Bernard Friedman

The Rate and Cost of Hospital Readmissions for Preventable Conditions

The study estimates the rate and cost of preventable readmissions within 6 months after a first preventable admission, by age-group, and by payer and race within age-group. The descriptive results are contrasted with several hypotheses. The hospital discharge data are for residents of New York, Pennsylvania, Tennessee, and Wisconsin in 1999, from files of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. About 19 percent of persons with an initial preventable admission had at least one preventable readmission rate within 6 months. Hospital cost for preventable readmissions during 6 months was about

Racial/Ethnic Disparities in Potentially Preventable Readmissions: The Case of Diabetes

730 million. There were substantial differences in readmission rates by payer group and by race. Some evidence suggests that preventable readmissions may partly reflect complexity of underlying problems. Interventions to reduce cost might focus on identifying high-risk patients before discharge and devising new approaches to follow-up.

Hospital utilization, costs, and mortality for adults with multiple chronic conditions, Nationwide Inpatient Sample, 2009.

OBJECTIVESnConsiderable differences in prevalence of diabetes and management of the disease exist among racial/ethnic groups. We examined the relationship between race/ethnicity and hospital readmissions for diabetes-related conditions.nnnMETHODSnNonmaternal adult patients with Medicare, Medicaid, or private insurance coverage hospitalized for diabetes-related conditions in 5 states were identified from the 1999 State Inpatient Databases of the Healthcare Cost and Utilization Project. Racial/ethnic differences in the likelihood of readmission were estimated by logistic regression with adjustment for patient demographic, clinical, and socioeconomic characteristics and hospital attributes.nnnRESULTSnThe risk-adjusted likelihood of 180-day readmission was significantly lower for non-Hispanic Whites than for Hispanics across all 3 payers or for non-Hispanic Blacks among Medicare enrollees. Within each payer, Hispanics from low-income communities had the highest risk of readmission. Among Medicare beneficiaries, Blacks and Hispanics had higher percentages of readmission for acute complications and microvascular disease, while Whites had higher percentages of readmission for macrovascular conditions.nnnCONCLUSIONSnRacial/ethnic disparities are more evident in 180-day than in 30-day readmission rates, and greatest among the Medicare population. Readmission diagnoses vary by race/ethnicity, with Blacks and Hispanics at higher risk for those complications more likely preventable with effective postdischarge care.

Annual Report on Health Care for Children and Youth in the United States: Trends in Racial/Ethnic, Income, and Insurance Disparities Over Time, 2002–2009

Objective Our objective was to provide a national estimate across all payers of the distribution and cost of selected chronic conditions for hospitalized adults in 2009, stratified by demographic characteristics. Analysis We analyzed the Nationwide Inpatient Sample (NIS), the largest all-payer inpatient database in the United States. Use, cost, and mortality estimates across payer, age, sex, and race/ethnicity are produced for grouped or multiple chronic conditions (MCC). The 5 most common dyads and triads were determined. Results In 2009, there were approximately 28 million adult discharges from US hospitals other than those related to pregnancy and maternity; 39% had 2 to 3 MCC, and 33% had 4 or more. A higher number of MCC was associated with higher mortality, use of services, and average cost. The percentages of Medicaid, privately insured patients, and ethnic/racial groups with 4 or more MCC were highly sensitive to age. Summary This descriptive analysis of multipayer inpatient data provides a robust national view of the substantial use and costs among adults hospitalized with MCC.

Annual Report on Health Care for Children and Youth in the United States: Focus on Trends in Hospital Use and Quality

OBJECTIVEnTo examine trends in childrens health access, utilization, and expenditures over time (2002-2009) by race/ethnicity, income, and insurance status/expected payer.nnnMETHODSnData include a nationally representative random sample of children in the United States in 2002-2009 from the Medical Expenditure Panel Survey (MEPS) and a nationwide sample of pediatric hospitalizations in 2005 and 2009 from the Healthcare Cost and Utilization Project (HCUP).nnnRESULTSnThe percentage of children with private insurance coverage declined from 65.3% in 2002 to 60.6% in 2009. At the same time, the percentage of publicly insured children increased from 27.0% in 2002 to 33.1% in 2009. Fewer children reported being uninsured in 2009 (6.3%) compared to 2002 (7.7%). The most significant progress was for Hispanic children, for whom the percentage of uninsured dropped from 15.0% in 2002 to 10.3% in 2009. The uninsured were consistently the least likely to have access to a usual source of care, and this disparity remained unchanged in 2009. Non-Hispanic whites were most likely to report a usual source of care in both 2002 and 2009. The percentage of children with a doctor visit improved for whites and Hispanics (2009 vs 2002). In contrast, black children saw no improvement during this time period. Between 2002 and 2009, childrens average total health care expenditures increased from

Factors associated with adoption of robotic surgical technology in US hospitals and relationship to radical prostatectomy procedure volume

1294 to

What Hospital Inpatient Services Contributed the Most to the 2001–2006 Growth in the Cost per Case?

1914. Average total expenditures nearly doubled between 2002 and 2009 for white children with private health insurance. Among infants, hospitalizations for pneumonia decreased in absolute number (41,000 to 34,000) and as a share of discharges (0.8% to 0.7%). Fluid and electrolyte disorders also decreased over time. Influenza appeared only in 2009 in the list of top 15 diagnoses with 11,000 hospitalization cases. For children aged 1 to 17, asthma hospitalization increased in absolute number (from 119,000 to 134,000) and share of discharges (6.6% to 7.6%). Skin infections appeared in the top 15 categories in 2009, with 57,000 cases (3.3% of total).nnnCONCLUSIONSnDespite significant improvement in insurance coverage, disparities by race/ethnicity and income persist in access to and use of care. Hispanic children experienced progress in a number of measures, while black children did not. Because racial/ethnic and socioeconomic disparities are often reported as single cross-sectional studies, our approach is innovative and improves on prior studies by examining population trends during the time period 2002-2009. Our study sheds light on childrens disparities during the most recent economic crisis.

