Systematic Review and Meta-Analysis of the Financial Impact of 30-Day Readmissions for Selected Medical Conditions: A Focus on Hospital Quality Performance.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) established the Hospital Quality Initiative in 2010 to enhance patient safety, reduce hospital readmissions, improve quality, and minimize healthcare costs. In response, this study aims to systematically review the literature and conduct a meta-analysis to estimate the average cost of procedure-specific 30-day risk-standardized unplanned readmissions for Acute Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia, Coronary Artery Bypass Graft (CABG), and Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA). METHODS: Eligibility Criteria: This study included English language original research papers from the USA, encompassing various study designs. Exclusion criteria comprise studies lacking empirical evidence on hospital financial performance. INFORMATION SOURCES: A comprehensive search using relevant keywords was conducted across databases from January 1990 to December 2019 (updated in March 2021), covering peer-reviewed articles and gray literature. Risk of Bias: Bias in the included studies was assessed considering study design, adjustment for confounding factors, and potential effect modifiers. SYNTHESIS OF RESULTS: The review adhered to PRISMA guidelines. Employing Monte Carlo simulations, a meta-analysis was conducted with 100,000 simulated samples. Results indicated mean 30-day readmission costs: USD 16,037.08 (95% CI, USD 15,196.01-16,870.06) overall, USD 6852.97 (95% CI, USD 6684.44-7021.08) for AMI, USD 9817.42 (95% CI, USD 9575.82-10,060.43) for HF, and USD 21,346.50 (95% CI, USD 20,818.14-21,871.85) for THA/TKA. DISCUSSION: Despite the financial challenges that hospitals face due to the ACA and the Hospital Readmissions Reduction Program, this meta-analysis contributes valuable insights into the consistent cost trends associated with 30-day readmissions. CONCLUSIONS: This systematic review and meta-analysis provide comprehensive insights into the financial implications of 30-day readmissions for specific medical conditions, enhancing our understanding of the nexus between healthcare quality and financial performance.

Resources availability and COVID-19 mortality among US counties.

The COVID-19 was declared a pandemic by WHO on 03/2020 has claimed millions of lives worldwide. The US leads all countries in COVID-19-related deaths. Individual level (preexisting conditions and demographics) and county-level (availability of resources) factors have been attributed to increased risk of COVID-19-related deaths. This study builds on previous studies to assess the relationship between county-level resources and COVID-19 mortality among 2,438 US counties. We merged 2019 data from AHA, AHRF, and USA FACTS. The dependent variable was the total number of COVID-19-related deaths. Independent variables included county-level resources: (1) hospital staffing levels (FTE RNs, hospitalists, and intensivists) per 10,000 population; (2) hospital capacity (occupancy rate, proportion of teaching hospitals, and number of airborne infection control rooms per 10,000 population); and (3) macroeconomic resources [per capita income and location (urban/rural)]. We controlled for population 65+, racial/ethnic minority, and COVID-19 deaths per 1,000 population. A negative binomial regression was used. Hospital staffing per 10,000 population {FTE RN [IRR = 0.997; CI (0.995-0.999)], FTE hospitalists [IRR = 0.936; CI (0.897-0.978)], and FTE intensivists [IRR = 0.606; CI (0.516-0.712)]} was associated with lower COVID-19-related deaths. Hospital occupancy rate, proportion of teaching hospitals, and total number of airborne infection control rooms per 10,000 population were positively associated with COVID-19-related deaths. Per capita income and being in an urban county were positively associated with COVID-19-related deaths. Finally, the proportion of 65+, racial/ethnic minorities, and the number of cases were positively associated with COVID-19-related deaths. Our findings suggest that focusing on maintaining adequate hospital staffing could improve COVID-19 mortality.

Do Medicare and Medicaid Payer-Mix Change After the Privatization of Public Hospitals?

This study assessed the impact of public hospitals' privatization on payer-mix. We used a national sample of nonfederal, acute care, public hospitals in 1997 and followed them through 2013, resulting in a cohort of 492 hospitals (8,335 hospital-year observations). Privatization to for-profit (FP) status was associated with a greater increase in Medicare payer-mix (ß = 0.13; p ≤ .001), compared with a smaller increase for privatization to not-for-profit (NFP) status (ß = 0.02; p ≤ .05). FP privatization was associated with a greater decrease in Medicaid payer-mix (ß = -0.09; p ≤ .001), compared with NFP privatization (nonsignificant). There is a larger change in payer-mix after FP privatization than after NFP privatization.

Hospitalists, two decades later: Which US hospitals utilize them?

