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Ongoing consolidation by hospitals and providers threatens to further reduce competition in U.S. healthcare markets. Physician-owned hospitals (POHs) served as a rare countertrend for many years--a pathway for innovative and efficient alternatives to enter hospital markets and offer a bulwark against this consolidation. However, that countertrend came to an abrupt and enduring halt in 2010, when hospital incumbents leveraged passage of the Affordable Care Act to obtain an ill-conceived and unrelated ban on POHs. While health services researchers have scrutinized the POH ban, this Article analyzes it through a competition lens. It incorporates the growing attention in antitrust to labor markets and explores how physicians, through POHs, are particularly well-positioned to identify market opportunities. In doing so, physicians can defeat the market power possessed by hospital incumbents, upstream against physicians and downstream against payors and patients. This Article first provides an overview of the seemingly inexorable trends towards further consolidation among healthcare providers and the related competition concerns this consolidation raises. Next, the paper discusses the factors that positioned POHs to counterbalance these consolidation trends as market entrants and innovators, and how, after lobbying by incumbent hospitals and health systems, POHs faced regulatory pushback culminating in a federal ban on further POH growth and expansion. The Article then describes how market power by hospital incumbents in both upstream and downstream markets accentuates the incentives and importance of physicians in identifying opportunities for market entry and innovation. It further discusses how the POH ban affects healthcare competition, identifies the potential benefits of relaxing the ban, and suggests more narrowly tailored policy options that could mitigate policymakers' concerns about POHs--concerns that may not be unique to physician ownership and do not justify depriving the market of POH competition. The Article concludes with our recommendation that Congress remove the ban on POHs and apply more appropriately tailored policies. [ABSTRACT FROM AUTHOR]

Health care costs now comprise nearly one-fifth of the United States' gross domestic product, with the last 25 years marked by rising administrative costs, a lack of labor productivity growth, and rising patient and physician dissatisfaction. Policy experts have responded with a series of reforms that have – ironically - increased patient and physician administrative burden with little meaningful effect on cost and quality. Artificial intelligence (AI), a topic of great consternation, can serve as the "wheat thresher" for health care delivery, empowering and freeing both patients and physicians by decreasing administrative burden and improving labor productivity. In this Viewpoint, we discuss three principal areas where AI poses an unprecedented opportunity to reduce cost, improve care, and markedly enhance the patient and physician experience: (1) automation of administrative process, (2) augmentation of clinical practice, and (3) automation of elements of clinical practice. [ABSTRACT FROM AUTHOR]

Background: Timely discharge to post-acute care (PAC) settings, such as skilled nursing facilities, requires early identification of eligible patients. We sought to develop and internally validate a model which predicts a patient's likelihood of requiring PAC based on information obtained in the first 24 h of hospitalization. Methods: This was a retrospective observational cohort study. We collected clinical data and commonly used nursing assessments from the electronic health record (EHR) for all adult inpatient admissions at our academic tertiary care center from September 1, 2017 to August 1, 2018. We performed a multivariable logistic regression to develop the model from the derivation cohort of the available records. We then evaluated the capability of the model to predict discharge destination on an internal validation cohort. Results: Age (adjusted odds ratio [AOR], 1.04 [per year]; 95% Confidence Interval [CI], 1.03 to 1.04), admission to the intensive care unit (AOR, 1.51; 95% CI, 1.27 to 1.79), admission from the emergency department (AOR, 1.53; 95% CI, 1.31 to 1.78), more home medication prescriptions (AOR, 1.06 [per medication count increase]; 95% CI 1.05 to 1.07), and higher Morse fall risk scores at admission (AOR, 1.03 [per unit increase]; 95% CI 1.02 to 1.03) were independently associated with higher likelihood of being discharged to PAC facility. The c-statistic of the model derived from the primary analysis was 0.875, and the model predicted the correct discharge destination in 81.2% of the validation cases. Conclusions: A model that utilizes baseline clinical factors and risk assessments has excellent model performance in predicting discharge to a PAC facility. [ABSTRACT FROM AUTHOR]

