Jason M. Hockenberry

Associations Between Reduced Hospital Length of Stay and 30-Day Readmission Rate and Mortality: 14-Year Experience in 129 Veterans Affairs Hospitals

BACKGROUND Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions. OBJECTIVE To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration. DESIGN Observational study from 1997 to 2010. SETTING All 129 acute care Veterans Affairs hospitals in the United States. PATIENTS 4,124,907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage). MEASUREMENTS Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals. RESULTS For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected). LIMITATIONS This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used. CONCLUSION Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission. PRIMARY FUNDING SOURCE Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.

The effect of medical marijuana laws on adolescent and adult use of marijuana, alcohol, and other substances

We estimate the effect of medical marijuana laws (MMLs) in ten states between 2004 and 2012 on adolescent and adult use of marijuana, alcohol, and other psychoactive substances. We find increases in the probability of current marijuana use, regular marijuana use and marijuana abuse/dependence among those aged 21 or above. We also find an increase in marijuana use initiation among those aged 12-20. For those aged 21 or above, MMLs further increase the frequency of binge drinking. MMLs have no discernible impact on drinking behavior for those aged 12-20, or the use of other psychoactive substances in either age group.

Insurance Status, Use of Mental Health Services, and Unmet Need for Mental Health Care in the United States

OBJECTIVE The purpose of this study was to provide updated national estimates and correlates of service use, unmet need, and barriers to mental health treatment among adults with mental disorders. METHODS The sample included 36,647 adults ages 18-64 (9,723 with any mental illness and 2,608 with serious mental illness) from the 2011 National Survey on Drug Use and Health. Logistic regression models were used to examine predictors of mental health treatment and perceived unmet need. RESULTS Substantial numbers of adults with mental illness did not receive treatment (any mental illness, 62%; serious mental illness, 41%) and perceived an unmet need for treatment (any mental illness, 21%; serious mental illness, 41%). Having health insurance was a strong correlate of mental health treatment use (any mental illness: private insurance, adjusted odds ratio [AOR]=1.63, 95% confidence interval [CI]=1.29-2.06; Medicaid, AOR=2.66, CI=2.04-3.46; serious mental illness: private insurance, AOR=1.65, CI=1.12-2.45; Medicaid, AOR=3.37, CI=2.02-5.61) and of lower odds of perceived unmet need (any mental illness: private insurance, AOR=.78, CI=.65-.95; Medicaid, AOR=.70, CI=.54-.92). Among adults with any mental illness and perceived unmet need, 72% reported at least one structural barrier and 47% reported at least one attitudinal barrier. Compared with respondents with insurance, uninsured individuals reported significantly more structural barriers and fewer attitudinal barriers. CONCLUSIONS Low rates of treatment and high unmet need persist among adults with mental illness. Strategies to reduce both structural barriers, such as cost and insurance coverage, and attitudinal barriers are needed.

State Parity Laws and Access to Treatment for Substance Use Disorder in the United States Implications for Federal Parity Legislation

IMPORTANCE The passage of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act incorporated parity for substance use disorder (SUD) treatment into federal legislation. However, prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment. OBJECTIVE To examine the effect of state-level SUD parity laws on state-aggregate SUD treatment rates and to shed light on the impact of the recent federal SUD parity legislation. DESIGN, SETTING, AND PARTICIPANTS We conducted a quasi-experimental study using a 2-way (state and year) fixed-effect method. We included all known specialty SUD treatment facilities in the United States and examined treatment rates from October 1, 2000, through March 31, 2008. Our main source of data was the National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment. INTERVENTIONS State-level SUD parity laws during the study period. MAIN OUTCOMES AND MEASURES State-aggregate SUD treatment rates in (1) all specialty SUD treatment facilities and (2) specialty SUD treatment facilities accepting private insurance. RESULTS The implementation of any SUD parity law increased the treatment rate by 9% (P < .001) in all specialty SUD treatment facilities and by 15% (P = .02) in facilities accepting private insurance. Full parity and parity only if SUD coverage is offered increased the SUD treatment rate by 13% (P = .02) and 8% (P = .04), respectively, in all facilities and by 21% (P = .03) and 10% (P = .04), respectively, in facilities accepting private insurance. CONCLUSIONS AND RELEVANCE We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association is more pronounced in states with more comprehensive parity laws. Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment.

Cost of readmission: can the Veterans Health Administration (VHA) experience inform national payment policy?

Context:Scrutiny of hospital readmissions has led to the development and implementation of policies targeted at reducing readmission rates. Objective:To assess whether historic hospital readmission rates predict risk-adjusted patient readmission and to measure the costs of readmission, thus informing reimbursement policies under consideration by non-Veterans Health Administration payers. Design, Settings, and Participants:Multivariable hospital-fixed effects regression analyses of patients admitted to 129 Veterans Health Administration hospitals between 2005 and 2009 for 3 common conditions, acute myocardial infarction (AMI), community-acquired pneumonia (CAP), and congestive heart failure (CHF). Main Outcome Measures:We examined whether previous hospital readmission rates predicted risk-adjusted readmission or 30-day episode cost of care for subsequent patients. We then examined the 30-day inpatient hospitalization episode cost differences between those who had a readmission in the episode and those who did not. Results:Hospital readmission rates in the previous quarter are not predictive of individual patient risk-adjusted readmission or of patients’ inpatient hospitalization episode cost in the subsequent quarter. Relative to those who were not readmitted within 30 days of index visit discharge, readmitted patients had 30-day episode costs that were 53.3% (P<0.001), 82.8% (P<0.001), and 79.8% (P<0.001) higher for AMI, CAP, and CHF hospitalization episodes, respectively. Conclusions:Previous hospital readmission rates are poor predictors of readmission for future individual patients, therefore, policies using these measures to guide subsequent reimbursement are problematic for hospitals that are financially constrained. Our findings indicate current diagnosis related group payments would need to be raised by 10.0% for AMI, 11.5% for CAP, and 16.6% for CHF if these are to become 30-day bundled payments.

