Managed care and inpatient mortality in adults: effect of primary payer.

BACKGROUND: Because managed care is increasingly prevalent in health care finance and delivery, it is important to ascertain its effects on health care quality relative to that of fee-for-service plans. Some stakeholders are concerned that basing gatekeeping, provider selection, and utilization management on cost may lower quality of care. To date, research on this topic has been inconclusive, largely because of variation in research methods and covariates. Patient age has been the only consistently evaluated outcome predictor. This study provides a comprehensive assessment of the association between managed care and inpatient mortality for Medicare and privately insured patients. METHODS: A cross-sectional design was used to examine the association between managed care and inpatient mortality for four common inpatient conditions. Data from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases for 11 states were linked to data from the American Hospital Association Annual Survey Database. Hospital discharges were categorized as managed care or fee for service. A phased approach to multivariate logistic modeling examined the likelihood of inpatient mortality when adjusting for individual patient and hospital characteristics and for county fixed effects. RESULTS: Results showed different effects of managed care for Medicare and privately insured patients. Privately insured patients in managed care had an advantage over their fee-for-service counterparts in inpatient mortality for acute myocardial infarction, stroke, pneumonia, and congestive heart failure; no such advantage was found for the Medicare managed care population. To the extent that the study showed a protective effect of privately insured managed care, it was driven by individuals aged 65 years and older, who had consistently better outcomes than their non-managed care counterparts. CONCLUSIONS: Privately insured patients in managed care plans, especially older adults, had better outcomes than those in fee-for-service plans. Patients in Medicare managed care had outcomes similar to those in Medicare FFS. Additional research is needed to understand the role of patient selection, hospital quality, and differences among county populations in the decreased odds of inpatient mortality among patients in private managed care and to determine why this result does not hold for Medicare.

Age-related Disparities in Trauma Center Access for Severe Head Injuries Following the Release of the Updated Field Triage Guidelines.

OBJECTIVE: In 2006, the American College of Surgeons' Committee on Trauma and the Centers for Disease Control and Prevention released field triage guidelines with special consideration for older adults. Additional considerations for direct transport to a Level I or II trauma center (TC) were added in 2011, reflecting perceived undertriage to TCs for older adults. We examined whether age-based disparities in TC care for severe head injury decreased following introduction of the 2011 revisions. METHODS: A pre-post design analyzing the 2009 and 2012 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases with multivariable logistic regressions considered changes in 1) the trauma designation of the emergency department where treatment was initiated and 2) transfer to a TC following initial treatment at a non-TC. RESULTS: Compared with adults aged 18 to 44 years, after multivariable adjustment, in both years TC care was less likely for adults aged 45 to 64 years (odds ratio [OR] = 0.76 in 2009 and 0.74 in 2012), aged 65 to 84 years (OR = 0.61 and 0.59), and aged 85+ years (OR = 0.53 and 0.56). Between 2009 and 2012, the likelihood of TC care increased for all age groups, with the largest increase among those aged 85+ years (OR = 1.18), which was statistically different (p = 0.02) from the increase among adults aged 18 to 44 years (OR = 1.12). The analysis of transfers yielded similar results. CONCLUSIONS: Although patterns of increased TC treatment for all groups with severe head trauma indicate improvements, age-based disparities persisted.

Surgical site infections following ambulatory surgery procedures.

IMPORTANCE: Surgical site infections can result in substantial morbidity following inpatient surgery. Little is known about serious infections following ambulatory surgery. OBJECTIVE: To determine the incidence of clinically significant surgical site infections (CS-SSIs) following low- to moderate-risk ambulatory surgery in patients with low risk for surgical complications. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of ambulatory surgical procedures complicated by CS-SSIs that require a postsurgical acute care visit (defined as subsequent hospitalization or ambulatory surgical visit for infection) using the 2010 Healthcare Cost and Utilization Project State Ambulatory Surgery and State Inpatient Databases for 8 geographically dispersed states (California, Florida, Georgia, Hawaii, Missouri, Nebraska, New York, and Tennessee) representing one-third of the US population. Index cases included 284 098 ambulatory surgical procedures (general surgery, orthopedic, neurosurgical, gynecologic, and urologic) in adult patients with low surgical risk (defined as not seen in past 30 days in acute care, length of stay less than 2 days, no other surgery on the same day, and discharged home and no infection coded on the same day). MAIN OUTCOMES AND MEASURES: Rates of 14- and 30-day postsurgical acute care visits for CS-SSIs following ambulatory surgery. RESULTS: Postsurgical acute care visits for CS-SSIs occurred in 3.09 (95% CI, 2.89-3.30) per 1000 ambulatory surgical procedures at 14 days and 4.84 (95% CI, 4.59-5.10) per 1000 at 30 days. Two-thirds (63.7%) of all visits for CS-SSI occurred within 14 days of the surgery; of those visits, 93.2% (95% CI, 91.3%-94.7%) involved treatment in the inpatient setting. All-cause inpatient or outpatient postsurgical visits, including those for CS-SSIs, following ambulatory surgery occurred in 19.99 (95% CI, 19.48-20.51) per 1000 ambulatory surgical procedures at 14 days and 33.62 (95% CI, 32.96-34.29) per 1000 at 30 days. CONCLUSIONS AND RELEVANCE: Among patients in 8 states undergoing ambulatory surgery, rates of postsurgical visits for CS-SSIs were low relative to all causes; however, they may represent a substantial number of adverse outcomes in aggregate. Thus, these serious infections merit quality improvement efforts to minimize their occurrence.

