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Background Because managed care is increasingly prevalent in health care finance and delivery, it is important to ascertain its effects on health care quality relative to that of fee-for-service plans. Some stakeholders are concerned that basing gatekeeping, provider selection, and utilization management on cost may lower quality of care. To date, research on this topic has been inconclusive, largely because of variation in research methods and covariates. Patient age has been the only consistently evaluated outcome predictor. This study provides a comprehensive assessment of the association between managed care and inpatient mortality for Medicare and privately insured patients. Methods A cross-sectional design was used to examine the association between managed care and inpatient mortality for four common inpatient conditions. Data from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases for 11 states were linked to data from the American Hospital Association Annual Survey Database. Hospital discharges were categorized as managed care or fee for service. A phased approach to multivariate logistic modeling examined the likelihood of inpatient mortality when adjusting for individual patient and hospital characteristics and for county fixed effects. Results Results showed different effects of managed care for Medicare and privately insured patients. Privately insured patients in managed care had an advantage over their fee-for-service counterparts in inpatient mortality for acute myocardial infarction, stroke, pneumonia, and congestive heart failure; no such advantage was found for the Medicare managed care population. To the extent that the study showed a protective effect of privately insured managed care, it was driven by individuals aged 65 years and older, who had consistently better outcomes than their non-managed care counterparts. Conclusions Privately insured patients in managed care plans, especially older adults, had better outcomes than those in fee-for-service plans. Patients in Medicare managed care had outcomes similar to those in Medicare FFS. Additional research is needed to understand the role of patient selection, hospital quality, and differences among county populations in the decreased odds of inpatient mortality among patients in private managed care and to determine why this result does not hold for Medicare.

Readmission for congestive heart failure (CHF) is the most common reason for readmission among Medicare fee-for-service patients. Yet CHF readmissions are not just a Medicare problem. This study examined who is likely to be readmitted for CHF, using all-payer hospital discharges from 14 of the states participating in the Healthcare Cost and Utilization Project. Patients with the strongest positive association with readmission were discharged against medical advice, covered by Medicaid, and had more severe loss of function and certain comorbidities such as drug abuse, renal failure, or psychoses. Weak negative relationship between readmission and cost of index admission provides some evidence that hospitals with higher readmission rates do not systematically use fewer resources in treating patients in initial encounters. High readmission rate for Medicaid patients suggests that state and federal governments should target Medicaid populations and drug abuse treatment for better care coordination to reduce readmissions and health care costs.

Study objective Emergency departments (EDs) are an integral part of the US health care system, and yet national data sources on the care received in the ED are poorly understood, thereby limiting their usefulness for analyses. We provide a comparison of data sources that can be used to examine utilization and quality of care in the ED nationally. Data sources and comparisons This article compares 7 data sources available in 2005 for conducting analyses of ED encounters: the American Hospital Association Annual Survey Database ™ , Hospital Market Profiling Solution©, National Emergency Department Inventory, Nationwide Emergency Department Sample, National Hospital Ambulatory Medical Care Survey, National Electronic Injury Surveillance System–All-Injury Program, and the National Health Interview Survey. In addition to describing the type and scope of data collection, available characteristics, and sponsor of the ED data sources, we compare (where possible) estimates of the total number of EDs, national and regional volume of ED visits, national and regional admission rates (percentage of ED visits resulting in hospital admission), patient characteristics, hospital characteristics, and reasons for visit generated by the various data sources. Major findings The different data sources yielded estimates of the number of EDs that ranged from 4,609 to 4,884 and the number of ED encounters from more than 109 million to more than 116 million. Admission rates across data sources varied from 12.0% to 15.3%. Although comparisons of the 7 data sources were somewhat limited by differences in available information and operational definitions, variation in estimates of utilization and patterns of care existed by region, expected payer, and patient and hospital characteristics. The rankings and estimates of the top 5 first-listed conditions seen in the ED are relatively consistent between the 2 data sources with diagnoses, although the Nationwide Emergency Department Sample estimates 1.3 to 5.8 times more ED visits for each chronic and acute all-listed condition examined relative to the National Hospital Ambulatory Medical Care Survey. Conclusion Each of the data sources described in this article has unique advantages and disadvantages when used to examine patterns of ED care, making the different data sources appropriate for different applications. Analysts should select a data source according to its construction and should bear in mind its strengths and weaknesses in drawing conclusions based on the estimates it yields.

