Mortality for Time-Sensitive Conditions at Urban vs Rural Hospitals During the COVID-19 Pandemic.

Importance: COVID-19 pandemic-related disruptions to the health care system may have resulted in increased mortality for patients with time-sensitive conditions. Objective: To examine whether in-hospital mortality in hospitalizations not related to COVID-19 (non-COVID-19 stays) for time-sensitive conditions changed during the pandemic and how it varied by hospital urban vs rural location. Design, Setting, and Participants: This cohort study was an interrupted time-series analysis to assess in-hospital mortality during the COVID-19 pandemic (March 8, 2020, to December 31, 2021) compared with the prepandemic period (January 1, 2017, to March 7, 2020) overall, by month, and by community COVID-19 transmission level for adult discharges from 3813 US hospitals in the State Inpatient Databases for the Healthcare Cost and Utilization Project. Exposure: The COVID-19 pandemic. Main Outcomes and Measures: The main outcome measure was in-hospital mortality among non-COVID-19 stays for 6 time-sensitive medical conditions: acute myocardial infarction, hip fracture, gastrointestinal hemorrhage, pneumonia, sepsis, and stroke. Entropy weights were used to align patient characteristics in the 2 time periods by age, sex, and comorbidities. Results: There were 18 601 925 hospitalizations; 50.3% of patients were male, 38.5% were aged 18 to 64 years, 45.0% were aged 65 to 84 years, and 16.4% were 85 years or older for the selected time-sensitive medical conditions from 2017 through 2021. The odds of in-hospital mortality for sepsis increased 27% from the prepandemic to the pandemic periods at urban hospitals (odds ratio [OR], 1.27; 95% CI, 1.25-1.29) and 35% at rural hospitals (OR, 1.35; 95% CI, 1.30-1.40). In-hospital mortality for pneumonia had similar increases at urban (OR, 1.48; 95% CI, 1.42-1.54) and rural (OR, 1.46; 95% CI, 1.36-1.57) hospitals. Increases in mortality for these 2 conditions showed a dose-response association with the community COVID-19 level (low vs high COVID-19 burden) for both rural (sepsis: 22% vs 54%; pneumonia: 30% vs 66%) and urban (sepsis: 16% vs 28%; pneumonia: 34% vs 61%) hospitals. The odds of mortality for acute myocardial infarction increased 9% (OR, 1.09; 95% CI, 1.06-1.12) at urban hospitals and was responsive to the community COVID-19 level. There were significant increases in mortality for hip fracture at rural hospitals (OR, 1.32; 95% CI, 1.14-1.53) and for gastrointestinal hemorrhage at urban hospitals (OR, 1.15; 95% CI, 1.09-1.21). No significant change was found in mortality for stroke overall. Conclusions and Relevance: In this cohort study, in-hospital mortality for time-sensitive conditions increased during the COVID-19 pandemic. Mobilizing strategies tailored to the different needs of urban and rural hospitals may help reduce the likelihood of excess deaths during future public health crises.

Quality of Care Before and After Mergers and Acquisitions of Rural Hospitals.

