Search

End-stage kidney disease (ESKD) is common in the U.S. There is no cure, and survival requires either dialysis or kidney transplant. Medicare provides coverage for most ESKD patients in the U.S., though non-citizens are excluded from most current policies providing standard ESKD care, especially regarding kidney transplants. Despite being eligible to be organ donors, non-citizens often have few avenues to be organ recipients—a major equity problem. Overall, transplants are cost-saving compared to dialysis, and non-citizens have comparable outcomes to the general population. We reviewed the literature regarding the vastly different policies across the U.S., with a focus on current Illinois policy, including updates regarding Illinois legislation which passed in 2014 providing non-citizens to receive coverage for transplants. Unfortunately, despite legislation providing avenues for transplants, funds were not allocated, and the bill has not had the impact that was expected when initially passed. We outline opportunities for improving current policies.

Background In 2017, the neonatal intensive care unit (NICU) at Rush University Medical Center (RUMC) implemented a protocol to provide individualized vitamin D supplementation dosing for very low-birth-weight (VLBW) and very preterm infants. This study evaluated the association of demographic and socioeconomic factors, vitamin D dose, and health indicators, including bone mineral status, measured by alkaline phosphatase and phosphorus levels; linear growth velocity; and occurrence of fractures. Method This retrospective cross-sectional study included 227 VLBW or very preterm infants (34 VLBW, 12 very preterm, and 181 VLBW and very preterm) born in and discharged from the RUMC NICU between February 1, 2017, and October 31, 2019. Vitamin D dose was classified as adjusted (supplemental dose of 800 IU/day, n = 169) or standard (recommended dose of 400 IU/day, n = 58), per the protocol. Binary logistic and linear regression models were constructed to test the associations between infant and maternal characteristics and vitamin D dose group and between vitamin D dose group and health indicators. Results The analysis found a statistically significant association between maternal age, gestational age, infant birth weight, and race/ethnicity and receipt of an adjusted vitamin D dose. No significant associations were found between health indicators and vitamin D dose. Conclusion Sociodemographic factors may influence vitamin D deficiency in VLBW and very preterm infants in the NICU. At this time, there is insufficient evidence to support a tailored approach, but further research in this area is warranted. This article is protected by copyright. All rights reserved.

OBJECTIVES Hospitals have begun designing programs tailored to patients with intellectual disabilities to address their specific healthcare needs and social determinants of health. This study aimed to determine whether these programs improve hospital outcomes for patients with intellectual disabilities. STUDY DESIGN This cross-sectional, retrospective study analyzed data for patients with a primary or secondary diagnosis of intellectual disability and/or autism who were discharged from 5 hospitals participating in Vizient's Clinical Data Base/Resource Manager between January 2010 and September 2018. METHODS Generalized linear regression models were constructed to test the association between tailored program status and length of stay, cost, and cost per day, and a binary logistic regression model was constructed to test the association between tailored program status and 30-day readmission. A secondary analysis stratified patients by 3M All Patient Refined Diagnosis Related Groups grouper (the standard for inpatient classification) admission severity of illness (ASOI) score. RESULTS Of the 6618 patients included in the study, 29% were treated at hospitals with tailored programs. After controlling for patient demographic characteristics and clinical factors, patients treated at hospitals without programs had higher total costs (relative risk [RR], 1.06; P = .038) and cost per day (RR, 1.11; P

Controversy exists over how to ethically distribute health care resources and which factors should determine access to health care services. Although the US has traditionally used a market-based private insurance model that does not ensure universal coverage, the Patient Protection and Affordable Care Act (ACA) in the United States aims to increase equitable access to health care by increasing the accessibility, affordability, and quality of health care services. This article evaluates the impact of the ACA on equitable mental health care delivery according to access factors that can hinder or facilitate the delivery of mental health services based on need. The ACA has successfully expanded coverage to millions of Americans and promoted coordination and access to mental health care; however, financial and non-financial access barriers to mental health care and access disparities remain. Reform efforts should not undervalue the gains that the ACA has made but should attempt to balance considerations of cost and increasing free-market mechanisms with decreasing remaining health care disparities.

The study aim was to determine the relationship between hospitalization costs and mother's own milk (MOM) dose for very low birth weight (VLBW; 1500 g) infants during the initial neonatal intensive care unit (NICU) stay. Additionally, because MOM intake during the NICU hospitalization is associated with a reduction in the risk of late-onset sepsis, necrotizing enterocolitis (NEC), and bronchopulmonary dysplasia (BPD), we aimed to quantify the incremental cost of these potentially preventable complications of prematurity.The study included 430 VLBW infants enrolled in the Longitudinal Outcomes of Very Low Birthweight Infants Exposed to Mothers' Own Milk prospective cohort study between 2008 and 2012 at Rush University Medical Center in Chicago, IL, USA. NICU hospitalization costs included hospital, feeding, and physician costs. The average marginal effect of MOM dose and prematurity-related complications known to be reduced by MOM intake on NICU hospitalization costs were estimated using generalized linear regression.The mean NICU hospitalization cost was $190,586 (standard deviation $119,235). The marginal cost of sepsis was $27,890 (95% confidence interval [CI] $2934-$52,646), of NEC was $46,103 (95% CI $16,829-$75,377), and of BPD was $41,976 (95% CI $24,660-59,292). The cumulative proportion of MOM during the NICU hospitalization was not significantly associated with cost.A reduction in the incidence of complications that are potentially preventable with MOM intake has significant cost implications. Hospitals should prioritize investments in initiatives to support MOM feedings in the NICU.

