2020

The Impact Of The COVID-19 Pandemic On Hospital Admissions In The United States

Health Affairs

John D. Birkmeyer, Amber Barnato, Nancy Birkmeyer, Robert Bessler, and Jonathan Skinner

Hospital admissions in the US fell dramatically with the onset of the coronavirus disease 2019 (COVID-19) pandemic. However, little is known about differences in admissions patterns among patient groups or the extent of the rebound. In this study of approximately 1 million medical admissions from a large nationally representative hospitalist group, we found that declines in non-COVID-19 admissions from February to April 2020 were generally similar across patient demographic subgroups and exceeded 20% for all primary admission diagnoses. By late June/early July 2020, overall non-COVID-19 admissions had rebounded to 16% below pre-pandemic baseline volume (8% including COVID-19 admissions). Non-COVID-19 admissions were substantially lower for patients residing in majority-Hispanic neighborhoods (32% below baseline) and remained well below baseline for patients with pneumonia (−44%), COPD/asthma (−40%), sepsis (−25%), urinary tract infection (−24%) and acute ST-elevation myocardial infarction (STEMI), −22%). Health system leaders and public health authorities should focus on efforts to ensure that patients with acute medical illnesses can obtain hospital care as needed during the pandemic to avoid adverse outcomes.

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Association of Regional Practice Environment Intensity and the Ability of Internists to Practice High-Value Care After Residency

JAMA Network

Weifeng Weng, PhD; Jessica Van Parys, PhD; Rebecca S. Lipner, PhD; Jonathan S. Skinner, PhD; Brenda E. Sirovich, MD, MS

Use of healthcare services and physician practice patterns have been shown to vary widely across the United States. Although practice patterns—in particular, physicians’ ability to provide high-quality, high-value care—develop during training, the association of a physician’s regional practice environment with that ability is less well understood.

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Variation in Bariatric Surgery Costs and Complication Rates in the Military Health System

Military Medicine

William Patrick Luan, DrPH; LCDR Todd C. Leroux , MSC, USN; Cara Olsen, DrPH;
Lt. Gen. (Ret.) Douglas Robb , MC, USAF; Jonathan S. Skinner, PhD; Patrick Richard, PhD

Within the Military Health System (MHS), facilities have struggled to meet minimum recommended volume thresholds for certain procedures. Understanding variations in complication rates and cost can help policymakers tailor policy to target improvement. Our objective was to quantify the variation in bariatric surgery complication rates and costs across a sample of military hospitals. Materials and Methods: We study a retrospective cohort of 38 military surgeons practicing in 21 military treatment facilities from 2007 to 2014 who performed 1,277 bariatric surgeries. Data from the Centralized Credentials and Quality Assurance System, which provides education and training characteristics of physicians, were linked to patient encounter data from the MHS Data Repository. Physicians were included if they performed at least five bariatric surgeries over the study period. Patients were included if they had a diagnosis of obesity (body mass index > 30) and underwent a bariatric weight loss surgery. We calculated and summarized inpatient costs and complication rates across both surgeons and facilities using multivariable mixed-effects linear or logistic models. We used these models to calculate adjusted complication rates and average costs across both providers and hospitals to characterize variation in bariatric outcomes within the MHS. This study was considered exempt by the Uniformed Services University Institutional Review Board. Results: We find evidence of large variations in both complication rates and costs per admission. Overall, we found a 15.5% complication rate across the sample. When comparing averages across facilities, we find large variation in complications (49.4% coefficient of variation [CV]) and procedure costs (25.9% CV). Controlling for patient comorbidities, BMI, and year attenuates much of the variation (12.6% CV complications, 4.4% CV cost), but cannot completely explain differences across facilities. Our model suggests that complications cost 32% more than complication-free surgeries on average suggesting that quality improvement efforts could potentially yield large savings. Conclusions: We find large variations in complication rates even after controlling for patient health. Furthermore, surgical complications are a significant determinant of cost. Policymakers should target efforts to improve surgical quality across facilities and physicians. Surgical quality improvement initiatives could produce savings to the MHS through reduced complications and improved surgical readiness.

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Residential Setting and the Cumulative Financial Burden of Dementia in the 7 Years Before Death

JAGS

Amy S. Kelley, MD, MSHS, Kathleen McGarry, PhD, Evan Bollens-Lund, MA, Omari-Khalid Rahman, MA, Mohammed Husain, MA, Katelyn B. Ferreira, MPH, and Jonathan S. Skinner, PhD

Care for older adults with dementia during the final years of life is costly, and families shoulder much of this burden. We aimed to assess the financial burden of care for those with and without dementia, and to explore differences across residential settings.

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Opportunities and Challenges of Claims-Based Quality Assessment

Circulation: Cardiovascular Quality and Outcomes

Lauren Gilstrap, MD, MPH, Jonathan S. Skinner, PhD, Barbara Gladders, MS, A. James O’Malley, PhD, Amber E. Barnato, MD,MPH, Anna N. A. Tosteson, ScD, Andrea M. Austin, PhD

To combat the high cost and increasing burden of quality reporting, the Medicare Payment Advisory (MedPAC) has recommended using claims data wherever possible to measure clinical quality. In this article, we use a cohort of Medicare beneficiaries with heart failure with reduced ejection fraction and existing quality metrics to explore the impact of changes in quality metric methodology on measured quality performance, the association with patient outcomes, and hospital rankings.

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No date for the PROM: the association between patient-reported health events and clinical coding in primary car

Journal of Patient-Reported Outcomes

Paul J. Barr , Scott A. Berry , Wendolyn S. Gozansky , Deanna B. McQuillan , Colleen Ross , Don Carmichael, Andrea M. Austin , Travis D. Satterlund , Karen E. Schifferdecker , Lora Council , Michelle D. Dannenberg , Ariel T. Wampler , Eugene C. Nelson and Jonathan Skinner

Objective: It is unclear whether data from patient-reported outcome measures (PROMs) are captured and used by clinicians despite policy initiatives. We examined the extent to which fall risk and urinary incontinence (UI) reported on PROMS and provided to clinicians prior to a patient visit are subsequently captured in the electronic medical record (EMR). Additionally, we aimed to determine whether the use of PROMs and EMR documentation is higher for visits where PROM data was provided to clinicians.

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Residential Setting and the Cumulative Financial Burden of Dementia in the 7  Years Before Death

Journal of the American Geriatric Society
Kelley AS, McGarry K, Bollens-Lund E, Rahman OK, Husain M, Ferreira KB, Skinner JS.

Care for older adults with dementia during the final years of life is costly, and families shoulder much of this burden. We aimed to assess the financial burden of care for those with and without dementia, and to explore differences across residential settings. Using the Health and Retirement Study (HRS) and linked claims, we examined total healthcare spending and proportion by payer-Medicare, Medicaid, out-of-pocket, and calculated costs of informal caregiving-over the last 7 years of life, comparing those with and without dementia and stratifying by residential setting. We found that, consistent with prior studies, people with dementia experience significantly higher costs, with a disproportionate share falling on patients and families. This pattern is most striking among community residents with dementia, whose families shoulder 64% of total expenditures (including $176,180 informal caregiving costs and $55,550 out-of-pocket costs), compared with 43% for people with dementia residing in nursing homes ($60,320 informal caregiving costs and $105,590 out-of-pocket costs). These findings demonstrate disparities in financial burden shouldered by families of those with dementia, particularly among those residing in the community. They highlight the importance of considering the residential setting in research, programs, and policies.

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