Zeynal Karaca

Duration of patients’ visits to the hospital emergency department

BackgroundLength of stay is an important indicator of quality of care in Emergency Departments (ED). This study explores the duration of patients’ visits to the ED for which they are treated and released (T&R).MethodsRetrospective data analysis and multivariate regression analysis were conducted to investigate the duration of T&R ED visits. Duration for each visit was computed by taking the difference between admission and discharge times. The Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for 2008 were used in the analysis.ResultsThe mean duration of T&R ED visit was 195.7 minutes. The average duration of ED visits increased from 8 a.m. until noon, then decreased until midnight at which we observed an approximately 70-minute spike in average duration. We found a substantial difference in mean duration of ED visits (over 90 minutes) between Mondays and other weekdays during the transition time from the evening of the day before to the early morning hours. Black / African American patients had a 21.4-minute longer mean duration of visits compared to white patients. The mean duration of visits at teaching hospitals was substantially longer than at non-teaching hospitals (243.8 versus 175.6 minutes). Hospitals with large bed size were associated with longer duration of visits (222.2 minutes) when compared to hospitals with small bed size (172.4 minutes) or those with medium bed size (166.5 minutes). The risk-adjusted results show that mean duration of visits on Mondays are longer by about 4 and 9 percents when compared to mean duration of visits on non-Monday workdays and weekends, respectively.ConclusionsThe duration of T&R ED visits varied significantly by admission hour, day of the week, patient volume, patient characteristics, hospital characteristics and area characteristics.

Racial Disparity in Duration of Patient Visits to the Emergency Department: Teaching Versus Non-teaching Hospitals.

Introduction: The sources of racial disparity in duration of patients’ visits to emergency departments (EDs) have not been documented well enough for policymakers to distinguish patient-related factors from hospital- or area-related factors. This study explores the racial disparity in duration of routine visits to EDs at teaching and non-teaching hospitals. Methods: We performed retrospective data analyses and multivariate regression analyses to investigate the racial disparity in duration of routine ED visits at teaching and non-teaching hospitals. The Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) were used in the analyses. The data include 4.3 million routine ED visits encountered in Arizona, Massachusetts, and Utah during 2008. We computed duration for each visit by taking the difference between admission and discharge times. Results: The mean duration for a routine ED visit was 238 minutes at teaching hospitals and 175 minutes at non-teaching hospitals. There were significant variations in duration of routine ED visits across race groups at teaching and non-teaching hospitals. The risk-adjusted results show that the mean duration of routine ED visits for Black/African American and Asian patients when compared to visits for white patients was shorter by 10.0 and 3.4%, respectively, at teaching hospitals; and longer by 3.6 and 13.8%, respectively, at non-teaching hospitals. Hispanic patients, on average, experienced 8.7% longer ED stays when compared to white patients at non-teaching hospitals. Conclusion: There is significant racial disparity in the duration of routine ED visits, especially in non-teaching hospitals where non-White patients experience longer ED stays compared to white patients. The variation in duration of routine ED visits at teaching hospitals when compared to non-teaching hospitals was smaller across race groups.

Antimicrobial resistance prevalence and rates of hospitalization with septicemia in the diagnosis in adults in different US states

Objectives Rates of hospitalization with sepsis/septicemia and associated mortality in the US have risen significantly during the last two decades. Antibiotic resistance may contribute to the rates of sepsis-related outcomes through lack of clearance of bacterial infections following antibiotic treatment during different stages of infection. However, there is limited information about the relation between prevalence of resistance to various antibiotics in different bacteria and rates of sepsis-related outcomes. Methods For different age groups of adults (18-49y,50-64y,65-74y,75-84y,85+y) and combinations of antibiotics/bacteria, we evaluated associations between state-specific prevalence (percentage) of resistant samples for a given combination of antibiotics/bacteria among catheter-associated urinary tract infections in the CDC Antibiotic Resistance Patient Safety Atlas data between 2011-2014 and rates of hospitalization with septicemia (ICD-9 codes 038.xx present on the discharge diagnosis) reported to the Healthcare Cost and Utilization Project (HCUP), as well as rates of mortality with sepsis (ICD-10 codes A40-41.xx present on death certificate). Results Among the different combinations of antibiotics/bacteria, prevalence of resistance to fluoroquinolones in E. coli had the strongest association with septicemia hospitalization rates for individuals aged over 50y, and with sepsis mortality rates for individuals aged 18-84y. A number of positive correlations between prevalence of resistance for different combinations of antibiotics/bacteria and septicemia hospitalization/sepsis mortality rates in adults were also found. Conclusions Our findings, as well as our related work on the relation between antibiotic use and sepsis rates support the association between resistance to/use of certain antibiotics and rates of sepsis-related outcomes, suggesting the potential utility of antibiotic replacement.

Levels of prescribing for four major antibiotic classes and rates of septicemia hospitalization in different US states

Background Rates of sepsis/septicemia hospitalization in the US have risen significantly during recent years, and antibiotic resistance and use may contribute to those rates through various mechanisms. Methods We used multivariate Poisson regression to relate state-specific rates of outpatient prescribing overall for four antibiotic classes: fluoroquinolones, penicillins, macrolides, and cephalosporins between 2011-2012 to state-specific counts of hospitalizations with septicemia (ICD-9 codes 038.xx present anywhere on discharge diagnosis) in each of the following age groups of adults: (18-49y, 50-64y, 65-74y, 75-84y, 85+y) reported to the Healthcare Cost and Utilization Project (HCUP) between 2011-2012, adjusting for median household income and population density. Results The regression coefficients were positive for the rates of prescribing of fluoroquinolones, penicillins, as well as cephalosporins in the analysis for adults aged 18-49y, and negative for macrolides, and cephalosporins in the analyses for adults aged 50+y. Conclusions Antibiotic stewardship, particularly for fluoroquinolones, as well as penicillins could be beneficial for reducing the rates of sepsis hospitalization. Negative estimates in the regression analyses suggest that the relative share of the use of different antibiotics in the treatment of various syndromes may affect the rates of sepsis hospitalization. Further studies of those issues are needed to inform antibiotic prescribing guidelines.

