Multidisciplinary teams, efficient communication, procedure services, and telehealth improve cirrhosis care: A qualitative study.

BACKGROUND: Cirrhosis care and outcomes are improved with access to subspecialty gastroenterology and hepatology care. In qualitative interviews, we investigated clinicians' perceptions of factors that optimize or impede cirrhosis care. METHODS: We conducted 24 telephone interviews with subspecialty clinicians at 7 Veterans Affairs medical centers with high- and low-complexity services. Purposive sampling stratified Veterans Affairs medical centers on timely post-hospitalization follow-up, a quality measure. We asked open-ended questions about facilitators and barriers of care coordination, access to appointments, procedures, transplantation, management of complications, keeping up to date with medical knowledge, and telehealth use. RESULTS: Key themes that facilitated care were structural: multidisciplinary teams, clinical dashboards, mechanisms for appointment tracking and reminders, and local or virtual access to transplant and liver cancer specialists through the "specialty care access network extension for community health care outcomes" program. Coordination and efficient communication between transplant and non-transplant specialists and between transplant and primary care facilitated timely care. Same-day access to laboratory, procedural, and clinical services is an indicator of high-quality care. Barriers included lack of on-site procedural services, clinician turnover, patient social needs related to transportation, costs, and patient forgetfulness due to HE. Telehealth enabled lower complexity sites to obtain recommendations for complex patient cases. Barriers to telehealth included lack of credit (eg, VA billing equivalent), inadequate staff, lack of audiovisual technology support, and patient and staff discomfort with technology. Telehealth was optimal for return visits, cases where physical examination was nonessential, and where distance and transportation precluded in-person care. Rapid telehealth uptake during the COVID-19 pandemic was a positive disruptor and facilitated use. CONCLUSIONS: We identify multi-level factors related to structure, staffing, technology, and care organization to optimize cirrhosis care delivery.

SARS-CoV-2 Sequelae and Postdischarge Health Care Visits Over 5 Months Follow-up Among Children Hospitalized for COVID-19 or MIS-C.

Although post-acute sequelae of COVID-19 among adult survivors has gained significant attention, data in children hospitalized for severe acute respiratory syndrome coronavirus 2 is limited. This study of commercially insured US children shows that those hospitalized with COVID-19 or multisystem inflammatory syndrome in children have a substantial burden of severe acute respiratory syndrome coronavirus 2 sequelae and associated health care visits postdischarge.

Trends in Outpatient Care and Use of Telemedicine After Hospital Discharge in a Large Commercially Insured Population.

This cross-sectional study examines changes in use of telemedicine vs in-person care among a commercially insured population durring the COVID-19 pandemic.

DLMM as a lossless one-shot algorithm for collaborative multi-site distributed linear mixed models.

Linear mixed models are commonly used in healthcare-based association analyses for analyzing multi-site data with heterogeneous site-specific random effects. Due to regulations for protecting patients' privacy, sensitive individual patient data (IPD) typically cannot be shared across sites. We propose an algorithm for fitting distributed linear mixed models (DLMMs) without sharing IPD across sites. This algorithm achieves results identical to those achieved using pooled IPD from multiple sites (i.e., the same effect size and standard error estimates), hence demonstrating the lossless property. The algorithm requires each site to contribute minimal aggregated data in only one round of communication. We demonstrate the lossless property of the proposed DLMM algorithm by investigating the associations between demographic and clinical characteristics and length of hospital stay in COVID-19 patients using administrative claims from the UnitedHealth Group Clinical Discovery Database. We extend this association study by incorporating 120,609 COVID-19 patients from 11 collaborative data sources worldwide.

Informal Caregivers Provide Considerable Front-Line Support In Residential Care Facilities And Nursing Homes.

Informal care, or care provided by family and friends, is the most common form of care received by community-dwelling older adults with functional limitations. However, less is known about informal care provision within residential care settings including residential care facilities (for example, assisted living) and nursing homes. Using data from the Health and Retirement Study (2016) and the National Health and Aging Trends Study (2015), we found that informal care was common among older adults with functional limitations, whether they lived in the community, a residential care facility, or a nursing home. The hours of informal care provided were also nontrivial across all settings. This evidence suggests that informal caregiving and some of the associated burdens do not end when a person transitions from the community to residential care or a nursing home setting. It also points to the large role that families play in the care and well-being of these residents, which is especially important considering the recent visitor bans during the COVID-19 epidemic. Family members are an invisible workforce in nursing homes and residential care facilities, providing considerable front-line work for their loved ones. Providers and policy makers could improve the lives of both the residents and their caregivers by acknowledging, incorporating, and supporting this workforce.

