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The Patient Driven Payment Model (PDPM) was implemented in U.S. skilled nursing facilities (SNFs) in October 2019, shortly before COVID-19. This new payment model aimed to reimburse SNFs for patients' nursing needs rather than the previous model which reimbursed based on the volume of therapy received. Through 156 semi-structured interviews with 40 SNF administrators from July 2020 to December 2021, this qualitative study clarifies the impact of COVID-19 on the administration of PDPM at SNFs. Interview data were analyzed using modified grounded theory and thematic analysis. Our findings show that SNF administrators shifted focus from management of the PDPM to COVID-19-related delivery of care adaptations, staff shortfalls, and decreased admissions. As the pandemic abated, administrators re-focused their attention to PDPM. Policy makers should consider the continued impacts of the pandemic at SNFs, particularly on delivery of care, admissions, and staffing, on the ability of SNF administrators to administer a new payment model. [ABSTRACT FROM AUTHOR]

Objective: To quantify racial, ethnic, and income‐based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). Data Sources: 2016–2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. Data Collection/Extraction Methods: Not Applicable. Study Design: We use multinomial‐logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five‐category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. Principal Findings: Of the 3+ million Medicare beneficiaries with a HH start‐of‐care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual‐level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low‐income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income‐based disparities persisted within HHAs. Black‐White, Hispanic‐White, and AIAN‐White disparities were largely driven by between‐HHA differences, whereas income‐based disparities were mostly due to within‐HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. Conclusions: Both within‐ and between‐HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes. [ABSTRACT FROM AUTHOR]

Objective: The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high‐volume preferred skilled nursing facility (SNF) partners. Data Sources: The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017–2019. Study Design: We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics. Data Collection: Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019. Principal Findings: Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital‐SNF relationship, and (c) comparing patients with more versus less advanced ADRD. Conclusions: Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high‐volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems). [ABSTRACT FROM AUTHOR]

See related Editorial by Unroe and Towsley in this issue. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end‐of‐life care transfers. Advanced practice clinicians (APCs)—which include nurse practitioners and physician assistants—increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end‐of‐life care versus hospice utilization and hospitalization for older adults with ADRD. METHODS: Using Medicare data, we identified nursing home‐ (N=517,490) and community‐dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score‐weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month. RESULTS: For both nursing home‐ and community‐dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates. DISCUSSION: APCs are an important group of providers delivering end‐of‐life primary care to individuals with ADRD. HIGHLIGHTS: For both nursing home‐ and community‐dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life.Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume. [ABSTRACT FROM AUTHOR]

In a multi‐payer health care system, economic theory suggests that different payers can impose spillover effects on one another. This study aimed to evaluate the spillover effect of the Patient Driven Payment Model (PDPM) on Medicare Advantage (MA) enrollees, despite it being designed for Traditional Medicare (TM) beneficiaries. We applied a regression discontinuity approach by comparing therapy utilization before and after the implementation of PDPM in October 2019 focusing on patients newly admitted to skilled nursing facilities. The results showed that both TM and MA enrollees experienced a decrease in individual therapy minutes and an increase in non‐individual therapy minutes. The estimated reduction in total therapy use was 9 min per day for TM enrollees and 3 min per day for MA enrollees. The effect of PDPM on MA beneficiaries varied depending on the level of MA penetration, with the smallest effect in facilities with the highest MA penetration quartile. In summary, the PDPM had directionally similar effects on therapy utilization for both TM and MA enrollees, but the magnitudes were smaller for MA beneficiaries. These results suggest that policy changes intended for TM beneficiaries may spillover to MA enrollees and should be assessed accordingly. [ABSTRACT FROM AUTHOR]

Policy PointsPublic reporting is associated with both mitigating and exacerbating inequities in high‐quality home health agency use for marginalized groups.Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does.Targeted federal, state, and local interventions should focus on raising awareness about the five‐star quality ratings among marginalized populations for whom inequities have been exacerbated. Context: Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high‐quality, long‐term care for older adults. The objective of this study is to evaluate the impact of the home health five‐star ratings on changes in high‐quality home health agency use by race, ethnicity, income status, and place‐based factors. Methods: We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high‐quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five‐star rating introduction on the use of high‐quality home health agencies, we use a longitudinal observational pretest–posttest design. Findings: After the introduction of the home health five‐star ratings in 2016, we found that adjusted rates of high‐quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high‐quality home health agency use between low‐income and higher‐income home health patients was exacerbated after the introduction of the five‐star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high‐quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high‐quality home health agency use. Other neighborhoods experience a nonsignificant change in high‐quality home health agency use. Conclusions: Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low‐income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five‐star ratings. [ABSTRACT FROM AUTHOR]

