Justin Fox

Use of Hospital-Based Acute Care Among Patients Recently Discharged From the Hospital

IMPORTANCE Current efforts to improve health care focus on hospital readmission rates as a marker of quality and on the effectiveness of transitions in care during the period after acute care is received. Emergency department (ED) visits are also a marker of hospital-based acute care following discharge but little is known about ED use during this period. OBJECTIVES To determine the degree to which ED visits and hospital readmissions contribute to overall use of acute care services within 30 days of discharge from acute care hospitals, to describe the reasons patients return for ED visits, and to describe these patterns among Medicare beneficiaries and those not covered by Medicare insurance. DESIGN, SETTING, AND PARTICIPANTS Prospective study of patients aged 18 years or older (mean age: 53.4 years) who were discharged between July 1, 2008, and September 31, 2009, from acute care hospitals in 3 large, geographically diverse states (California, Florida, and Nebraska) with data recorded in the Healthcare Cost and Utilization Project state inpatient and ED databases. MAIN OUTCOME MEASURES The 3 primary outcomes during the 30-day period after hospital discharge were ED visits not resulting in admission (treat-and-release encounters), hospital readmissions from any source, and a combined measure of ED visits and hospital readmissions termed hospital-based acute care. RESULTS The final cohort included 5,032,254 index hospitalizations among 4,028,555 unique patients. In the 30 days following discharge, 17.9% (95% CI, 17.9%-18.0%) of hospitalizations resulted in at least 1 acute care encounter. Of these 1,233,402 postdischarge acute care encounters, ED visits comprised 39.8% (95% CI, 39.7%-39.9%). For every 1000 discharges, there were 97.5 (95% CI, 97.2-97.8) ED treat-and-release visits and 147.6 (95% CI, 147.3-147.9) hospital readmissions in the 30 days following discharge. The number of ED treat-and-release visits ranged from a low of 22.4 (95% CI, 4.6-65.4) encounters per 1000 discharges for breast malignancy to a high of 282.5 (95% CI, 209.7-372.4) encounters per 1000 discharges for uncomplicated benign prostatic hypertrophy. Among the highest volume discharges, the most common reason patients returned to the ED was always related to their index hospitalization. CONCLUSIONS AND RELEVANCE After discharge from acute care hospitals in 3 states, ED visits within 30 days were common among adults and accounted for 39.8% of postdischarge hospital-based acute care visits. Improving care transitions should focus not only on decreasing readmissions but also on ED visits.

Delegates or Trustees? A Theory of Political Accountability

Politicians vary in both their competence and their policy preferences. We show that how voters trade off competence against ideological congruence has key implications for the type of representation incumbents provide. When voters privilege competence, they encourage trustee representation, and when voters emphasize ideological congruence, they encourage delegate representation. Selection on competence is most likely to occur when uncertainty about the policy preferences of politicians is minimal. A surprising implication of our analysis is that ideological congruence between incumbents and voters is not a necessary precondition for trustee representation to be rewarded at the ballot box.

Laparoscopic colectomy for the treatment of cancer has been widely adopted in the United States.

BACKGROUND: Fewer than 10% of patients with colon cancer in the United States are reportedly treated with a laparoscopic colectomy despite the benefits it has over the open approach. This estimate, however, may be artificially low because of inaccurate case identification. OBJECTIVE: The aim of this study was to estimate the proportion of colon resections performed laparoscopically for the treatment of colon cancer and to identify factors associated with its use. DESIGN: This study is a retrospective review of the 2008 to 2009 Nationwide Inpatient Sample. SETTINGS, PATIENTS, INTERVENTIONS: Adult patients with a diagnosis of colon cancer who underwent an elective colectomy were included. MAIN OUTCOME MEASURES: The overall proportion of colon resections performed laparoscopically was calculated. Multivariable regression modeling was used to identify patient and hospital characteristics associated with undergoing a laparoscopic procedure. RESULTS: During the study period, 9075 (weighted = 45,549) patients were identified with 50% treated via the laparoscopic approach. Patients were more likely to undergo a laparoscopic procedure if their median annual income was

Judicial Review as a Response to Political Posturing

63,000+ based on home zip code (adjusted relative risk = 1.08 (1.02–1.16)) and less likely if they were 70+ years of age (adjusted relative risk = 0.93 (0.87–1.00)), female (adjusted relative risk = 0.96 (0.92–0.99)), and had Medicaid (adjusted relative risk =0.84 (0.73–0.97)), or 3+ chronic conditions (adjusted relative risk = 0.84 (0.79–0.89)). Treatment at teaching hospitals (adjusted relative risk =1.10 (1.00–1.20)) and high-volume centers (adjusted relative risk =1.41 (1.22–1.63)) was associated with undergoing a laparoscopic colectomy, whereas treatment at rural hospitals was associated with less frequent use of laparoscopic colectomy (adjusted relative risk = 0.76 (0.64–0.90)). LIMITATIONS: This study is subject to the limitations of using administrative data. CONCLUSIONS: There has been widespread adoption of the laparoscopic approach to colon resection for cancer in the United States. Disparities in access remain, with application of this technique favoring patients with a higher socioeconomic status and those able to be treated at higher-volume, academic, and nonrural centers.

