are hospitalized compared to when they are at home.  So, we were very interested, first, in hand colonization in older patients who have recently been transferred from the acute care hospital to a post-acute care (PAC) facility for rehabilitation or other medical care before fully returning home. We were also interested in evaluating whether these organisms persisted.

MedicalResearch.com: What are the main findings?

Dr. Mody: We recruited and followed 357 patients (54.9 percent female with an average age of 76 years). The dominant hands of patients were swabbed at baseline when they were first enrolled in a post-acute care facility, at day 14 and then monthly for up to 180 days or until discharge.

The study found:

  • To our surprise, nearly one-quarter (86 of 357) of patients had at least one multi-drug resistant organism on their hands when they were transferred from the hospital to the post-acute care facility
  • During follow-up, 34.2 percent of patients’ hands (122 of 357) were colonized with a resistant organism and 10.1 percent of patients (36 of 357) newly acquired one or more resistant organisms.
  • Overall, 67.2 percent of colonized patients (82 of 122) remained colonized at discharge from PAC.

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Skilled Nursing and Readmissions Drive Up Post Hospital Discharge Spending

MedicalResearch.com Interview with:
Anup Das

Medical Scientist Training Program
Department of Health Management and Policy
University of Michigan, Ann Arbor

Medical Research: What is the background for this study? What are the main findings?

Response: The Centers for Medicare & Medicaid Services (CMS) recently added a new measure of episode spending to the Hospital Value Based Purchasing program. Participation in this program allows hospitals to receive a financial bonus if they perform well on the included measures. This is the first spending measure in the program, and this change now incentivizes hospitals to improve their quality as well as their spending. The measure evaluates spending from three days before a hospitalization through 30 days post-discharge.

In this study, we find that while high-cost hospitals had higher spending levels in each of the three components of an episode of care (pre-admission, index admission, and post-discharge), differences in post-discharge spending were the main determinants of hospital performance on this measure. High-cost hospitals spent on average $4,691 more than low-cost hospitals in post-discharge care. The majority of post-discharge spending comes from skilled nursing facility or readmission costs. Similarly, hospitals that did worse on this new measure of spending over time did so because of increases in their post-discharge spending.

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Mission of Safety Net Hospitals Prevents Streamlining Health Care

Richard S. Hoehn, MD Division of Transplant Surgery Department of Surgery, University of Cincinnati School of Medicine Cincinnati, OHMedicalResearch.com Interview with:
Richard S. Hoehn, MD
Division of Transplant Surgery
Department of Surgery
University of Cincinnati School of Medicine
Cincinnati, OH

Medical Research: What is the background for this study? What are the main findings?

Dr. Hoehn: Safety-net hospitals are hospitals that either have a stated purpose of maintaining an “open door policy” to all patients, regardless of their ability to pay, or simply have a significantly high burden of patients with Medicaid or no insurance. As healthcare policy and reimbursement change to focus on both “quality” metrics as well as cost containment, these hospitals may find themselves in a precarious situation. Current literature suggests that increased safety-net burden corresponds to inferior surgical outcomes. If this is true, safety-net hospitals will have inferior outcomes and suffer more financial penalties than other centers. This decrease in resources may adversely affect patient care, leading to even worse outcomes and further financial penalties, potentially creating a downward spiral that exacerbates disparities in surgical care that already exist in our country.

Medical Research: What are the main findings?

Dr. Hoehn: Our study analyzed 9 major surgical operations using the University HealthSystem Consortium clinical database, which represents 95% of academic medical centers in the United States. We sought to determine the effect of patient and hospital characteristics on the inferior outcomes at safety-net hospitals. As expected, we found that safety-net hospitals had higher rates of patients who were of black race, of lowest socioeconomic status, had government insurance, had extreme severity of illness, and needed emergent operations. They also had the highest rates of post-operative mortality, 30-day readmissions, and highest costs associated with care.

Next we performed a multivariate analysis controlling for patient age, race, socioeconomic status, and severity of illness, as well as hospital procedure-specific volume. Using this model, we found that the increased mortality and readmission rates at safety-net hospitals were somewhat reduced, but the increased costs were not affected. Safety-net hospitals still provided surgical care that was 23-35% more expensive, despite controlling for patient characteristics. This suggests that intrinsic hospital characteristics may be responsible for the increased costs at safety-net hospitals.

To further investigate this finding, we analyzed Medicare Hospital Compare data and found that safety-net hospitals performed worse on Surgical Care Improvement Project (SCIP) measures, had higher rates of reported surgical complications, and also had much slower measures of emergency department throughput (time from arrival to evaluation, treatment, admission, etc). This corresponded with our finding that hospital characteristics may be driving increased costs at safety-net hospitals.

