Impact of an educational program and decision tool on choice of maternity hospital: the delivery decisions randomized clinical trial.

BACKGROUND: Reducing cesarean rates is a public health priority. To help pregnant people select hospitals with lower cesarean rates, numerous organizations publish publically hospital cesarean rate data. Few pregnant people use these data when deciding where to deliver. We sought to determine whether making cesarean rate data more accessible and understandable increases the likelihood of pregnant people selecting low-cesarean rate hospitals. METHODS: We conducted a 1:1 randomized controlled trial in 2019-2021 among users of a fertility and pregnancy mobile application. Eligible participants were trying to conceive for fewer than five months or were 28-104 days into their pregnancies. Of 189,456 participants approached and enrolled, 120,621 participants met entry criteria and were included in analyses. The intervention group was offered an educational program explaining the importance of hospital cesarean rates and an interactive tool presenting hospital cesarean rates as 1-to-5-star ratings. Control group users were offered an educational program about hospital choice and a hospital choice tool without cesarean rate data. The primary outcome was the star rating of the hospital selected by each patient during pregnancy. Secondary outcomes were the importance of cesarean rates in choosing a hospital and delivery method (post-hoc secondary outcome). RESULTS: Of 120,621 participants (mean [SD] age, 27.8 [7.9]), 12,284 (10.2%) reported their choice of hospital during pregnancy, with similar reporting rates in the intervention and control groups. Intervention group participants selected hospitals with higher star ratings (2.52 vs 2.16; difference, 0.37 [95% CI, 0.32 to 0.43] p < 0.001) and were more likely to believe that the hospitals they chose would impact their chances of having cesarean deliveries (38.5% vs 33.1%, p < 0.001) but did not assign higher priority to cesarean delivery rates when choosing their hospitals (76.2% vs 74.3%, p = 0.05). There was no difference in self-reported cesarean rates between the intervention and control groups (31.4% vs 31.4%, p = 0.98). CONCLUSION: People offered an educational program and interactive tool to compare hospital cesarean rates were more likely to use cesarean data in selecting a hospital and selected hospitals with lower cesarean rates but were not less likely to have a cesarean. CLINICAL TRIAL REGISTRATION: Registered December 9, 2016 at clinicaltrials.gov, First enrollment November 2019. ID NCT02987803, https://clinicaltrials.gov/ct2/show/NCT02987803.

Legislation Increased Medicare Telestroke Billing, But Underbilling And Erroneous Billing Remain Common.

In the Furthering Access to Stroke Telemedicine (FAST) Act, passed as part of a budget omnibus in 2018, Congress permanently expanded Medicare payment for telemedicine consultations for acute stroke ("telestroke") from delivery only in rural areas to delivery in both urban and rural areas, effective January 1, 2019. Using a controlled time-series analysis, we found that one year after FAST Act implementation, billing for Medicare telestroke increased substantially in emergency departments at both directly affected urban hospitals and indirectly affected rural hospitals. However, at that time only a minority of hospitals with known telestroke capacity had ever billed Medicare for that service, and there was substantial billing inconsistent with Medicare requirements. As Congress considers options for Medicare telemedicine payment after the COVID-19 pandemic, our findings, which are consistent with confusion among providers regarding telemedicine billing requirements, suggest that simplified payment rules would help ensure that expanded reimbursement achieves its intended impact.

A methodology for identifying behavioral health advanced practice registered nurses in administrative claims.

OBJECTIVE (STUDY QUESTION): Advanced practice registered nurses (APRNs) play an increased role in mental illness treatment. Health services research that uses claims to study mental health is often limited because behavioral health nurse practitioners (i.e., APRNs who specialize in mental illness, also known as psychiatric mental health APRNs) cannot be easily identified in claims data. We describe two methodologies to identify behavioral health APRNs in administrative claims. DATA SOURCES/STUDY SETTING (W/ HOSPITAL/INSTITUTION SETTING ANONYMIZED): We use 2010-2018 claims from the traditional Medicare fee-for-service program along with 2010-2019 commercial claims and Medicare Advantage data from the OptumLabs Data Warehouse (OLDW). Self-reported specialty data from the National Plan & Provider Enumeration System (NPPES) were used for validation. STUDY DESIGN: For each APRN, we calculated the percentage of visit diagnoses and of prescriptions in each database that were for mental health and classified those with ≥80% as behavioral health APRNs. We validated our definition with NPPES self-reported specialty for Medicare data. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Among APRNs with 10+ visits, 10,978 (8.1%) in Medicare and 9829 (11.7%) in commercial claims data met our visit-based criteria as behavioral health APRNs. Among APRNs with 10+ prescriptions, 8160 (6.2%) in Medicare and 16,538 (9.0%) in commercial claims data met our prescription-based criteria as behavioral health APRNs. Among the APRNs who self-reported they were behavioral health APRNs, 92.8% and 90.5% met our visit-based and prescription-based criteria, respectively. CONCLUSIONS: We present and validate two methods of identifying behavioral health APRNs in claims that can be used by other researchers.

Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks.

Importance: It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed. Objective: To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to. Design, Setting, and Participants: This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified. Exposures: For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics. Main Outcomes and Measures: Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients. Results: Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients. Conclusions and Relevance: This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.

Reperfusion Treatment and Stroke Outcomes in Hospitals With Telestroke Capacity.

Importance: Telestroke is increasingly used in hospital emergency departments, but there has been limited research on its impact on treatment and outcomes. Objective: To describe differences in care patterns and outcomes among patients with acute ischemic stroke who present to hospitals with and without telestroke capacity. Design, Setting, and Participants: Patients with acute ischemic stroke who first presented to hospitals with telestroke capacity were matched with patients who presented to control hospitals without telestroke capacity. All traditional Medicare beneficiaries with a primary diagnosis of acute ischemic stroke (approximately 2.5 million) who presented to a hospital between January 2008 and June 2017 were considered. Matching was based on sociodemographic and clinical characteristics, hospital characteristics, and month and year of admission. Hospitals included short-term acute care and critical access hospitals in the US without local stroke expertise. In 643 hospitals with telestroke capacity, there were 76 636 patients with stroke who were matched 1:1 to patients at similar hospitals without telestroke capacity. Data were analyzed in July 2020. Main Outcomes and Measures: Receipt of reperfusion treatment through thrombolysis with alteplase or thrombectomy, mortality at 30 days from admission, spending through 90 days from admission, and functional status as measured by days spent living in the community after discharge. Results: In the final sample of 153 272 patients, 88 386 (57.7%) were female, and the mean (SD) age was 78.8 (10.4) years. Patients cared for at telestroke hospitals had higher rates of reperfusion treatment compared with those cared for at control hospitals (6.8% vs 6.0%; difference, 0.78 percentage points; 95% CI, 0.54-1.03; P < .001) and lower 30-day mortality (13.1% vs 13.6%; difference, 0.50 percentage points; 95% CI, 0.17-0.83, P = .003). There were no differences in days spent living in the community following discharge or in spending. Increases in reperfusion treatment were largest in the lowest-volume hospitals, among rural residents, and among patients 85 years and older. Conclusions and Relevance: Patients with ischemic stroke treated at hospitals with telestroke capacity were more likely to receive reperfusion treatment and have lower 30-day mortality.