Background The current understanding of advanced Parkinson disease (PD) and its treatment is largely based on data from outpatient visits. The most advanced and disabled individuals with PD are disconnected from both care and research. A previous pilot study among older, multimorbid patients with advanced PD demonstrated the feasibility of interdisciplinary home visits to reach the target population, improve care quality, and potentially avoid institutionalization. Objective The aim of this study protocol is to investigate whether interdisciplinary home visits can prevent a decline in quality of life of patients with PD and prevent worsening of caregiver strain. The protocol also explores whether program costs are offset by savings in health care utilization and institutionalization compared with usual care. Methods In this single-center, controlled trial, 65 patient-caregiver dyads affected by advanced PD (Hoehn and Yahr stages 3-5 and homebound) are recruited to receive quarterly interdisciplinary home visits over 1 year. The 1-year intervention is delivered by a nurse and a research coordinator, who travel to the home, and it is supported by a movement disorder specialist and social worker (both present by video). Each dyad is compared with age-, sex-, and Hoehn and Yahr stage–matched control dyads drawn from US participants in the longitudinal Parkinson’s Outcome Project registry. The primary outcome measure is the change in patient quality of life between baseline and 1 year. Secondary outcome measures include changes in Hoehn and Yahr stage, caregiver strain, self-reported fall frequency, emergency room visits, hospital admissions, and time to institutionalization or death. Intervention costs and changes in health care utilization will be analyzed in a budget impact analysis to explore the potential for model adaptation and dissemination. Results The protocol was funded in September 2017 and approved by the Rush Institutional Review Board in October 2017. Recruitment began in May 2018 and closed in November 2019 with 65 patient-caregiver dyads enrolled. All study visits have been completed, and analysis is underway. Conclusions To our knowledge, this is the first controlled trial to investigate the effects of interdisciplinary home visits among homebound individuals with advanced PD and their caregivers. This study also establishes a unique cohort of patients from whom we can study the natural course of advanced PD, its treatments, and unmet needs. Trial Registration ClinicalTrials.gov NCT03189459; http://clinicaltrials.gov/ct2/show/NCT03189459. International Registered Report Identifier (IRRID) PRR1-10.2196/31690

Healthcare policy makers should ensure optimal patient access to medical nutrition (MN) as part of the management of nutrition-related disorders and conditions. Questions remain whether current healthcare policies reflect the clinical and economic benefits of MN. The objective of this article is to characterize coverage and reimbursement of MN, defined as food for special medical purposes/medical food for a diverse set of countries, including Australia, Belgium, Brazil, Canada, China, France, Germany, Hong Kong, Italy, Japan, The Netherlands, Singapore, Spain, United Kingdom, and United States.Data sources included published literature and online sources. ISPOR's Nutrition Economics Special Interest Group developed a data collection form to guide data extraction that included reimbursement coverage, years that reimbursement policies were established, and presence of a formal health technology assessment (HTA) for MN technologies.Reimbursement coverage of MN technologies varied across the countries that were reviewed. All but 3 countries limited coverage to specific formulations of products, regardless of demonstrated clinical benefit. The year that reimbursement policies were established varied across countries (ranging from 1984 to 2017), and only 4 countries regularly update policies. France and Brazil are the only countries with a formal HTA process for MN technologies.Most countries have limited MN reimbursement, have not updated reimbursement policies, and lack HTA for MN technologies. These limitations may lead to suboptimal access to MN technologies where they are indicated to manage nutrition-related disorders and conditions, with the potential of negatively affecting patient and healthcare system outcomes.

Patients with autism spectrum disorder and/or intellectual disability (ASD/ID) face unique health care challenges. In addition to hospital experiences characterized by fear and insufficient staff training, these patients have 1.5-times longer lengths of stay (LOS) than patients without ASD/ID, and 3.4% of patients with ASD/ID have prolonged LOS (i.e., ≥30 days). Little research exists on factors related to prolonged LOS of patients with ASD/ID, hindering efforts to develop and implement evidence-based practices to improve care and reduce prolonged LOS. The purpose of the current study was to describe factors related to prolonged LOS of adult patients with ASD/ID in acute care settings using a retrospective chart review of 10 patients discharged from one academic medical center. Findings indicate that health care institutions should evaluate performance with this patient population and identify evidence-based strategies to provide a safe environment for care and reduce LOS that is due to non-health care needs. [ Journal of Psychosocial Nursing and Mental Health Services, 57 (7), 17–22.]