Variation among states in prescribing of opioid pain relievers and benzodiazepines — United States, 2012

INTRODUCTION Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation. METHODS CDC analyzed a commercial database (IMS Health) to assess the potential for improved prescribing of OPR and other drugs. CDC calculated state rates and measures of variation for OPR, long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines. RESULTS In 2012, prescribers wrote 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States. State rates varied 2.7-fold for OPR and 3.7-fold for benzodiazepines. For both OPR and benzodiazepines, rates were higher in the South census region, and three Southern states were two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast. Rates varied 22-fold for one type of OPR, oxymorphone. CONCLUSIONS Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety. IMPLICATIONS FOR PUBLIC HEALTH State policy makers might reduce the harms associated with the abuse of prescription drugs by implementing changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.

Chiropractic Episodes and the Co-Occurrence of Chiropractic and Health Services Use Among Older Medicare Beneficiaries

OBJECTIVE The purpose of this study was to define and characterize episodes of chiropractic care among older Medicare beneficiaries and to evaluate the extent to which chiropractic services were used in tandem with conventional medicine. METHODS Medicare Part B claims histories for 1991 to 2007 were linked to the nationally representative survey on Assets and Health Dynamics among the Oldest Old baseline interviews (1993-1994) to define episodes of chiropractic sensitive care using 4 approaches. Chiropractic and nonchiropractic patterns of service use were examined within these episodes of care. Of the 7447 Assets and Health Dynamics among the Oldest Old participants, 971 used chiropractic services and constituted the analytic sample. RESULTS There were substantial variations in the number and duration of episodes and the type and volume of services used across the 4 definitions. Depending on how the episode was constructed, the mean number of episodes per chiropractic user ranged from 3.74 to 23.12, the mean episode duration ranged from 4.7 to 28.8 days, the mean number of chiropractic visits per episode ranged from 0.88 to 2.8, and the percentage of episodes with co-occurrent use of chiropractic and nonchiropractic providers ranged from 4.9% to 10.9% over the 17-year period. CONCLUSION Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals

BACKGROUND Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs) are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. However, little is understood about APP roles in inpatient medicine. OBJECTIVE Describe APPs role in inpatient medicine. DESIGN Observational cross-sectional cohort study. SETTING One hundred twenty-four Veterans Health Administration (VHA) hospitals. PARTICIPANTS Chiefs of medicine (COMs) and nurse managers. MEASUREMENTS Surveys included inpatient medicine scope of practice for APPs and perceived healthcare quality. We conducted bivariate unadjusted and multivariable adjusted analyses. RESULTS One hundred eighteen COMs (95.2%) and 198 nurse managers (75.0%) completed surveys. Of 118 medicine services, 56 (47.5%) employed APPs; 27 (48.2%) used NPs only, 15 (26.8%) PAs only, and 14 (25.0%) used both. Full-time equivalents for NPs was 0.5 to 7 (mean = 2.22) and PAs was 1 to 9 (mean = 2.23). Daily caseload was similar at 4 to 10 patients (mean = 6.5 patients). There were few significant differences between tasks. The presence of APPs was not associated with patient or nurse manager satisfaction. Presence of NPs was associated with greater overall inpatient and discharge coordination ratings by COMs and nurse managers, respectively; the presence of PAs was associated with lower overall inpatient coordination ratings by nurse managers. CONCLUSIONS NPs and PAs work on half of VHA inpatient medicine services with broad, yet similar, scopes of practice. There were few differences between their roles and perceptions of care. Given their very different background, regulation, and reimbursement, this has implications for inpatient medicine services that plan to hire NPs or PAs.

Factors Associated with Prolonged Observation Services Stays and the Impact of Long Stays on Patient Cost

BACKGROUND Patients are treated using observation services (OS) when their care needs exceed standard outpatient care (i.e., clinic or emergency department) but do not qualify for admission. Medicare and other private payers seek to limit this care setting to 48 hours. DATA SOURCE/STUDY SETTING Healthcare Cost and Utilization Project data from 10 states and data collected from two additional states for 2009. STUDY DESIGN Bivariate analyses and hierarchical linear modeling were used to examine patient- and hospital-level predictors of OS stays exceeding 48 (and 72) hours (prolonged OS). Hierarchical models were used to examine the additional cost associated with longer OS stays. PRINCIPAL FINDINGS Of the 696,732 patient OS stays, 8.8 percent were for visits exceeding 48 hours. Having Medicaid or no insurance, a condition associated with no OS treatment protocol, and being discharged to skilled nursing were associated with having a prolonged OS stay. Among Medicare patients, the mean charge for OS stays was

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns.

10,373. OS visits of 48-72 hours were associated with a 42 percent increase in costs; visits exceeding 72 hours were associated with a 61 percent increase in costs. CONCLUSION Patient cost sharing for most OS stays of less than 24 hours is lower than the Medicare inpatient deductible. However, prolonged OS stays potentially increase this cost sharing.