Despite policies aimed at incentivizing clinical integration, few data exist on whether fragmentation of care is associated with worse outcomes for elderly patients undergoing major surgery.
To ...determine whether postdischarge surgical care fragmentation is associated with worse outcomes and whether distances between hospitals explain differences in patient outcomes.
We used the 100% Medicare inpatient file for claims from January 1, 2009, through November 30, 2011. Data on hospital structural features, including zip code of location, were obtained from the 2011 American Hospital Association Annual Survey. We identified patients who underwent coronary artery bypass grafting, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement.
Thirty-day surgical mortality.
A total of 93 062 patients who underwent the surgical procedures of interest were subsequently readmitted within 30 days of discharge; 23 278 of these patients (25.0%) were readmitted to a hospital other than the one where their procedure was performed. Patients who were readmitted to a different hospital generally lived farther from the index hospital than those who were readmitted to the index hospital (20.7 vs 7.4 miles, P < .001). We found large state-level variations in the proportion of surgical patients who were readmitted elsewhere. Patients readmitted to a different hospital that was the same distance from their home as the index hospital had 48% higher odds of mortality (odds ratio, 1.48; 95% CI, 1.24-1.78; P < .001) than patients who were admitted to the index hospital.
Of older US patients undergoing major surgery, 1 in 4 is readmitted to a hospital other than the one where the initial operation was performed. Even taking distance traveled into account, postsurgical care fragmentation is associated with a substantially higher risk of death. Focusing on clinical integration may improve outcomes for older US patients undergoing complex surgery.
Summary Background Although the extent of hospital and intensive-care use at the end of life is well known, patterns of surgical care during this period are poorly understood. We examined national ...patterns of surgical care in the USA among elderly fee-for-service Medicare beneficiaries in their last year of life. Methods We did a retrospective cohort study of elderly beneficiaries of fee-for-service Medicare in the USA, aged 65 years or older, who died in 2008. We identified claims for inpatient surgical procedures in the year before death and examined the relation between receipt of an inpatient procedure and both age and geographical region. We calculated an end-of-life surgical intensity (EOLSI) score for each hospital referral region defined as proportion of decedents who underwent a surgical procedure during the year before their death, adjusted for age, sex, race, and income. We compared patient characteristics with Rao-Scott χ2 tests, resource use with generalised estimating equations, regional differences with generalised estimating equations Wald tests, and end-of-life surgical intensity scores with Spearman's partial-rank-order correlation coefficients. Findings Of 1 802 029 elderly beneficiaries of fee-for-service Medicare who died in 2008, 31·9% (95% CI 31·9–32·0; 575 596 of 1 802 029) underwent an inpatient surgical procedure during the year before death, 18·3% (18·2–18·4; 329 771 of 1 802 029) underwent a procedure in their last month of life, and 8·0% (8·0–8·1; 144 162 of 1 802 029) underwent a procedure during their last week of life. Between the ages of 80 and 90 years, the percentage of decedents undergoing a surgical procedure in the last year of life decreased by 33% (35·3% 95% CI 34·7–35·9; 8858 of 25 094 to 23·6% 22·9–24·3; 3340 of 14 152). EOLSI score in the highest intensity region (Munster, IN) was 34·4 (95% CI 33·7–35·1) and in the lowest intensity region (Honolulu, HI) was 11·5 (11·3–11·7). Regions with a high number of hospital beds per head had high end-of-life surgical intensity (r=0·37, 95% CI 0·27–0·46; p<0·0001), as did regions with high total Medicare spending (r=0·50, 0·41–0·58; p<0·0001). Interpretation Many elderly people in the USA undergo surgery in the year before their death. The rate at which they undergo surgery varies substantially with age and region and might suggest discretion in health-care providers' decisions to intervene surgically at the end of life. Funding None.
Minimising the health harms of climate change and optimising universal health coverage will only be achieved through an integrated agenda and aligned solutions, say Renee Salas and Ashish Jha
Patients' perceptions of their care, especially in the hospital setting, are not well known. Data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey provide a ...portrait of patients' experiences in U.S. hospitals.
We assessed the performance of hospitals across multiple domains of patients' experiences. We examined whether key characteristics of hospitals that are thought to enhance patients' experiences (i.e., a high ratio of nurses to patient-days, for-profit status, and nonacademic status) were associated with a better experience for patients. We also examined whether a hospital's performance on the HCAHPS survey was related to its performance on indicators of the quality of clinical care.