Purpose Hospitals catering to the unique needs of international patients often make substantial investments in their international program. Research has yet to evaluate the return on investment (ROI) of establishing these programs. The purpose of this paper is to quantify the economic benefits and costs of international patient programs and evaluate the ROI of international patients for US hospitals by program maturity and size. Design/methodology/approach Operational information about 29 health systems with international patient programs in the USA was obtained from the US Cooperative for International Patient Programs (USCIPP) Annual Benchmarking Survey. A Spearman correlation coefficient was used to test the association between international program investments and revenue. Mann–Whitney U tests were used to test whether ROI differs significantly by program maturity and size. Findings It was found that 14 (48.3 per cent) international programs were established and 10 (34.5 per cent) programs were large in size. The median estimated organizational total gross revenue less operating expense for all programs was positive ($15.6m). Total gross revenue less operating expense was higher for large programs ($105.6m) than for small programs ($9.2m) (p p Originality/value The results suggest that hospital investment in international programs yields substantial returns for the health systems studied. New programs rely on staff from other areas of the organization while developing operational processes and relationships with providers and payers abroad. Examining the ROI can help hospitals develop a business case for an international program and understand any economies of scale from increased investment.

Background Despite high initiation rates for mother's own milk (MOM) provision, MOM feeding at discharge from the neonatal intensive care unit (NICU) drops precipitously and reveals a racial/ethnic disparity. This study sought to identify factors that (1) predict MOM feeding at NICU discharge, and (2) mediate racial/ethnic disparity in MOM feeding at discharge. Methods Secondary analysis of prospective cohort study of 415 mothers and their very low birth weight infants. Variables were grouped into five categories (demographics, neighborhood structural, social, maternal health, and MOM pumping). Significant predictors from each category were entered into a multivariable logistic regression model. Results Although 97.6% of infants received MOM feedings, black infants were significantly less likely to receive MOM feeding at discharge. Positive predictors were daily pumping frequency, reaching pumped MOM volume ≥500 mL/day by 14 days, and maternal age. Negative predictors were low socioeconomic status (SES) and perceived breastfeeding support from the infant's maternal grandmother. Low SES, maternal age, and daily pumping frequency mediated the racial/ethnic differences. Conclusions Multiple potentially modifiable factors predict MOM feeding at NICU discharge. Importantly, low SES, pumping frequency, and maternal age were identified as the mediators of racial and ethnic disparity. Strategies to mitigate the effects of modifiable factors should be developed and evaluated in future research.

BACKGROUND The current understanding of advanced Parkinson disease (PD) and its treatment is largely based on data from outpatient visits. The most advanced and disabled individuals with PD are disconnected from both care and research. A previous pilot study among older, multimorbid patients with advanced PD demonstrated the feasibility of interdisciplinary home visits to reach the target population, improve care quality, and potentially avoid institutionalization. OBJECTIVE The aim of this study protocol is to investigate whether interdisciplinary home visits can prevent a decline in quality of life of patients with PD and prevent worsening of caregiver strain. The protocol also explores whether program costs are offset by savings in health care utilization and institutionalization compared with usual care. METHODS In this single-center, controlled trial, 65 patient-caregiver dyads affected by advanced PD (Hoehn and Yahr stages 3-5 and homebound) are recruited to receive quarterly interdisciplinary home visits over 1 year. The 1-year intervention is delivered by a nurse and a research coordinator, who travel to the home, and it is supported by a movement disorder specialist and social worker (both present by video). Each dyad is compared with age-, sex-, and Hoehn and Yahr stage–matched control dyads drawn from US participants in the longitudinal Parkinson’s Outcome Project registry. The primary outcome measure is the change in patient quality of life between baseline and 1 year. Secondary outcome measures include changes in Hoehn and Yahr stage, caregiver strain, self-reported fall frequency, emergency room visits, hospital admissions, and time to institutionalization or death. Intervention costs and changes in health care utilization will be analyzed in a budget impact analysis to explore the potential for model adaptation and dissemination. RESULTS The protocol was funded in September 2017 and approved by the Rush Institutional Review Board in October 2017. Recruitment began in May 2018 and closed in November 2019 with 65 patient-caregiver dyads enrolled. All study visits have been completed, and analysis is underway. CONCLUSIONS To our knowledge, this is the first controlled trial to investigate the effects of interdisciplinary home visits among homebound individuals with advanced PD and their caregivers. This study also establishes a unique cohort of patients from whom we can study the natural course of advanced PD, its treatments, and unmet needs. CLINICALTRIAL ClinicalTrials.gov NCT03189459; http://clinicaltrials.gov/ct2/show/NCT03189459. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/31690