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Lump Sum Payments To Long-term Care Hospitals May Have Created Incentive To Discharge Patients

Yan S. Kim, MD PhD Delivery Science Fellow Division of Research Kaiser Permanente Northern California Oakland, CA 94612MedicalResearch.com Interview with:
Yan S. Kim, MD PhD
Delivery Science Fellow Division of Research
Kaiser Permanente Northern California
Oakland, CA 94612

Medical Research: What is the background for this study? What are the main findings?

Dr. Kim: Long-term care hospitals first emerged in the 1980s as an alternative to lengthy acute-care hospital stays for patients with complex medical problems who need prolonged hospital-level care.  In 2002, Medicare changed its payment method for these facilities from cost-based to a lump sum per admission based on the diagnosis.  Under this system, which is still in place, Medicare pays these hospitals a higher rate for patients who stay a minimum number of days based on the patient’s condition.  Shorter stays are paid much less and longer stays do not necessary generate higher reimbursements.

Using Medicare data, we analyzed a national sample of patients who required prolonged mechanical ventilation – the most common, and among the most costly, conditions for patients in long-term care hospitals – to examine whether this payment policy has created incentives to base discharge decisions on payments.  We found that in the years after the policy’s implementation there was a substantial spike in the percentage of discharges on and immediately after the minimum-stay threshold was met, while very few patients were discharged before the threshold. By contrast, prior to 2002, discharges were evenly distributed around the day that later became the short-stay threshold.  These findings confirm that the current payment policy has created unintended incentives for long-term care hospitals to base the timing of patient discharges on payments and highlight how responsive these hospitals are to payment incentives.

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Electronic Medical Records Did Not Improve Stroke Outcomes Or Quality Of Care

Dr. Karen E. Joynt, MD MPH Cardiovascular Division Brigham and Women's Hospital and VA Boston Healthcare System Department of Health Policy and Management, Harvard School of Public HealthMedicalResearch.com Interview with:
Karen E. Joynt, MD MPH

Cardiovascular Division,
Brigham and Women’s Hospital and VA Boston Healthcare System
Department of Health Policy and Management
Harvard T.H. Chan School of Public Health

MedicalResearch: What is the background for this study?  What are the main findings?

Dr. Joynt: While there is a great deal of optimism about the potential of Electronic Health Records (EHRs) to improve health care, there is little national data examining whether hospitals that have implemented EHRs have higher-quality care or better patient outcomes.  We used national data on 626,473 patients with ischemic stroke to compare quality and outcomes between hospitals with versus without EHRs.  We found no difference in quality of care, discharge home (a marker of good functional status), or in-hospital mortality between hospital with versus without EHRs.  We did find that the chances of having a long length of stay were slightly lower in hospitals with EHRs than those without them.

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Medicare RAC Audits Fraught With Delays, High Costs and Lack of Transparency

Ann M. Sheehy, M.D., M.S. Associate Professor Division Head, Hospital Medicine University of Wisconsin Department of MedicineMedicalResearch.com Interview with:
Ann M. Sheehy, M.D., M.S.

Associate Professor
Division Head, Hospital Medicine
University of Wisconsin Department of Medicine

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Sheehy: Outpatient (observation) and inpatient status determinations are important for hospitalized Medicare beneficiaries. The Recovery Audit program, more commonly known as the RACs (Recovery Audit Contractors), is charged with surveillance and enforcement of such status determinations. Surveillance in the Medicare program is necessary, and Medicare fraud and abuse should not be tolerated. However, there are increasing concerns regarding RAC accuracy, auditor financial incentives, and the volume of audits and overpayment determinations auditors allege. We therefore studied Complex Medicare Part A RAC audits at 3 academic medical centers, the University of Wisconsin, the University of Utah, and Johns Hopkins, to determine the impact and trends of such audits.

There was a nearly 300% increase in RAC overpayment determinations in just 2 years at the study hospitals. Each year, the hospitals won a greater percent of contested cases, winning 68.0% of cases with decisions in 2013. Two-thirds of all favorable decisions for the hospitals occurred in the discussion period. Because discussion is not considered part of the formal appeals process, this is omitted from reports of RAC accuracy. None of the overpayment determinations contested the need for the care delivered, rather contested the billing location, outpatient or inpatient. The hospitals averaged 5 FTE each to manage the audit and appeals process. Claims still in appeals had been in process for a mean of 555 days without decisions.

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