In health care, lack of transparency about the cost of health care services to patients during clinical encounters has contributed to increased costs and high out-of-pocket expenses. Federal policy has responded to the need for more transparency and spurred discussion about ethics and the clinician's role in being transparent with patients at the point of service. This article investigates and encourages state, private market, and federal policy efforts to address what health care costs patients. This article also applies the ethical framework of principlism to cases and considers what a "shoppable service" model would demand of clinicians in practice. [ABSTRACT FROM AUTHOR]

Objective: To examine the changes in health insurance coverage, access to care, and health services utilization among nonelderly sexual minority and heterosexual adults between pooled years 2013-2014 and 2017-2018.Data Sources: Data on 3223 sexual minorities (lesbians, gay men, bisexual individuals, and other nonheterosexual populations) and 86 181 heterosexuals aged 18-64 years were obtained from the 2013, 2014, 2017, and 2018 National Health Interview Surveys.Study Design: Unadjusted and regression-adjusted estimates compared changes in health insurance status, access to care, and health services utilization for nonelderly adults by sexual minority status. Regression-adjusted changes were obtained from logistic regression models controlling for demographic and socioeconomic characteristics.Principal Findings: Uninsurance declined for both sexual minority adults (5 percentage points, P < .05) and heterosexual adults (2.5 percentage points, P < .001) between 2013-2014 and 2017-2018. Reductions in uninsurance for sexual minority and heterosexual adults were associated with increases in Medicaid coverage. Sexual minority and heterosexual adults were also less likely to report unmet medical care in 2017-2018 compared with 2013-2014. Low-income adults (regardless of sexual minority status) experienced relatively large increases in Medicaid coverage and substantial improvements in access to care over the study period. The gains in coverage and access to care across the study period were generally similar for heterosexual and sexual minority adults.Conclusions: Sexual minority and heterosexual adults have experienced improvements in health insurance coverage and access to care in recent years. Ongoing health equity research and public health initiatives should continue to monitor health care access and the potential benefits of recent health insurance expansions by sexual orientation and sexual minority status when possible. [ABSTRACT FROM AUTHOR]

This Viewpoint explores a critical source of administrative burden and physician frustration—the explosive growth of health care quality metrics—and how improving these metrics could combat clinician burnout. [ABSTRACT FROM AUTHOR]

Rationale: Administration of intravenous crystalloid solutions is a fundamental therapy for sepsis, but the effect of crystalloid composition on patient outcomes remains unknown.Objectives: To compare the effect of balanced crystalloids versus saline on 30-day in-hospital mortality among critically ill adults with sepsis.Methods: Secondary analysis of patients from SMART (Isotonic Solutions and Major Adverse Renal Events Trial) admitted to the medical ICU with an International Classification of Diseases, 10th Edition, Clinical Modification System code for sepsis, using multivariable regression to control for potential confounders.Measurements and Main Results: Of 15,802 patients enrolled in SMART, 1,641 patients were admitted to the medical ICU with a diagnosis of sepsis. A total of 217 patients (26.3%) in the balanced crystalloids group experienced 30-day in-hospital morality compared with 255 patients (31.2%) in the saline group (adjusted odds ratio [aOR], 0.74; 95% confidence interval [CI], 0.59-0.93; P = 0.01). Patients in the balanced group experienced a lower incidence of major adverse kidney events within 30 days (35.4% vs. 40.1%; aOR, 0.78; 95% CI, 0.63-0.97) and a greater number of vasopressor-free days (20 ± 12 vs. 19 ± 13; aOR, 1.25; 95% CI, 1.02-1.54) and renal replacement therapy-free days (20 ± 12 vs. 19 ± 13; aOR, 1.35; 95% CI, 1.08-1.69) compared with the saline group.Conclusions: Among patients with sepsis in a large randomized trial, use of balanced crystalloids was associated with a lower 30-day in-hospital mortality compared with use of saline.Clinical trial registered with www.clinicaltrials.gov (NCT02444988). [ABSTRACT FROM AUTHOR]