Preventable illness and out-of-area travel of children in New York counties.

OBJECTIVEnThe aim of this study was to describe selected trends in hospital inpatient care for children between 2000 and 2007.nnnSTUDY DESIGNnAnalysis was conducted of administrative data from annual nationwide databases of hospital discharges from the Agency for Healthcare Research and Qualitys Healthcare Cost and Utilization Project, along with survey data from a nationally representative random sample of children from the Medical Expenditure Panel Survey. Hospital utilization rates and expenses, risk-adjusted rates of potentially avoidable hospitalization, and safety indicators in the hospital are calculated and tracked with established and downloadable software.nnnRESULTSnThe rate of hospital discharges for children aged 15 to 17 years declined significantly, mainly due to fewer maternity-related discharges. The leading principal conditions by age group were similar to the report for 1995 to 2000; however, the rate of admissions for skin infections doubled to 9 per 10,000. Hospital cost per discharge increased by an annual average of 4.5% per year compared with 2.6% annual growth in the gross domestic product deflator. Medicaid is increasingly important relative to private insurance as a payer for hospital care for children. The rate of potentially preventable hospitalizations for both acute and chronic conditions declined substantially (18%, adjusted for age and gender). Several measures of patient safety improved--the rates of postoperative sepsis, iatrogenic pneumothorax, and selected infections due to medical care declined by 14.2%, 17.8%, and 23.5%, respectively. However, the rate of accidental punctures and lacerations and the rate of decubitus ulcer increased by 25.6% and 34.5%, respectively. The trends in safety indicators varied somewhat by age group, income quartile of zip codes, insurance, region, and type of location without a consistent pattern.nnnCONCLUSIONS/IMPLICATIONSnAlthough teenage pregnancy rates were declining, there was a worsening trend in skin infections. The latter may eventually be impacted by recent publication of new guidelines for treatment by office-based physicians. A gradually increasing role of Medicaid as a payer for hospital care for children will likely put an increasing strain on public resources in advance of the full implementation of the health insurance reforms recently enacted. The decline in potentially avoidable admissions reduces the use of the most expensive resources. For asthma and diabetes, children in the lowest income zip codes had persistently higher rates of admission, but the rate fell by one third during the period. Children in the South and West regions had substantial and significant declines in preventable admissions. Particular indicators of safety were improving, whereas others were worsening. Trends were not the same in all types of hospitals, all regions, and income categories. This is already a rich area for further research on the impact of quality improvement strategies; however, attention is needed to developing more tools to more thoroughly track quality of care for children.

New Evidence on Hospital Profitability by Payer Group and the Effects of Payer Generosity

Objective:Robotic technology has diffused rapidly despite high costs and limited additive reimbursement by major payers. We aimed to identify the factors associated with hospitals decisions to adopt robotic technology and the consequences of these decisions. Methods:This observational study used data on hospitals and market areas from 2005 to 2009. Included were hospitals in census-based statistical areas within states in the State Inpatient Database that participated in the American Hospital Association annual surveys and performed radical prostatectomies. The likelihood that a hospital would acquire a robotic facility and the rates of radical prostatectomy relative to the prevalence of robots in geographic market areas were assessed using multivariable analysis. Results:Hospitals in areas where a higher proportion of other hospitals had already acquired a robot were more likely to acquire one (P = 0.012), as were those with more than 300 beds (P < 0.0001) and teaching hospitals (P < 0.0001). There was a significant association between years with a robot and the change in the number of radical prostatectomies (P < 0.0001). More radical prostatectomies were performed in areas where the number of robots per 100,000 men was higher (P < 0.0001). Adding a single robot per 100,000 men in an area was associated with a 30% increase in the rate of radical prostatectomies. Conclusions:Local area robot competition was associated with the rapid spread of robot technology in the United States. Significantly more radical prostatectomies were performed in hospitals with robots and in market areas of hospitals with robotic technology.

The Use of Expensive Health Technologies in the Era of Managed Care: The Remarkable Case of Neonatal Intensive Care

OBJECTIVEnTo demonstrate a refined cost-estimation method that converts detailed charges for inpatient stays into costs at the department level to enable analyses that can unravel the sources of rapid growth in inpatient costs.nnnDATA SOURCESnHealthcare Cost and Utilization Project State Inpatient Databases and Medicare Cost Reports for all community, nonrehabilitation hospitals in nine states that reported detailed charges in 2001 and 2006 (n = 10,280,416 discharges).nnnSTUDY DESIGNnWe examined the cost per discharge across all discharges and five subgroups (medical, surgical, congestive heart failure, septicemia, and osteoarthritis).nnnDATA COLLECTION/EXTRACTION METHODSnWe created cost-to-charge ratios (CCRs) for 13 cost-center or department-level buckets using the Medicare Cost Reports. We mapped service-code-level charges to a CCR with an internally developed crosswalk to estimate costs at the service-code level.nnnPRINCIPAL FINDINGSnSupplies and devices were leading contributors (24.2 percent) to the increase in mean cost per discharge across all discharges. Intensive care unit and room and board (semiprivate) charges also substantially contributed (17.6 percent and 11.3 percent, respectively). Imaging and other advanced technological services were not major contributors (4.9 percent).nnnCONCLUSIONSnPayers and policy makers may want to explore hospital stay costs that are rapidly rising to better understand their increases and effectiveness.