National Documentation and Coding Practices of Noncompliance: The Importance of Social Determinants of Health and the Stigma of African-American Bias.

Patient records serve many purposes, one of which includes monitoring the quality of care provided that they can be analyzed through coding and documentation. Z-codes can provide additional information beyond a specific clinical disorder that may still warrant treatment. Social Determinants of Health have specific Z-codes that may help clinicians address social factors that may contribute to patients' health care outcomes. However, there are Z-codes that specify patient noncompliance which has a pejorative connotation that may stigmatize patients and prevent clinicians from examining nonadherence from a social determinant of health perspective. A retrospective cross-sectional study was performed to examine the associations of patient and encounter characteristics with the coding of patient noncompliance. Included in the study were all patients >18 years of age who were admitted to hospitals participating in the Vizient Clinical Data Base (CDB) between January 1, 2019 and December 31, 2019. Almost 9 million US inpatients were included in the study. Of those, 6.3% had a noncompliance Z-code. Use of noncompliance Z-codes was associated with the following odds estimate ratio in decreasing order: the presence of a social determinant of health (odds ratio [OR], 4.817), African American race (OR, 2.010), Medicaid insurance (OR, 1.707), >3 chronic medical conditions (OR, 1.546), living in an economically distressed community (OR, 1.320), male gender (OR, 1.313), nonelective admission status (OR, 1.245), age <65 years (OR, 1.234). More than 1 in 15 patient hospitalizations had a noncompliance code. Factors associated with these codes are difficult, if not impossible, for patients to modify. Disproportionate representation of Africa-Americans among hospitalizations with noncompliance coding is concerning and urgently deserves further exploration to determine the degree to which it may be a product of clinician bias, especially if the term noncompliance prevents health care providers from looking into socioeconomic factors that may contribute to patient nonadherence.

Improving Mortality Through a Multihospital, Collaborative Quality Improvement Project.

Improving hospital mortality is a key focus of quality and safety efforts at both the local and national level. Structured interventions can assist organizations in determining whether interventional efforts have led to sustained improvement. The PARiHS framework (Promoting Action on Research Implementation in Health Services) can assist organizations in implementing research into practice. This study investigates the use of the PARiHS framework in implementing a multihospital quality improvement project aimed at improving observed-to-expected mortality as measured by Vizient's Clinical Data Base (CDB). Structured interventions during the study period included mortality reviews, clinical documentation improvement opportunities, educational webinars, training and support in the use of CDB to explore ongoing opportunities for mortality improvement and quarterly reports to each participating hospital's leadership team on their performance. Data were gathered from an improvement collaborative in the Upper Midwest, which comprised 34 hospitals, of which 17 participated in the intervention. Measurement occurred from Quarter 4 2016 through Quarter 3 2020 and consisted of a preintervention, intervention, and postintervention period. Although both participating and nonparticipating hospitals achieved a significant reduction in their mortality observed-to-expected ratio from the preintervention period through the postintervention period, the participating hospitals achieved a greater reduction in their observed-to-expected mortality ratio ( P < 0.0004). In addition, the participating hospitals achieved a relative 21% improvement in the mortality domain rank of the Vizient Quality & Accountability Study.

Effect of mortality from COVID-19 on inpatient outcomes.

When hospitals first encountered coronavirus disease 2019 (COVID-19), there was a dearth of therapeutic options and nearly 1 in 3 patients died from the disease. By the summer of 2020, as deaths from the disease declined nationally, multiple single-center studies began to report declining mortality of patients with COVID-19. To evaluate the effect of COVID-19 on hospital-based mortality, we searched the Vizient Clinical Data Base for outcomes data from approximately 600 participating hospitals, including 130 academic medical centers, from January 2017 through December 2020. More than 32 million hospital admissions were included in the analysis. After an initial spike, mortality from COVID-19 declined in all regions of the country to under 10% by June 2020 and remained constant for the remainder of the year. Despite this, inpatient, all-cause mortality has increased since the beginning of the pandemic, even those without respiratory failure. Inpatient mortality has particularly increased in elderly patients and in those requiring intubation for respiratory failure. Since June 2020, COVID-19 kills one in every 10 patients admitted to the hospital with this diagnosis. The addition of this new disease has raised overall hospital mortality especially those who require intubation for respiratory failure.

Empirical analysis of domestic medical travel for elective cardiovascular procedures.

OBJECTIVES: To investigate whether domestic medical travel (DMT; traveling outside of one's home region but within the United States for medical care) and surgeon volume affect clinical outcomes and costs for patients undergoing elective cardiovascular procedures. STUDY DESIGN: Retrospective, cross-sectional analysis of patient discharge data from US academic medical centers. METHODS: Patients were classified as medical travelers if they received elective, nonemergent care more than 250 miles from home. High-volume surgeons (HVSs) were those above the 75th percentile compared with other study surgeons in the annual number of cardiovascular surgeries performed. Multivariable regression models were fit to test the relationships among complications, mortality, length of stay (LOS), cost, DMT status, and surgeon volume, controlling for sociodemographic and clinical factors. RESULTS: Patients who traveled to HVSs were more likely to be male, white, have lower severity of illness, and have health insurance through an indemnity plan or preferred provider organization with coverage outside of the patient's home region. Patients who traveled to HVSs had shorter LOS and fewer complications than those who received care from local, low-volume surgeons. There was no significant difference in mortality between travelers and nontravelers. CONCLUSIONS: Patients who travelled to HVSs for elective cardiovascular procedures had outcomes similar to or better than those of patients who received care locally from low-volume surgeons. We found no increase in complications or LOS, despite potentially complex logistical arrangements required by travelers. More work is needed to evaluate the potential of DMT to improve the value of care provided for selected procedures.

Collaborating to improve the global competitiveness of US academic medical centers.

President Obama announced the National Export Initiative in his 2010 State of the Union address and set the ambitious goal of doubling US exports by the end of 2014 to support millions of domestic jobs. Understanding the competitive position of US health care in the global market for international patients, University Health System Consortium (UHC), an alliance of 116 academic medical centers and 272 of their affiliated hospitals, representing 90 percent of the nation's non-profit academic medical centers partnered with Rush University, a private University in Chicago, IL and the International Trade Administration of the US Department of Commerce International Trade Administration (ITA) to participate in the Market Development Cooperator Program. The goal of this private-public partnership is to increase the global competitiveness of the US health care industry, which represents over 16 percent of the GDP, amongst foreign health care providers. This article provides an overview of the US health care market and outlines the aims of the US Cooperative for International Patient Programs, the end result of the partnership between UHC, ITA and Rush University.