Objective: To characterize the experiences of nursing home administrators as they manage facilities across the United States during the COVID‐19 pandemic. Data Sources and Study Setting: We conducted 156 interviews, consisting of four repeated interviews with administrators from 40 nursing homes in eight health care markets across the country from July 2020 through December 2021. Study Design: We subjected the interview transcripts to a rigorous qualitative analysis to identify overarching themes using a modified grounded theory approach to applied thematic analysis. Data Collection Methods: In‐depth, semi‐structured qualitative interviews were conducted virtually or by phone, and audio‐recorded, with participants' consent. Audio recordings were transcribed. Principal Findings: Interviews with nursing home administrators revealed a number of important cross‐cutting themes. In interviewing each facility's administrator four times over the course of the pandemic, we heard perspectives regarding the stages of the pandemic, and how they varied by the facility and changed over time. We also heard how policies implemented by federal, state, and local governments to respond to COVID‐19 were frequently changing, confusing, and conflicting. Administrators described the effect of COVID‐19 and efforts to mitigate it on residents, including how restrictions on activities, communal dining, and visitation resulted in cognitive decline, depression, and weight loss. Administrators also discussed the impact of COVID‐19 on staff and staffing levels, reporting widespread challenges in keeping facilities staffed as well as strategies used to hire and retain staff. Administrators described concerns for the sustainability of the nursing home industry resulting from the substantial costs and pressures associated with responding to COVID‐19, the reductions in revenue, and the negative impact of how nursing homes appeared in the media. Conclusions: Findings from our research reflect nursing home administrator perspectives regarding challenges operating during COVID‐19 and have substantial implications for policy and practice. [ABSTRACT FROM AUTHOR]

Purpose: Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on patient outcomes. Methods: Using 100% Medicare data on postacute HH episodes from 2007 to 2014, we estimated the impact of higher payments on beneficiaries outcomes using difference‐in‐differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010. Findings: Our sample included 5.6 million postacute HH episodes (18% rural). In the preperiod, the 30‐ and 60‐day rehospitalization rates for urban HH episodes were 11.30% and 18.23% compared to 11.38% and 18.39% for rural HH episodes. After 2010, 30‐ and 60‐day rehospitalization rates declined, 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference‐in‐difference estimate was 0.29 percentage points (P =.005) and 0.57 percentage points (P <.001) for 30‐ and 60‐day rehospitalization, respectively. Conclusions: Increasing payments resulted in a statistically significant reduction in rehospitalizations for rural postacute HH episodes. The add‐on payment is set to sunset in 2022 and its impact on access and quality to HH for rural older adults should be reconsidered. [ABSTRACT FROM AUTHOR]

Background Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees. Methods and findings This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation. Conclusions Compared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs., Author(s): Amit Kumar 1, Momotazur Rahman 1, Amal N. Trivedi 1,2, Linda Resnik 1,2, Pedro Gozalo 1,2, Vincent Mor 1,2,* Introduction In the United States, Medicare provides health insurance coverage [...]

Introduction: We compare nursing‐home and hospital admissions among residents with Alzheimer's disease and related dementias (ADRD) in memory‐care assisted living to those in general assisted living. Methods: Retrospective study of Medicare beneficiaries with ADRD in large (>25 bed) assisted‐living communities. We compared admission to a hospital, to a nursing home, and long‐term (>90 day) admission to a nursing home between the two groups, using risk differences and survival analysis. Results: Residents in memory‐care assisted living had a lower adjusted risk of hospitalization (risk difference = −1.8 percentage points [P =.014], hazard ratio = 0.93 [0.87–1.00]), a lower risk of nursing‐home admission (risk difference = −2.2 percentage points [P <.001], hazard ratio = 0.87 [−.79–0.95]), and a lower risk of a long‐term nursing home admission (risk difference = −1.1 percentage points [P <.001], hazard ratio = 0.71 [0.57–0.88]). Discussion: Memory care is associated with reduced rates of nursing‐home placement, particularly long‐term stays, compared to general assisted living. [ABSTRACT FROM AUTHOR]