RATIONALE: Many hospitals were unable to accommodate the rapid surge of critically ill patients with COVID-19 requiring intensive care unit (ICU) admission in the spring of 2020. As a result, some patients were transferred to tertiary referral centers with increased surge capacity and an ability to provide a higher level of care for patients in respiratory failure requiring mechanical ventilation. In general, interhospital transfers have higher disease severity, longer length of stay, and higher mortality. Our study investigated whether patients with COVID-19 who were transferred to a tertiary referral center had higher severity of illness and poorer health outcomes compared to patients who were directly admitted. METHODS: This was a single center, retrospective cohort study of adult patients with COVID-19 who received mechanical ventilation. Demographic and clinical variables were extracted from the electronic medical record for patients admitted and discharged between March 17, 2020 and September 30, 2020. Patients were classified as either directly admitted or admitted via interhospital transfer. Inverse probability weighted regression models were constructed to test the association between transfer status and outcomes, including in-hospital death versus survival to hospital discharge, and number of days from intubation to discharge, adjusting for patient demographic characteristics and severity of illness. RESULTS: Of 1,785 patients admitted to Rush University Medical Center with COIVD-19, 174 (10%) were transferred from another hospital and 1,611 were directly admitted through the emergency department. A total of 119 transfer patients and 183 direct admits required mechanical ventilation. Transfer patients differed from direct admits in being more likely to have English as a preferred language (71% vs 56%,), younger age (median 57 vs 60 years), higher BMI (median, 34 vs 31), and more likely to have received ECMO (12% vs 3%), p

Resource scarcity forces health care systems to set priorities and navigate trade-offs in how they choose to fund different services. Distributive justice principles can help guide health systems to fairly allocate scarce resources in a society. In most countries, mental health care and psychotherapy, in particular, tend to be under-prioritized even though psychotherapy can be an effective treatment for mental health disorders. To create ethical funding systems that support appropriate access to psychotherapy, health care funding systems must consider how they allocate and distribute health care resources through health care financing, coverage criteria, and reimbursement mechanisms. Five health care systems are assessed according to how they finance and reimburse psychotherapy. These health systems use various and often pluralistic approaches that encompass differing distributive justice principles. Although distribution priorities and values may differ, fair and transparent processes that involve all key stakeholders are vital for making ethical decisions on access and distribution.

Purpose The objective of this study is to examine the association between an academic medical center and free clinic referral partnership and subsequent hospital utilization and costs for uninsured patients discharged from the academic medical center's emergency department (ED) or inpatient hospital. Methods This retrospective, cross-sectional study included 6014 uninsured patients age 18 and older who were discharged from the academic medical center's ED or inpatient hospital between July 2016 and June 2017 and were followed for 90 days in the organization's electronic medical record to identify the occurrence and cost of subsequent same-hospital ED visits and hospital admissions. The occurrence of any subsequent ED visits or hospital admissions and the cost of subsequent hospital care were compared by free clinic referral status after inverse probability of treatment weighting. Results Overall, 330 (5.5%) of uninsured patients were referred to the free clinic. Compared with patients referred to the free clinic, patients not referred had greater odds of any subsequent ED visits or hospital admissions within 90 days (odds ratio, 1.8; 95% confidence interval: 1.7-2.0). For patients with any subsequent ED visits or hospital admissions, the mean cost of care for those who were not referred to the free clinic was 2.3 times higher (95% confidence interval: 2.0-2.7) compared to referred patients. Conclusion An academic medical center-free clinic partnership for follow-up care after discharge from the ED or hospital admission is a promising approach for improving access to care for uninsured patients.

Supplemental Digital Content is available in the text., IMPORTANCE: Studying interhospital transfer of critically ill patients with coronavirus disease 2019 pneumonia in the spring 2020 surge may help inform future pandemic management. OBJECTIVES: To compare outcomes for mechanically ventilated patients with coronavirus disease 2019 transferred to a tertiary referral center with increased surge capacity with patients admitted from the emergency department. DESIGN, SETTING, PARTICIPANTS: Observational cohort study of single center urban academic medical center ICUs. All patients admitted and discharged with coronavirus disease 2019 pneumonia who received invasive ventilation between March 17, 2020, and October 14, 2020. MAIN OUTCOME AND MEASURES: Demographic and clinical variables were obtained from the electronic medical record. Patients were classified as emergency department admits or interhospital transfers. Regression models tested the association between transfer status and survival, adjusting for demographics and presentation severity. RESULTS: In total, 298 patients with coronavirus disease 2019 pneumonia were admitted to the ICU and received mechanical ventilation. Of these, 117 were transferred from another facility and 181 were admitted through the emergency department. Patients were primarily male (64%) and Black (38%) or Hispanic (45%). Transfer patients differed from emergency department admits in having English as a preferred language (71% vs 56%; p = 0.008) and younger age (median 57 vs 61 yr; p < 0.001). There were no differences in race/ethnicity or primary payor. Transfers were more likely to receive extracorporeal membrane oxygenation (12% vs 3%; p = 0.004). Overall, 50 (43%) transferred patients and 78 (43%) emergency department admits died prior to discharge. There was no significant difference in hospital mortality or days from intubation to discharge between the two groups. CONCLUSIONS AND RELEVANCE: In a single-center retrospective cohort, no significant differences in hospital mortality or length of stay between interhospital transfers and emergency department admits were found. While more study is needed, this suggests that interhospital transfer of critically ill patients with coronavirus disease 2019 can be done safely and effectively.