Importance: Rural hospitals are increasingly merging with other hospitals. The associations of hospital mergers with quality of care need further investigation. Objectives: To examine changes in quality of care for patients at rural hospitals that merged compared with those that remained independent. Design, Setting, and Participants: In this case-control study, mergers at community nonrehabilitation hospitals in Federal Office of Rural Health Policy-eligible zip codes during 2009 to 2016 in 32 states were identified from Irving Levin Associates and the American Hospital Association Annual Survey. Outcomes for inpatient stays for select conditions and elective procedures were derived from the Healthcare Cost and Utilization Project State Inpatient Databases. Difference-in-differences linear probability models were used to assess premerger to postmerger changes in outcomes for patients discharged from merged vs comparison hospitals that remained independent. Data were analyzed from February to December 2020. Exposures: Hospital mergers. Main Outcomes and Measures: The main outcome was in-hospital mortality among patients admitted for acute myocardial infarction (AMI), heart failure, stroke, gastrointestinal hemorrhage, hip fracture, or pneumonia, as well as complications during stays for elective surgeries. Results: A total of 172 merged hospitals and 266 comparison hospitals were analyzed. After matching, baseline patient characteristics were similar for 303 747 medical stays and 175 970 surgical stays at merged hospitals and 461 092 medical stays and 278 070 surgical stays at comparison hospitals. In-hospital mortality among AMI stays decreased from premerger to postmerger at merged hospitals (9.4% to 5.0%) and comparison hospitals (7.9% to 6.3%). Adjusting for patient, hospital, and community characteristics, the decrease in in-hospital mortality among AMI stays 1 year postmerger was 1.755 (95% CI, -2.825 to -0.685) percentage points greater at merged hospitals than at comparison hospitals (P < .001). This finding held up to 4 years postmerger (DID, -2.039 [95% CI, -3.388 to -0.691] percentage points; P = .003). Greater premerger to postmerger decreases in mortality at merged vs comparison hospitals were also observed at 5 years postmerger among stays for heart failure (DID, -0.756 [95% CI, -1.448 to -0.064] percentage points; P = .03), stroke (DID, -1.667 [95% CI, -3.050 to -0.283] percentage points; P = .02), and pneumonia (DID, -0.862 [95% CI, -1.681 to -0.042] percentage points; P = .04). Conclusions and Relevance: These findings suggest that rural hospital mergers were associated with better mortality outcomes for AMI and several other conditions. This finding is important to enhancing rural health care and reducing urban-rural disparities in quality of care.

Return on Investment for a Payer-Provider Partnership to Improve Care Management of Employees and Early Retirees.

OBJECTIVE: A large employer partnered with local health care providers to pilot test an intensive nurse care manager program for employees and retirees. We evaluated its impact on health care utilization and costs. METHODS: A database was developed containing 2011 to 2015 health care enrollment and claims data for 2914 patients linked to their nurse care manager data. We used a difference-in-difference design to compare health care costs and utilization of members recruited for the pilot program and a propensity-score-matched comparison group. RESULTS: We found statistically significant reductions in doctors' office visits and prescription drug costs. A return-on-investment analysis determined that the program saved $0.83 for every dollar spent over the 2-year pilot study period. CONCLUSIONS: Employer-driven care management programs can succeed at reducing utilization, although they may not achieve cost neutrality in the short run.

The Impact Of Medicare ACOs On Improving Integration And Coordination Of Physical And Behavioral Health Care.

The accountable care organization (ACO) model holds the promise of reducing costs and improving the quality of care by realigning payment incentives to focus on health outcomes instead of service volume. One key to managing the total cost of care is improving care coordination for and treatment of people with behavioral health disorders. We examined qualitative data from ninety organizations participating in Medicare ACO demonstration programs from 2012 through 2015 to determine whether and how they focused on behavioral health care. These ACOs had mixed degrees of engagement in improving behavioral health care for their populations. The biggest challenges included a lack of behavioral health care providers, data availability, and sustainable financing models. Nonetheless, we found substantial interest in integrating behavioral health care into primary care across a majority of the ACOs.

Ten modifiable health risk factors are linked to more than one-fifth of employer-employee health care spending.

An underlying premise of the Affordable Care Act provisions that encourage employers to adopt health promotion programs is an association between workers' modifiable health risks and increased health care costs. Employers, consultants, and vendors have cited risk-cost estimates developed in the 1990s and wondered whether they still hold true. Examining ten of these common health risk factors in a working population, we found that similar relationships between such risks and total medical costs documented in a widely cited study published in 1998 still hold. Based on our sample of 92,486 employees at seven organizations over an average of three years, $82,072,456, or 22.4 percent, of the $366,373,301 spent annually by the seven employers and their employees in the study was attributed to the ten risk factors studied. This amount was similar to almost a quarter of spending linked to risk factors (24.9 percent) in the 1998 study. High risk for depression remained most strongly associated with increased per capita annual medical spending (48 percent, or $2,184, higher). High blood glucose, high blood pressure, and obesity were strongly related to increased health care costs (31.8 percent, 31.6 percent, and 27.4 percent higher, respectively), as were tobacco use, physical inactivity, and high stress. These findings indicate ongoing opportunities for well-designed and properly targeted employer-sponsored health promotion programs to produce substantial savings.

Recent experience in health promotion at Johnson & Johnson: lower health spending, strong return on investment.