We found moderately high levels of satisfaction with care (e.g., on average, 67.4% of a hospital's patients said that they would definitely recommend the hospital), with a high degree of correlation among the measures of patients' experiences (Cronbach's alpha, 0.94). As compared with hospitals in the bottom quartile of the ratio of nurses to patient-days, those in the top quartile had a somewhat better performance on the HCAHPS survey (e.g., 63.5% vs. 70.2% of patients responded that they "would definitely recommend" the hospital; P<0.001). Hospitals with a high level of patient satisfaction provided clinical care that was somewhat higher in quality for all conditions examined. For example, those in the top quartile of HCAHPS ratings performed better than those in the bottom quartile with respect to the care that patients received for acute myocardial infarction (actions taken to provide appropriate care as a proportion of all opportunities for providing such actions, 95.8% vs. 93.1% in unadjusted analyses; P<0.001) and for pneumonia (90.5% vs. 88.6% in unadjusted analyses, P<0.001).
This portrait of patients' experiences in U.S. hospitals offers insights into areas that need improvement, suggests that the same characteristics of hospitals that lead to high nurse-staffing levels may be associated with better experiences for patients, and offers evidence that hospitals can provide both a high quality of clinical care and a good experience for the patient.
Social distancing remains an important strategy to combat the COVID-19 pandemic in the United States. However, the impacts of specific state-level policies on mobility and subsequent COVID-19 case ...trajectories have not been completely quantified. Using anonymized and aggregated mobility data from opted-in Google users, we found that state-level emergency declarations resulted in a 9.9% reduction in time spent away from places of residence. Implementation of one or more social distancing policies resulted in an additional 24.5% reduction in mobility the following week, and subsequent shelter-in-place mandates yielded an additional 29.0% reduction. Decreases in mobility were associated with substantial reductions in case growth two to four weeks later. For example, a 10% reduction in mobility was associated with a 17.5% reduction in case growth two weeks later. Given the continued reliance on social distancing policies to limit the spread of COVID-19, these results may be helpful to public health officials trying to balance infection control with the economic and social consequences of these policies.
Evidence linking electronic health record (EHR) adoption to better care is mixed. More nuanced measures of adoption, particularly those that capture the common incremental approach of adding ...functions over time in US hospitals, could help elucidate the relationship between adoption and outcomes. We used data for the period 2008-13 to assess the relationship between EHR adoption and thirty-day mortality rates. We found that baseline adoption was associated with a 0.11-percentage-point higher rate per function. Over time, maturation of the baseline functions was associated with a 0.09-percentage-point reduction in mortality rate per year per function. Each new function adopted in the study period was associated with a 0.21-percentage-point reduction in mortality rate per year per function. We observed effect modification based on size and teaching status, with small and nonteaching hospitals realizing greater gains. These findings suggest that national investment in hospital EHRs should yield improvements in mortality rates, but achieving them will take time.
Understanding whether and why there are racial disparities in readmissions has implications for efforts to reduce readmissions.
To determine whether black patients have higher odds of readmission ...than white patients and whether these disparities are related to where black patients receive care.
Using national Medicare data, we examined 30-day readmissions after hospitalization for acute myocardial infarction (MI), congestive heart failure (CHF), and pneumonia. We categorized hospitals in the top decile of proportion of black patients as minority-serving. We determined the odds of readmission for black patients compared with white patients at minority-serving vs non-minority-serving hospitals.
Medicare Provider Analysis Review files of more than 3.1 million Medicare fee-for-service recipients who were discharged from US hospitals in 2006-2008.
Risk-adjusted odds of 30-day readmission.
Overall, black patients had higher readmission rates than white patients (24.8% vs 22.6%, odds ratio OR, 1.13; 95% confidence interval CI, 1.11-1.14; P < .001); patients from minority-serving hospitals had higher readmission rates than those from non-minority-serving hospitals (25.5% vs 22.0%, OR, 1.23; 95% CI, 1.20-1.27; P < .001). Among patients with acute MI and using white patients from non-minority-serving hospitals as the reference group (readmission rate 20.9%), black patients from minority-serving hospitals had the highest readmission rate (26.4%; OR, 1.35; 95% CI, 1.28-1.42), while white patients from minority-serving hospitals had a 24.6% readmission rate (OR, 1.23; 95% CI, 1.18-1.29) and black patients from non-minority-serving hospitals had a 23.3% readmission rate (OR, 1.20; 95% CI, 1.16-1.23; P < .001 for each); patterns were similar for CHF and pneumonia. The results were unchanged after adjusting for hospital characteristics including markers of caring for poor patients.
Among elderly Medicare recipients, black patients were more likely to be readmitted after hospitalization for 3 common conditions, a gap that was related to both race and to the site where care was received.
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