Objective: To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection. Data Sources: We utilized 2014–2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website. Data Collection/Extraction Methods: We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee‐for‐Service home health users. Study Design: This admission‐level assessment compared HHA selection before (July 2014–June 2015) and after (February–December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs. Principal Findings: The introduction of star ratings was associated with a 0.88‐percentage‐point increase in the probability of selecting a high‐quality HHA and a 0.81‐percentage‐point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare–Medicaid dual‐eligible beneficiaries experienced larger increases in their likelihood of selecting high‐rated agencies than inpatient, white, and nondual beneficiaries. Conclusions: The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection. [ABSTRACT FROM AUTHOR]

Patients receiving home health services from high-quality home health agencies often experience fewer adverse outcomes (for example, hospitalizations) than patients receiving services from low-quality agencies. Using administrative data from 2016 and regression analysis, we examined individual- and neighborhood-level racial, ethnic, and socioeconomic factors associated with the use of high-quality home health agencies. We found that Black and Hispanic home health patients had a 2.2-percentage-point and a 2.5-percentage-point lower adjusted probability of high-quality agency use, respectively, compared with their White counterparts within the same neighborhoods. Low-income patients had a 1.2-percentage-point lower adjusted probability of high-quality agency use compared with their higher-income counterparts, whereas home health patients residing in neighborhoods with higher proportions of marginalized residents had a lower adjusted probability of high-quality agency use. Some 40-77 percent of the disparities in high-quality agency use were attributable to neighborhood-level factors. Ameliorating these inequities will require policies that dismantle structural and institutional barriers related to residential segregation. [ABSTRACT FROM AUTHOR]

Objective: To examine whether stronger referral relationships between hospitals and skilled nursing facilities (SNF) are associated with lower-risk patients being admitted to SNF. Data Sources/Collection: We used MedPAR data to estimate referral relationship strength and nursing home survey data (OSCAR and CASPER) to determine the risk of patient admissions at nearly 14 000 SNFs from 2008 to 2014. Study Design: We examined the association of hospital referral concentration with the percentage of higher- risk patients admitted to non- hospital- based (freestanding) SNFs using an instrumental variables approach. We used the distance between patients and SNFs and hospitals and SNFs as the instrument. Data Collection/Extraction Methods: We used previously collected MedPAR and OSCAR/CASPER survey data. Principal Findings: We find greater observed referral concentration among freestanding SNFs is associated with lower percentages of patients with pressure sores (coefficient, -2.64; 95% CI, [-2.82 to -2.46]), catheters (-0.55; [-0.74 to -0.36]), and physical restraints (-0.16; [-0.29 to -0.03]) at admission to a skilled nursing facility. Conclusions: We find evidence that freestanding SNFs with stronger hospital referral relationships may be admitting less risky patients, possibly contributing to disparities across SNFs. [ABSTRACT FROM AUTHOR]

Introduction: Understanding rural‐urban variation in the diagnostic incidence and prevalence of Alzheimer's disease and related dementias (ADRD) will inform policies to improve timely diagnosis and access to supportive services for older adults in rural communities. Methods: Using 2008 to 2015 national claims data for fee‐for‐service Medicare beneficiaries (roughly 170 million person‐years), we computed unadjusted and adjusted diagnostic incidence and prevalence estimates for ADRD in metropolitan, micropolitan, and rural counties, and examined differences in survival rates. Results: Risk‐adjusted ADRD diagnostic incidence was higher in rural versus metropolitan counties despite lower prevalence. Among beneficiaries diagnosed with ADRD in 2008, metropolitan county residents experienced longer survival compared to residents in rural and micropolitan counties. Discussion: These data suggest that older adults in rural communities may be underdiagnosed with ADRD, and/or diagnosed at later stages of dementia. Further work is needed to develop strategies to reduce this disparity. [ABSTRACT FROM AUTHOR]