Ethnic differences in potentially preventable hospitalizations among Asian Americans, Native Hawaiians, and other Pacific Islanders: implications for reducing health care disparities.

OBJECTIVES: A serious challenge to eliminating US health disparities stems from the inability to reliably measure outcomes, particularly for numerically small populations. Our study aimed to produce reliable estimates of health care quality among Native Hawaiian (NH), Other Pacific Islander (PI), and Asian American (AA) subgroups. DESIGN: Prevention Quality Indicators (PQIs) from the Agency for Healthcare Research and Quality were used to calculate 3 PQI composites and 8 individual chronic condition indicators. Data sources were the Healthcare Cost and Utilization Project State Inpatient Databases and the Hawaii Health Survey. MAIN OUTCOME MEASURES: Risk-adjusted PQI rates for adults were computed for 2005 through 2007. Relative rates for 2007 were calculated for each racial/ethnic group and compared to Whites. Statistical significance was based on P < .05 from a two-sided t test. RESULTS: The combined AANHPI group had higher overall and chronic PQI composite rates than Whites in 2007. When disaggregated into discrete racial/ethnic subgroups, Chinese and Japanese had lower rates than Whites for all 3 composites, whereas NH and Other PI subgroups typically had the worst health outcomes. Trends in PQI rates from 2005 through 2007 showed persistent gaps between groups, especially across chronic PQIs. CONCLUSIONS: Despite recent efforts to reduce racial/ethnic health care disparities, significant gaps remain in potentially preventable hospitalization rates. Practical tools that measure inequities across diverse, numerically small populations may suggest ways to optimally funnel limited resources toward improving racial/ethnic differences in health outcomes.

What hospital inpatient services contributed the most to the 2001-2006 growth in the cost per case?

OBJECTIVE: To demonstrate a refined cost-estimation method that converts detailed charges for inpatient stays into costs at the department level to enable analyses that can unravel the sources of rapid growth in inpatient costs. DATA SOURCES: Healthcare Cost and Utilization Project State Inpatient Databases and Medicare Cost Reports for all community, nonrehabilitation hospitals in nine states that reported detailed charges in 2001 and 2006 (n = 10,280,416 discharges). STUDY DESIGN: We examined the cost per discharge across all discharges and five subgroups (medical, surgical, congestive heart failure, septicemia, and osteoarthritis). DATA COLLECTION/EXTRACTION METHODS: We created cost-to-charge ratios (CCRs) for 13 cost-center or department-level buckets using the Medicare Cost Reports. We mapped service-code-level charges to a CCR with an internally developed crosswalk to estimate costs at the service-code level. PRINCIPAL FINDINGS: Supplies and devices were leading contributors (24.2 percent) to the increase in mean cost per discharge across all discharges. Intensive care unit and room and board (semiprivate) charges also substantially contributed (17.6 percent and 11.3 percent, respectively). Imaging and other advanced technological services were not major contributors (4.9 percent). CONCLUSIONS: Payers and policy makers may want to explore hospital stay costs that are rapidly rising to better understand their increases and effectiveness.

Trends in manufacturer prices of brand name prescription drugs used by older Americans--first quarter 2004 update.

This Issue Brief reports on changes in manufacturers' prescription drug prices during the first three months of 2004 (January through March) for the brand name prescription drugs most widely used by Americans age 50 and over. This report is the first quarterly update in an ongoing study of changes in drug manufacturer prices-that is, manufacturers' prices charged for drugs they sold to wholesalers. A baseline study published in May 2004 by the AARP Public Policy Institute identified steady increases in the average annual manufacturer price from calendar year 2000 through calendar year 2003. This report's focus is on changes in the prices that brand name drug manufacturers charge to wholesalers for sales to retail pharmacies. The manufacturer's charge to wholesalers is the most substantial component of a prescription drug's retail price. When there is an increase in the manufacturer price to wholesalers for a brand name drug, this added cost is generally passed on as a similar percent change in the retail price to most prescription purchasers. The report presents three measures of price change (see methodological appendix). The first set of findings are annual rates of change in manufacturers' prices for widely used brand name drugs, using both rolling average and point-to-point estimates; information is presented on percentage change in manufacturer price and on potential dollar changes in consumer spending. The second set of findings are three-month percentage changes in prices (i.e., changes from December 31, 2003 through March 31, 2004); the distribution of percentage price changes is shown, as well as differences in average percentage price changes by manufacturer and by therapeutic category.

Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life.

OBJECTIVES: To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. PARTICIPANTS: The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. EVIDENCE: (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. CONSENSUS PROCESS: The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. CONCLUSIONS: Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.