The objective of this study was to assess the size and scope of non-patient collaborations undertaken by U.S.-based hospitals and health systems and the impact of these collaborations on international inpatient volumes at the U.S.-based campus of these organizations. This study included in-depth, semi-structured telephone interviews with leaders from international programs in U.S. health systems. Interview questions included the presence of different modes of non-patient collaborations abroad, financial and other organizational motivations for engaging in non-patient collaborations abroad, and institutional commitment for global and international activities. Of the 40 organizations participating in this study, 83% provided international education programs, 50% provided consulting and advisory services, 20% provided management services, and 10% owned patient care or educational facilities abroad. U.S.-based hospitals and health systems with international patient programs frequently engage in non-pa...

Objectives: Published estimates of willingness to pay (WTP) for quality adjusted life years (QALYs) based on elicited preferences vary widely, especially across health procedures. The study evaluated the revealed WTP for QALYs by older adult patients who paid fully out-of-pocket for common inpatient procedures in the United States.Methods: Patient-level discharge data were from academic medical center members of the University Health System Consortium Clinical Data Base from 2005 to 2015 (now Vizient) for patients who paid ‘cash-in-full.’ The median, 25th percentile, and 75th percentile of charges, payments, and payment to charge ratio were examined and combined with available measures on QALYs by procedure.Results: Among patients over age 50 from 22 academic medical centers there were 846 self-pay patients, and the majority were international. The mean out-of-pocket payment was $57731 and the payment to charge ratio was 0.53. For the five procedures with available QALYs, the lower bound median pa...

Best practices translating the evidence for high-dose human milk (HM) feeding for preterm infants during neonatal intensive care unit (NICU) hospitalization have been described, but their implementation has been compromised. Although the rates of any HM feeding have increased over the last decade, efforts to help mothers maintain HM provision through to NICU discharge have remained problematic. Special emphasis should be placed on prioritizing the early lactation period of coming to volume so that mothers have sufficient HM volume to achieve their personal HM feeding goals. Donor HM does not provide the same risk reduction as own mother's HM.

Background: The association between human milk (HM) feeding in the NICU and neurodevelopmental (ND) outcome in very low birth weight (VLBW) infants is unclear. Limitations of previous studies include a lack of exact estimates of HM dose and of generalizability to minority populations. Objective: To determine the impact on ND outcome of an exact dose of HM received in the NICU in a diverse, contemporary cohort of VLBW infants. Methods: We included 430 VLBW infants born in the period 2008-2012 for whom the mean daily dose (DD) of HM received during the stay in the NICU (NICU HM-DD) was calculated prospectively from the daily nutritional intake from admission to discharge. Outcomes included Bayley-III index scores at 20 months' corrected age (CA) as assessed upon ND follow-up, which were collected retrospectively. Multivariable linear regression analyses controlled for neonatal and social risk factors. Results: Each 10 mL/kg/day increase in NICU HM-DD was associated with a 0.35 increase in cognitive index score (95% CI [0.03-0.66], p = 0.03), but no significant associations were detected for the language or motor indices. Conclusions: There is a significant dose-dependent association between NICU HM intake and cognitive scores at 20 months' CA. Further follow-up will determine whether these findings persist at school age, and could help alleviate the special-education and health-care burden in this population.

As the healthcare landscape rapidly changes, graduate allied health programs must position themselves to educate the next generation of healthcare professionals in a highly competitive landscape. No studies have directly measured the relative importance of attributes in program selection by prospective healthcare students.We surveyed graduate healthcare management program applicants in the 2018 admissions cycle (n=512) to determine which attributes were most important in program choice. We utilized conjoint analysis to estimate utilities and importance scores of six attributes: program ranking, cost, work experience, geography, distance to home, and salary. We then conducted a market simulation to predict relative market share of academic programs.The most important attribute to prospective students was the projected starting salary, with US News and World Report ranking and tuition cost the second and third most important attributes, respectively. Each attribute was relatively inelastic respective to tuition cost.While future leaders placed the most value on earnings when selecting a program, they also valued rankings and cost. By focusing on these factors, programs can target their marketing efforts to recruit the best potential future healthcare leaders, while this method can be replicated to gauge the most important relative attributes for a variety of healthcare professions.

Background Changes in reproductive hormones during menopause are associated with accumulation of intra-abdominal adipose tissue (IAAT), a subclinical indicator of cardiometabolic disease risk. Independent of reproductive hormones, unhealthy lifestyle contributes to IAAT gain. The Women in the Southside Health and Fitness (WISHFIT) Study aims to develop a lifestyle approach to slowing IAAT accumulation as women begin the menopausal transition. Methods The primary aim is to develop and conduct a proof-of-concept test of a multi-component, multi-level behavioral intervention targeting jointly physical activity, diet, and psychological well-being. Participants attend group sessions over 2 years to experiment with healthy living through both experiential and didactic learning, cultivate a health network, and draw on community resources to sustain change. The primary endpoint is 2-year IAAT progression, assessed using computerized tomography. Behavioral targets of treatment and secondary endpoints will be evaluated at 6, 12, 18 and 24 months. Change in social networks and community support will be assessed at 2 years. Results WISHFIT recruited 71 pre- and peri-menopausal Caucasian and African American women (mean ± SD age = 47.6 ± 3.4 yrs; BMI = 33.6 ± 7.3 kg/m2; 52% African American). Baseline IAAT was 2104.1 ± 1201.3 cm3. IAAT, physical activity, BMI, and self-reported family income and resilience differed by ethnicity at baseline. Conclusions WISHFIT is a multi-component, multi-level intervention aimed at producing a sustained improvement in physical activity, diet, and psychological well-being early in the menopausal transition to slow menopause-related accumulation of IAAT. It provides a model for the process of developing a behavioral treatment to manage a chronic disease.