A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention

We use an agency model to analyze the impact of judicial review on the incentives of elected leaders to “posture” by enacting bold but ill-advised policies. We find that judicial review may exacerbate posturing by rescuing leaders from the consequences of unwise policies, but may also discourage posturing by alerting voters to unjustified government action. We further find that judges will defer to the decision of elected leaders unless posturing is sufficiently likely. We then show how judicial review affects voter welfare, both through its effect on policy choice and through its effect on the efficacy of the electoral process in selecting leaders. We also analyze how the desirability of judicial review is affected by characteristics of the leaders and the judges.

Partisanship and the Effectiveness of Oversight

Objectives:Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in todays health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed. Methods:All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted. Results:A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2 ± 26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded

Legislative Cooperation among Impatient Legislators

17.5 million. Notable independent risk factors for IH were ostomy reversal (HR = 2.76), recent chemotherapy (HR = 2.04), bariatric surgery (HR = 1.78), smoking history (HR = 1.74), liver disease (HR = 1.60), and obesity (HR = 1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statistic = 0.78). Conclusions:This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.

Hospital readmissions and emergency department visits following laparoscopic and open colon resection for cancer.

We examine the welfare effects of partisanship in a model of checks and balances. An executive makes a policy proposal and an overseer then decides whether or not to veto the executives proposal. Both the executive and the overseer have private information as to the correct policy to pursue, and both are motivated by the desire to appear competent. A partisan overseer is one who, in addition to seeking to promote her own reputation, cares how her decision will impact the executives reputation. Our main result is that partisanship can improve the efficacy of an oversight regime, as the distortions caused by a partisan overseers desire to affect the executives reputation can offset the distortions caused by her desire to enhance her own. Our results provide a new rationale for divided government, as partisan considerations are often necessary to prevent the overseer from rubber stamping all executive proposals.

Influence without Bribes: A Noncontracting Model of Campaign Giving and Policymaking

Sufficient conditions for legislative cooperation are identified within the context of a model of repeated legislative interaction. We show that in many environments, cooperation is sustainable even among impatient legislators. Special attention is given to the case of repeated spatial bargaining; we find that when the dimensionality of the policy space is sufficiently large, parameterizations of the model which do not admit cooperation are rare and atypical. Furthermore, contrary to conventional wisdom, we demonstrate that legislative cooperation is possible in a one-dimensional policy space. The developed theory is applied to address various claims in the substantive literature on legislative parties.

Older Patient Experiences in the Mammography Decision-Making Process

BACKGROUND: Laparoscopic colectomy for the treatment of colon cancer has been widely adopted in community practice, in part, because of shorter hospitalizations. The benefits of a shorter hospital stay are only realized if readmissions and emergency department visits, collectively termed revisits, do not increase after discharge. We conducted a population-based analysis to determine whether hospitals with higher laparoscopic colectomy rates have higher revisit rates. OBJECTIVE: The aim of this study was to determine whether hospital utilization after discharge is increased for patients undergoing laparoscopic colectomy for cancer. DESIGN: This is a retrospective cohort study. SETTINGS: Data were gathered from the Healthcare Cost and Utilization Project’s inpatient and emergency department databases for California. These databases include data from all nonfederal hospitals in the State of California. PATIENTS: Patients who underwent elective colectomy for cancer from 2008 to 2009 were included. INTERVENTIONS: The primary intervention was elective colectomy with the use of the open or laparoscopic approach. MAIN OUTCOME MEASURES: The correlation between hospital laparoscopy rates and hospital readmission rates, emergency department visit rates, and revisit rates was calculated. RESULTS: Overall, 6760 patients were treated at 176 hospitals. For every 100 patients discharged, there were 14.0 readmissions and 9.2 emergency department encounters. At the hospital level, laparoscopy rates varied considerably (median = 45.7%, range = 2.2%–88.9%), as did the risk-standardized readmission (12.1%, 8.6%–16.5%), emergency department encounter (7.8%, 4.1%–18.0%), and revisit rates (17.9%, 13.0%–26.4%). A hospital’s laparoscopy rate was not significantly correlated with its risk-standardized readmission (weighted correlation coefficient = 0.05, p = 0.50), emergency department encounter (–0.11, p = 0.16), or revisit (–0.03, p = 0.70) rates. LIMITATIONS: There are inherent limitations when using administrative data. CONCLUSIONS: Hospitals where a greater proportion of colon resections for cancer are approached laparoscopically do not have higher 30-day, risk-standardized readmission, emergency department encounter, or revisit rates.