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Objective: To estimate the costs, effectiveness, and cost-effectiveness of prevention interventions for out-of-treatment substance abusers at risk for HIV. This is the first cost-effectiveness study of an AIDS intervention that focuses on drug use as an outcome.Study Design: We examined data from the North Carolina Cooperative Agreement site (NC CoOp). All individuals in the study were given the revised NIDA standard intervention and randomly assigned to either a longer, more personalized enhanced intervention or no additional intervention. We estimated the cost of each intervention and, using simple means analysis and multiple regression models, estimated the incremental effectiveness of the enhanced intervention relative to the standard intervention. Finally, we computed cost-effectiveness ratios for several drug use outcomes and compared them to a "back-of-the-envelope" estimate of the benefit of reducing drug use.Principal Findings: The estimated cost of implementing the standard intervention is $187.52, and the additional cost of the enhanced intervention is $124.17. Cost-effectiveness ratios range from $35.68 to $139.52 per reduced day of drug use, which are less than an estimate of the benefit per reduced drug day.Conclusions: The additional cost of implementing the enhanced intervention is relatively small and compares favorably to a rough estimate of the benefits of reduced days of drug use. Thus, the enhanced intervention should be considered an important additional component of an AIDS prevention strategy for out-of-treatment substance abusers. [ABSTRACT FROM AUTHOR]

Objectives: Patients who are referred to home health care after an acute care hospitalization may not receive home health care, resulting in incomplete home health referrals. This study examines the prevalence of incomplete referrals to home health, defined as not receiving home health care within 7 days after an initial hospital discharge, and investigates the relationship between home health referral completion and patient outcomes., Design: Retrospective cohort study., Setting and Participants: Medicare beneficiaries who are discharged from short-term acute care hospitals between October 2015 and December 2016 with a discharge status code on the hospital claim indicating home health care., Methods: Patient characteristics and outcomes were compared between Medicare beneficiaries with complete and incomplete home health referrals after hospital discharge. The outcomes included mortality, readmission rate, and total spending over a 1-year episode following hospitalization. These outcomes were risk-adjusted using patient demographic, socioeconomic, clinical characteristic, hospital characteristic, and state fixed effects., Results: Approximately 29% of the 724,700 hospitalizations in the analytic dataset had incomplete home health referrals after discharge. The rate of incomplete home health referrals varied among clinical conditions, ranging from 17% among joint/musculoskeletal patients and 38% among digestive/endocrine patients. Risk-adjusted 1-year mortality and readmission rates were 1.4 and 2.4 percentage points lower and total spending was $1053 higher among patients with complete home health referrals as compared with those with incomplete home health referrals after hospital discharge., Conclusions and Implications: The analysis revealed that almost 1 in 3 patients discharged from a hospital with a discharge status of home health does not receive home health care. In addition, complete home health referrals are associated with lower mortality and readmission rates and higher spending. As home health care utilization increases, policymakers should pay attention to the tradeoff between quality and cost when implementing alternative policies and payment models., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Long-term acute care hospitals (LTACHs) treat mechanical ventilator patients who are difficult to wean and expected to be on mechanical ventilator for a prolonged period. However, there are varying views on who should be transferred to LTACHs and when they should be transferred. The purpose of this study is to assess the relationship between length of stay in a short-term acute care hospital (STACH) after endotracheal intubation (time to LTACH) and weaning success and mortality for ventilated patients discharged to an LTACH., Methods: Using 2014-2015 Medicare claims and assessment data, we identified patients who had an endotracheal intubation in STACH and transferred to an LTACH with prolonged mechanical ventilation (defined as 96 or more consecutive hours on a ventilator). We controlled for age, gender, STACH stay procedures and diagnoses, Elixhauser comorbid conditions, and LTACH quality characteristics. We used instrumental variable estimation to account for unobserved patient and provider characteristics., Results: The study cohort included 13,622 LTACH cases with median time to LTACH of 18 days. The unadjusted ventilator weaning rate at LTACH was 51.7%, and unadjusted 90-day mortality rate was 43.7%. An additional day spent in STACH after intubation is associated with 11.6% reduction in the odds of weaning, representing a 2.5 percentage point reduction in weaning rate at 18 days post endotracheal intubation. We found no statistically significant relationship between time to LTACH and the odds of 90-day mortality., Conclusions: Discharging ventilated patients earlier from STACH to LTACH is associated with higher weaning probability for LTACH patients on prolonged mechanical ventilation. Our findings suggest that delaying ventilated patients' discharge to LTACH may negatively influence the patients' chances of being weaned from the ventilator.

