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Background: Spine conditions are costly and a major cause of disability. A growing body of evidence suggests that healthcare utilization and spending are driven by provider availability, which varies geographically and is a topic of healthcare policy debate., Objective: To estimate the effect of provider availability on spine spending., Design: Retrospective cohort study using relocation as a natural experiment., Participants: Fee-for-service Medicare beneficiaries over age 65 who relocated to a new hospital referral region between 2010 and 2014., Main Measures: We used generalized linear models to evaluate how changes in per-beneficiary availability of three types of healthcare providers (primary care physicians, spine surgeons, and chiropractors) affected annual per-beneficiary spine spending. We evaluated increases and decreases in provider availability separately. To account for the relative sizes of the provider workforces, we also calculated estimates of the effects of changes in national workforce size on changes in national spine spending., Key Results: The association between provider availability and spending was generally stronger among beneficiaries who experienced a decrease (versus an increase) in availability. Of the three provider groups, spine surgeon availability was most strongly associated with spending. Among beneficiaries who experienced a decrease in availability, a decrease in one spine surgeon per 10,000 beneficiaries was associated with a decrease of $36.97 (95% CI: $12.51, $61.42) in annual spending per beneficiary, versus a decrease of $1.41 (95% CI: $0.73, $2.09) for a decrease in primary care physician availability. However, changes in the national workforce size of primary care physicians were associated with the largest changes in national spine spending., Conclusions: Provider availability affects individual spine spending, with substantial changes observed at the national level. The effect depends on provider type and whether availability increases or decreases. Policymakers should consider how changes in the size of the physician workforce affect healthcare spending.

Background Context: Although the high cost of spine surgery is generally recognized, there is little information on the extent to which payments vary across hospitals., Purpose: To examine the variation in episode payments for spine surgery in the national Medicare population. We also sought to determine the root causes for observed variations in payment at high cost hospitals., Study Design: All patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were included., Patient Sample: Included 185,954 episodes of spine surgery performed between 2005 and 2007., Outcome Measures: Payments per episode of spine surgery., Methods: All patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were identified (n=185,954 episodes of spine surgery). Hospitals were ranked on least to most expensive and grouped into quintiles. Results were risk- and price-adjusted using the empirical Bayes method. We then assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variations in payment., Results: Episode payments for hospitals in the highest quintile were more than twice as high as those made to hospitals in the lowest quintile ($34,171 vs. $15,997). After risk- and price-adjustment, total episode payments to hospitals in the highest quintile remained $9,210 (47%) higher. Procedure choice, including the use of fusion, was a major determinant of the total episode payment. After adjusting for procedure choice, however, hospitals in the highest quintile continued to be 28% more expensive than those in the lowest. Differences in the use of postacute care accounted for most of this residual variation in payments across hospitals. Hospital episode payments varied to a similar degree after subgroup analyses for disc herniation, spinal stenosis, and spondylolisthesis. Hospitals expensive for one condition were also found to be expensive for services provided for other spinal diagnoses., Conclusions: Medicare payments for episodes of spine surgery vary widely across hospitals. As they respond to the new financial incentives inherent in health care reform, high cost hospitals should focus on the use of spinal fusion and postacute care., (Published by Elsevier Inc.)

Background Although common and preventable, healthcare-acquired infections (HAI) are associated with high risk for hospital readmission. This risk may increase when follow-up care is not provided. However, whether infection-related readmissions are more common in older adults discharged from the hospital to a skilled nursing facility (SNF) vs. home or home healthcare is unknown. Methods We used 2013–14 national discharge data and logistic regression models to retrospectively examine the relationship of discharge disposition (home, SNF, home healthcare) with unplanned readmission for the same HAI observed at the index admission, among Medicare beneficiaries 65, controlling for patient sociodemographics, comorbidity score, and length of stay during index hospitalization. Results Of 318,134 index admissions involving HAI treatment, 158,682 (50%) were discharged to a SNF, 76,523 (24%) to home, and 82,929 (26%) to home health. Overall, 7,867 (2.5%) of index admissions involving treatment for an HAI resulted in a linked HAI readmission. HAI readmissions were more common for Clostridium difficile infections (4.0%) and urinary tract infections (UTI, 2.3%) than for ventilator-acquired pneumonia (1.4%) or surgical site infections (1.1%) (P < 0.001). Being discharged home or to home healthcare, compared with a SNF, was associated with increased odds (OR: 1.63, P < 0.001 for each) of HAI readmission. This was equivalent to a 1.2% lower risk of a linked HAI readmission for those discharged to a SNF compared with home or home healthcare. This risk difference was observed to increase with greater patient comorbidity scores. Conclusion We conclude that C lostridium difficile and UTIs result in higher risk for readmission than other HAIs. Patients discharged to nursing facilities are protected from readmission. Further research into identifying modifiable mechanisms for HAI readmission, in order to improve post-hospital care of infection at home, is needed. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]