Hospital Consult - January 2016
Hospital Access Management - Hospital Case Management - Hospital Employee Health
Hospital Infection Control - Hospital Peer Review - Healthcare Risk Management
Case Management Advisor - IRB Advisor - Medical Ethics Advisor - Same-Day Surgery
Hospitals Penalized in Rankings for High Percentage of DNR Orders
BOSTON – Hospitals that attract a larger proportion of patients with “do not resuscitate” (DNR) orders might have much higher quality levels than their rankings suggest.
That’s according to a study appearing recently in JAMA Internal Medicine. Boston University School of Medicine researchers examined how hospital differences in patient preferences for life-sustaining treatments, such as DNR orders, affected hospital rankings for pneumonia. They found that including patient decisions about life-sustaining treatments in the statistical mortality models potentially lowered hospital rankings, affecting hospital ratings which, in turn, had an effect on reimbursements and financial penalties.
"Our findings suggest that current methods of comparing hospitals, which do not account for patient DNR status, penalize potentially high-quality hospitals admitting a larger proportion of patients who had chosen to forgo resuscitation,” explained corresponding author Allan Walkey, MD, MS. “Therefore, accounting for DNR status in programs that compare hospital mortality outcomes may substantially affect publicly reportable hospital rankings and hospital reimbursements.”
The retrospective, population-based cohort study was conducted among adults hospitalized with pneumonia in 303 California hospitals between Jan. 1 and Dec. 31, 2011. Of the 90,644 pneumonia cases (5.4% of admissions) identified, the mean age was 72.5 and the majority of patients were female and white.
Hospital DNR rates varied, according to the results which found that, without accounting for individual patient DNR status, higher hospital-level DNR rates were associated with increased patient mortality, with an adjusted odds ratio of 1.17. After accounting for patient DNR status and between-hospital variation in the association between DNR status and mortality, however, the study determined that hospitals with higher DNR rates actually had lower mortality -- an adjusted OR of 0.79.
“Only 14 of 27 hospitals (51.9%) characterized as low-performing outliers without accounting for DNR status remained outliers after DNR adjustment,” the authors wrote, adding that hospital DNR rates were not significantly associated with composite quality measures of processes of care for pneumonia but were positively correlated with patient satisfaction scores.
The researchers called for improvement of methods to standardize and report DNR status in hospital discharge records and how that is considered in hospital rankings.
“Without accounting for patient preferences for life-sustaining treatments, hospitals admitting more patients who chose a 'DNR' status appeared to be poorer quality hospitals for patient mortality measures,” Walkey added in a Boston University press release. “However, our results suggested the opposite: Hospitals with a larger number of patients who chose 'DNR' status tended to have greater patient satisfaction, high performance on measures of pneumonia care, and lower mortality after accounting for patient 'DNR' preferences.”
[Webinar] Advance Care Planning Payments and Standards on February 3 – 3:30pm ET
Costs of QI Program for Colorectal Surgery Offset by Savings
BALTIMORE – Putting into place a new quality improvement program to speed recovery of colorectal surgery patients might come at a cost, but those expenses are more than offset by the savings, according to an “article in press” from the Journal of the American College of Surgeons.
Study authors, led by Johns Hopkins Medical Institutions researchers, conceded that the patient-centric program requires significant upfront investments in patient educational materials, dedicated time for frontline providers to develop and implement the pathway, and to develop a framework for measuring their performance.
The researchers argue, however, that the programs can save money for hospitals of various sizes and volumes of colorectal surgery.
For the analysis, the study team evaluated the lengths of stay and costs documented in six published reports of Enhanced Recovery After Surgery (ERAS) programs that were implemented in U.S. hospitals for patients undergoing colorectal procedures between 2003 and 2015. Data from those reports were then used to generate a financial model reflecting the net financial effect of implementing ERAS.
Included in the data were implementation costs, reductions in length of stay, and the per-day reductions in direct variable costs associated with shorter hospital stays, as well as annual surgical caseload.
Key elements of ERAS programs, which create evidence-based protocols that promote the adoption of a standardized approach to perioperative care, include counseling about expectations for the procedure and hospitalization for patients and their families, optimizing preoperative and postoperative nutrition, minimizing the use of narcotic pain management, and promoting early mobility after surgery.
The result, according to the previous studies, has been reduced complications, hospital stays, and costs, as well as improved patient experience.
“With the model described in this study, surgeons can plug in their case volumes and current length of stay and cost metrics and determine the potential cost savings, based on published U.S. studies, they might expect at their hospital,” said lead study author Elizabeth Wick, MD, FACS, in an American College of Surgeons press release. “The model gives surgeons a framework for having a sophisticated discussion about how to initiate these types of programs with hospital administrators and what type of return on investment can be anticipated.”
For example, hospitals with an assumed annual number of 100 colorectal procedures would have $117,875 in costs for implementation of ERAS in the first year and $107,875 in annual maintenance costs, compared to $552,783 initially and $356,944 annually thereafter for a large colorectal surgery program performing 500 procedures a year.
Study authors suggest that the costs are more than offset by net savings. At The Johns Hopkins Hospital, they write, ERAS protocols reduced length of stay on average by 1.9 days (26.4%) and direct variable costs by $1,897 per patient. With an annual caseload of 500 patients, ERAS protocols yielded a total cost savings of $948,500, according to the study, which translated into net annual savings of $395,717.