The prevention and treatment of hypothermia is an important part of routine anesthesia care. Avoidance of perioperative hypothermia was introduced as a quality metric in 2010. We sought to assess the integrity of the perioperative hypothermia metric in routine care at a single large center. Perioperative temperatures from all anesthetics of at least 60 min duration between January 2012 and 2017 were eligible for inclusion in analysis. Temperatures were displayed graphically, assessed for normality, and analyzed using paired comparisons. Automatically-recorded temperatures were obtained from several monitoring sites. Provider-entered temperatures were non-normally distributed, exhibiting peaks at temperatures at multiples of 0.5 °C. Automatically-acquired temperatures, on the other hand, were more normally distributed, demonstrating smoother curves without peaks at multiples of 0.5 °C. Automatically-acquired median temperature was highest, 36.8 °C (SD = 0.8 °C), followed by the three manually acquired temperatures (nurse-documented postoperative temperature, 36.5 °C [SD = 0.6 °C]; intraoperative manual temperature, 36.5 °C [SD = 0.6 °C]; provider-documented postoperative temperature, 36.1 °C [SD = 0.6 °C]). Provider-entered temperatures exhibit values that are unlikely to represent a normal probability distribution around a central physiologic value. Manually-entered perioperative temperatures appear to cluster around salient anchoring values, either deliberately, or as an unintended result driven by cognitive bias. Automatically-acquired temperatures may be superior for quality metric purposes. [ABSTRACT FROM AUTHOR]

Objective: To create a natural language processing (NLP) algorithm to identify transgender patients in electronic health records.Design: We developed an NLP algorithm to identify patients (keyword + billing codes). Patients were manually reviewed, and their health care services categorized by billing code.Setting: Vanderbilt University Medical Center.Participants: 234 adult and pediatric transgender patients.Main Outcome Measures: Number of transgender patients correctly identified and categorization of health services utilized.Results: We identified 234 transgender patients of whom 50% had a diagnosed mental health condition, 14% were living with HIV, and 7% had diabetes. Largely driven by hormone use, nearly half of patients attended the Endocrinology/Diabetes/Metabolism clinic. Many patients also attended the Psychiatry, HIV, and/or Obstetrics/Gynecology clinics. The false positive rate of our algorithm was 3%.Conclusions: Our novel algorithm correctly identified transgender patients and provided important insights into health care utilization among this marginalized population. [ABSTRACT FROM AUTHOR]

The 30-day surgical mortality metric is endorsed by the National Quality Forum for value-based purchasing purposes. However, its integrity has been questioned, as there is documented evidence of hospital manipulation of this measure, by way of inappropriate palliative care designation and changes in patient selection. To determine if there is evidence of potential manipulation, we retrospectively analyzed 1,725,291 surgical admissions from 158 United States hospitals participating in the National Inpatient Sample from 2010 to 2011. As a way of evaluating unnecessary life-prolonging measures, we determined that a significant increase in mortality rate after post-operative day 30 (day 31–35) would indicate manipulation. We compared the post-operative mortality rates for each hospital between Post-Operative Day 26–30 and Post-Operative Day 31–35 using Wilcoxon signed-rank tests. After application of the Bonferroni correction, the results showed that none of the hospitals had a statistically significant increase in mortality after post-operative day 30. This analysis fails to impugn the integrity of this measure, as we did not identify any evidence of potential manipulation of the 30-day surgical mortality metric. [ABSTRACT FROM AUTHOR]

