Mark Aaron Unruh

Does Reducing Length of Stay Increase Rehospitalization of Medicare Fee‐for‐Service Beneficiaries Discharged to Skilled Nursing Facilities?

To analyze the relationship between length of stay and rehospitalization.

Use of Health Information Exchange and Repeat Imaging Costs

PURPOSE The aim of this study was to quantify the association between health information exchange (HIE) use and cost savings attributable to repeat imaging. METHODS Imaging procedures associated with HIE were compared with concurrent controls on the basis of propensity score matching over the period from 2009 to 2010 in a longitudinal cohort study. The study sample (n = 12,620) included patients ages 18 years and older enrolled in the two largest commercial health plans in a 13-county region of western New York State served by the Rochester Regional Health Information Organization. The primary outcome was a continuous measure of costs associated with repeat imaging. The determinant of interest, HIE use, was defined as system access after the initial imaging procedure and before repeat imaging. RESULTS HIE use was associated with an overall estimated annual savings of

Antipsychotic use in nursing home residents admitted with hip fracture.

32,460 in avoided repeat imaging, or

Medicaid Bed-Hold Policies and Hospitalization of Long-Stay Nursing Home Residents

2.57 per patient. Basic imaging (radiography, ultrasound, and mammography) accounted for 85% of the estimated avoided cases of repeat imaging. Advanced imaging (CT and MRI) accounted for 13% of avoided procedures but constituted half of the estimated savings (50%). CONCLUSIONS HIE systems may reduce costs associated with repeat imaging. Although inexpensive imaging procedures constituted the largest proportion of avoided repeat imaging in our study, most of the estimated cost savings were due to small reductions in repeated advanced imaging procedures. HIE systems will need to be leveraged in ways that facilitate greater reductions in advanced imaging to achieve appreciable cost savings.

Hospitalization event notifications and reductions in readmissions of Medicare fee-for-service beneficiaries in the Bronx, New York

To evaluate the association between receiving antipsychotics and the outcomes of a cohort of nursing home (NH) residents with and without presumed delirium after hip fracture.

Growth Of New York Physician Participation In Meaningful Use Of Electronic Health Records Was Variable, 2011–12

OBJECTIVE To evaluate the effect of Medicaid bed-hold policies on hospitalization of long-stay nursing home residents. DATA SOURCES A nationwide random sample of long-stay nursing home residents with data elements from Medicare claims and enrollment files, the Minimum Data Set, the Online Survey Certification and Reporting System, and Area Resource File. The sample consisted of 22,200,089 person-quarters from 754,592 individuals who became long-stay residents in 17,149 nursing homes over the period beginning January 1, 2000 through December 31, 2005. STUDY DESIGN Linear regression models using a pre/post design adjusted for resident, nursing home, market, and state characteristics. Nursing home and year-quarter fixed effects were included to control for time-invariant facility influences and temporal trends associated with hospitalization of long-stay residents. PRINCIPAL FINDINGS Adoption of a Medicaid bed-hold policy was associated with an absolute increase of 0.493 percentage points (95% CI: 0.039-0.946) in hospitalizations of long-stay nursing home residents, representing a 3.883 percent relative increase over the baseline mean. CONCLUSIONS Medicaid bed-hold policies may increase the likelihood of hospitalization of long-stay nursing home residents and increase costs for the federal Medicare program.

Meaningful Use of Electronic Health Records by Outpatient Physicians and Readmissions of Medicare Fee-for-service Beneficiaries.

Objective: Follow-up with a primary care provider after hospital discharge has been associated with a reduced likelihood of readmission. However, primary care providers are frequently unaware of their patients’ hospitalizations. Event notification may be an effective tool for reducing readmissions by notifying primary care providers when their patients have been admitted to and discharged from a hospital. Materials and Methods: We examined the effect of an event notification system on 30-day readmissions in the Bronx, New York. The Bronx has among the highest readmission rates in the country and is a particularly challenging setting to improve care due to the low socioeconomic status of the county and high rates of poor health behaviors among its residents. The study cohort included 2559 Medicare fee-for-service beneficiaries associated with 14 141 hospital admissions over the period January 2010 through June 2014. Linear regression models with beneficiary-level fixed-effects were used to estimate the impact of event notifications on readmissions by comparing the likelihood of rehospitalization for a beneficiary before and after event notifications were active. Results: The unadjusted 30-day readmission rate when event notifications were not active was 29.5% compared to 26.5% when alerts were active. Regression estimates indicated that active hospitalization alert services were associated with a 2.9 percentage point reduction in the likelihood of readmission (95% confidence interval: −5.5, −0.4). Conclusions: Alerting providers through event notifications may be an effective tool for improving the quality and efficiency of care among high-risk populations.

Demand-Side Factors Associated with the Purchase of Long-Term Care Insurance

The federal government has invested

Differences in Medicare Billing of Internal Medicine Physicians According to Sex

30 billion to promote the adoption and use of electronic health records (EHRs) through the Medicare and Medicaid EHR Incentive Programs. However, the associations between the characteristics of physicians, practices, and markets and the patterns of provider participation in ongoing federal meaningful-use incentive programs over time have been largely unexplored. In this article we describe the participation of New York physicians during the first two years of the meaningful-use initiative. We examined longitudinal patterns to identify characteristics associated with nonparticipation, late adoption of EHRs, noncontinuous participation, and switching programs. We found that 8.1 percent of 26,368 New York physicians participated in the Medicare incentive program in 2011, and 6.1 percent participated in the Medicaid program. Physician participation in the programs grew to 23.9 percent and 8.5 percent, respectively, in 2012. Many physicians in the Medicaid incentive program in 2011 did not participate in either program in 2012. Prior EHR use, access to financial resources, and organizational capacity were physician characteristics associated with early and consistent participation in the meaningful-use initiative. Annual participation requirements, coupled with different options to meet meaningful-use criteria under the incentive programs, create disparate groups of physicians, which illustrates the need to monitor participants for continued participation.

Temporal and Geographic variation in the validity and internal consistency of the Nursing Home Resident Assessment Minimum Data Set 2.0

Background: Nearly one-fifth of hospitalized Medicare fee-for-service beneficiaries are readmitted within 30 days. Participation in the Meaningful Use initiative among outpatient physicians may reduce readmissions. Objective: To evaluate the impact of outpatient physicians’ participation in Meaningful Use on readmissions. Subjects and Research Design: The study population included 90,774 Medicare fee-for-service beneficiaries from New York State (2010–2012). We compared changes in the adjusted odds of readmission for patients of physicians who participated in Meaningful Use—stage 1, before and after attestation as meaningful users, with concurrent patients of matched control physicians who used paper records or electronic health records without Meaningful Use participation. Three secondary analyses were conducted: (1) limited to patients with 3+ Elixhauser comorbidities; (2) limited to patients with conditions used by Medicare to penalize hospitals with high readmission rates (acute myocardial infarction, congestive heart failure, and pneumonia); and (3) using only patients of physicians with electronic health records who were not meaningful users as the controls. Main Outcome: Thirty-day readmission. Results: Patients of Meaningful Use physicians had 6% lower odds of readmission compared with patients of physicians who were not meaningful users, but the estimate was not statistically significant (odds ratio: 0.94, 95% confidence interval, 0.88–1.01). Estimated odds ratios from secondary analyses were broadly consistent with our primary analysis. Conclusions: Physician participation in Meaningful Use was not associated with reduced readmissions. Additional studies are warranted to see if readmissions decline in future stages of Meaningful Use where more emphasis is placed on health information exchange and outcomes.