Johnson & Johnson Family of Companies introduced its worksite health promotion program in 1979. The program evolved and is still in place after more than thirty years. We evaluated the program's effect on employees' health risks and health care costs for the period 2002-08. Measured against similar large companies, Johnson & Johnson experienced average annual growth in total medical spending that was 3.7 percentage points lower. Company employees benefited from meaningful reductions in rates of obesity, high blood pressure, high cholesterol, tobacco use, physical inactivity, and poor nutrition. Average annual per employee savings were $565 in 2009 dollars, producing a return on investment equal to a range of $1.88-$3.92 saved for every dollar spent on the program. Because the vast majority of US adults participate in the workforce, positive effects from similar programs could lead to better health and to savings for the nation as a whole.

The relationship between health risks and health and productivity costs among employees at Pepsi Bottling Group.

OBJECTIVE: To evaluate relationships between modifiable health risks and costs and measure potential cost savings from risk reduction programs. METHODS: Health risk information from active Pepsi Bottling Group employees who completed health risk assessments between 2004 and 2006 (N = 11,217) were linked to medical care, workers' compensation, and short-term disability cost data. Ten health risks were examined. Multivariate analyses were performed to estimate costs associated with having high risk, holding demographics, and other risks constant. Potential savings from risk reduction were estimated. RESULTS: High risk for weight, blood pressure, glucose, and cholesterol had the greatest impact on total costs. A one-percentage point annual reduction in the health risks assessed would yield annual per capita savings of $83.02 to $103.39. CONCLUSIONS: Targeted programs that address modifiable health risks are expected to produce substantial cost reductions in multiple benefit categories.

Clinical inertia in depression treatment.

OBJECTIVE: To explore reasons for clinical inertia in the management of persistent depression symptoms. RESEARCH DESIGN: We characterized patterns of treatment adjustment in primary care and their relation to the patient's clinical condition by modeling transition to a given treatment "state" conditional on the current state of treatment. We assessed associations of patient, clinician, and practice barriers with adjustment decisions. SUBJECTS: Survey data on patients in active care for major depression were collected at 6-month intervals over a 2-year period for the quality improvement for depression (QID) studies. MEASURES: Patient and clinician characteristics were collected at baseline. Depression severity and treatment were measured at each interval. RESULTS: Approximately, one-third of the observation periods ending with less than a full response resulted in an adjustment recommendation. Clinicians often respond correctly to the combination of severe depression symptoms and less than maximal treatment by changing the treatment. Appropriate adjustment is less common, however, in management of less severely depressed patients who do not improve after starting treatment, particularly if their care already meets minimal treatment intensity guidelines. CONCLUSIONS: Our findings suggest that quality improvement efforts should focus on promoting appropriate adjustments for patients with persistent depression symptoms, particularly those with less severe depression.

Clinician- and organization-level factors in the adoption of evidence-based care for depression in primary care.

BACKGROUND AND PURPOSE: Although more individuals are receiving care for depression than those in the past, they often do not receive high-quality care. Strategies to improve quality have focused on changing clinician behavior and more recently on reducing practice barriers. Both strategies hold promise but have had widely varying success either because practices have not successfully removed barriers or because removing barriers alone is not sufficient for improving care. It is unknown under which circumstances clinicians with a high propensity toward recognizing depression and providing depression care can overcome barriers. We explore organizational and clinician factors affecting patient receipt of guideline-concordant services. METHODOLOGY/APPROACH: We use data from adult patients with major depression receiving care in a geographically diverse group of primary care practices participating in the Quality Improvement for Depression study. We estimate the effects of barriers and clinician propensity on six aspects of depression care and adequate treatment. FINDINGS: Barriers and propensity interact in affecting depression services. In comparison with similar clinicians in practices with few barriers, high-propensity clinicians working in practices with more barriers are less likely to provide depression education and are likely to provide fewer follow-up calls and fewer follow-up visits. High-propensity clinicians are more likely to offer antidepressants in practices with more barriers. PRACTICE IMPLICATIONS: To improve the quality of care, efforts should both eliminate practice barriers and increase clinician propensity to provide care. Future research on factors associated with quality improvement can benefit from an approach which specifies how organizational and clinician factors interact to enact change.