Understanding factors associated with readmission disparities among Delta region, Delta state, and other hospitals.

OBJECTIVES: To understand the factors that potentially account for differences in 30-day readmission ratios for pneumonia, heart failure, and acute myocardial infarction (AMI) among hospitals in the Mississippi Delta region (Delta region), in Delta states excluding the hospitals in the Delta region (Delta state), and in the rest of the nation (other). STUDY DESIGN: A longitudinal study design from 2013 to 2016. METHODS: The dependent variables were 30-day readmission ratios for AMI, heart failure, and pneumonia. The key independent variables were 2 hospital categories (Delta region and Delta state), year dummies for 2014-2016, and the interactions among hospital categories and year dummies. We conducted 2 analyses for each study condition by estimating models with and without controls for hospital and community characteristics. RESULTS: The coefficients for the interactions among year dummies and Delta region and Delta state hospitals were negative, indicating that Delta region and Delta state hospitals had higher reductions in readmissions than did other hospitals. After controlling for hospital and community characteristics, the disparities in readmissions for pneumonia and AMI in 2013 between Delta region and other hospitals were weakened (P >.05). Major teaching hospitals and percentage of black population were positively associated with readmissions for all study conditions (P values ranged from <.05 to <.001). CONCLUSIONS: Disparities in 30-day readmissions for the study conditions among Delta region, Delta state, and other hospitals were reduced under the Hospital Readmissions Reduction Program (HRRP). However, community factors that are not currently used for adjustment in HRRP were associated with readmission ratios. Revisions of HRRP should consider including community characteristics in risk adjustment models.

Maternal mortality in the Mississippi Delta region.

OBJECTIVE: To compare the maternal mortality rate (MMR) in the Mississippi Delta region of the United States with that of the non-Delta region states. METHODS: Analyzed data come from national birth certificate and death certificate data for 1999-2007. Data were aggregated for analysis by region, counties of the Delta Regional Authority, non-Delta regions of the eight Delta states, and the 42 non-Delta states. The MMR was calculated using birth data as the denominator and maternal mortality data as the numerator. RESULTS: During the 9 years of the study, there were more than 36 million births in the United States and 5002 reported maternal deaths. The national MMR was 13.5/100,000 (95% confidence interval [CI] 13.1-13.9/100,000). The MMR reported in the non-Delta states was 13.6/100,000 (95% CI 13.2-14.0/100,000); in the non-Delta counties of the Delta states, the MMR was 13.1/100,000 (95% CI 12.1-14.0/100,000); and the MMR was 18.5/100,000 (95% CI 16.1-20.9/100,000) in Delta counties. The odds of maternal death in Delta counties is 1.39 times (95% CI 1.22-1.59) higher compared with non-Delta counties or non-Delta states. There was no statistically significant difference between the MMR in non-Delta states and the MMR in non-Delta counties of Delta states. After controlling for maternal race/ethnicity, age, marital status, and education in a multivariable model, the MMR in the Delta counties compared with non-Delta counties and non-Delta states remains significantly increased (odds ratio 1.16, 95% CI 1.01-1.32). CONCLUSIONS: Overall, maternal mortality is significantly greater in the Delta region of the United States compared with the non-Delta portion. After controlling for maternal race/ethnicity, age, marital status, and education, the odds of maternal death remains 16% higher in the Delta region of the United States compared with the non-Delta United States.

Mode of delivery trends by hospital type: an 18-year comparison of a military hospital with university and community hospitals.

OBJECTIVE: To determine the rate of mode of delivery over 18 years in a military teaching hospital as compared to university and community hospitals. METHODS: From January 1992 to December 2009, we retrospectively calculated yearly rates for mode of delivery from a military hospital, two university hospitals, a community hospital in South Carolina and all community hospitals in Arkansas. RESULTS: Over the 18-year period, 803,249 deliveries occurred from all hospitals. Overall the cesarean delivery rates have significantly increased across all practice models (22.7% + 0.9 versus 33.0% + 0.9, p = <0.001). The rate of increase has been greatest in university hospitals (21.8-37%) followed by community hospitals (26.7-32.9%) and the military hospital (19.6-29.2%). The rate of forceps-assisted deliveries has decreased dramatically across all practice models (11.6% + 1.3 versus 1.1% + 0.1, p = <0.001). The decline in forceps use was 6.4 to 1.1% in community hospital, 12.6 to 1.4% in university hospitals, and 15.7 to 0.9% in military hospitals. CONCLUSIONS: The overall cesarean delivery rate has increased in all practice models but less so in the military. Forceps deliveries have dramatically decreased overall especially in the military hospital.

Effect of hospital-based comprehensive care clinic on health costs for Medicaid-insured medically complex children.

OBJECTIVE: To evaluate the effect on all state Medicaid costs of a children's hospital-based multidisciplinary clinic that provides comprehensive and coordinated care for medically complex children. DESIGN: Before-after intervention study. Patients' health care costs for up to 1 year before enrollment in the clinic were compared with patients' health care costs for up to 1 year after enrollment in the clinic. Patients were enrolled in our study from August 2006 to May 2008. SETTING: Tertiary care children's hospital in a rural state. PARTICIPANTS: A total of 225 medically complex children who had at least 2 chronic medical conditions and who were followed up by at least 2 pediatric subspecialists. INTERVENTION: Multidisciplinary teams ensure that each patient receives all the necessary medical, nutritional, and developmental care and that there is improved coordination of care with primary care providers, subspecialists, hospitalists, and community-based services. MAIN OUTCOME MEASURES: Using Arkansas Medicaid claims data, we examined the medical costs for all outpatient, inpatient, emergency department, and prescription drug claims. Costs were calculated on a per month per patient basis and summarized for annual costs. RESULTS: The mean annual cost per patient per month decreased by $1766 for inpatient care (P < .001) and by $6.00 for emergency department care (P < .001). Although the cost per patient per month for outpatient claims (P < .05) and prescriptions (P < .001) increased, the overall cost to Medicaid per patient per month decreased by $1179 (P < .001). CONCLUSIONS: This hospital-based multidisciplinary clinic resulted in a significant decrease in total Medicaid costs for medically complex children.

Trends in hospitalizations associated with pediatric traumatic brain injuries.

OBJECTIVES: The goals were to describe trends in pediatric traumatic brain injury hospitalizations in the United States and to provide national benchmarks for state and regional comparisons. METHODS: Analysis of existing data (1991-2005) from the Nationwide Inpatient Sample, the largest longitudinal, all-payer, inpatient care database in the United States, was performed. Children 0 to 19 years of age were included. Annual rates of traumatic brain injury-related hospitalizations, stratified according to age, gender, severity of traumatic brain injury, and outcome, were determined. RESULTS: From 1991 to 2005, the estimated annual incidence rate of pediatric hospitalizations associated with traumatic brain injury decreased 39%, from 119.4 to 72.7 hospitalizations per 100,000. The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point. Fatal hospitalization rates decreased from 3.5 deaths per 100,000 in 1991-1993 to 2.8 deaths per 100,000 in 2003-2005. The rate of mild traumatic brain injury hospitalizations accounted for most of the overall decrease, whereas nonfatal hospitalization rates for moderate and severe traumatic brain injuries remained relatively unchanged. CONCLUSIONS: Although pediatric hospitalization rates for mild traumatic brain injuries have decreased over the past 15 years, rates for moderate and severe traumatic brain injuries are relatively unchanged. Our study provides national estimates of pediatric traumatic brain injury hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies.