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Psychiatric Conditions Affect Hospital Readmissions, Penalties

DETROIT – Medicare and Medicaid should take into account co-existing psychiatric illness when assessing hospital readmissions for three common medical conditions used to penalize hospitals with "excessive" readmission rates, according to a collaborative study by 11 major U.S. healthcare providers.

The study, published in the journal Psychiatric Services, focuses on readmission rates – an issue of increasing concern to U.S. hospitals since October 2012, when CMS linked readmissions to reimbursement as part of the Affordable Care Act.

"CMS chose three general medical conditions -- heart failure, acute myocardial infarction and pneumonia – as a way of assessing excessive re-hospitalizations and penalizing providers by reducing payment for healthcare services," said lead author Brian K. Ahmedani, PhD, of the Center for Health Policy and Health Services Research at the Henry Ford Health System.

Because excessive hospital readmissions – those occurring within 30 days of the original admission –account for more than $17 billion of Medicare costs each year, CMS is expected to add other diagnoses to the three already used as standards, according to background in the article.

"So to avoid reimbursement penalties, it is very important for healthcare providers across the U.S. to develop effective interventions to reduce 30-day readmissions," Ahmedani explained. "The question is, where to start to provide the most reductions in readmissions at the lowest cost?”

That is why the current study focuses on psychiatric conditions, which are known to be highly comorbid with heart failure, acute myocardial infarction (AMI) and pneumonia, he responded.

For the study, more than 160,000 patients were identified as having been admitted to the 11 Mental Health Research Network-affiliated healthcare centers between January 2009 and December 2011 for any of the three medical conditions targeted by CMS.

“Approximately 18% of all individuals with index inpatient hospitalizations for HF, AMI, and pneumonia were readmitted within 30 days,” according to the results. “The rate of readmission was 5% greater for individuals with a psychiatric comorbidity compared with those without a psychiatric comorbidity (21.7% and 16.5%, respectively, p<.001).”

In fact, according to the researchers, nearly 30% of the patients admitted to the hospital with heart failure, AMI or pneumonia were diagnosed in the previous year as having a mental health condition.

“Because depression, anxiety and substance abuse appeared to be the most common diagnoses among the patients we studied, and because each was associated with increased readmission rates, these disorders may be the most appropriate for healthcare systems to focus their primary screening efforts,” Ahmedani said.



ICUs Vary Widely on How Pre-Existing Care Limits Are Managedhcm for hospital consult

PHILADELPHIA – If you believe your intensive care unit is fairly standard in how it manages care of patients who have set preexisting limits on life-sustaining therapies, you might need to rethink that.

A study published only recently by JAMA Internal Medicine finds that ICUs across the United States vary greatly in how they deal with do-not-resuscitate (DNR) orders and the prohibition of interventions such as feeding tubes or dialysis.

For the study, a team led by University of Pennsylvania researchers examined a retrospective cohort of patients from 141 intensive care units in 105 hospitals from April 2001 through December 2008 –a total of 277,693 study subjects. Only 4.8% of ICU admissions were found to be patients with preexisting limits on care.

DNR orders were the most common care limitations for the patients with care restrictions, including preferences prohibiting chest compressions, intubation and use of defibrillation to restart their hearts. Another 21% of patients had documented restrictions on acceptable therapies, ranging from dialysis to nutritional support such as feeding, with 4% expressing a preference for comfort measures only.

Treatment limitations were more typical among older patients, average age 78, as well as those with preexisting chronic illnesses conditions, including chronic respiratory disease (14%) and chronic kidney disease (13%). In addition, more than half (52%) of patients with directives were admitted to the ICU from the emergency department, and 35% died during the hospital stay studied.

Interestingly, the researchers found that these patients' preferences to refrain from use of lifesaving measures didn’t always affect their care; 23% of patients admitted with treatment limitations nonetheless received CPR in the ICU. In total, 41% of patients who entered with treatment limitations received one or more forms of life support in the ICU, and 18% had a reversal of previous treatment limitations during their stay in the unit.

That varied greatly across ICUs, however, with less than 5% of patients at some ICUs undergoing a change in preference and greater than 90% in others.

When ICU care was managed by a critical care physician, the odds improved that the preexisting limitations on care would change and care would escalate, according to the report. That also was the case when care was provided at suburban hospitals compared to urban settings.

"The variability here is astounding and no matter how hard we tried, we could not make it go away by accounting for any differences among the patients admitted to different ICUs," noted senior author Scott Halpern, MD, PhD, MBE, assistant professor of Medicine, Epidemiology, and Medical Ethics and Health Policy at Penn. "Surprisingly, for patients who had already outlined 'I don't want this or that procedure or treatment at end of life,' escalations of treatment intensity were nonetheless more common than de-escalations.”

"There seems to be great potential for better aligning the outcomes of critical care with the outcomes people desire through a better understanding of how treatment decisions are made for patients who can and cannot communicate their preferences,” Halpern added.


