Objective To characterize Medicare expenditures on initial breast cancer care and examine variation in expenditures across hospital referral regions ( HRR s). Data Source We identified 29,110 women with localized breast cancer diagnosed in 2005–2008 and matched controls from the Surveillance, Epidemiology, and End Results‐Medicare linked database. Study Design Using hierarchical generalized linear models, we estimated per patient Medicare expenditure on initial breast cancer care across HRR s and assessed the contribution of patient, cancer, and treatment factors to regional variation via incremental models. Principal Findings Mean Medicare expenditure for initial breast cancer care was $19,255 per patient. The average expenditures varied from $15,053 in the lowest‐spending HRR quintile to $23,480 in the highest‐spending HRR quintile. Patient sociodemographic, comorbidity, and tumor characteristics explained only 1.8 percent of the difference in expenditures between the lowest‐ and highest‐spending quintiles, while use of specific treatment modalities explained 14.5 percent of the difference. Medicare spending on radiation therapy differed the most across the quintiles, with the use of intensity modulated radiation therapy increasing from 1.7 percent in the lowest‐spending quintile to 11.6 percent in the highest‐spending quintile. Conclusions Medicare expenditures on initial breast cancer care vary substantially across regions. Treatment factors are major contributors to the variation.
Objectives To determine the prevalence, recognition, co‐occurrence, and recent onset of geriatric syndromes in individuals transferred from the hospital to a skilled nursing facility ( SNF ). Design Quality improvement project. Setting Acute care academic medical center and 23 regional partner SNF s. Participants Medicare beneficiaries hospitalized between January 2013 and April 2014 and referred to SNF s (N = 686). Measurements Project staff measured nine geriatric syndromes: weight loss, lack of appetite, incontinence, and pain (standardized interview); depression (Geriatric Depression Scale); delirium (Brief Confusion Assessment Method); cognitive impairment (Brief Interview for Mental Status); and falls and pressure ulcers (hospital medical record using hospital‐implemented screening tools). Estimated prevalence, new‐onset prevalence, and common coexisting clusters were determined. The extent to which treating physicians commonly recognized syndromes and communicated them to SNF s in hospital discharge documentation was evaluated. Results Geriatric syndromes were prevalent in more than 90% of hospitalized adults referred to SNF s; 55% met criteria for three or more coexisting syndromes. The most‐prevalent syndromes were falls (39%), incontinence (39%), loss of appetite (37%), and weight loss (33%). In individuals who met criteria for three or more syndromes, the most common triad clusters were nutritional syndromes (weight loss, loss of appetite), incontinence, and depression. Treating hospital physicians commonly did not recognize and document geriatric syndromes in discharge summaries, missing 33% to 95% of syndromes present according to research personnel. Conclusion Geriatric syndromes in hospitalized older adults transferred to SNF s are prevalent and commonly coexist, with the most frequent clusters including nutritional syndromes, depression, and incontinence. Despite the high prevalence, this clinical information is rarely communicated to SNF s on discharge.
Background Hospital readmissions from skilled nursing facilities ( SNF s) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives. Objectives To determine the percentage of readmissions from post‐acute care that are considered potentially avoidable from hospital and SNF perspectives. Design Prospective cohort study. Setting One academic medical center and 23 SNF s. Participants We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNF s. We included Medicare patients who were discharged to one of 23 regional SNF s between January 2013 and January 2015, and readmitted to the hospital within 30 days. Measurements Hospital‐based physicians and SNF ‐based staff performed structured root‐cause analyses ( RCA ) on a sample of readmissions from a participating SNF to the index hospital. RCA s reported avoidability and factors contributing to readmissions. Results The 30‐day unplanned readmission rate to the index hospital from SNF s was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF . The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNF s, respectively. Conclusion A substantial percentage of hospital readmissions from SNF s are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.
