Sherry Glied

The impact of comorbid disease and injuries on resource use and expenditures in parkinsonism

To the Editor: The article by Pressley et al. provides important information about health care use in Parkinson disease (PD).1 Incidentally, this study shed interesting light on falls and injury mechanisms in PD. Earlier studies noted that arm fractures seemed rare in PD.2 The current survey strongly indicates that injuries in PD affect the upper extremities less often than the lower extremities. In fact, recalculation of the original data shows that in PD, the risk of upper extremity injuries was almost significantly lower compared with controls (table). At first sight, this is unexpected because patients with PD fall predominantly forward (figure 1A)3; such forward falls typically cause wrist fractures because subjects land on the outstretched hand.4 We propose two explanations. One possibility is that patients keep their hands in pockets of their clothes owing to shame of hand tremors. Another explanation is that arm movements are delayed or abnormally directed in PD. We examined protective arm movements in patients with PD placed …

Technological Innovation and Inequality in Health

The effect of education on health has been increasing over the past several decades. We hypothesize that this increasing disparity is related to health-related technical progress: more-educated people are the first to take advantage of technological advances that improve health. We test this hypothesis using data on disease-specific mortality rates for 1980 and 1990, and cancer registry data for 1973–1993. We estimate education gradients in mortality using compulsory schooling as a measure of education. We then relate these gradients to two measures of health-related innovation: the number of active drug ingredients available to treat a disease, and the rate of change in mortality from that disease. We find that more-educated individuals have a greater survival advantage in those diseases for which there has been more health-related technological progress.

Costs of Healthcare- and Community-Associated Infections With Antimicrobial-Resistant Versus Antimicrobial-Susceptible Organisms

OBJECTIVE We compared differences in the hospital charges, length of hospital stay, and mortality between patients with healthcare- and community-associated bloodstream infections, urinary tract infections, and pneumonia due to antimicrobial-resistant versus -susceptible bacterial strains. METHODS A retrospective analysis of an electronic database compiled from laboratory, pharmacy, surgery, financial, and patient location and device utilization sources was undertaken on 5699 inpatients who developed healthcare- or community-associated infections between 2006 and 2008 from 4 hospitals (1 community, 1 pediatric, 2 tertiary/quaternary care) in Manhattan. The main outcome measures were hospital charges, length of stay, and mortality among patients with antimicrobial-resistant and -susceptible infections caused by Staphylococcus aureus, Enterococcus faecium, Enterococcus faecalis, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. RESULTS Controlling for multiple confounders using linear regression and nearest neighbor matching based on propensity score estimates, resistant healthcare- and community-associated infections, when compared with susceptible strains of the same organism, were associated with significantly higher charges (

CMS Changes in Reimbursement for HAIs: Setting A Research Agenda

15,626; confidence interval [CI],

Cost-Effectiveness Analysis of Long-Term Moderate Exercise Training in Chronic Heart Failure

4339-

How the Affordable Care Act and Mental Health Parity and Addiction Equity Act Greatly Expand Coverage of Behavioral Health Care

26,913 and

Does State AFDC Generosity Affect Child SSI Participation

25,573; CI,

Health care costs: on the rise again.

9331-

Primary care expenditures before the onset of Alzheimer’s disease

41,816, respectively) and longer hospital stays for community-associated infections (3.3; CI, 1.5-5.4). Patients with resistant healthcare-associated infections also had a significantly higher death rate (0.04; CI, 0.01-0.08). CONCLUSIONS With careful matching of patients infected with the same organism, antimicrobial resistance was associated with higher charges, length of stay, and death rates. The difference in estimates after accounting for censoring for death highlight divergent social and hospital incentives in reducing patient risk for antimicrobial resistant infections.

The Change From Brand-Name to Generic Aromatase Inhibitors and Hormone Therapy Adherence for Early-Stage Breast Cancer

Background:The Centers for Medicare and Medicaid Services (CMS) promulgated regulations commencing October 1, 2008, which deny payment for selected conditions occurring during the hospital stay and are not present on admission. Three of the 10 hospital-acquired conditions covered by the new CMS policy involve healthcare-associated infections, which are a common, expensive, and often preventable cause of inpatient morbidity and mortality. Objective:To outline a research agenda on the impact of CMSs payment policy on the healthcare system and the prevention of healthcare-associated infections. Methods:An invitational daylong conference was convened in April 2009. Including the planning committee and speakers there were 41 conference participants who were national experts and senior researchers. Results:Building upon a behavioral model and organizational theory and management research a conceptual framework was applied to organize the wide range of issues that arose. A broad array of research topics was identified. Thirty-two research agenda items were organized in the areas of incentives, environmental factors, organizational factors, clinical outcomes, staff outcomes, and financial outcomes. Methodological challenges are also discussed. Conclusions:This policy is a first significant step to move output-based inpatient funding to outcome-based funding, and this agenda is applicable to all hospital-acquired conditions. Studies beginning soon will have the best hope of capturing data for the years preceding the policy change, a key element in nonexperimental research. The CMS payment policy offers an excellent opportunity to understand and influence the use of financial incentives for improving patient safety.