Hospitalists, or specialists of hospital medicine, have long been practicing in Canada and Europe. However, it was not until the mid-1990s, when hospitals in the U.S. started widespread adoption of hospitalists. Since then, the number of hospitalists has grown exponentially in the U.S. from a few hundred to over 50,000 in 2016. Prior studies on hospitalists have well documented benefits hospitals gain from adopting this innovative staffing strategy. However, there is a dearth of research documenting predictors of hospitals' adoption of hospitalists. To fill this gap, this longitudinal study (2003-2015) purposes to determine organizational and market characteristics of U.S. hospitals that utilize hospitalists. Our findings indicate that private not-for-profit, system affiliated, teaching, and urban hospitals, and those located in higher per capita income markets have a higher probability of utilizing hospitalists. Additionally, large or medium, profitable hospitals, and those that treat sicker patients have a higher probability of adoption. Finally, hospitals with a high proportion of Medicaid patients have a lower probability of utilizing hospitalists. Our results suggest that hospitals with greater slack resources and those located in munificent counties are more likely to use hospitalists, while their under-resourced counterparts may experience more barriers in adopting this innovative staffing strategy.

Hospitals' use of hospitalists: Implications for financial performance.

BACKGROUND: Hospitalists, or physicians specializing in hospital-based practice, have grown significantly since they were first introduced in the United States in the mid-1990s. Prior studies on the impact of hospitalists have focused on costs and length of stay. However, there is dearth of research exploring the relationship between hospitals' use of hospitalists and organizational performance. PURPOSE: Using a national longitudinal sample of acute care hospitals operating in the United States between 2007 and 2014, this study explores the impact of hospitalists staffing intensity on hospitals' financial performance. METHODOLOGY: Data sources for this study included the American Hospital Association Annual Survey, the Area Health Resources File, and the Centers for Medicare & Medicaid Services' costs reports and Case Mix Index files. Data were analyzed using a panel design with facility and year fixed effects regression. RESULTS: Results showed that hospitals that switched from not using hospitalists to using a high hospitalist staffing intensity had both increased patient revenues and higher operating costs per adjusted patient day. However, the higher operating costs from high hospitalist staffing intensity were offset by increased patient revenues, resulting in a marginally significant increase in operating profitability (p < .1). PRACTICE IMPLICATIONS: These findings suggest that the rise in the use of hospitalists may be fueled by financial incentives such as increased revenues and profitability in addition to other drivers of adoption.

Hospital cultural competency as a systematic organizational intervention: Key findings from the national center for healthcare leadership diversity demonstration project.

BACKGROUND: Cultural competency or the ongoing capacity of health care systems to provide for high-quality care to diverse patient populations (National Quality Forum, 2008) has been proposed as an organizational strategy to address disparities in quality of care, patient experience, and workforce representation. But far too many health care organizations still do not treat cultural competency as a business imperative and driver of strategy. PURPOSES: The aim of the study was to examine the impact of a systematic, multifaceted, and organizational level cultural competency initiative on hospital performance metrics at the organizational and individual levels. METHODOLOGY/APPROACH: This demonstration project employs a pre-post control group design. Two hospital systems participated in the study. Within each system, two hospitals were selected to serve as the intervention and control hospitals. Executive leadership (C-suite) and all staff at one general medical/surgical nursing unit at the intervention hospitals experienced a systematic, planned cultural competency intervention. Assessments and interventions focused on three organizational level competencies of cultural competency (diversity leadership, strategic human resource management, and patient cultural competency) and three individual level competencies (diversity attitudes, implicit bias, and racial/ethnic identity status). In addition, we evaluated the impact of the intervention on diversity climate and workforce diversity. FINDINGS: Overall performance improvement was greater in each of the two intervention hospitals than in the control hospital within the same health care system. Both intervention hospitals experienced improvements in the organizational level competencies of diversity leadership and strategic human resource management. Similarly, improvements were observed in the individual level competencies for diversity attitudes and implicit bias for Blacks among the intervention hospitals. Furthermore, intervention hospitals outperformed their respective control hospitals with respect to diversity climate. PRACTICE IMPLICATIONS: A focused and systematic approach to organizational change when coupled with interventions that encourage individual growth and development may be an effective approach to building culturally competent health care organizations.

Blueprint for Sustainable Change in Diversity Management and Cultural Competence: Lessons From the National Center for Healthcare Leadership Diversity Demonstration Project.

EXECUTIVE SUMMARY: How can healthcare leaders build a sustainable infrastructure to leverage workforce diversity and deliver culturally and linguistically appropriate care to patients? To answer that question, two health systems participated in the National Center for Healthcare Leadership's diversity leadership demonstration project, November 2008 to December 2013. Each system provided one intervention hospital and one control hospital.The control hospital in each system participated in pre- and postassessments but received no preassessment feedback and no intervention support. Each intervention hospital's C-suite leadership and demonstration project manager worked with a diversity coach provided by the National Center for Healthcare Leadership to design and implement an action plan to improve diversity and cultural competence practices and build a sustainable infrastructure. Plans explored areas of strength and areas for improvement that were identified through preintervention assessments. The assessments focused on five competencies of strategic diversity management and culturally and linguistically appropriate care: diversity leadership, strategic human resource management, organizational climate, diversity climate, and patient cultural competence.This article describes each intervention hospital's success in action plan implementation and reports results of postintervention interviews with leadership to provide a blueprint for sustainable change.

