Causal Impact of the Hospital Readmissions Reduction Program on Hospital Readmissions and Mortality

Estimating causal effects of the Hospital Readmissions Reduction Program (HRRP), part of the Affordable Care Act, has been very controversial. Associational studies have demonstrated decreases in hospital readmissions, consistent with the intent of the program, although analyses with different data sources and methods have differed in estimating effects on patient mortality. To address these issues, we define the estimands of interest in the context of potential outcomes, we formalize a Bayesian structural time-series model for causal inference, and discuss the necessary assumptions for estimation of effects using observed data. The method is used to estimate the effect of the passage of HRRP on both the 30-day readmissions and 30-day mortality. We show that for acute myocardial infarction and congestive heart failure, HRRP caused reduction in readmissions while it had no statistically significant effect on mortality. However, for pneumonia, HRRP had no statistically significant effect on readmissions but caused an increase in mortality.Comment: 10 pages, 1 figure, 2 table

Reprising Ramadan-Related Angina Pectoris: A Potential Strategy for Risk Reduction

Patient: Male, 69 Final Diagnosis: Coronary artery disease Symptoms: Angina pectoris Medication: Aspirin Clinical Procedure: Coronary artery bypass surgery Specialty: Cardiology Objective: Unusual clinical course Background: A preponderance of evidence supports short-term aspirin usage to reduce transiently increased cardiovascular risk in clinical conditions that promote acute myocardial ischemia. Case Report: We report on the case of a 69-year-old male of Muslim Indian heritage with multiple cardiovascular risk factors who experienced the onset of angina pectoris while fasting for Ramadan for more than 16 hours daily for 30 days in July 2015. While symptom free for 2 months on medical management after ending his fast, he underwent quadruple coronary artery bypass surgery for severe 4-vessel disease following an acute anterior myocardial infarction. A percutaneous coronary intervention with stent placement was subsequently required for persistent myocardial ischemia on stress-MIBI testing due to occlusion of the graft to left anterior descending artery. Presently asymptomatic, he decided to forgo fasting for Ramadan in June 2016. Conclusions: Based on this case, measures for primary cardiovascular prevention among the 1.2 billion susceptible males at similar high short-term cardiac risk while fasting for Ramadan are proposed. The value of aspirin for attenuating high short-term cardiovascular risk in clinical conditions conferring transient inflammatory stress is considered. Low-dose aspirin usage at evening meals while fasting for Ramadan is prudent for primary cardiovascular protection of males who may have non-obstructive coronary atherosclerosis to mitigate the risk for rupture of potentially vulnerable plaques. Based in part on conclusive evidence for protection of middle-aged males from first myocardial infarction in a randomized prospective primary prevention trial, this measure is concordant with recommendations from sub-specialty societies for primary cardiovascular prevention for persons at above-average risk demonstrated by validated biomarkers and from the United States Preventive Services Task Force

Trends in Diagnosis Related Groups for inpatient admissions and associated changes in payment from 2012 to 2016

Importance: Hospitals are reimbursed based on Diagnosis Related Groups (DRGs), which are defined, in part, by patients having 1 or more complications or comorbidities within a given DRG family. Hospitals have made substantial investment in efforts to document these complications and comorbidities. Objective: To examine temporal trends in DRGs with a major complication or comorbidity, compare these findings with 2 alternative measures of disease severity, and estimate associated changes in payment. Design, Setting, and Participants: This retrospective cohort study used data from the all-payer National Inpatient Sample for admissions assigned to 1 of the top 20 reimbursed DRG families at US acute care hospitals from January 1, 2012, to December 31, 2016. Data were analyzed from July 10, 2018, to May 29, 2019. Exposures: Quarter year of hospitalization. Main Outcomes and Measures: The primary outcome was the proportion of DRGs with a major complication or comorbidity. Secondary outcomes were comorbidity scores, risk-adjusted mortality rates, and estimated payment. Changes in assigned DRGs, comorbidity scores, and risk-adjusted mortality rates were analyzed by linear regression. Payment changes were estimated for each DRG by calculating the Centers for Medicare & Medicaid Services weighted payment using 2012 and 2016 case mix and hospitalization counts. Results: Between 2012 and 2016, there were 62 167 976 hospitalizations for the 20 highest-reimbursed DRG families; the sample was 32.9% male and 66.8% White, with a median age of 57 years (interquartile range, 31-73 years). Within 15 of these DRG families (75%), the proportion of DRGs with a major complication or comorbidity increased significantly over time. Over the same period, comorbidity scores were largely stable, with a decrease in 6 DRG families (30%), no change in 10 (50%), and an increase in 4 (20%). Among 19 DRG families with a calculable mortality rate, the risk-adjusted mortality rate significantly decreased in 8 (42%), did not change in 9 (47%), and increased in 2 (11%). The observed DRG shifts were associated with at least $1.2 billion in increased payment. Conclusions and Relevance: In this cohort study, between 2012 and 2016, the proportion of admissions assigned to a DRG with major complication or comorbidity increased for 15 of the top 20 reimbursed DRG families. This change was not accompanied by commensurate increases in disease severity but was associated with increased payment