Reimagining Financing and Payment of Long-Term Care.

The COVID-19 pandemic revealed fundamental problems with the structure of long-term care financing and payment in the United States. The piecemeal system that exists suffers from several key problems, including underfunding, fragmentation across types and sites of care, and substantial variation in payment across states and populations. These problems result in inefficient allocation of resources, limited access to care, substandard quality, and inequities in both access and quality. We propose a new federal benefit for long-term care, most likely as part of the Medicare program. Essential features of this benefit include taxpayer subsidies, along the lines of other Medicare benefits, and coverage across the range of long-term care services, including both residential and home- and community-based care. A new federal benefit has the most potential to break down administrative barriers and improve resource allocation, to ensure adequate payment rates across all states, to expand access to care by spreading risk across the entire Medicare population, and to improve equity by extending coverage to all Medicare beneficiaries who want it. A new federal benefit is politically challenging, requiring bold action by Congress, and entails the risks of administrative challenges and unintended consequences. However, in this case, retaining the status quo remains the far greater risk.

Understanding Drivers of Coronavirus Disease 2019 Vaccine Hesitancy Among Blacks.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has disproportionately affected communities of color, with black persons experiencing the highest rates of disease severity and mortality. A vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has the potential to reduce the race mortality gap from COVID-19; however, hesitancy toward the vaccine in the black community threatens vaccine uptake. METHODS: We conducted focus groups with black barbershop and salon owners living in zip codes of elevated COVID-19 prevalence to assess their attitudes, beliefs, and norms around a COVID-19 vaccine. We used a modified grounded theory approach to analyze the transcripts. RESULTS: We completed 4 focus groups (N = 24 participants) in July and August 2020. Participants were an average age of 46 years, and 89% were black non-Hispanic. Hesitancy against the COVID-19 vaccine was high due to mistrust in the medical establishment, concerns with the accelerated timeline for vaccine development, limited data on short- and long-term side effects, and the political environment promoting racial injustice. Some participants were willing to consider the vaccine once the safety profile is robust and reassuring. Receiving a recommendation to take the vaccine from a trusted healthcare provider served as a facilitator. Health beliefs identified were similar to concerns around other vaccines and included the fear of getting the infection with vaccination and preferring to improve one's baseline physical health through alternative therapies. CONCLUSIONS: We found that hesitancy of receiving the COVID-19 vaccine was high; however, provider recommendation and transparency around the safety profile might help reduce this hesitancy.

Trends in Post-Acute Care Utilization During the COVID-19 Pandemic.

OBJECTIVE: To examine the effect of the COVID-19 pandemic on post-acute care utilization and spending. DESIGN: We used a large national multipayer claims data set from January 2019 through October 2020 to examine trends in posthospital discharge location and spending. SETTING AND PARTICIPANTS: We identified and included 975,179 hospital discharges who were aged ≥65 years. METHODS: We summarized postdischarge utilization and spending in each month of the study: (1) the percentage of patients discharged from the hospital to home for self-care and to the 3 common post-acute care locations: home with home health, skilled nursing facility (SNF), and inpatient rehabilitation; (2) the rate of discharge to each location per 100,000 insured members in our cohort; (3) the total amount spent per month in each post-acute care location; and (4) the percentage of spending in each post-acute care location out of the total spending across the 3 post-acute care settings. RESULTS: The percentage of patients discharged from the hospital to home or to inpatient rehabilitation did not meaningfully change during the pandemic whereas the percentage discharged to SNF declined from 19% of discharges in 2019 to 14% by October 2020. Total monthly spending declined in each of the 3 post-acute care locations, with the largest relative decline in SNFs of 55%, from an average of $42 million per month in 2019 to $19 million in October 2020. Declines in total monthly spending were smaller in home health (a 41% decline) and inpatient rehabilitation (a 32% decline). As a percentage of all post-acute care spending, spending on SNFs declined from 39% to 31%, whereas the percentage of post-acute care spending on home health and inpatient rehabilitation both increased. CONCLUSIONS AND IMPLICATIONS: Changes in posthospital discharge location of care represent a significant shift in post-acute care utilization, which persisted 9 months into the pandemic. These shifts could have profound implications on the future of post-acute care.

