Preethy Nayar

Data Envelopment Analysis Comparison of Hospital Efficiency and Quality

Using a sample of Virginia hospitals, performance measures of quality were examined as they related to technical efficiency. Efficiency scores for the study hospitals were computed using Data Envelopment Analysis (DEA). The study found that the technically efficient hospitals were performing well as far as quality measures were concerned. Some of the technically inefficient hospitals were also performing well with respect to quality. DEA can be used to benchmark both dimensions of hospital performance: technical efficiency and quality. The results have policy implications in view of growing concern that hospitals may be improving their efficiency at the expense of quality.

Benchmarking urban acute care hospitals: Efficiency and quality perspectives

BACKGROUND Over the last couple of decades, hospitals in the United States are facing pressures to maximize performance in terms of production efficiency and quality. An increasing emphasis on value-based purchasing on the part of third-party payers as well as the prevalence of pay for performance initiatives create an imperative for more accurate assessments of health care provider performance. PURPOSES The objectives of this study were to measure hospital performance in terms of both technical efficiency and quality using data envelopment analysis (DEA) models in urban acute care hospitals. METHODOLOGY/APPROACH In this observational cross-sectional study of a nationally representative sample of 371 urban acute care hospitals, hospital performance was assessed using slack-based additive DEA models. The technical inputs included in the DEA models were total number of beds setup and staffed, nonphysician full-time equivalent staffing, and nonpayroll operating expenses. The technical outputs were adjusted patient days, total number of outpatient visits, and training full-time equivalent, obtained from the American Hospital Association 2008 database. The quality measures used for the quality of care dimension of performance were survival rates for acute myocardial infarction, congestive heart failure, and pneumonia obtained from the Nationwide Inpatient Sample 2008 data. FINDINGS Less than 20% of the sample hospitals were optimally performing for both quality and efficiency. Tobit regression analysis of the DEA scores found that public, small, teaching hospitals had higher DEA efficiency and quality scores. PRACTICE IMPLICATIONS DEA is a promising tool for benchmarking both aspects of performance: efficiency and quality of hospitals. Because quality is a multidimensional construct, the choice of an appropriate composite quality measure has to be addressed in future research. However, incorporating quality into the DEA models would be a better reflection of the hospital product.

Rural Veterans’ Perspectives of Dual Care

The purpose of this study was to develop an in-depth understanding of the barriers and enablers of effective dual care (care obtained from the Veterans Health Administration [VHA] and the private health system) for rural veterans. Telephone interviews of a random sample of 1,006 veterans residing in rural Nebraska were completed in 2010. A high proportion of the rural veterans interviewed reported receiving dual care. The common reasons cited for seeking care outside the VHA (or VA [Veterans Administration]) included having an established relationship with a non-VA provider and distance to the nearest VA medical center. Almost half of the veterans who reported having a personal doctor or nurse reported that this was a non-VA provider. Veterans reported high levels of satisfaction with the quality of care they receive. Ordinal logistic regression models found that veterans who were Medicare beneficiaries, and who rated their health status higher had higher satisfaction with dual care. The reasons cited by the veterans for seeking care at the VHA (quality of VHA care, lower costs of VHA care, entitlement) and veterans perceptions about dual care (confused about where to seek care for different ailments, perceived lack of coordination between VA and non VA providers) were significant predictors of veterans’ satisfaction with dual care. This study will guide policymakers in the VA to design a shared care system that can provide seamless, timely, high quality and veteran centered care.

Preventable hospitalizations: Does rurality or non-physician clinician supply matter?

This study examines the relationship between rurality as well as the proportion of non-physician clinicians and county rates of ambulatory care sensitive hospitalizations (ACSHs) for pediatric, adult and elderly populations in Nebraska. The study design was a cross-sectional observational study of county level factors that affect the county level rates of ACSHs using Poisson regression models. Rural (non-metro) counties have significantly higher ACSHs for both pediatric and adult population, but not for the elderly. Frontier counties have significantly higher adult ACSHs. The proportion of primary care providers who are non-physician clinicians does not have a significant association with ACSHs for any of the age groups. The results indicate that rurality may have a greater impact on pediatric and adult ACSHs and the proportion of NPCs in the primary care provider workforce does not significantly impact ACSH rates.

Transitions in Dual Care for Veterans: Non-Federal Physician Perspectives

Many veterans receive care from both the Veterans Health Administration (VHA) and the non-VHA health system, or dual care. Non-federal physicians practicing in Nebraska were surveyed to examine their perspectives on the organization and delivery of dual care provided to veterans. A paper-based survey was mailed to all 1,287 non-federal primary care physicians (PCPs) and a purposive sample of 765 specialist physicians practising in Nebraska. Rural physicians are more likely to incorporate care coordination practices in their clinical practice, compared to urban physicians. More rural physicians report difficulties in patient transfers, and referrals to the VHA, in prescribing for veteran patients, and in contacting a VHA provider in an emergent situation regarding their veteran patient. More PCPs also report difficulties in referrals to the VHA. However, more rural and primary care physicians follow up with their veteran patients post referral to the VHA. There was agreement among the physicians that the current dual care system needed improvements to provide timely, efficient, coordinated and high quality care to veterans. The specific areas identified for improvement were coordination of care, information sharing, medication management, streamlining of patient transfers, reimbursement for care provided outside the VA, and better delineation and clarity of the boundaries of each system and roles and responsibilities of VA and non-VA providers in the care of veterans.