Background/Objectives: We sought to compare the post‐acute and long‐term care experience of Medicare beneficiaries with and without Alzheimer Disease and Related Dementias (ADRD), and whether differences changed from January 1, 2007 to September 30, 2015. Design Retrospective cross‐sectional trend study using Medicare claims linked to the Centers for Medicare & Medicaid Services' (CMS) Minimum Data Set. Setting: CMS‐certified skilled nursing facilities (skilled nursing facility (SNF), n = 17,043). Participants: Fee‐for‐service Medicare beneficiaries aged ≥66 years (n = 6,614,939) discharged from a hospital to a SNF who had not lived in a nursing home during the year before hospitalization. Measurements ADRD was defined by the Chronic Condition Data Warehouse. Outcome measures included: (1) successful discharge defined as being in SNF less than 90 days, then discharged back to the community, alive without subsequent inpatient health care for 30 continuous days; (2) became long‐stay resident in SNF; (3) death in SNF within 90 days; (4) hospital readmission within 30 days of entering SNF; and (5) transferred to another nursing home within 30 days of entering SNF. Results: Successful discharge of beneficiaries with ADRD increased from 43.4% in 2007 to 53.9% in 2015 (average annual percent change (AAPC) = 2.1 (95% CI = 2.0–2.2)); those without ADRD also increased (from 59.1% to 63.6%, AAPC = 0.9 (95% CI = 0.7–1.1)) but not as fast as those with ADRD (P <.01). The proportion of all beneficiaries who became long‐stay or were readmitted to the hospital decreased (P <.05). The proportion with ADRD who became long‐stay was nearly three times higher than those without throughout the study (15.0% vs 5.5% in 2007; 11.3% vs 4.3% in 2015). Conclusion: Though disparity in ADRD in becoming long‐stay residents remains, the increase in successful discharges among those with ADRD also stresses the increasing importance of community as a care setting for adults with ADRD. [ABSTRACT FROM AUTHOR]

Introduction: Patients with Alzheimer’s disease and related dementias (ADRD) face substantial challenges in selecting, and remaining enrolled in, health insurance. Little is known about how patients with ADRD experience theMedicare Advantage (MA) program. Methods:We used, hospital, outpatient, and post-acute care data to identifyMAbeneficiaries with and without ADRD in 2014. Multinomial logit models estimated the percentage of peoplewho disenrolled to traditionalMedicare (TM) or switched to a differentMA plan in 2015. Results: Among non-dually eligible beneficiaries, 9.0% (95% confidence interval [CI]: 8.0, 9.1) withADRDdisenrolled while 19.7% (95% CI: 19.6, 19.9) switched planswithin MA compared to a disenrollment rate of 4.2% (95% CI: 4.2, 4.2) and switching rate of 22.8% (95% CI: 22.9, 22.8) for persons without ADRD. Discussion: MA enrollees with ADRD tend to disenroll at substantially higher rates than those without ADRD. This may be indicative of their care needs not being met in the program. [ABSTRACT FROM AUTHOR]

This study examines rates of home dialysis and transplant at dialysis facilities that serve patients with high social risk to understand how they fare under the End-Stage Renal Disease Treatment Choices Model. [ABSTRACT FROM AUTHOR]