County community health associations of net voting shift in the 2016 U.S. presidential election

Importance In the U.S. presidential election of 2016, substantial shift in voting patterns occurred relative to previous elections. Although this shift has been associated with both education and race, the extent to which this shift was related to public health status is unclear. Objective: To determine the extent to which county community health was associated with changes in voting between the presidential elections of 2016 and 2012. Design: Ecological study with principal component analysis (PCA) using principal axis method to extract the components, then generalized linear regression. Setting: General community. Participants: All counties in the United States. Exposures Physically unhealthy days, mentally unhealthy days, percent food insecure, teen birth rate, primary care physician visit rate, age-adjusted mortality rate, violent crime rate, average health care costs, percent diabetic, and percent overweight or obese. Main outcome The percentage of Donald Trump votes in 2016 minus percentage of Mitt Romney votes in 2012 (“net voting shift”). Results: Complete public health data was available for 3,009 counties which were included in the analysis. The mean net voting shift was 5.4% (+/- 5.8%). Of these 3,009 counties, 2,641 (87.8%) had positive net voting shift (shifted towards Trump) and 368 counties (12.2%) had negative net voting shift (shifted away from Trump). The first principal component (“unhealthy score”) accounted for 68% of the total variance in the data. The unhealthy score included all health variables except primary care physician rate, violent crime rate, and health care costs. The mean unhealthy score for counties was 0.39 (SD 0.16). Higher normalized unhealthy score was associated with positive net voting shift (22.1% shift per unit unhealthy, p < 0.0001). This association was stronger in states that switched Electoral College votes from 2012 to 2016 than in other states (5.9% per unit unhealthy, p <0.0001). Conclusions and relevance Substantial association exists between a shift toward voting for Donald Trump in 2016 relative to Mitt Romney in 2012 and measures of poor public health. Although these results do not demonstrate causality, these results suggest a possible role for health status in political choices

Current State of Value-Based Purchasing Programs.

The United States healthcare system is rapidly moving toward rewarding value. Recent legislation, such as the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act (MACRA), solidified the role of value-based payment in Medicare. Many private insurers are following Medicare’s lead. Much of the policy attention has been on programs such as accountable care organizations and bundled payments; yet, value-based purchasing (VBP) or pay-for-performance, defined as providers being paid fee-for-service with payment adjustments up or down based on value metrics, remains a core element of value payment in MACRA and will likely remain so for the foreseeable future. This review article summarizes the current state of VBP programs and provides analysis of the strengths, weaknesses, and opportunities for the future. Multiple inpatient and outpatient VBP programs have been implemented and evaluated, with the impact of those programs being marginal. Opportunities to enhance the performance of VBP programs include improving the quality measurement science, strengthening both the size and design of incentives, reducing health disparities, establishing broad outcome measurement, choosing appropriate comparison targets, and determining the optimal role of VBP relative to alternative payment models. VBP programs will play a significant role in healthcare delivery for years to come, and they serve as an opportunity for providers to build the infrastructure needed for value-oriented care

Generalized linear regression estimates adjusted for demographic variables and unhealthy component.

<p>Generalized linear regression estimates adjusted for demographic variables and unhealthy component.</p

Hospital Variation in 30‐Day Readmissions Following Transcatheter Aortic Valve Replacement

Background Data on hospital variation in 30-day readmission rates after transcatheter aortic valve replacement (TAVR) are limited. Further, whether such variation is explained by differences in hospital characteristics and hospital practice patterns remains unknown. Methods and Results We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TAVRs. Hierarchical logistic regression models were used to examine between-hospital variation in 30-day all-cause risk-standardized readmission rate (RSRR) after TAVR and to explore reasons underlying hospital variation in 30-day RSRR. The study included 27&nbsp;091 index TAVRs performed across 325 hospitals. The median (interquartile range) hospital-level 30-day RSRR was 11.9% (11.1%-12.8%) ranging from 8.8% to 16.5%. After adjusting for differences in patient characteristics, there was significant between-hospital variation in 30-day RSRR (hospital odds ratio, 1.59; 95% CI, 1.39-1.77). Differences in length of stay and discharge disposition accounted for 15% of the between-hospital variance in RSRRs. There was no significant association between hospital characteristics and 30-day readmission rates after TAVR. There was statistically significant but weak correlation between 30-day RSRR after TAVR and that after surgical aortic valve replacement, percutaneous coronary intervention, acute myocardial infarction, heart failure, and pneumonia (r=0.132-0.298; P&lt;0.001 for all). Causes of 30-day readmission varied across hospitals, with noncardiac readmissions being more common at the bottom 5% hospitals (ie, those with the highest RSRRs). Conclusions There is significant variation in 30-day RSRR after TAVR across hospitals that is not entirely explained by differences in patient or hospital characteristics as well as hospital-wide practice patterns. Noncardiac readmissions are more common in hospitals with the highest RSRRs

Baseline demographics of county-level data^*.

<p>Baseline demographics of county-level data^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0185051#t001fn001" target="_blank">*</a>}.</p