Lena M. Chen

Primary Care Visit Duration and Quality: Does Good Care Take Longer?

BACKGROUND It is unclear if increasing pressure on primary care physicians to be more efficient has affected visit duration or quality of care. We sought to describe changes in the duration of adult primary care visits and in the quality of care provided during these visits and to determine whether quality of care is associated with visit duration. METHODS We conducted a retrospective analysis of visits by adults 18 years or older to a nationally representative sample of office-based primary care physicians in the United States. RESULTS Between 1997 and 2005, US adult primary care visits to physicians increased from 273 million to 338 million annually, or 10% on a per capita basis. The mean visit duration increased from 18.0 to 20.8 minutes (P < .001 for trend). Visit duration increased by 3.4 minutes for general medical examinations and for the 3 most common primary diagnoses of diabetes mellitus (4.2 minutes, P = .002 for trend), essential hypertension (3.7 minutes, P < .001 for trend), and arthropathies (5.9 minutes, P < .001 for trend). Comparing the early period (1997-2001) with the late period (2002-2005), quality of care improved for 1 of 3 counseling or screening indicators and for 4 of 6 medication indicators. Providing appropriate counseling or screening generally took 2.6 to 4.2 minutes. Providing appropriate medication therapy was not associated with longer visit duration. CONCLUSIONS Adult primary care visit frequency, quality, and duration increased between 1997 and 2005. Modest relationships were noted between visit duration and quality of care. Providing counseling or screening required additional physician time, but ensuring that patients were taking appropriate medications seemed to be independent of visit duration.

Intensive Care Unit Admitting Patterns in the Veterans Affairs Health Care System

BACKGROUND Critical care resource use accounts for almost 1% of US gross domestic product and varies widely among hospitals. However, we know little about the initial decision to admit a patient to the intensive care unit (ICU). METHODS To describe hospital ICU admitting patterns for medical patients after accounting for severity of illness on admission, we performed a retrospective cohort study of the first nonsurgical admission of 289,310 patients admitted from the emergency department or the outpatient clinic to 118 Veterans Affairs acute care hospitals between July 1, 2009, and June 30, 2010. Severity (30-day predicted mortality rate) was measured using a modified Veterans Affairs ICU score based on laboratory data and comorbidities around admission. The main outcome measure was direct admission to an ICU. RESULTS Of the 31,555 patients (10.9%) directly admitted to the ICU, 53.2% had 30-day predicted mortality at admission of 2% or less. The rate of ICU admission for this low-risk group varied from 1.2% to 38.9%. For high-risk patients (predicted mortality >30%), ICU admission rates also varied widely. For a 1-SD increase in predicted mortality, the adjusted odds of ICU admission varied substantially across hospitals (odds ratio = 0.85-2.22). As a result, 66.1% of hospitals were in different quartiles of ICU use for low- vs high-risk patients (weighted κ = 0.50). CONCLUSIONS The proportion of low- and high-risk patients admitted to the ICU, variation in ICU admitting patterns among hospitals, and the sensitivity of hospital rankings to patient risk all likely reflect a lack of consensus about which patients most benefit from ICU admission.

Association Between a Hospital’s Rate of Cardiac Arrest Incidence and Cardiac Arrest Survival

IMPORTANCE National efforts to measure hospital performance in treating cardiac arrest have focused on case survival, with the hope of improving survival after cardiac arrest. However, it is plausible that hospitals with high case-survival rates do a poor job of preventing cardiac arrests in the first place. OBJECTIVE To describe the association between inpatient cardiac arrest incidence and survival rates. DESIGN Within a large, national registry, we identified hospitals with at least 50 adult in-hospital cardiac arrest cases between January 1, 2000, and November 30, 2009. We used multivariable hierarchical regression to evaluate the correlation between a hospitals cardiac arrest incidence rate and its case-survival rate after adjusting for patient and hospital characteristics. MAIN OUTCOMES AND MEASURES The correlation between a hospitals incidence rate and case-survival rate for cardiac arrest. RESULTS Of 102,153 cases at 358 hospitals, the median hospital cardiac arrest incidence rate was 4.02 per 1000 admissions (interquartile range, 2.95-5.65 per 1000 admissions), and the median hospital case-survival rate was 18.8% (interquartile range, 14.5%-22.6%). In crude analyses, hospitals with higher case-survival rates also had lower cardiac arrest incidence (r, -0.16; P = .003). This relationship persisted after adjusting for patient characteristics (r, -0.15; P = .004). After adjusting for potential mediators of this relationship (ie, hospital characteristics), the relationship between incidence and case survival was attenuated (r, -0.07; P = .18). The one modifiable hospital factor that most attenuated this relationship was a hospitals nurse-to-bed ratio (r, -0.12; P = .03). CONCLUSIONS AND RELEVANCE Hospitals with exceptional rates of survival for in-hospital cardiac arrest are also better at preventing cardiac arrests, even after adjusting for patient case mix. This relationship is partially mediated by measured hospital attributes. Performance measures focused on case-survival rates seem an appropriate first step in quality measurement for in-hospital cardiac arrest.

Will Bundled Payments Change Health Care? Examining the Evidence Thus Far in Cardiovascular Care

Episode-based, “bundled” payments have come to the forefront of the national discussion on combating rising healthcare costs. In the currently dominant fee-for-service model for reimbursement, hospitals, physicians, and postacute care providers file distinct claims and are paid separately for provided services even when they are related to a single episode of care. However, this approach to payment encourages fragmented care, with little incentive for resource stewardship, coordination, or communication across multiple providers. In contrast, bundled payments seek to align the interests of providers by providing a fixed payment for all services given during a single episode of care. This payment is distributed among all providers in a healthcare system involved with that patient, including hospitals and other facilities. Although not a new policy initiative, bundled payments have resurfaced in the current era of healthcare reform, with its advocates arguing that it can curtail healthcare costs while simultaneously improving quality. Cardiovascular care is the arena in which implementation of bundled payments is arguably most visible and may be most impactful. Many previous demonstrations of bundled payments have concentrated on cardiovascular conditions, and it is likely that future efforts will continue to do so, with good reason. First, cardiovascular diseases are common, costly, and deadly1 and therefore are important in national discussions for healthcare reform. Second, care for cardiovascular disease involves multiple providers from different disciplines (primary care, cardiology, cardiac surgery, anesthesiology, radiology). Lastly, cardiovascular patients receive care in multiple healthcare settings (hospital, outpatient primary care and subspecialty clinics, skilled nursing facility, etc). Given all these factors, bundled payments have the potential to substantially improve care coordination and to generate savings for cardiovascular care. In the present article, we further explore bundled payment initiatives and their potential advantages and disadvantages, focusing our review on previous and current bundled payment programs for …

Use of Health IT for Higher-Value Critical Care

With an aging population and growing demand for critical care, the number of staffed ICU beds in the U.S. may be increasingly inadequate. A promising approach to the problem is the application of advances in health information technology to triage decisions.

Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults

Importance As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions. Objective To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions. Design, Setting, and Participants This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals’ length of stay (LOS) mode were evaluated among a risk and postoperative complication–matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals’ mean surgical episode payments according to their change in LOS mode during the study period. Exposure Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers. Main Outcomes and Measures Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care. Results A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication–matched patients were significantly lower among hospitals with lowest vs highest LOS mode (

Composite Quality Measures for Common Inpatient Medical Conditions

26 482 vs

Costs of quality improvement: a survey of four acute care hospitals.

29 250 for colectomy,

Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program

44 777 vs

Use of Medical Consultants for Hospitalized Surgical Patients: An Observational Cohort Study

47 675 for CABG, and