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Objective: To identify organizational complementarities of adoption and use of electronic health records (EHRs) and assess what organizational strategies were associated with more advanced EHR use. Data Sources: Primary survey data of US hospitals combined with secondary data from the American Hospital Association Annual Survey and IT Supplement. Study Design: In this cross-sectional study, we describe hospital organizational practices around EHR adoption and use and identify how these practices coalesce into distinct strategies. We then assess the association between those organizational strategies and adoption of advanced EHR functions. Data Collection: Primary data collection consisted of surveys sent to 797 US acute care hospitals in 2018-2019, with 451 complete respondents. Principal Findings: There was significant variation in hospital organizational practices for EHR adoption and use. Factor analysis identified practices in three domains: leadership engagement, human capital, and systems integration. Hospitals in the top quartile of the leadership engagement factor were 14 percentage points more likely to have adopted patient engagement EHR functions (P = 0.01) while hospitals in the top quartile of human capital were 14 percentage points less likely to have adopted these functions (P = 0.02). Hospitals in the top quartile of systems integration were 12 percentage points more likely to have adopted patient engagement functions (P = 0.02) and 14 percentage points more likely to have adopted EHR data analytics functions (P = 0.02). Conclusions: Our findings suggest that specific organizational strategies are associated with more advanced EHR adoption. Hospital leaders interested in realizing more value from their EHR investment may find it useful to know that there is an association between adoption of more advanced EHR functions, and engaging senior leadership as well as building connectivity between clinical and administrative systems. KEYWORDS electronic health records, hospitals, information technology in health, organizational behavior and management, Technology Adoption/Diffusion/Use, 1 | INTRODUCTION Following the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, electronic health records (EHR) were rapidly adopted by hospitals across [...]

Objective: This study explores differences in spending and utilization of health care services for an older person with frailty before and after a hip fracture. Data Sources: We used individual-level patient data from five care settings. Study Design: We compared utilization and spending of an older person aged older than 65 years for 365 days before and after a hip fracture across 11 countries and five domains of care as follows: acute hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. Utilization and spending were age and sex standardized.. Data Collection/Extraction Methods: The data were compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries as follows: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. Principal Findings: The sample ranged from 1859 patients in Spain to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia. The majority of patients across countries were female. Relative to other countries, the United States had the lowest inpatient length of stay (11.3), but the highest number of days were spent in post-acute care rehab (100.7) and, on average, had more visits to specialist providers (6.8 per year) than primary care providers (4.0 per year). Across almost all sectors, the United States spent more per person than other countries per unit ($13,622 per hospitalization, $233 per primary care visit, $386 per MD specialist visit). Patients also had high expenditures in the year prior to the hip fracture, mostly concentrated in the inpatient setting. Conclusion: Across 11 high-income countries, there is substantial variation in health care spending and utilization for an older person with frailty, both before and after a hip fracture. The United States is the most expensive country due to high prices and above average utilization of post-acute rehab care. KEYWORDS health systems, hip fracture, international comparisons, What is known on this topic * Health systems spend different amounts caring for patients. * Older persons with frailty are more likely to incur high levels of spending as [...]

Objective: To establish a methodological approach to compare two high-need, highcost (HNHC) patient personas internationally. Data sources: Linked individual-level administrative data from the inpatient and outpatient sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. Study design: We outline a methodological approach to identify HNHC patient types for international comparisons that reflect complex, priority populations defined by the National Academy of Medicine. We define two patient profiles using accessible patient-level datasets linked across different domains of care-hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, long-term care, homehealth care, and outpatient drugs. The personas include a frail older adult with a hip fracture with subsequent hip replacement and an older person with complex multimorbidity, including heart failure and diabetes. We demonstrate their comparability by examining the characteristics and clinical diagnoses captured across countries. Data collection/extraction methods: Data collected by ICCONIC partners. Principal findings: Across 11 countries, the identification of HNHC patient personas was feasible to examine variations in healthcare utilization, spending, and patient outcomes. The ability of countries to examine linked, individual-level data varied, with the Netherlands, Canada, and Germany able to comprehensively examine care across all seven domains, whereas other countries such as England, Switzerland, and New Zealand were more limited. All countries were able to identify a hip fracture persona and a heart failure persona. Patient characteristics were reassuringly similar across countries. Conclusion: Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries. KEYWORDS international comparison, vignettes, What is known on this topic * International comparisons of health systems mostly rely on comparisons of the inpatient setting. * Little comparative work examines patterns of spending and utilization [...]