In light of recent health policy efforts to promote price transparency, this perspective reviews the challenges and benefits of price transparency. These price transparency efforts include the recent executive order and associated rulemaking directing providers to disclose negotiated and out-of-pocket costs for "shoppable" healthcare services. First, we explore the previous efforts of states and health plans targeted at price transparency, reviewing lessons for future implementation. Second, we address the value of price transparency in light of various policy concerns and objections. Finally, we jointly hypothesize potential effects of and opportunities presented by price transparency for patients, physicians, and other healthcare industry stakeholders. [ABSTRACT FROM AUTHOR]

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Rationale: Saline is the intravenous fluid most commonly administered to critically ill adults, but it may be associated with acute kidney injury and death. Whether use of balanced crystalloids rather than saline affects patient outcomes remains unknown.Objectives: To pilot a cluster-randomized, multiple-crossover trial using software tools within the electronic health record to compare saline to balanced crystalloids.Methods: This was a cluster-randomized, multiple-crossover trial among 974 adults admitted to a tertiary medical intensive care unit from February 3, 2015 to May 31, 2015. The intravenous crystalloid used in the unit alternated monthly between saline (0.9% sodium chloride) and balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A). Enrollment, fluid delivery, and data collection were performed using software tools within the electronic health record. The primary outcome was the difference between study groups in the proportion of isotonic crystalloid administered that was saline. The secondary outcome was major adverse kidney events within 30 days (MAKE30), a composite of death, dialysis, or persistent renal dysfunction.Measurements and Main Results: Patients assigned to saline (n = 454) and balanced crystalloids (n = 520) were similar at baseline and received similar volumes of crystalloid by 30 days (median [interquartile range]: 1,424 ml [500-3,377] vs. 1,617 ml [500-3,628]; P = 0.40). Saline made up a larger proportion of the isotonic crystalloid given in the saline group than in the balanced crystalloid group (91% vs. 21%; P < 0.001). MAKE30 did not differ between groups (24.7% vs. 24.6%; P = 0.98).Conclusions: An electronic health record-embedded, cluster-randomized, multiple-crossover trial comparing saline with balanced crystalloids can produce well-balanced study groups and separation in crystalloid receipt. Clinical trial registered with www.clinicaltrials.gov (NCT 02345486). [ABSTRACT FROM AUTHOR]

Background: Prior studies in critically ill patients suggest the supra-physiologic chloride concentration of 0.9% ("normal") saline may be associated with higher risk of renal failure and death compared to physiologically balanced crystalloids. However, the comparative effects of 0.9% saline and balanced fluids are largely unexamined among patients outside the intensive care unit, who represent the vast majority of patients treated with intravenous fluids.Methods/design: This study, entitled Saline Against Lactated Ringer's or Plasma-Lyte in the Emergency Department (SALT-ED), is a pragmatic, cluster, multiple-crossover trial at a single institution evaluating clinical outcomes of adults treated with 0.9% saline versus balanced crystalloids for intravenous fluid resuscitation in the emergency department. All adults treated in the study emergency department receiving at least 500 mL of isotonic crystalloid solution during usual clinical care and subsequently hospitalized outside the intensive care unit are included. Treatment allocation of 0.9% saline versus balanced crystalloids is assigned by calendar month, with study patients treated during the same month assigned to the same fluid type. The first month (January 2016) was randomly assigned to balanced crystalloids, with each subsequent month alternating between 0.9% saline and balanced crystalloids. For balanced crystalloid treatment, clinicians can choose either Lactated Ringer's or Plasma-Lyte A©. The study period is set at 16 months, which will result in an anticipated estimated sample size of 15,000 patients. The primary outcome is hospital-free days to day 28, defined as the number of days alive and out of the hospital from the index emergency department visit until 28 days later. Major secondary outcomes include proportion of patients who develop acute kidney injury by creatinine measurements; major adverse kidney events by hospital discharge or day 30 (MAKE30), which is a composite outcome of death, new renal replacement therapy, and persistent creatinine elevation >200% of baseline; and in-hospital mortality.Discussion: This ongoing pragmatic trial will provide the most comprehensive evaluation to date of clinical outcomes associated with 0.9% saline compared to physiologically balanced fluids in patients outside the intensive care unit.Trial Registration: ClinicalTrials.gov, NCT02614040 . Registered on 18 November 2015. [ABSTRACT FROM AUTHOR]