Importance: Critical access hospitals (CAHs) provide care to rural communities. Increasing mortality rates have been reported for CAHs relative to non-CAHs. Because Medicare reimburses CAHs at cost, CAHs may report fewer diagnoses than non-CAHs, which may affect risk-adjusted comparisons of outcomes.Objective: To assess serial differences in risk-adjusted mortality rates between CAHs and non-CAHs after accounting for differences in diagnosis coding.Design, Setting, and Participants: Serial cross-sectional study of rural Medicare Fee-for-Service beneficiaries admitted to US CAHs and non-CAHs for pneumonia, heart failure, chronic obstructive pulmonary disease, arrhythmia, urinary tract infection, septicemia, and stroke from 2007 to 2017. The final date of follow-up was December 31, 2017.Exposure: Admission to a CAH vs non-CAH.Main Outcomes and Measures: Discharge diagnosis count including trends from 2010 to 2011 when Medicare expanded the allowable number of billing codes for hospitalizations, and combined in-hospital and 30-day postdischarge mortality adjusted for demographics, primary diagnosis, preexisting conditions, and with vs without further adjustment for Hierarchical Condition Category (HCC) score to understand the contribution of in-hospital secondary diagnoses.Results: There were 4 094 720 hospitalizations (17% CAH) for 2 850 194 unique Medicare beneficiaries (mean [SD] age, 76.3 [11.7] years; 55.5% women). Patients in CAHs were older (median age, 80.1 vs 76.8 years) and more likely to be female (58% vs 55%). In 2010, the adjusted mean discharge diagnosis count was 7.52 for CAHs vs 8.53 for non-CAHs (difference, -0.99 [95% CI, -1.08 to -0.90]; P < .001). In 2011, the CAH vs non-CAH difference in diagnoses coded increased (P < .001 for interaction between CAH and year) to 9.27 vs 12.23 (difference, -2.96 [95% CI, -3.19 to -2.73]; P < .001). Adjusted mortality rates from the model with HCC were 13.52% for CAHs vs 11.44% for non-CAHs (percentage point difference, 2.08 [95% CI, 1.74 to 2.42]; P < .001) in 2007 and increased to 15.97% vs 12.46% (difference, 3.52 [95% CI, 3.09 to 3.94]; P < .001) in 2017 (P < .001 for interaction). Adjusted mortality rates from the model without HCC were not significantly different between CAHs and non-CAHs in all years except 2007 (12.19% vs 11.74%; difference, 0.45 [95% CI, 0.12 to 0.79]; P = .008) and 2010 (12.71% vs 12.28%; difference, 0.42 [95% CI, 0.07 to 0.77]; P = .02).Conclusions and Relevance: For rural Medicare beneficiaries hospitalized from 2007 to 2017, CAHs submitted significantly fewer hospital diagnosis codes than non-CAHs, and short-term mortality rates adjusted for preexisting conditions but not in-hospital comorbidity measures were not significantly different by hospital type in most years. The findings suggest that short-term mortality outcomes at CAHs may not differ from those of non-CAHs after accounting for different coding practices for in-hospital comorbidities. [ABSTRACT FROM AUTHOR]

BACKGROUND: To quantify changes to the electronic health record (EHR) market in Rhode Island and to assess the degree of EHR market consolidation between 2009 and 2017. METHODS: The EHR market in Rhode Island is represented by three measures: the proportion of physicians who have adopted an EHR, the number of EHR vendors in use, and EHR market competitiveness, captured by the Herfindahl--Hirschman Index (HHI). RESULTS: The EHR market became more consolidated overall between 2009 and 2017. Among outpatient physicians, the market has remained competitive, despite ongoing consolidation. In contrast, the EHR market among inpatient physicians crossed into the "highly concentrated" zone in 2015. DISCUSSION: While consolidation in the EHR market may facilitate the exchange of data across health systems, potentially reducing duplicative testing and facilitating timely diagnosis, limiting competition may affect vendors' responsiveness to calls for improved usability and innovation. [ABSTRACT FROM AUTHOR]

A small proportion of high-need (HN) Medicare beneficiaries account for a large share of medical expenditures in the United States. Identifying hospitals with the best outcomes for HN patients is central to identifying and spreading evidence-based practices to improve care for this population. The objective of this study was to identify and characterize top-performing hospitals for HN patients. Administrative claims data from 2013–2014 were used to identify HN beneficiaries and their treating hospital; hospitals were ranked based on their HN beneficiaries' outcomes in 2015. Hospitalization, mortality, and days spent in community were assessed, and all outcomes were risk standardized for age, sex, dual eligibility, and hospital referral region. American Hospital Association and aggregated inpatient claims data characterized hospitals. Logistic regression models estimated the odds of ranking in the top 20% on all outcomes. Of 2253 hospitals with at least 500 HN patients in the United States, 92 (4.1%) ranked in the top 20% across all outcomes. No hospital characteristics were associated with being top performing across all outcomes, but urban hospitals were significantly less likely to perform well on hospitalization and private, for-profit hospitals performed better on mortality. Small hospitals, Accountable Care Organization providers, and those providing palliative care services were more likely to rank highly on days spent in the community. Top-performing hospitals served fewer minority, dual eligible, and HN patients, suggesting that case mix may explain some of the differences in performance, and that additional work is needed to examine programs and practices at outstanding hospitals. [ABSTRACT FROM AUTHOR]