Patient and Hospital Factors Associated With Differences in Mortality Rates Among Black and White US Medicare Beneficiaries Hospitalized With COVID-19 Infection.

Importance: Black patients hospitalized with COVID-19 may have worse outcomes than White patients because of excess individual risk or because Black patients are disproportionately cared for in hospitals with worse outcomes for all. Objectives: To examine differences in COVID-19 hospital mortality rates between Black and White patients and to assess whether the mortality rates reflect differences in patient characteristics by race or by the hospitals to which Black and White patients are admitted. Design, Setting, and Participants: This cohort study assessed Medicare beneficiaries admitted with a diagnosis of COVID-19 to 1188 US hospitals from January 1, 2020, through September 21, 2020. Exposure: Hospital admission for a diagnosis of COVID-19. Main Outcomes and Measures: The primary composite outcome was inpatient death or discharge to hospice within 30 days of admission. We estimated the association of patient-level characteristics (including age, sex, zip code-level income, comorbidities, admission from a nursing facility, and days since January 1, 2020) with differences in mortality or discharge to hospice among Black and White patients. To examine the association with the hospital itself, we adjusted for the specific hospitals to which patients were admitted. We used simulation modeling to estimate the mortality among Black patients had they instead been admitted to the hospitals where White patients were admitted. Results: Of the 44 217 Medicare beneficiaries included in the study, 24 281 (55%) were women; mean (SD) age was 76.3 (10.5) years; 33 459 participants (76%) were White, and 10 758 (24%) were Black. Overall, 2634 (8%) White patients and 1100 (10%) Black patients died as inpatients, and 1670 (5%) White patients and 350 (3%) Black patients were discharged to hospice within 30 days of hospitalization, for a total mortality-equivalent rate of 12.86% for White patients and 13.48% for Black patients. Black patients had similar odds of dying or being discharged to hospice (odds ratio [OR], 1.06; 95% CI, 0.99-1.12) in an unadjusted comparison with White patients. After adjustment for clinical and sociodemographic patient characteristics, Black patients were more likely to die or be discharged to hospice (OR, 1.11; 95% CI, 1.03-1.19). This difference became indistinguishable when adjustment was made for the hospitals where care was delivered (odds ratio, 1.02; 95% CI, 0.94-1.10). In simulations, if Black patients in this sample were instead admitted to the same hospitals as White patients in the same distribution, their rate of mortality or discharge to hospice would decline from the observed rate of 13.48% to the simulated rate of 12.23% (95% CI for difference, 1.20%-1.30%). Conclusions and Relevance: This cohort study found that Black patients hospitalized with COVID-19 had higher rates of hospital mortality or discharge to hospice than White patients after adjustment for the personal characteristics of those patients. However, those differences were explained by differences in the hospitals to which Black and White patients were admitted.

Nursing Home Staffing Levels Did Not Change Significantly During COVID-19.

Prior research and the popular press have anecdotally reported inadequate nursing home staffing levels during the COVID-19 pandemic. Maintaining adequate staffing levels is critical to ensuring high-quality nursing home care and an effective response to the pandemic. We therefore sought to examine nursing home staffing levels during the first nine months of 2020 (compared with the same period in 2019), using auditable daily payroll-based staffing data from the Centers for Medicare and Medicaid Services. We found that the total number of hours of direct care nursing declined in nursing homes during the COVID-19 pandemic, as did the average nursing home census. When we accounted for changes in census, the number of nurse staff hours per resident day remained steady or, if anything, increased slightly during the pandemic. The observed increases in staff hours per resident day were small but concentrated in nursing homes operating in counties with high COVID-19 prevalence, in nursing homes with low Medicaid census (which typically have more financial resources), and in not-for-profit nursing homes (which typically invest more in staffing). These findings raise concerns that although the number of staff hours in nursing homes did not decline, the perception of shortages has been driven by increased stresses and demands on staff time due to the pandemic, which are harder to quantify.

Variation in US Hospital Mortality Rates for Patients Admitted With COVID-19 During the First 6 Months of the Pandemic.