Aims: This study examines the effects of recent changes in Medicare long-term care hospital (LTCH) payments on treatment patterns and outcomes for severe wound patients discharged from short-term acute care hospitals (STACHs)., Materials and Methods: The rolling implementation of a new Medicare payment policy was used to develop a difference-in-difference model. The study population consisted of Medicare beneficiaries subjected to the payment policy changes and hospitalized for stage 3, 4, or unstageable wounds; non-healing surgical wounds; and fistula. Using 2015-Q1-2017 Medicare claims data, changes in outcomes were examined for severe wound patients exposed to the new policy (treatment) and those that were not (comparison). All outcomes were modeled using linear regressions and adjusted for patient clinical characteristics. Analysis was conducted in a full sample and a sample with high-LTCH-use propensity., Results: Severe wound patients exposed to the new policy experienced 4.1 and 7.5 percentage point (pp) reductions in LTCH use relative to the comparison group in the full sample and high-LTCH-propensity sample, respectively (p < .01 and p = .039). No statistically significant change was found in 60-day mortality or Medicare spending after the policy change in the treatment group as compared to the comparison group (p > .10). However, among severe wound patients who are exposed to the new policy in the high-LTCH-propensity sample, readmission and post-discharge sepsis rates increased after the policy change relative to the comparison group (readmission rate = 8.1 pp, p = .075; sepsis rate = 7.0 pp, p = .033)., Limitations: The findings are based on data from a limited timeframe around the policy change and, thus, provide only early evidence on the effects of the new policy., Conclusion: The new LTCH payment policy is associated with no changes in Medicare spending and mortality, but higher readmissions and post-discharge sepsis rates among severe wound patients with a high likelihood to use an LTCH.

Objective: To investigate the potential spillover effects of the Hospital Readmissions Reduction Program (HRRP) on readmissions for nontargeted conditions and patient populations. We examine HRRP effects on nontargeted conditions separately and on non-Medicare populations in Florida and California., Data Sources: From 2007-2013, 100 percent Medicare inpatient claims data, 2007-2013 State Inpatient Database (SID) for Florida, and 2007-2011 SID for California., Study Design: We conducted an interrupted time series analysis to estimate the change in 30-day all-cause unplanned readmission trends after the start of HRRP using logistic regression., Principal Findings: Hospitals with the largest reductions in targeted Medicare readmissions experienced higher reductions in nontargeted Medicare readmissions. Among nontargeted conditions, reductions were higher for neurology and surgery conditions than for the cardiovascular and cardiorespiratory conditions, which are clinically similar to the targeted conditions. For non-Medicare patients, readmission trends for targeted conditions in Florida and California did not change after HRRP., Conclusions: Our findings are consistent with positive spillover benefits associated with HRRP. The extent of these benefits, however, varies across condition and patient groups. The observed patterns suggest a complex response, including a role of nonfinancial factors, in driving lower readmissions., (© Health Research and Educational Trust.)

In 2016, Medicare's Hospital-Acquired Condition Reduction Program (HAC-RP) will reduce hospital payments by $364 million. Although observers have questioned the validity of certain HAC-RP measures, less attention has been paid to the determination of low-performing hospitals (bottom quartile) and the assignment of penalties. This study investigated possible bias in the HAC-RP by simulating hospitals' likelihood of being in the worst-performing quartile for 8 patient safety measures, assuming identical expected complication rates across hospitals. Simulated likelihood of being a poor performer varied with hospital size. This relationship depended on the measure's complication rate. For 3 of 8 measures examined, the equal-quality simulation identified poor performers similarly to empirical data (c-statistic approximately 0.7 or higher) and explained most of the variation in empirical performance by size (Efron's R 2 > 0.85). The Centers for Medicare & Medicaid Services could address potential bias in the HAC-RP by stratifying by hospital size or using a broader "all-harm" measure.

