Background: Readmissions after ischemic strokes are common and associated with high morbidity and cost. Whether early follow-up after stroke can reduce readmissions remains unclear. We examined the relationship between follow-up after stroke hospitalization with primary care or neurology and readmissions at 30 and 90 days. Methods: A retrospective cohort study was performed using PharMetrics claims database of US commercial insurers from 2009 to 2015. Inclusion: (1) inpatient admission with primary diagnosis of ischemic stroke, (2) discharge home, (3) age 18-89, (4) 1 year of enrollment prior to stroke and 3 months after discharge. Exclusion: (1) stroke transfers, (2) repeat admission for stroke. The primary outcome was all-cause 30-day and 90-day hospital readmission. Multivariable Cox models were used with primary care and neurology visits specified as time-dependent covariates, adjusting for patient demographics, comorbidities (calculated for one year prior to stroke) and stroke severity measures. Results: The cohort consisted of 16,965 patients (table). Readmissions at 30 days occurred in 6.56% of patients at a median (interquartile range) of 12 days (5-20). Readmissions at 90 days occurred in 13.2% of patients at a median of 31 days (12-58). By 30 days, 50.2% had a primary care visit and 17.1% had a neurology visit. Patients with a primary care visit within 30 days had a 23% lower rate of readmission than those who did not (hazard ratio [HR], 0.77; 95% confidence interval, 0.66-0.89). The association is less strong for primary care visits within 90 days and readmissions (HR 0.88; 0.80-0.98). Neurology follow-up did produce benefit but did not reach significance. Conclusion: Early outpatient follow-up with primary care is associated with a significant reduction in hospital readmission. Even though this was an insured population, almost half of all patients did not receive primary care follow-up at 30 days, which represents an opportunity for intervention.
Background: Rates of receipt of left ventricular assist devices (LVADs) are less than expected for racial/ethnic minorities. A major etiology of this disparity changed over the past few years with broader access to insurance. Thus, we hypothesized that changes in the census-adjusted rate of receipt of LVADs would be higher for racial/ethnic minorities than Caucasians independent of sex and age. Methods: Using the Interagency Registry of Mechanically Assisted Circulatory Support, we analyzed 10,795 patients (African-American 24.8%, Asian 1.5%, Caucasian 67.4%, Hispanic 6.3%, female 21.4%) who had an LVAD implanted between 2012-2015. Linear models were fit to annual census-adjusted rate of LVAD implantation, and the rate of change in receipt of LVADs was compared for each racial/ethnic minority to Caucasians, stratified by sex and age group. Results: Between 2012 and 2015, African-Americans had an increase in the census-adjusted annual rate of receipt of LVADs per 100,000 [+0.26 (95% CI: 0.17-0.34)], while others exhibited no significant changes [Caucasian: +0.06 (95%CI: -0.03-0.14); Hispanic: +0.04 (95%CI: -0.05-0.12); Asian: +0.04 (95%CI: -0.04-0.13)]. When stratified by sex, the observed increase in rate of receipt of LVAD for African-Americans relative to Caucasians was present for both sexes [African-American women: +0.14 (95%CI: 0.01-0.27); African-American men: +0.28 (95%CI: 0.15-0.41)]. No increase was observed in either sex among other racial/ethnic groups ( Figure 1a ). When stratified by age group, the observed increase in rate of receipt of LVAD for African-Americans relative to Caucasians was limited to those aged 40-59 years [African-Americans aged: 20-39: +0.09 (95%CI: -0.20-0.39); 40-49: +0.41 (95%CI: 0.11-0.70); 50-59: +0.31 (95%CI: 0.01-0.60); 60-69: +0.22 (95%CI: -0.08-0.51); 70+: +0.07 (95%CI: -0.23-0.36)]. No differences by age group were observed among other racial/ethnic groups compared to Caucasians ( Figure 1b) . Conclusions: From 2012-2015, rates of receipt of LVADs increased for African-Americans but not other racial/ethnic groups in comparison to Caucasians. Similar patterns were seen when stratified by sex. When stratified by age, the increase in rate was limited to middle-aged African-Americans.
Cross-subsidies are often considered the principal mechanism through which hospitals provide unprofitable care. Yet, hospitals' reliance on and extent of cross-subsidization are difficult to establish. We exploit entry by cardiac specialty hospitals as an exogenous shock to incumbent hospitals' profitability and in turn to their ability to cross-subsidize unprofitable services. Using patient-level data from general short-term hospitals in Arizona and Colorado before and after entry, we find that the hospitals most exposed to entry reduced their provision of services considered to be unprofitable (psychiatric, substance- abuse, and trauma care) and expanded their admissions for neurosurgery, a highly profitable service.
BackgroundIn efforts to improve the quality of care, many have suggested that health care adopt management approaches that have been successful in the manufacturing and technology sectors.However, there is relatively little information about how these practices are disseminated in hospitals, and whether they are associated with better performance. MethodsWe adapted an approach used to measure management and organizational practices in manufacturing to collect management data on cardiac units, scoring performance on 18 practices, covering "Lean" methods, tracking of key performance indicators, setting targets, and incentivizing employees.Multivariate analyses assessed the relationship of management practices with process of care measures, 30-day risk adjusted mortality, and 30-day readmissions for acute myocardial infarction (AMI). ResultsWe measured management practices for 597 cardiac units, representing 51.5% of hospitals with interventional cardiac catheterization laboratories and at least 25 annual AMI discharges.We found a wide distribution in management practices, with fewer than 20% of hospitals scoring a "4" or "5" (best practice) on more than 9 measures.In multivariate analyses, management practices were significantly correlated with mortality (P=0.01) and 6 out of 6 process measures (P<0.05).No statistically significant association was found between management and 30-day readmissions. ConclusionsThe use of management practices adopted from manufacturing sectors was associated with higher process of care measures and lower 30-day AMI mortality.Given the wide differences in management practices across hospitals, dissemination of these practices may be beneficial in achieving high quality outcomes.* CI denotes confidence interval based on statistical bootstrap with hospital clustering.