Quality of end-of-life care among rural medicare beneficiaries with colorectal cancer

BACKGROUND Although previous research has documented rural disparities in hospice use, limited data exist on the roles of geographic access in different types of end-of-life indicators among cancer survivors. METHODS Medicare claims data were used to identify beneficiaries with colorectal cancer who died in 2008 (N = 34,975). We evaluated rural-urban differences in ER visits 90 days before death, inpatient hospital admissions ≤90 days before death, intensive care unit (ICU) use ≤90 days before death, hospice care use at any time, and hospice enrollment <3 days before death. RESULTS About 60% of beneficiaries in rural areas lived in counties with the 2 lowest socioecomonic levels compared to only 5.3% of beneficiaries in metropolitan areas. After adjusting for demographic factors and comorbidities, beneficiaries in rural counties had a lower number of ICU days (RR = 0.65) and were less likely to ever use hospice (OR = 0.78) compared to those in metropolitan counties. Beneficiaries from racial/ethnic minority groups, those with lower socioeconomic status, and those with a higher comorbidity index were less likely to ever use hospice but they tended to use ER, inpatient care, and ICU. CONCLUSIONS Evidence for disparities due to geographic access and socioeconomic factors warrant increased efforts to remove systemic and structural barriers. Future research should focus on exploring and evaluating potential policy and practice interventions to improve the quality of life among elderly cancer survivors living in rural communities and those from socioeconomically disadvantaged backgrounds.

The impact of Medicare's Prospective Payment System on staffing of long-term acute care hospitals: the early evidence.

BACKGROUND Long-term acute care hospitals (LTACHs) treat patients with complex medical conditions requiring hospital care for extended periods of time. In the last decade, Medicare saw spiraling costs for post-acute care settings. The Balanced Budget Act mandated the use of Prospective Payment System (PPS) for all post-acute care settings including LTACHs. Medicare shifted to PPS for LTACHs in October 2002. PURPOSE This study analyzes the early effect of Medicares PPS on the staffing intensity of LTACHs. METHODOLOGY/APPROACH The study uses panel data of measures of hospital and market characteristics in years 2001 through 2004. The impact of the payment mechanism, market, and organizational variables on the staffing intensity of LTACHs is evaluated using fixed-effects (within-groups) regression analysis. FINDINGS The fixed-effects regression models found that Medicares PPS was associated with higher staffing intensity of the LTACHs in years 2003 and 2004. Market-level per capita income was significantly positively associated with staffing intensity. No secular trend in staffing intensity was found. PRACTICE IMPLICATIONS The concern that the cost containment incentives of PPS would result in lowered staffing levels of LTACHs was not borne out by this study. Further follow-up is required to assess in the longer term the effects of PPS on staffing and quality of care in LTACHs.

Frontier America's Health System Challenges and Population Health Outcomes

PURPOSE The objective of this cross-sectional descriptive study was to examine and compare the county-level characteristics including demographic factors, health system factors, and population health outcomes of frontier and nonfrontier counties in the United States. All counties in the United States were studied using the merged County Health Rankings 2011 and the Area Resource File 2009 databases. Of a total of 3,141 counties in the County Health Rankings 2011 database, 438 were identified as frontier counties using the conventional definition of fewer than 7 persons per square mile. FINDINGS Frontier counties were found to have a significantly higher proportion of elderly, Hispanic, and Native American residents than nonfrontier counties. Frontier counties have lower household income and lower levels of illiteracy. Frontier counties also have significantly fewer primary care physicians and higher uninsurance rates. Although frontier counties have a lower percentage of ZIP codes with healthy food and recreational facilities, the incidence of obesity is lower in frontier areas. CONCLUSIONS Empirical literature on the population health outcomes and health system factors of frontier areas is limited. Frontier communities in the United States face significant challenges in terms of having populations with a higher need for primary care such as the elderly and poor. In addition, they face access barriers due to geographic remoteness. The availability of reliable data on population outcomes will enable policy makers to monitor the health status of frontier populations and to design solutions to the access issues that these populations face.

Rural-Urban Differences in Costs of End-of-Life Care for Elderly Cancer Patients in the United States

PURPOSE The objective of this study was to examine the rural-urban differences in Medicare expenditures on end-of-life care for elderly cancer patients in the United States. METHODS We analyzed Medicare claims data for 175,181 elderly adults with lung, colorectal, female breast, or prostate cancer diagnosis who died in 2008. The end-of-life costs were quantified as total Medicare expenditures for the last 12 months of care including inpatient, outpatient, physician services, hospice, home health, skilled nursing facilities (SNF), and durable medical expenditure. Linear regression models were used to estimate rural-urban differences in log-transformed end-of-life costs and logistic regressions were used to estimate probability of service use, adjusting for demographics, socioeconomic status, and comorbidities. FINDINGS On average, elderly cancer patients cost Medicare

Needs Assessment for Behavioral Health Workforce: a State-Level Analysis

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