[Webinar] New CMS QAPI Standards and Revised QAPI Worksheet on February 1 – 1pm ET
Hospital Bottom Lines Saw Benefit in States Expanding Medicaid
ANN ARBOR, MI – In states that expanded their Medicaid programs as part of the Affordable Care Act, the amount of care their hospitals provided to uninsured patients plummeted, according to a new study.
The article, published recently in Health Affairs, suggests one of the key parts of the Affordable Care Act worked as intended, allowing hospitals a chance to recoup more of the cost of care they provide instead of having to absorb it when low-income patients are unable to pay.
For the study, University of Michigan Institute of Healthcare Policy and Innovation researchers looked at hospital discharges in a sample of states that expanded Medicaid, finding that, in all, hospital stays by uninsured patients went down 50% between the end of 2013 and the middle of 2014. At the same time, hospital stays by patients with Medicaid went up 20%.
On the other hand, states that didn’t expand Medicaid after a Supreme Court decision made it optional continued with the same or higher demand for care from the uninsured.
"In expansion states, we see exactly what we would expect to happen after Medicaid became available to more people," lead author Sayeh Nikpay, PhD, MPH, said in a University of Michigan press release. "Even in these early months, the shift from uninsured to Medicaid contrasts sharply with the steady demand for uninsured care in non-expansion states. This has implications for the financial status of hospitals."
The researchers used the newly available hospital discharge payment source data from the Agency for Healthcare Research and Quality's HCUP Fast Stats program. Expansion states studied were Arizona, California, Colorado, Hawaii, Iowa, Kentucky, Minnesota, New Jersey, and New York, while the non-expansion states were Florida, Georgia, Indiana, Missouri, Virginia, and Wisconsin.
Among the findings were that Kentucky, where Medicaid enrollment has nearly doubled since expansion, showed a 13.5% point drop in uninsured hospital stays in just the first six months after expansion. In Georgia, meanwhile, where Medicaid was not expanded, uninsured hospital stays rose by seven percentage points in early 2014, according to the study.
Nurse Staffing, Work Environment Affect In-Hospital Cardiac Arrest Survival
PHILADELPHIA – While in-hospital cardiac arrest (IHCA) survival rates might be low across the board in hospitals, some hospitals do much better at saving those lives than others. What makes the difference?
A study published recently in the journal Medical Care sought to answer that question. The University of Pennsylvania School of Nursing-led research found that better nurse staffing and a favorable work environment both were big contributors to success.
"These results add to a large body of literature suggesting that outcomes are better when nurses have a more reasonable workload and work in good hospital work environments," study authors wrote. "Improving nurse working conditions holds promise for improving survival following IHCA."
Despite the opportunity for early intervention in the hospital setting, less than a fourth of patients with IHCA are discharged from the hospital alive, according to background information in the article.
For the study employing the American Heart Association's "Get With The Guidelines-Resuscitation" database, researchers analyzed 2005-07 data from more than 11,000 adults with IHCA at 75 hospitals in four states. National surveys of hospital characteristics and nurse staffing were used to analyze how those factors played into hospital survival rates after IHCA.
With just 15% of the patients with IHCA surviving to hospital discharge, most of the events occurred in an intensive care unit (ICU), and 80% were witnessed. In fact, 88% of patients were on cardiac monitoring equipment when the cardiac arrest occurred.
The review found that factors affecting the chance of survival included whether the patients were being monitored and if they had a "shockable" heart rhythm.
Even after taking those and other issues into account, the study found that hospitals with higher nurse staffing levels had higher IHCA survival rates. On general medical-surgical units, each additional patient per nurse was associated with a 5% relative reduction in the odds of survival, according to the report.
At the same time, the likelihood of survival was 16% lower at hospitals where surveys indicated poor work environments.
While nurse staffing levels in ICUs did not significantly affect the chances of survival after IHCA, possibly because of increasing standardization, that appeared to be a factor on general medical-survival units.
“Nearly half of IHCAs occur on medical-surgical units, which also have the most variable staffing levels and the most problematic work environments,” the authors wrote, suggesting that having too large of a patient load interferes with nurses' ability to effectively monitor patients closely, identify changes in patient condition, and intervene with lifesaving efforts quickly when seconds are a life-and-death matter.
Upcoming Live Hospital [Webinars]
TJC Sentinel Event Policy, Patient Safety Systems & CMS RCA Requirements
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Discharge Solutions to Prevent Hospital Readmissions
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Telemedicine, the Cost-effective Alternative: Real-time CMS & TJC Standards
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New Pharmacy & Medication Standards: the CMS CoPs
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New CMS QAPI Standards and Revised QAPI Worksheet
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Advance Care Planning Payments and Standards
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The IMPACT Act and its effect on Discharge Planning Standards
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Safe Opioid Use: Meeting the CMS CoP Hospital Requirements
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Violence Prevention in Healthcare: OSHA Requirements
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Hospital Utilization Review Programs: Current CMS CoPs
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Transitional Planning Under New and Proposed CMS Guidelines
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Restraint and Seclusion: The Most Problematic of All CMS Standards
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CMS Medical Records: What You Need to Know
Live: February 23 Credits: 1.5 CE
Give Falls the Slip: TJC & CMS Hospital CoPs & Standards
Live: February 29 Credits: 2 CE