Background: Demand for total hip arthroplasty (THA) is high and expected to continue to grow during the next decade. Although much of this growth includes working-aged patients, cost-effectiveness studies on THA have not fully incorporated the productivity effects from surgery., Questions/purposes: We asked: (1) What is the expected effect of THA on patients' employment and earnings? (2) How does accounting for these effects influence the cost-effectiveness of THA relative to nonsurgical treatment?, Methods: Taking a societal perspective, we used a Markov model to assess the overall cost-effectiveness of THA compared with nonsurgical treatment. We estimated direct medical costs using Medicare claims data and indirect costs (employment status and worker earnings) using regression models and nonparametric simulations. For direct costs, we estimated average spending 1 year before and after surgery. Spending estimates included physician and related services, hospital inpatient and outpatient care, and postacute care. For indirect costs, we estimated the relationship between functional status and productivity, using data from the National Health Interview Survey and regression analysis. Using regression coefficients and patient survey data, we ran a nonparametric simulation to estimate productivity (probability of working multiplied by earnings if working minus the value of missed work days) before and after THA. We used the Australian Orthopaedic Association National Joint Replacement Registry to obtain revision rates because it contained osteoarthritis-specific THA revision rates by age and gender, which were unavailable in other registry reports. Other model assumptions were extracted from a previously published cost-effectiveness analysis that included a comprehensive literature review. We incorporated all parameter estimates into Markov models to assess THA effects on quality-adjusted life years and lifetime costs. We conducted threshold and sensitivity analyses on direct costs, indirect costs, and revision rates to assess the robustness of our Markov model results., Results: Compared with nonsurgical treatments, THA increased average annual productivity of patients by USD 9503 (95% CI, USD 1446-USD 17,812). We found that THA increases average lifetime direct costs by USD 30,365, which were offset by USD 63,314 in lifetime savings from increased productivity. With net societal savings of USD 32,948 per patient, total lifetime societal savings were estimated at almost USD 10 billion from more than 300,000 THAs performed in the United States each year., Conclusions: Using a Markov model approach, we show that THA produces societal benefits that can offset the costs of THA. When comparing THA with other nonsurgical treatments, policymakers should consider the long-term benefits associated with increased productivity from surgery., Level of Evidence: Level III, economic and decision analysis.

Background: Little evidence exists on the effects of receiving care in a long-term acute care hospital (LTCH)., Objective: To examine LTCH effects on mortality and Medicare payments overall and among high-acuity patients., Research Design: A retrospective cohort study of Medicare beneficiaries using probit and generalized linear models. An instrumental variable technique was used to adjust for selection bias., Subjects: Medicare beneficiaries within 5 major diagnostic categories and not on prolonged mechanical ventilation., Measures: Mortality (365 d) and Medicare payments (180 d) during an episode of care., Results: LTCH care is associated with increases in Medicare payments ranging from $3146 to $17,589 (P<0.01) with no mortality benefit for 3 categories and payment reductions of $5419 and $5962 (P<0.01) at lower or similar mortality for 2 categories. LTCH patients with multiple organ failure experience lower mortality at similar or lower payments (3 categories) or similar mortality at lower payments (1 category) compared with patients in other settings, with mortality benefits between 5.4 and 9.7 percentage points (P<0.05) and payment reductions between $13,806 and $20,809 (P<0.01). For 1 category, we found no difference in mortality or payments between LTCH and non-LTCH patients with multiple organ failure. For patients with ≥3 days in intensive care, LTCH care is associated with improved mortality and lower payments in 4 and 3 categories, respectively., Conclusions: Receiving care in an LTCH may improve outcomes for some patients. Further research is needed to better define patients for whom care in these hospitals is beneficial.