Objectives. Considerable differences in prevalence of diabetes and management of the disease exist among racial/ethnic groups. We examined the relationship between race/ethnicity and hospital readmissions for diabetes-related conditions. Methods. Nonmaternal adult patients with Medicare, Medicaid, or private insurance coverage hospitalized for diabetes-related conditions in 5 states were identified from the 1999 State Inpatient Databases of the Healthcare Cost and Utilization Project. Racial/ethnic differences in the likelihood of readmission were estimated by logistic regression with adjustment for patient demographic, clinical, and socioeconomic characteristics and hospital attributes. Results. The risk-adjusted likelihood of 180-day readmission was significantly lower for non-Hispanic Whites than for Hispanics across all 3 payers or for non-Hispanic Blacks among Medicare enrollees. Within each payer, Hispanics from low-income communities had the highest risk of readmission. Among Medicare beneficiaries, Blacks and Hispanics had higher percentages of readmission for acute complications and microvascular disease, while Whites had higher percentages of readmission for macrovascular conditions. Conclusions. Racial/ethnic disparities are more evident in 180-day than in 30-day readmission rates, and greatest among the Medicare population. Readmission diagnoses vary by race/ethnicity, with Blacks and Hispanics at higher risk for those complications more likely preventable with effective postdischarge care.

Efforts to quantify, monitor, understand, and reduce disparities in health care are critically dependent on the collection of high-quality data that support such analyses. In producing the first National Healthcare Disparities Report (NHDR), a number of gaps in data were encountered that limited the ability to assess racial, ethnic, and socioeconomic disparities in health care.The objectives of this study were to identify and quantify gaps in data related to disparities in health care and discuss efforts to fill these gaps in future NHDRs.: Data on specific racial, ethnic, and socioeconomic groups were often not collected or collected in formats that differed from federal standards. When collected, data were often insufficient to generate reliable estimates for specific racial, ethnic, and socioeconomic groups. These effects were magnified when attempting to assess disparities within many of the agency's priority populations such as women, children, the elderly, low-income populations, and rural residents. Future NHDRs begin to fill some of these gaps in data, but some gaps will likely persist and new gaps will likely arise as the availability of data for specific populations vary from year to year.Gaps in data limit the ability to address racial, ethnic, and socioeconomic disparities in health care. Although many federal efforts are underway to improve data collection, some groups and populations pose unique challenges for data collection that will be difficult to overcome.

OBJECTIVE—To describe the extent to which hospitalizations for patients with diabetes reflect multiple stays by the same individuals and to examine how multiple hospitalizations vary by patient demographic and socioeconomic characteristics. RESEARCH DESIGN AND METHODS—Using the Healthcare Cost and Utilization Project complete discharge data for five states (California, Missouri, New York, Tennessee, and Virginia) in 1999, we identified 648,748 nonneonatal, nonmaternal patients who had one or more hospitalizations listing diabetes. Multiple hospitalizations were measured as percent of patients with multiple stays, percent of total stays represented by multiple stays, and average number of stays per patient. Total hospital costs were also examined. Stratified analysis and regression were performed to assess differences by age, sex, race/ethnicity, payer, location, and income. RESULTS—Among patients with diabetes who had been hospitalized, 30% had two or more stays accounting for >50% of total hospitalizations and hospital costs. Controlled for patient age, sex, and clinical characteristics, the likelihood of having multiple hospitalizations was higher for Hispanics and non-Hispanic blacks compared with non-Hispanic whites, as well as for patients covered by Medicare or Medicaid and those living in low-income areas. The prevalence of diabetes complications and multiple conditions differed by age, race/ethnicity, and payer among patients with multiple stays. CONCLUSIONS—Multiple hospitalizations are common among patients with diabetes but vary by age, race/ethnicity, payer, and income, with those populations traditionally considered to be more vulnerable experiencing higher likelihoods of multiple stays. Significant opportunities exist to reduce the proportion of multiple hospitalizations for patients with diabetes. Clinical and policy interventions to improve the quality of care and outcomes for these patients should be designed accordingly and have the potential to pay major dividends.