Importance: It is unknown how much the mortality of patients with coronavirus disease 2019 (COVID-19) depends on the hospital that cares for them, and whether COVID-19 hospital mortality rates are improving. Objective: To identify variation in COVID-19 mortality rates and how those rates have changed over the first months of the pandemic. Design, Setting, and Participants: This cohort study assessed 38 517 adults who were admitted with COVID-19 to 955 US hospitals from January 1, 2020, to June 30, 2020, and a subset of 27 801 adults (72.2%) who were admitted to 398 of these hospitals that treated at least 10 patients with COVID-19 during 2 periods (January 1 to April 30, 2020, and May 1 to June 30, 2020). Exposures: Hospital characteristics, including size, the number of intensive care unit beds, academic and profit status, hospital setting, and regional characteristics, including COVID-19 case burden. Main Outcomes and Measures: The primary outcome was the hospital's risk-standardized event rate (RSER) of 30-day in-hospital mortality or referral to hospice adjusted for patient-level characteristics, including demographic data, comorbidities, community or nursing facility admission source, and time since January 1, 2020. We examined whether hospital characteristics were associated with RSERs or their change over time. Results: The mean (SD) age among participants (18 888 men [49.0%]) was 70.2 (15.5) years. The mean (SD) hospital-level RSER for the 955 hospitals was 11.8% (2.5%). The mean RSER in the worst-performing quintile of hospitals was 15.65% compared with 9.06% in the best-performing quintile (absolute difference, 6.59 percentage points; 95% CI, 6.38%-6.80%; P < .001). Mean RSERs in all but 1 of the 398 hospitals improved; 376 (94%) improved by at least 25%. The overall mean (SD) RSER declined from 16.6% (4.0%) to 9.3% (2.1%). The absolute difference in rates of mortality or referral to hospice between the worst- and best-performing quintiles of hospitals decreased from 10.54 percentage points (95% CI, 10.03%-11.05%; P < .001) to 5.59 percentage points (95% CI, 5.33%-5.86%; P < .001). Higher county-level COVID-19 case rates were associated with worse RSERs, and case rate declines were associated with improvement in RSERs. Conclusions and Relevance: Over the first months of the pandemic, COVID-19 mortality rates in this cohort of US hospitals declined. Hospitals did better when the prevalence of COVID-19 in their surrounding communities was lower.

Assessment of Receipt of the First Home Health Care Visit After Hospital Discharge Among Older Adults.

Importance: Home health care is one of the fastest growing postacute services in the US and is increasingly important in the era of coronavirus disease 2019 and payment reform, yet it is unknown whether patients who need home health care are receiving it. Objective: To examine how often patients referred to home health care at hospital discharge receive it and whether there is evidence of disparities. Design, Setting, and Participants: This cross-sectional study used Medicare data regarding the postacute home health care setting from October 1, 2015, through September 30, 2016. The participants were Medicare fee-for-service and Medicare Advantage beneficiaries who were discharged alive from a hospital with a referral to home health care (2 379 506 discharges). Statistical analysis was performed from July 2019 to June 2020. Exposures: Hospital referral to home health care. Main Outcomes and Measures: Primary outcomes included whether discharges received their first home health care visit within 14 days of hospital discharge and the number of days between hospital discharge and the first home health visit. Differences in the likelihood of receiving home health care across patient, zip code, and hospital characteristics were also examined. Results: Among 2 379 506 discharges from the hospital with a home health care referral, 1 358 697 patients (57.1%) were female, 468 762 (19.7%) were non-White, and 466 383 (19.6%) were dually enrolled in Medicare and Medicaid; patients had a mean (SD) age of 73.9 (11.9) years and 4.1 (2.1) Elixhauser comorbidities. Only 1 284 300 patients (54.0%) discharged from the hospital with a home health referral received home health care services within 14 days of discharge. Of the remaining 1 095 206 patients (46.0%) discharged, 37.7% (896 660 discharges) never received any home health care, while 8.3% (198 546 discharges) were institutionalized or died within 14 days without a preceding home health care visit. Patients who were Black or Hispanic received home health at lower rates than did patients who were White (48.0% [95% CI, 47.8%-48.1%] of Black and 46.1% [95% CI, 45.7%-46.5%] of Hispanic discharges received home health within 14 days compared with 55.3% [95% CI, 55.2%-55.4%] of White discharges). In addition, disadvantaged patients waited longer for their first home health care visit. For example, patients living in high-unemployment zip codes waited a mean of 2.0 days (95% CI, 2.0-2.0 days), whereas those living in low-unemployment zip codes waited 1.8 days (95% CI, 1.8-1.8 days). Conclusions and Relevance: Disparities in the use of home health care remain an issue in the US. As home health care is increasingly presented as a safer alternative to institutional postacute care during coronavirus disease 2019, and payment reforms continue to pressure hospitals to discharge patients home, ensuring the availability of safe and equitable care will be crucial to maintaining high-quality care.