Accounting for the growth of observation stays in the assessment of Medicare\u27s Hospital Readmissions Reduction Program

IMPORTANCE: Decreases 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. OBJECTIVE: To examine whether the HRRP was associated with decreases in 30-day readmissions after accounting for observation stays. DESIGN, SETTING, AND PARTICIPANTS: This 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 infarction, and pneumonia) vs nontarget conditions under scenarios that excluded and included observation stays. MAIN OUTCOMES AND MEASURES: Thirty-day inpatient admissions and observation stays. RESULTS: The study included 8 944 295 hospitalizations (mean [SD] age, 78.7 [8.2] years; 58.6% were female; 1.3% Asian; 10.0% Black; 2.0% Hispanic; 0.5% North American Native; 85.0% White; and 1.2% other or unknown). Observation stays increased from 2.3% to 4.4% (91.3% relative increase) of index hospitalizations among target conditions and 14.1% to 21.3% (51.1% relative increase) of index hospitalizations for nontarget conditions. Readmission rates decreased significantly after the announcement of the HRRP and returned to baseline by the time penalties were implemented for both target and nontarget conditions regardless of whether observation stays were included. When only inpatient hospitalizations were counted, decreasing readmissions accrued into a -1.48 percentage point (95% CI, -1.65 to -1.31 percentage points) absolute reduction in readmission rates by the postpenalty period for target conditions and -1.13 percentage point (95% CI, -1.30 to -0.96 percentage points) absolute reduction in readmission rates by the postpenalty period for nontarget conditions. This reduction corresponded to a statistically significant differential change of -0.35 percentage points (95% CI, -0.59 to -0.11 percentage points). Accounting for observation stays more than halved the absolute decrease in readmission rates for target conditions (-0.66 percentage points; 95% CI, -0.83 to -0.49 percentage points). Nontarget conditions showed an overall greater decrease during the same period (-0.76 percentage points; 95% CI, -0.92 to -0.59 percentage points), corresponding to a differential change in readmission rates of 0.10 percentage points (95% CI, -0.14 to 0.33 percentage points) that was not statistically significant. CONCLUSIONS AND RELEVANCE: The findings of this study suggest that the reduction of readmissions associated with the implementation of the HRRP was smaller than originally reported. More than half of the decrease in readmissions for target conditions appears to be attributable to the reclassification of inpatient admission to observation stays

Using Routinely Collected EHR Data to Optimize Patient Care, Refine Clinical Care Guidelines, And Inform Healthcare Policies for Vulnerable or Low-Resource HIV Patients

Thesis (Ph.D.)--University of Washington, 2020University of Washington Abstract Using Routinely Collected EHR Data to Optimize Patient Care, Refine Clinical Care Guidelines, And Inform Healthcare Policies for Vulnerable or Low-Resource HIV Patients Canada Parrish Chair of the Supervisory Committee: Paul Fishman Department of Health Services Despite major achievements in HIV care over the last several decades, more effort is needed to improve service delivery to low-resource and vulnerable communities. Observational data from routine clinical sources represent a source of information for optimizing HIV care in settings where large, randomized trials are not feasible, or for populations typically excluded from clinical trials. This research used observational data from the centralized iSante EHR for Haitian HIV patients enrolled in care, as well as the CFAR Network of Integrated Clinical Systems (CNICS) electronic medical records-based network which integrates clinical data from HIV-infected persons in the United States. The specific aims included: defining the association between early linkage to care and various types of substance use; determining the causal effect of extending ART (antiretroviral therapy) prescription lengths on retention in care; assessing the potential subgroup differences in the effect of increasing ART prescription length and exploring refining existing ART guidelines. We found that those with substance use entered care earlier than those who did not report substance use, extending ART intervals causes an increase in retention in care; this effect does differ across patient subgroups, though a uniform ART guideline remains appropriate. This research provided insight into how to optimize care for key populations in efforts to reach national and global HIV care benchmarks

Evaluation of an Emergency Department Influenza Vaccination Program: Uptake Factors and Opportunities

Introduction: Influenza vaccines are commonly provided through community health events and primary care appointments. However, acute unscheduled healthcare visits such as emergency department (ED) visits are increasingly viewed as important vaccination opportunities. Emergency departments may be well-positioned to complement broader public health efforts with integrated vaccination programs.  Methods: We studied an ED-based influenza vaccination initiative in an urban hospital and examined patient-level factors associated with screening and vaccination uptake. Our analyses included patient visits to the ED from October 1, 2019-April 1, 2020. Results: The influenza screening and vaccination program proved feasible. Of the 20,878 ED visits that occurred within the study period, 3,565 (17.1%) included a screening for influenza vaccine eligibility; a small proportion (11.5%) of the patients seen had multiple screenings. Among the patients screened eligible for the vaccine, 916 ultimately received an influenza vaccination while in the ED (43.7% of eligible patients). There was significant variability in the characteristics of patients who were and were not screened and vaccinated. Age, gender, race, preferred language, and receipt of a flu vaccine in prior years were associated with screening and/or receiving a vaccine in the ED.  Conclusion: Vaccination programs in the ED can boost community vaccination rates and play a role in both preventing and treating current and future vaccine-preventable public health crises, although efforts must be made to deliver services equitably

Substance use and HIV stage at entry into care among people with HIV.

BackgroundInformation regarding the impact of substance use on the timing of entry into HIV care is lacking. Better understanding of this relationship can help guide approaches and policies to improve HIV testing and linkage.MethodsWe examined the effect of specific substances on stage of HIV disease at entry into care in over 5000 persons with HIV (PWH) newly enrolling in care. Substance use was obtained from the AUDIT-C and ASSIST instruments. We examined the association between early entry into care and substance use (high-risk alcohol, methamphetamine, cocaine/crack, illicit opioids, marijuana) using logistic and relative risk regression models adjusting for demographic factors, mental health symptoms and diagnoses, and clinical site.ResultsWe found that current methamphetamine use, past and current cocaine and marijuana use was associated with earlier entry into care compared with individuals who reported no use of these substances.ConclusionEarly entry into care among those with substance use suggests that HIV testing may be differentially offered to people with known HIV risk factors, and that individuals with substances use disorders may be more likely to be tested and linked to care due to increased interactions with the healthcare system