A structured interview was conducted with Medicare patients readmitted to a private, tertiary teaching hospital from skilled nursing facilities (SNFs) to assess their perspectives of readmission preventability and their role in the readmission.Data were collected at Vanderbilt University Medical Center using a 6-item interview administered at the bedside to Medicare beneficiaries with unplanned hospital readmissions from 23 SNFs within 60 days of a previous hospital discharge. Mixed analytical methods were applied, including a content analysis that evaluated factors contributing to hospital readmission as perceived by consumers.Among 208 attempted interviews, 156 were completed, of which 53 (34%) respondents rated their readmission as preventable. 28.3% of the 53 consumers attributed the readmission to hospital factors, 52.8% attributed it to the SNF, and 18.9% believed both sites could have prevented the readmission. The primary driver of the readmission was a family member/caregiver in 31 cases and the patient in 24 of the 156 cases, amounting to 55 (35.3%) consumer-driven readmissions. Contributing factors included: premature hospital discharge (16.3%); poor discharge planning (16.3%); a clinical issue not resolved in the hospital (14.3%); inadequate treatment at the SNF (69.4%); improper medication management at the SNF (20.4%); and poor decision-making regarding the transfer (14.3%).Interviewing readmitted patients provides information relevant to reducing readmissions that may otherwise be omitted from hospital and SNF records. Consumers identified quality issues at both the hospital and SNF and perceived themselves as initiating a significant number of readmissions.
Objectives To assess multiple geriatric syndromes in a sample of older hospitalized adults discharged to skilled nursing facilities ( SNF s) and subsequently to home to determine the prevalence and stability of each geriatric syndrome at the point of these care transitions. Design Descriptive, prospective study. Setting One large university‐affiliated hospital and four area SNF s. Participants Fifty‐eight hospitalized Medicare beneficiaries discharged to SNF s (N = 58). Measurements Research personnel conducted standardized assessments of the following geriatric syndromes at hospital discharge and 2 weeks after SNF discharge to home: cognitive impairment, depression, incontinence, unintentional weight loss, loss of appetite, pain, pressure ulcers, history of falls, mobility impairment, and polypharmacy. Results The average number of geriatric syndromes per participant was 4.4 ± 1.2 at hospital discharge and 3.8 ± 1.5 after SNF discharge. There was low to moderate stability for most syndromes. On average, participants had 2.9 syndromes that persisted across both care settings, 1.4 syndromes that resolved, and 0.7 new syndromes that developed between hospital and SNF discharge. Conclusion Geriatric syndromes were prevalent at the point of each care transition but also reflected significant within‐individual variability. These findings suggest that multiple geriatric syndromes present during a hospital stay are not transient and that most syndromes are not resolved before SNF discharge. These results underscore the importance of conducting standardized screening assessments at the point of each care transition and effectively communicating this information to the next provider to support the management of geriatric conditions.
To evaluate the contributions of patient and treatment factors to overall expenditures and regional variation for initial treatment of localized prostate cancer (CaP) in the Medicare program.Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified 47,517 beneficiaries with localized CaP during 2005-2009 and matched noncancer controls. We employed hierarchical generalized linear models to estimate risk-standardized cancer-related expenditures for each hospital referral region. To identify key contributors to the variation, we sequentially added patient characteristics, treatment intensity (the percentage of patients receiving curative treatments), ancillary procedures (biopsy, hormone therapy, and imaging), and specific treatment modalities into the model. We categorized the expenditures according to the type of services to identify their relative impact on the expenditure variations.The mean expenditure on CaP-related care per CaP beneficiary was $15,900, including $1800 on surgery, $11,200 on radiotherapy, and $1900 on ancillary procedures. The expenditure difference between quintiles 5 and 1 was $6200. Patient characteristics explained 8.4% of this difference. Treatment intensity and treatment modalities accounted for an additional 21.2% and 31.2% of the variation, respectively. Between the highest and lowest expenditure quintiles, the difference in radiotherapy expenditure was $5000, whereas that in surgery or ancillary procedures was <$200.There is substantial geographic variation in CaP expenditures, and the specific modality of radiotherapy is the most important contributor to this variation. Efforts to address the CaP care costs, such as bundled payment development, require targeting both treatment intensity and use of costly modalities.