The Affordable Healthcare Act has, among other changes, created greater incentives to reduce health disparities in low-income communities across the country, which heightened the importance and expectations of community health workers (CHWs) as part of the clinical care team. These heightened expectations have begun to transition what has historically been a paraprofessional role into one that involves more clearly defined competencies and development needs. In an effort to meet these needs in the city of Chicago, a CHW basic certificate program was developed and launched at Malcolm X college (one of the seven city Colleges of Chicago), in collaboration with several community partners. This article presents the experience of this program, the challenges faced in its implementation, and lessons from this experience that may be relevant to others involved in the professional preparation of CHWs.

Background The use of left ventricular assist devices (LVADs) in the United States has increased since the Food and Drug Administration approved the 1st device in 1994. Despite a rapid increase in the number of LVADs implanted per year, there are substantial variations in procedure volume among hospitals and surgeons. This study evaluated the association between hospital and surgeon volumes of LVAD procedures and in-hospital mortality. Methods and Results We conducted a retrospective cross-sectional analysis of all patient discharges after an LVAD implantation from University HealthSystem Consortium (UHC) academic medical center members from January 2007 through June 2012. With the use of International Classification of Diseases–9th Edition, Clinical Modification, procedure code 37.66, we identified 7714 patients who received an LVAD from 581 surgeons across 88 hospitals. The primary outcome was all-cause in-hospital mortality. Annual hospital and surgeon LVAD procedure volumes were evaluated as both continuous variables and quintiles. Hierarchical binary logistic regression models were fitted to test the association of in-hospital mortality with hospital and surgeon volume, controlling for hospital and patient characteristics. Hospital volume was not associated with lower in-hospital mortality. Highest annual surgeon volume quintile was a significant predictor of lower in-hospital mortality (odds ratio 1.69; P Conclusions Surgeons' LVAD procedure volume, not annual hospital procedure volume, was associated with in-hospital mortality.

Background: Referrals to palliative care for patients at the end of life in the intensive care unit (ICU) often happen late in the ICU stay, if at all. The integration of a palliative medicine advanced practice nurse (APN) is one potential strategy for proactively identifying patients who could benefit from this service. Objective: To evaluate the association between the integration of palliative medicine APNs into the routine operations of ICUs and hospital costs at 2 different institutions, Montefiore Medical Center (MMC) and Rush University Medical Center. Methods: The association between collaborative palliative care consultation service programs and hospital costs per patient was evaluated for the 2 institutions. Hospital costs were compared for patients with and without a referral to palliative care using Mann-Whitney U tests. Results: Hospital nonroom and board costs at the Weiler campus of MMC were significantly lower for patients with palliative care compared with those who did not receive palliative care (Median = US$6643 vs US$12 399, P < .001). Cost differences for ICU patients with and without palliative care at Rush University Medical Center were not significantly different. Conclusion: Our evaluation suggests that the integration of APNs into a palliative care team for case finding may be a promising strategy, but more work is needed to determine whether reductions in cost are significant.

Objectives Frequent, nonurgent emergency department use continues to plague the American health care system through ineffective disease management and unnecessary costs. In 2012, the Illinois Medical Home Network (MHN) was implemented to, in part, reduce an overreliance on already stressed emergency departments through better care coordination and access to primary care. The purpose of this study is to characterize MHN patients and compare them with non-MHN patients for a preliminary understanding of MHN patients who visit the emergency department. Variables of interest include (1) frequency of emergency department use during the previous 12 months, (2) demographic characteristics, (3) acuity, (4) disposition, and (5) comorbidities. Methods We performed a retrospective data analysis of all emergency department visits at a large, urban academic medical center in 2013. Binary logistic regression analyses and analysis of variance were used to analyze data. Results Medical Home Network patients visited the emergency department more often than did non-MHN patients. Medical Home Network patients were more likely to be African American, Hispanic/Latino, female, and minors when compared with non-MHN patients. Greater proportions of MHN patients visiting the emergency department had asthma diagnoses. Medical Home Network patients possessed higher acuity but were more likely to be discharged from the emergency department compared with non-MHN patients. Conclusions This research may assist with developing and evaluating intervention strategies targeting the reduction of health disparities through decreased use of emergency department services in these traditionally underserved populations.