The presence of hospital-based palliative care programs: A resource dependence perspective.

BACKGROUND: The presence of hospital-based palliative care programs has risen over time in the United States. Nevertheless, organizational and environmental factors that contribute to the presence of hospital-based palliative care programs are unclear. PURPOSE: The aim of this study was to examine the role of organizational and environmental factors associated with the presence of hospital-based palliative care programs using resource dependence theory. METHODOLOGY: Panel data from 2000 to 2009 American Hospital Association Annual Survey and the Area Resource File were used in this study. A random-effect logistic regression was used to analyze the relationship between organizational and environmental factors and the presence of hospital-based palliative care programs. FINDINGS: Hospitals with higher Medicare inpatient days, located in counties with higher Medicare managed penetration, and larger hospitals had greater odds of having a hospital-based palliative care program. Although hospitals in counties that have a higher percentage of individuals 65 years and older, for-profit and government hospitals were less likely to have a hospital-based palliative care program. PRACTICE IMPLICATIONS: Hospitals will vary in the organizational resources available to them, as such, administrators' awareness of the relationship between resources and palliative care programs can help determine the relevance of a program in their hospital.

Public hospitals in financial distress: Is privatization a strategic choice?

BACKGROUND: As safety net providers, public hospitals operate in more challenging environments than private hospitals. Such environments put public hospitals at greater risk of financial distress, which may result in privatization and deterioration of the safety net. PURPOSE: The purpose of this study was to investigate whether financial distress is associated with privatization among public hospitals. METHODOLOGY/APPROACH: We used panel data merged from the American Hospital Association Annual Survey, Medicare Cost Reports, Area Resource File, and Local Area Unemployment Statistics. Our study population consisted of all U.S. nonfederal acute care public hospitals in 1997 tracked through 2009, resulting in 6,426 hospital-year observations. The dependent variable "privatization" was defined as conversion from public status to either private not-for-profit or private for-profit status. The main independent variable, "financial distress," was based on the Altman Z-score methodology. Control variables included market and organizational factors. Two random-effects logistic regression models with state and year fixed-effects were constructed. The independent and control variables were lagged by 1 year and 2 years for Models 1 and 2, respectively. FINDINGS: Public hospitals in financial distress had greater odds of being privatized than public hospitals not in financial distress: (OR = 4.53, p < .001) for Model 1 and (OR = 3.05, p = .001) for Model 2. PRACTICE IMPLICATIONS: Privatization eases access to resources and may provide financial relief to government entities from the burden of continuously funding a hospital operating at a loss, which in turn may help keep the hospital open and preserve access to care for the community. Privatizing a financially distressed public hospital may be a better strategic alternative than closure. The Altman Z-score could be used as a managerial tool to monitor hospitals' financial condition and take corrective actions.

Community benefits provided by religious, other nonprofit, and for-profit hospitals: a longitudinal analysis 2000-2009.

BACKGROUND: Nonprofit hospitals (NFPs) are expected to provide community benefits to justify the tax benefits they receive, but recent budgetary constraints have called into question the degree to which the tax benefits are justified. The empirical literature comparing community benefits provided by NFPs and their for-profit counterparts is mixed. However, NFPs are not a homogenous group and can include religious hospitals, community-owned hospitals, or academic medical centers. PURPOSE: This longitudinal study examines how religious hospitals compare with other NFPs and for-profit hospitals with respect to providing community benefits and how the provision of community benefits by hospitals has changed over time. METHODOLOGY: Using a pooled cross-sectional design, we examine two summated scores based on questions from the American Hospital Association annual survey that focus on community orientation among hospitals. We analyze two regressions with year, facility, and market controls to determine how religious hospitals compare with the other groups over time. FINDINGS: Overall, 11% of U.S. hospitals are religious. Religious hospitals were more likely to engage in each individual community benefit activity examined. In addition, the mean values of community benefits provided by religious hospitals, as measured on two summated scores, were significantly higher than those provided by other hospital types in bivariate and regression analyses. Overall, community benefits provided by all hospitals increased over time and then leveled off during the start of the recent economic downturn. PRACTICE IMPLICATIONS: As the debate continues regarding federal tax exemption status, policymakers should consider religious hospitals separately from NFPs. Managers at religious hospitals should consider how their increased levels of community benefits are related to their missions and set benchmarks that recognize and communicate those achievements.