Salary Gap Favoring Men Persists in Nursing

SAN FRANCISCO – For many years, nursing was considered a female profession, but long term dominance of the field hasn’t given women any salary advantages. In fact, a recent study finds that male nurses make $5,100 more on average per year than female colleagues in similar positions.

The research letter, published recently in the Journal of the American Medical Association, notes that, while the male-female salary gap has narrowed in many occupations, pay inequality persists in medicine in general and nursing in particular.

Using nationally representative data from the last six (1988-2008) quadrennial National Sample Survey of Registered Nurses (NSSRN) until it was discontinued, a study team led by researchers from the University of California San Francisco were able to determine salary trends by gender. To extend time trends to 2013, the study also looked at data from the American Community Survey (ACS), focusing on full-time employed RNs and their salaries.

The NSSRN sample, mean age 42, included 87,903 RNs – 7% male, 12% nonwhite, 67% married and 10% with graduate degrees. The ACS sample, mean age 45, included 205,825 RNs – 10% male, 19% nonwhite, 66% married, and 14% with graduate degrees.

“Both surveys showed that unadjusted male salaries were higher than female salaries during ever year,” the authors write.

In addition, no statistically significant changes in female vs. male salary levels were detected over time. The analysis estimated an overall adjusted earning difference of $5,148 annually.

The salary gap varied by setting; the difference was found to be $7,678 for ambulatory care and $3,873 for hospital nurses.

In addition, the gap was present in all specialties except orthopedics, ranging from $3,792 for chronic care to $6,034 for cardiology. Positions such as middle management or nurse anesthetists also demonstrated salary differences by gender, according to the study.

"The roles of RNs are expanding with implementation of the Affordable Care Act and emphasis on team-based care delivery,” the authors write. “A salary gap by gender is especially important in nursing because this profession is the largest in healthcare and is predominantly female, affecting approximately 2.5 million women. These results may motivate nurse employers, including physicians, to examine their pay structures and act to eliminate inequities.”


Subdural Hemorrhage Cases Expected to Skyrocket in Next Decades

NEW YORK – Will your hospital be prepared when, over the next 15 years, chronic subdural hemorrhage (SDH) is the most common adult brain condition requiring neurosurgical intervention in the United States?

A new report, published online recently by the Journal of Neurosurgery, warns that hospitals could be underequipped and understaffed with neurosurgeons to manage the projected increase in patients.

According to the study, led by researchers at NYU Langone Medical Center and the New York Harbor Veterans Affairs Medical Center, subdural hemorrhage, also known as subdural hematoma, is becoming more common in the elderly because of increased brain atrophy, greater use of anti-coagulant medications and thinning of the delicate vessels stretching between the surface of the brain and its coverings.

The result, warn study authors, is that even minor head injuries can result in bleeding on the surface of the brain that can accumulate over time and lead to serious complications. In fact, they point out, the trauma causing SDH often is so minor that patients have no history or memory of a head or brain trauma incident.

Researchers sought to quantify the future incidence rates for chronic SDH in both civilians and military veterans, who, along with patients with a history of alcohol abuse, are more likely to develop the condition.

To do that, they created a mathematical model after reviewing current data from VA hospital visits where SDHs were diagnosed, as well as civilian incidence rates from Finland and Japan where accurate incidence records are available. The model, which accounts for age, gender and alcohol consumption, is designed to predict the incidence of SDH occurring from 2012-2040 as the population ages.

By 2030, when as many as 25% of U.S. residents will be older than 65, the incidence of chronic SDH will reach approximately 121.4 cases per 100,000 people in the VA population, compared to a current 79.4, and 17.6 cases per 100,000 people in the general U.S. population.

"This study suggests that the medical community, particularly those caring for our aging veterans, may need to dedicate more healthcare resources for the prevention and management of SDH," said co-author Uzma Samadani, MD, PhD.

The study also indicates that patients with SDHs are likely to require longer hospital stays and will need more intensive physical therapy and rehabilitation than other cranial surgery patients.

"We have a very large population of elderly and the last of the 77 million baby boomers will have turned 65 by 2030. We can anticipate that 60,000 Americans per year will develop chronic SDHs. Knowing what is ahead of us gives us time to prepare,” Samadani pointed out.


Need to know CMS & TJC Documentation Requirements for Hospital? We've got you covered!
Attend this webinar to help identify issues that need to be documented in order to maintain reimbursement by CMS and avoid allegation of fraud, abuse, and improper documentation by the RACs (recovery audit contractors).

5.1.15-webinarTopic: Avoiding Legal Hazards in Documentation:
MS and TJC Requirements for Hospitals and Nurses

Speaker: Sue Dill Calloway, RN, MSN, JD
Date: May 1, 2015
Time: 10 AM - Noon PT & 1 - 3 PM ET
Accreditation: 2 CNE Credits Available