To assess the cost-effectiveness of mother's own milk supplemented with donor milk vs mother's own milk supplemented with formula for infants of very low birth weight in the neonatal intensive care unit (NICU).A retrospective analysis of 319 infants with very low birth weight born before (January 2011-December 2012, mother's own milk + formula, n = 150) and after (April 2013-March 2015, mother's own milk + donor milk, n = 169) a donor milk program was implemented in the NICU. Data were retrieved from a prospectively collected research database, the hospital's electronic medical record, and the hospital's cost accounting system. Costs included feedings and other NICU costs incurred by the hospital. A generalized linear regression model was constructed to evaluate the impact of feeding era on NICU total costs, controlling for neonatal and sociodemographic risk factors and morbidities. An incremental cost-effectiveness ratio was calculated for each morbidity that differed significantly between feeding eras.Infants receiving mother's own milk + donor milk had a lower incidence of necrotizing enterocolitis (NEC) than infants receiving mother's own milk + formula (1.8% vs 6.0%, P = .048). Total (hospital + feeding) median costs (2016 USD) were $169 555 for mother's own milk + donor milk and $185 740 for mother's own milk + formula (P = .331), with median feeding costs of $1317 and $936, respectively (P .001). Mother's own milk + donor milk was associated with $15 555 lower costs per infant (P = .045) and saved $1812 per percentage point decrease in NEC incidence.The additional cost of a donor milk program was small compared with the cost of a NICU hospitalization. After its introduction, the NEC incidence was significantly lower with small cost savings per case. We speculate that NICUs with greater NEC rates may have greater cost savings.

Aggressive/challenging behaviors (A/CB) are a major public health problem for individuals with intellectual disabilities (ID). A leading reason for psychiatric hospitalizations and incarcerations, such behaviors are costly to the health care system, agencies, and families. Social problem-solving (SPS) training programs for individuals with ID have had positive behavioral results, but most were conducted in clinical or forensic settings. None was a community-based preventive intervention, none examined whether the behaviors decreased in residential and work settings, and none addressed cost-effectiveness. In preliminary work, we modified an effective SPS training program (ADAPT: Attitude, Define, Alternatives, Predict, and Try out), using input from individuals with ID and residential staff, as a community-based preventive intervention that we delivered in group homes (STEPS: Steps to Effective Problem-solving). Individuals with ID have high rates of obesity, and our attention-control condition is a nutrition intervention: Food for Life. We describe the protocol for a randomized clinical trial to: (1) test the efficacy of the STEPS intervention for improving SPS skills and reducing A/CB compared to an attention-control nutrition intervention in group homes; (2) assess the mediating effect of residential staff SPS skills, group-home level SPS skills, and group cohesiveness on the improvement of SPS skills and reductions in A/CB; and (3) evaluate the cost-effectiveness of STEPS. We expect to show that STEPS is a preventive strategy to reduce A/CBs among individuals with ID and improve the cost-effectiveness of their care.

Without surgical treatment, neonatal hypoplastic left heart syndrome (HLHS) mortality in the first year of life exceeds 90 % and, in spite of improved surgical outcomes, many families still opt for non-surgical management. The purpose of this study was to investigate trends in neonatal HLHS management and to identify characteristics of patients who did not undergo surgical palliation. Neonates with HLHS were identified from a serial cross-sectional analysis using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 2000 to 2012. The primary analysis compared children undergoing surgical palliation to those discharged alive without surgery using a binary logistic regression model. Multivariate logistic regression was conducted to determine factors associated with treatment choice. A total of 1750 patients underwent analysis. Overall hospital mortality decreased from 35.3 % in 2000 to 22.9 % in 2012. The percentage of patients undergoing comfort care discharge without surgery also decreased from 21.2 to 14.8 %. After controlling for demographics and comorbidities, older patients at presentation were less likely to undergo surgery (OR 0.93, 0.91-0.96), and patients in 2012 were more likely to undergo surgery compared to those in prior years (OR 1.5, 1.1-2.1). Discharge without surgical intervention is decreasing with a 30 % reduction between 2000 and 2012. Given the improvement in surgical outcomes, further dialogue about ethical justification of non-operative comfort or palliative care is warranted. In the meantime, clinicians should present families with surgical outcome data and recommend intervention, while supporting their option to refuse.

The USA has developed a global reputation for providing high-quality, cutting-edge medical care, and individuals from across the world travel to the country to receive care for complex medical conditions. Beyond this goal of higher quality of care, however, very little is known about the motivational patterns influencing medical travellers' decision making, including the extent to which existing tourism theory and forecasting models apply to this specialized group. The present study seeks to contribute to the knowledge base by developing and testing a macro-level model of international medical travel to the USA. Using country-level data from the US Department of Commerce, World Health Organization, World Bank and Central Intelligence Agency, a two-part regression analysis was used to assess factors associated with the presence and volume of inbound medical travel by country of origin. The results indicate that travel time and out-of-pocket healthcare expenditure are significant predictors of inbound medical tourism from a given country, and travel time, travel cost, services trade and the number of outbound travellers are significant predictors of the total volume of inbound medical travellers by country. The results are discussed in the light of existing tourism research, and guidance for hospitals, policy makers and the tourism industry is provided on where to target resources for developing relationships with providers and payers abroad.