Objective: The objective of this study was to explore cross-country differences in spending and utilization across different domains of care for a multimorbid persona with heart failure and diabetes. Data Sources: We used individual-level administrative claims or registry data from inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States (US). Data Collection/Extraction Methods: Data collected by ICCONIC partners. Study Design: We retrospectively analyzed age-sex standardized utilization and spending of an older person (65-90 years) hospitalized with a heart failure exacerbation and a secondary diagnosis of diabetes across five domains of care: hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. Principal Findings: Sample sizes ranged from n = 1270 in Spain to n = 21,803 in the United States. Mean age (standard deviation [SD]) ranged from 76.2 (5.6) in the Netherlands to 80.3 (6.8) in Sweden. We observed substantial variation in spending and utilization across care settings. On average, England spent $10,956 per person in hospital care while the United States spent $30,877. The United States had a shorter length of stay over the year (18.9 days) compared to France (32.9) and Germany (33.4). The United States spent more days in facility-based rehabilitative care than other countries. Australia spent $421 per person in primary care, while Spain (Aragon) spent $1557. The United States and Canada had proportionately more visits to specialist providers than primary care providers. Across almost all sectors, the United States spent more than other countries, suggesting higher prices per unit. Conclusion: Across 11 countries, there is substantial variation in health care spending and utilization for a complex multimorbid persona with heart failure and diabetes. Drivers of spending vary across countries, with the United States being the most expensive country due to high prices and higher use of facility-based rehabilitative care. KEYWORDS diabetes, health care spending, heart failure, high-cost patients, high need, international comparison, What is known on this topic * Health systems are structured and financed differently. * Patients with complex multimorbidity are more susceptible to poor quality of care and incur higher [...]

Objective: This study explores variations in outcomes of care for two types of patient personas-an older frail person recovering from a hip fracture and a multimorbid older patient with congestive heart failure (CHF) and diabetes. Data Sources: We used individual-level patient data from 11 health systems. Study Design: We compared inpatient mortality, mortality, and readmission rates at 30, 90, and 365 days. For the hip fracture persona, we also calculated time to surgery. Outcomes were standardized by age and sex. Data Collection/Extraction Methods: Data was compiled by the International Collaborative on Costs, Outcomes and Needs in Care across 11 countries for the years 2016-2017 (or nearest): Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. Principal Findings: The hip sample across ranged from 1859 patients in Aragon, Spain, to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia, and the majority of hip patients across countries were female. The congestive heart failure (CHF) sample ranged from 742 patients in England to 21,803 in the United States. Mean age ranged from 77.2 in the United States to 80.3 in Sweden, and the majority of CHF patients were males. Average in-hospital mortality across countries was 4.1%. for the hip persona and 6.3% for the CHF persona. At the year mark, the mean mortality across all countries was 25.3% for the hip persona and 32.7% for CHF persona. Across both patient types, England reported the highest mortality at 1 year followed by the United States. Readmission rates for all periods were higher for the CHF persona than the hip persona. At 30 days, the average readmission rate for the hip persona was 13.8% and 27.6% for the CHF persona. Conclusion: Across 11 countries, there are meaningful differences in health system outcomes for two types of patients. KEYWORDS health systems, mortality, readmissions, What is known on this topic * Patient outcomes such as mortality and readmissions are commonly used as measures of performance of heatlh systems. * There are few sources of [...]

Health is influenced by many factors outside the health system. This is often expressed by decomposing contributors to health into factors that sum to 100 percent. In this commentary, we assess the (few) strengths and (many) limitations of such decompositions. We conclude that they fail to be useful for policy guidance. We conclude by proposing an alternative approach to assessing how various factors affect health: evaluations of interventions. KEYWORDS delivery of health care, economics, policy, public health, quality of health care, 1 | INTRODUCTION Cultural, environmental, political, and economic conditions--the 'social determinants'--shape our lives in ways that affect health. (1,2) A large literature documents associations between social circumstances and health outcomes [...]

Objective: To determine whether the exclusion of patients who die from adjusted 30-day readmission rates influences readmission rate measures and penalties under the Hospital Readmission Reduction Program (HRRP). Data Sources/Study Setting: 100% Medicare fee-for-service claims over the period July 1, 2012, until June 30, 2015. Study Design: We examine the 30-day readmission risk across the three conditions targeted by the HRRP: acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Using logistic regression, we estimate the readmission risk for three samples of patients: those who survived the 30-day period after their index admission, those who died over the 30-day period, and all patients who were admitted to see how they differ. Data Collection/Extraction Methods: We identified and extracted data for Medicare fee-for-service beneficiaries admitted with primary diagnoses of AMI (N = 497 931), CHF (N = 1 047 552), and pneumonia (N = 850 552). Results: The estimated hospital readmission rates for the survived and nonsurvived patients differed by 5%-8%, on average. Incorporating these estimates into overall readmission risk for all admitted patients changes the likely penalty status for 9% of hospitals. However, this change is randomly distributed across hospitals and is not concentrated amongst any one type of hospital. Conclusions: Not accounting for variations in mortality may result in inappropriate penalties for some hospitals. However, the effect of this bias is low due to low mortality rates amongst incentivized conditions and appears to be randomly distributed across hospital types. KEYWORDS hospitals, mortality, pay-for-performance, quality, readmissions, 1 | INTRODUCTION Improving hospitalized patients' outcomes has been a major focus for US policy makers. Of these outcomes, readmissions have received considerable attention, initially when the Centers for Medicare [...]