Young Adults, Health Insurance Expansions and Hospital Services Utilization

Under the dependent coverage expansion (DCE) provision of health reform adult children up to 26 years of age whose parents have employer-sponsored or individual health insurance are eligible for insurance under their parents’ health plan. Using a difference-in-differences approach and the 2008–2014 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases we examined the impact of the DCE on hospital services use. In analyses of individuals age <26 years (compared to individuals over 26) we found a 1.5% increase in non-pregnancy related inpatient visits in 2010 through 2013 during the initial DCE period and a 1.6% increase in 2014 when other state expansions went into effect. We found that the impact of the DCE persisted into 2014 when many state insurance expansions occurred, although effects varied for states adopting and not adopting Medicaid expansions.

The Effects of Medicare Accountable Organizations on Inpatient Mortality Rates

Studies have linked Accountable Care Organizations (ACOs) to improved primary care, but there is little research on how ACOs affect care in other settings. We examined whether Medicare ACOs have improved hospital quality of care, specifically focusing on preventable inpatient mortality. We used 2008-2014 Healthcare Cost and Utilization Project hospital discharge data from 34 states’ Medicare ACO and non-ACO hospitals in conjunction with data from the American Hospital Association Annual Survey and the Survey of Care Systems and Payment. We estimated discharge-level logistic regression models that measured the relationship between ACO affiliation and mortality following admissions for acute myocardial infarction, abdominal aortic aneurysm (AAA) repair, coronary artery bypass grafting, and pneumonia, controlling for patient demographic mix, hospital, and year. Our results suggest that, on average, Medicare ACO hospitals are not associated with improved mortality rates for the studied IQI conditions. Stakeholders may potentially consider providing ACOs with incentives or designing new programs for ACOs to target inpatient mortality reductions.

A Quantitative Observational Study of Physician Influence on Hospital Costs

Physicians serve as the nexus of treatment decision-making in hospitalized patients; however, little empirical evidence describes the influence of individual physicians on hospital costs. In this study, we examine the extent to which hospital costs vary across physicians and physician characteristics. We used all-payer data from 2 states representing 15 237 physicians and 2.5 million hospital visits. Regression analysis and propensity score matching were used to understand the role of observable provider characteristics on hospital costs controlling for patient demographics, socioeconomic characteristics, clinical risk, and hospital characteristics. We used hierarchical models to estimate the amount of variation attributable to physicians. We found that the average cost of hospital inpatient stays registered to female physicians was consistently lower across all empirical specifications when compared with male physicians. We also found a negative association between physicians’ years of experience and the average costs. The average cost of hospital inpatient stays registered to foreign-trained physicians was lower than US-trained physicians. We observed sizable variation in average costs of hospital inpatient stays across medical specialties. In addition, we used hierarchical methods and estimated the amount of remaining variation attributable to physicians and found that it was nonnegligible (intraclass correlation coefficient [ICC]: 0.33 in the full sample). Historically, most physicians have been reimbursed separately from hospitals, and our study shows that physicians play a role in influencing hospital costs. Future policies and practices should acknowledge these important dependencies. This study lends further support for alignment of physician and hospital incentives to control costs and improve outcomes.

The Impact of Health Information Exchanges on Emergency Department Length of Stay

Health information exchanges (HIEs) are expected to improve poor information coordination in emergency departments (EDs); however, whether and when HIEs are associated with better operational outcomes remains poorly understood. In this work, we study HIE and length of stay (LOS) relationship using a large dataset from the Healthcare Cost and Utilization Project consisting of about 7.4 million treat‐and‐release visits made to 63 EDs in Massachusetts. Overall, we find that HIE adoption is associated with a 10.2% reduction in LOS and the percentage reduction increases to 14.8% when the hospital is part of an integrated health system or to 21.0% when a patient has a previous visit to an HIE‐carrying hospital. We further find that (i) teaching hospitals benefit more from HIE adoption compared with non‐teaching hospitals, (ii) patients with severe or multiple comorbid conditions spend less time in the ED under HIE presence. Together, these results imply that (i) HIE adoption reduces overall ED LOS, (ii) wider HIE adoption would scale up the benefits for individual hospitals, (iii) magnitude of the association between HIE and LOS is higher when financial incentives for HIE adoption are stronger (e.g., integrated health systems), and (iv) the size of the reduction depends on certain contextual moderating factors. Given that HIEs are a key component of healthcare delivery and ongoing reforms, we believe that our findings have important implications and may inform policymakers regarding the nationwide HIE adoption.

A Sticky Wage, Limited Participation Model of Monetary Transmission

This paper studies to what extent surprise money growth may affect output, employment,and real wages from the supply side. Under nominal wage contracts, we analyze the effects of monetary shocks in a limited participation model. We observe that unanticipated money growth increases real wages, employment and output while decreasing prices. This modelling approach to the monetary transmission mechanism, while different from the more traditional demand side explanations, is consistent with empirical findings like procyclical real wages and countercyclical prices.