Background: Saline, the intravenous fluid most commonly administered to critically ill adults, contains a high chloride content, which may be associated with acute kidney injury and death. Whether using balanced crystalloids rather than saline decreases the risk of acute kidney injury and death among critically ill adults remains unknown.Methods: The Isotonic Solutions and Major Adverse Renal Events Trial (SMART) is a pragmatic, cluster-level allocation, cluster-level crossover trial being conducted between 1 June 2015 and 30 April 2017 in five intensive care units at Vanderbilt University Medical Center in Nashville, TN, USA. SMART compares saline (0.9% sodium chloride) with balanced crystalloids (clinician's choice of lactated Ringer's solution or Plasma-Lyte A®). Each intensive care unit is assigned to provide either saline or balanced crystalloids each month, with the assigned crystalloid alternating monthly over the course of the trial. All adults admitted to participating intensive care units during the study period are enrolled and followed until hospital discharge or 30 days after enrollment. The anticipated enrollment is approximately 14,000 patients. The primary outcome is Major Adverse Kidney Events within 30 days-the composite of in-hospital death, receipt of new renal replacement therapy, or persistent renal dysfunction (discharge creatinine ≥200% of baseline creatinine). Secondary clinical outcomes include in-hospital mortality, intensive care unit-free days, ventilator-free days, vasopressor-free days, and renal replacement therapy-free days. Secondary renal outcomes include new renal replacement therapy receipt, persistent renal dysfunction, and incidence of stage 2 or higher acute kidney injury.Discussion: This ongoing pragmatic trial will provide the largest and most comprehensive comparison to date of clinical outcomes with saline versus balanced crystalloids among critically ill adults.Trial Registration: For logistical reasons, SMART was prospectively registered separately for the medical ICU (SMART-MED; ClinicalTrials.gov identifier: NCT02444988 ; registered on 11 May 2015; date of first patient enrollment: 1 June 2015) and the nonmedical ICUs (SMART-SURG; ClinicalTrials.gov identifier: NCT02547779 ; registered on 9 September 2015; date of first patient enrollment: 1 October 2015). [ABSTRACT FROM AUTHOR]

Objective: To determine risk factors associated with tracheostomy placement after severe traumatic brain injury (TBI) and subsequent outcomes among those who did and did not receive a tracheostomy. Methods: This retrospective cohort study compared adult trauma patients with severe TBI (n= 583) who did and did not receive tracheostomy. A multivariable logistic regression model assessed the associations between age, sex, race, insurance status, admission GCS, AIS (Head, Face, Chest) and tracheostomy placement. Ordinal logistic regression models assessed tracheostomy’s influence on ventilator days and ICU LOS. To limit immortal time bias, Cox proportional hazards models assessed mortality at 1, 3 and 12-months. Results: In this multivariable model, younger age and private insurance were associated with increased probability of tracheostomy. AIS, ISS, GCS, race and sex were not risk factors for tracheostomy placement. Age showed a non-linear relationship with tracheostomy placement; likelihood peaked in the fourth decade and declined with age. Compared to uninsured patients, privately insured patients had an increased probability of receiving a tracheostomy (OR = 1.89 [95% CI = 1.09–3.23]). Mortality was higher in those without tracheostomy placement (HR = 4.92 [95% CI = 3.49–6.93]). Abbreviated injury scale-Head was an independent factor for time to death (HR = 2.53 [95% CI = 2.00–3.19]), but age, gender and insurance were not. Conclusions: Age and insurance status are independently associated with tracheostomy placement, but not with mortality after severe TBI. Tracheostomy placement is associated with increased survival after severe TBI. [ABSTRACT FROM PUBLISHER]