Importance In the Medicare Advantage (MA) program, Medicare enrollees may be steered by their health plan to specific hospitals. Little is known about the quality of hospitals that serve MA enrollees. Objective To compare the quality of hospitals that admit MA enrollees with the quality of those that admit traditional Medicare enrollees. Design, Setting, and Participants This cross-sectional study used data from the 2012 to 2016 Medicare Provider Analysis and Review to compare quality of care, as measured by the star rating given by the Centers for Medicare and Medicaid Services and readmission rates, in hospitals that serve MA enrollees and traditional Medicare enrollees using multinomial logit models. Participants were 7 130 610 Medicare beneficiaries admitted to 2994 acute care hospitals across the United States in 2016. Data were analyzed between August 2018 and August 2019. Exposures The exposure was MA enrollment. Adjusters included demographic and clinical characteristics and zip code fixed effects. Main Outcomes and Measures Hospital Compare star ratings and quintiles of performance in 30-day readmission rates. Results The sample included 7 130 610 Medicare beneficiaries in 2016 (54.3% female; mean [SD] age, 72.7 [13.2] years). Of 12 190 270 total hospitalizations, 1 211 293 traditional Medicare and 494 352 MA patients were admitted to 718 low-readmission hospitals and 1 205 586 traditional Medicare and 526 955 MA patients were admitted to 597 high-readmission hospitals. Accounting for observed patient characteristics, MA enrollees less often entered either low- or high-quality hospitals and were more often admitted to average-quality hospitals. For nonemergent hospitalizations, MA enrollees were 1.9 percentage points (95% CI, 1.5-2.2 percentage points) less likely to enter a low-readmissions hospital, 5.1 percentage points (95% CI, 4.6-5.6 percentage points) more likely to enter an average-readmissions hospital, and 3.2 percentage points (95% CI, 2.9-3.5 percentage points) less likely to enter a high-readmissions hospital compared with traditional Medicare enrollees. Patients with MA were also 2.6 percentage points (95% CI, 2.2-2.9 percentage points) less likely to enter a 1- to 2-star hospital, 5.5 percentage points (95% CI, 4.9-5.9 percentage points) more likely to enter a 3-star hospital, and 2.8 percentage points (95% CI, 2.5-3.2 percentage points) less likely to enter a 4- to 5-star hospital compared with traditional Medicare enrollees. The differences were less pronounced for emergency admissions. Conclusions and Relevance This study found that enrollees in MA plans were more likely to be admitted to average-quality hospitals instead of either high- or low-quality hospitals, suggesting that MA plans may be steering their enrollees to specific hospitals. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: As the national population of persons living with human immunodeficiency virus (HIV) ages, they will require greater postacute and long‐term care use. Little is known about the quality of nursing homes (NHs) to which patients with HIV are admitted. In this study, we assess the association between the number of persons with HIV admitted annually to a given NH (HIV concentration) and that NH's quality outcomes. DESIGN: A cross‐sectional comparative study. SETTING: NHs in nine states, from 2001 to 2012. PARTICIPANTS: A total of 46 918 NH‐years accounting for 67 301 admissions by patients with HIV. MEASUREMENTS: We used 100% Medicaid Analytic Extract, Minimum Dataset 2.0 and 3.0, and Medicare claims from 2001 to 2012 from nine states to examine the association between HIV concentration and NH quality. Persons were classified as HIV positive on the basis of all available data sources, and a NH's percentage of new admissions with HIV was calculated (HIV concentration). We then compared differences in star ratings, rehospitalization rates, NH survey deficiencies, and restraint use by a NH's percentage of admissions with HIV, using linear random effects models. RESULTS: After adjusting for NH characteristics, zip code characteristics, and state and year fixed effects, NHs with greater than 0% to 5% of admissions with HIV had a 0.6 lower star rating (P < .001), and a 0.4% percentage point higher 30‐day rehospitalization rate (P < .01), compared to those with no HIV admissions. NHs with 5% to 50% of admissions with HIV had 7.0 more deficiencies (P < .001), a 0.1 lower star rating (P < .001), and a 1.5 percentage point higher rehospitalization rate (P < .001). CONCLUSION: Persons with HIV were generally admitted to lower‐quality NHs compared to persons without HIV. More efforts are needed to ensure that persons with HIV have access to high‐quality NHs. J Am Geriatr Soc 67:2615–2621, 2019 [ABSTRACT FROM AUTHOR]