Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia.

OBJECTIVES: The authors describe the relation of provider characteristics to processes, costs, and outcomes of medical care for elderly patients hospitalized for community-acquired pneumonia. METHODS: Using Medicare claims data, Medicare beneficiaries discharged from Pennsylvania hospitals during 1990 with community-acquired pneumonia were identified. Claims data were used to ascertain mortality, readmissions, use of procedures and physician consultations, and the costs of care. The relationship of these measures to provider characteristics was analyzed using regression techniques to adjust for patient characteristics, including comorbidity and microbial etiology. RESULTS: Among 22,294 pneumonia episodes studied, 30-day mortality was 17.0%. After adjusting for patient characteristics, 30-day mortality and readmission rates were unrelated to hospital teaching status or urban location or to physician specialty. Use of procedures and physician consultations was more common and costs were 11% higher among patients discharged from teaching hospitals compared with nonteaching hospitals. Similarly, costs were 15% higher at urban hospitals compared with rural hospitals. General internists and medical subspecialists used more procedures and had higher costs than family practitioners. CONCLUSIONS: Processes and costs of care for community-acquired pneumonia varied by provider characteristics, but neither mortality nor readmission rates did. These differences cannot be explained by clinical variables in the database. Further studies should determine whether less costly patterns of care for pneumonia, and perhaps other conditions, could replace more costly ones without compromising patient outcomes.

Community-acquired pneumonia: can it be defined with claims data?

The use of administrative data to study pneumonia is limited because International Classification of Diseases, 9th revision, Clinical Modification (ICD9-CM) diagnosis codes do not specify whether pneumonia is community-acquired (CAP), a key clinical distinction. We classified 212 patients discharged with a diagnosis code for pneumonia as to whether or not they had CAP, using three administrative data-based systems (Diagnosis Related Groups (DRGs) alone, principal diagnosis alone, and a complex algorithm). We examined agreement with classification by clinician chart review. We also compared the length of stay (LOS) and mortality among the CAP populations identified with different methods. Agreement between the clinical review and the three administrative data methods ranged from 86 to 80%. Classification by DRG performed least well. Populations defined by claims data had similar mortality but shorter mean LOS (9.70, 9.40, and 7.91 days for the algorithm, principal diagnosis and DRG methods, respectively) than the clinically defined population (10.85 days). We conclude that studies of CAP using populations identified by claims may underestimate LOS.

Are small firms greater health risks?

To test whether use of health care services is a function of firm size, we analyzed a three-year database (1988-1990) of private insurance claims, representing 28,990 firms and approximately 1.4 million subscribers in western Pennsylvania. In this database both small and large firms had higher medically underwritten costs than mid-size firms had. Furthermore, risk-pooling alternatives that included small companies had a lower cost per subscriber than the risk pools that included large companies, especially companies of more than 500 contract holders. Age, sex, health status, and the types of hospitals used for inpatient care of pooled subscribers, in combination, were found to be the important determinants of costs. With risk adjustment based on these factors to correct for adverse risk selection, community rating can be a feasible approach to increasing the affordability and accessibility of health insurance to the majority of those who lack it.