This study examined disparities in the use of in-hospital diagnostic and therapeutic procedures for Hispanics with cerebrovascular disease compared to their non-Hispanic White counterparts.This is a cross-sectional study using 1996 hospital administrative data.Hispanics and non-Hispanic Whites with diagnosis codes indicating occlusion or stenosis of precerebral arteries or transient cerebral ischemia were included, with a total of 18,674 New York patients (5.1% Hispanic) and 22,624 California patients (11.1% Hispanic). Adjusted odds ratios compared Hispanics with non-Hispanic Whites for six diagnostic and therapeutic procedures for cerebrovascular disease, controlling for patient and hospital characteristics.Hispanics had higher rates of non-invasive diagnostic procedures (head CT scan, head/neck diagnostic ultrasound, echocardiogram, and head MRI). The odds of invasive diagnostic testing (cerebral arteriogram) and therapeutic procedures (carotid endarterectomy) were lower for Hispanics. Most findings remained unchanged in logistic regression models with patient and hospital characteristics. Adding a measure of the concentration of Hispanic patients by hospital eliminated or reduced observed differences between Hispanics and Whites.Controlling for each hospital's experience with Hispanic patients eliminated or reduced the magnitude of the disparities in procedure use, suggesting that the concentration of Hispanic patients in a hospital is associated with different patterns of procedure use.

Objective To provide an overview of inpatient operating room (OR) procedures in the United States. Design, Setting, and Patients Healthcare Cost and Utilization Project 2007 Nationwide Inpatient Sample discharge data from a sample of US short-term, acute-care, nonfederal hospitals. Main Outcome Measures National volume of OR procedures overall and by type of procedure, resource use and costs, most frequent and expensive procedures, and trends. Results Fifteen million OR procedures were performed in 2007 (495 procedures/10 000 population). Only 26.4% of hospitalizations involved an OR procedure; however, OR-related stays were responsible for 46.8% of hospital costs ($161 billion). Patients aged 65 years and older were 2 to 3 times more likely to experience OR procedures (eg, 1327 procedures/10 000 persons among those aged 65-84 years vs 626 procedures/10 000 persons for those aged 45-64 years). Compared with non-OR inpatients, OR patients were less severely ill (20.5% had the highest severity of illness vs 24.6% for non-OR patients) and used more resources ($2900/day for OR patients vs $1400/day for non-OR patients). The 15 most expensive procedures accounted for half of all procedure-related hospitalization costs and one-fourth of total hospital costs. Volumes for 4 of the most expensive procedures increased between 1997 and 2007: 20% for percutaneous transluminal coronary angioplasty, 46% for cesarean delivery, 46% for knee replacement, and 45% for spinal fusion. The volume of percutaneous transluminal coronary angioplasty declined 20% from 2006 to 2007, compared with a 56% increase in the prior decade. Conclusions Procedures in the OR represent a large portion of hospital costs, and these costs are concentrated in few procedure types.

Background Rural/urban variations in admissions for heart failure may be influenced by severity at hospital presentation and local practice patterns. Laboratory data reflect clinical severity and guide hospital admission decisions and treatment for heart failure, a costly chronic illness and a leading cause of hospitalization among the elderly. Our main objective was to examine the role of laboratory test results in measuring disease severity at the time of admission for inpatients who reside in rural and urban areas. Methods We retrospectively analyzed discharge data on 13,998 hospital discharges for heart failure from three states, Hawai’i, Minnesota, and Virginia. Hospital discharge records from 2008 to 2012 were derived from the State Inpatient Databases of the Healthcare Cost and Utilization Project, and were merged with results of laboratory tests performed on the admission day or up to two days before admission. Regression models evaluated the relationship between clinical severity at admission and patient urban/rural residence. Models were estimated with and without use of laboratory data. Results Patients residing in rural areas were more likely to have missing laboratory data on admission and less likely to have abnormal or severely abnormal tests. Rural patients were also less likely to be admitted with high levels of severity as measured by the All Patient Refined Diagnosis Related Groups (APR-DRG) severity subclass, derivable from discharge data. Adding laboratory data to discharge data improved model fit. Also, in models without laboratory data, the association between urban compared to rural residence and APR-DRG severity subclass was significant for major and extreme levels of severity (OR 1.22, 95 % CI 1.03–1.43 and 1.55, 95 % CI 1.26–1.92, respectively). After adding laboratory data, this association became non-significant for major severity and was attenuated for extreme severity (OR 1.12, 95 % CI 0.94–1.32 and 1.43, 95 % CI 1.15–1.78, respectively). Conclusion Heart failure patients from rural areas are hospitalized at lower severity levels than their urban counterparts. Laboratory test data provide insight on clinical severity and practice patterns beyond what is available in administrative discharge data.