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

Rising Great Plains fire campaign: Citizens' response to woody plant encroachment

Despite years of accumulating scientific evidence that fire is critical for maintaining the structure and function of grassland ecosystems in the US Great Plains, fire has not been restored as a fundamental grassland process across broad landscapes. The result has been widespread juniper encroachment and the degradation of the multiple valuable ecosystem services provided by grasslands. Here, we review the social-ecological causes and consequences of the transformation of grasslands to juniper woodlands and synthesize the recent emergence of prescribed burn cooperatives, an extensive societal movement by private citizens to restore fire to the Great Plains biome. We discuss how burn cooperatives have helped citizens overcome dominant social constraints that limit the application of prescribed fire to improve management of encroaching woody plants in grasslands. These constraints include the generally held assumptions and political impositions that all fires should be eliminated when wildfire danger increases.Peer reviewedNatural Resource Ecology and Managemen

Parent-Led Activity and Nutrition (plan) for Healthy Living: Design and Methods

Child obesity has become an important public health concern, especially in rural areas. Primary care providers are well positioned to intervene with children and their parents, but encounter many barriers to addressing child overweight and obesity. This paper describes the design and methods of a cluster-randomized controlled trial to evaluate a parent-mediated approach utilizing physician\u27s brief motivational interviewing and parent group sessions to treat child (ages 5–11 years) overweight and obesity in the primary care setting in Southern Appalachia. Specific aims of this pilot project will be 1) to establish a primary care based and parent-mediated childhood overweight intervention program in the primary care setting, 2) to explore the efficacy of this intervention in promoting healthier weight status and health behaviors of children, and 3) to examine the acceptability and feasibility of the approach among parents and primary care providers. If proven to be effective, this approach may be an exportable model to other primary care practices

Outcome of Hospitalization for COVID-19 in Patients with Interstitial Lung Disease. An International Multicenter Study.

Rationale: The impact of coronavirus disease (COVID-19) on patients with interstitial lung disease (ILD) has not been established.Objectives: To assess outcomes in patients with ILD hospitalized for COVID-19 versus those without ILD in a contemporaneous age-, sex-, and comorbidity-matched population.Methods: An international multicenter audit of patients with a prior diagnosis of ILD admitted to the hospital with COVID-19 between March 1 and May 1, 2020, was undertaken and compared with patients without ILD, obtained from the ISARIC4C (International Severe Acute Respiratory and Emerging Infection Consortium Coronavirus Clinical Characterisation Consortium) cohort, admitted with COVID-19 over the same period. The primary outcome was survival. Secondary analysis distinguished idiopathic pulmonary fibrosis from non-idiopathic pulmonary fibrosis ILD and used lung function to determine the greatest risks of death.Measurements and Main Results: Data from 349 patients with ILD across Europe were included, of whom 161 were admitted to the hospital with laboratory or clinical evidence of COVID-19 and eligible for propensity score matching. Overall mortality was 49% (79/161) in patients with ILD with COVID-19. After matching, patients with ILD with COVID-19 had significantly poorer survival (hazard ratio [HR], 1.60; confidence interval, 1.17-2.18; P = 0.003) than age-, sex-, and comorbidity-matched controls without ILD. Patients with an FVC of <80% had an increased risk of death versus patients with FVC ≥80% (HR, 1.72; 1.05-2.83). Furthermore, obese patients with ILD had an elevated risk of death (HR, 2.27; 1.39-3.71).Conclusions: Patients with ILD are at increased risk of death from COVID-19, particularly those with poor lung function and obesity. Stringent precautions should be taken to avoid COVID-19 in patients with ILD

Interactive effects of prescribed fire and livestock grazing on Seriphium plumosum in South African sour bushveld

Documented increases in woody plant abundance worldwide can reduce land value and grazing capacity. Throughout many grasslands and savannas in South Africa, Seriphium plumosum, an encroaching woody plant, has been rapidly displacing desirable native species. Cost-effective management techniques are required, in order to prevent encroachment. However, the effects of fire and grazing on S. plumosum are not well understood. We established a full factorial, completely randomised experiment to evaluate interactive effects of fire and livestock grazing on woody plant density and native plant diversity. Sixteen 100 m2 plots were aggregated within an area of rangeland and randomly assigned four treatments, including: i) ungrazed, not burned: ii) ungrazed, burned, iii) grazed, not burned, and iv) grazed, burned. Results indicate fire can reduce S. plumosum height (p &lt; 0.01) and canopy cover (p &lt; 0.01), while simultaneously maintaining the herbaceous community composition (p = 0.33). However, this treatment effect was not significant 24 months after a single treatment. This suggests that although fire holds promise for S. plumosum management, follow-up treatments are necessary to control the shrub. Additional research into the effects of altering components of the fire regime in combination with grazing could provide insight into more effective management. Keywords: bankrupt bush, plant community dynamics, Stoebe vulgaris, Stoebe plumosa, woody plant encroachmen