Although considerable recent attention has been given to the phenomenon of patients travelling to developing countries for lower-cost care, international medical travel by individuals in search of high-quality, complex hospital care has a long history and continues to be a thriving global market. Individuals travelling to developed countries for medical care are often in search of ‘solution shop’ medicine, where providers are organized to diagnose any problem. Competitive advantage is a dynamic process for tertiary and quarternary providers in developed countries that attract patients from across the world. Investments in both research and development and the hospital infrastructure draw patients in search of complex medical care, and providers further refine their effectiveness and efficiency. By training providers in other countries, this expertise is disseminated across borders, diffusing the competitive advantage, and new tests and treatments are developed. With this continual introduction of new tests and treatments, and the simultaneous development of local expertise in more common treatments, the types of services for which patients travel across borders also evolves. Competition for international patients with complex medical needs will continue to increase across countries, as risk-adjusted and publicly available quality measures are developed to compare outcomes for providers across countries.

Purpose – This paper aims to evaluate the potential of 24 country-level measures for predicting the number of outbound international medical travelers into the USA, including health and healthcare system, economic, social and diplomatic and travel pattern factors. Medical travel is recognized as a growing global market and is an important subject of inquiry for US academic medical centers, hospitals and policy makers. Few data-driven studies exist to shed light on efficient and effective strategies for attracting international medical travelers. Design/methodology/approach – This was a retrospective, cross-sectional study of the 194 member and/or observer countries of the United Nations. Data for medical traveler volume into the USA between 2008 and 2010 were obtained from the USA Department of Commerce, Office of Travel and Tourism Industries, Survey of International Air Travelers. Data on country-level factors were collected from publicly available databases, including the United Nations, World Bank and World Health Organization. Linear regression models with a negative binomial distribution and log link function were fit to test the association between each independent variable and the number of inbound medical travelers to the USA. Findings – Seven of the 24 country-level factors were significantly associated with the number of outbound medical travelers to the USA These factors included imports as a per cent of gross domestic product, trade in services as a per cent of gross domestic product, per cent of population living in urban areas, life expectancy, childhood mortality, incidence of tuberculosis and prevalence of human immunodeficiency virus. Practical implications – Results of this model provide evidence for a data-driven approach to strategic outreach and business development for hospitals and policy makers for attracting international patients to the USA for medical care. Originality/value – The model developed in this paper can assist US hospitals in promoting their services to international patients as well as national efforts in identifying “high potential” medical travel markets. Other countries could also adapt this methodology for targeting the international patient market.

Tax-exempt hospitals and health systems often borrow long-term debt to fund capital investments. Lenders use bond ratings as a standard metric to assess whether to lend funds to a hospital. Credit rating agencies have historically relied on financial performance measures and a hospital's ability to service debt obligations to determine bond ratings. With the growth in pay-for-performance-based reimbursement models, rating agencies are expanding their hospital bond rating criteria to include hospital utilization and value-based purchasing (VBP) measures. In this study, we evaluated the relationship between the Hospital VBP domains--Clinical Process of Care, Patient Experience of Care, Outcome, and Medicare Spending per Beneficiary (MSPB)--and hospital bond ratings. Given the historical focus on financial performance, we hypothesized that hospital bond ratings are not associated with any of the Hospital VBP domains. This was a retrospective, cross-sectional study of all hospitals that were rated by Moody's for fiscal year 2012 and participated in the Centers for Medicare & Medicaid Services' VBP program as of January 2014 (N = 285). Of the 285 hospitals in the study, 15% had been assigned a bond rating of Aa, and 46% had been assigned an A rating. Using a binary logistic regression model, we found an association between MSPB only and bond ratings, after controlling for other VBP and financial performance scores; however, MSPB did not improve the overall predictive accuracy of the model. Inclusion of VBP scores in the methodology used to determine hospital bond ratings is likely to affect hospital bond ratings in the near term.

People with intellectual disabilities (ID) represent a small but important group of hospitalized patients who have higher rates of complications than do patients without ID hospitalized for the same reasons. Complications are potentially avoidable conditions, such as healthcare-acquired infections, healthcare-acquired skin breakdown, falls, and medication errors and reactions. Addressing factors related to complications can focus efforts to improve hospital care. The purpose of this exploratory study was to analyze data from reviews of academic medical center charts (N = 70) about complications and to examine patient and hospitalization characteristics in relation to complications among adult patients (age ≥ 18 years) with ID hospitalized for nonpsychiatric reasons. Adults with ID tended to be twice as likely to have complications (χ2 = 2.893, df = 1, p = .09) if they had a surgical procedure and were nearly four times as likely to have complications (χ2 = 6.836, df = 1, p = .009) if they had multiple chronic health conditions (three of the following: history of cerebral palsy, autism spectrum symptoms, aggressive behavior, respiratory disorder, and admission through the emergency department). Findings suggest preliminary criteria for assessing risk for complications among hospitalized people with ID and the need for attention to their specific needs when hospitalized.

Country of origin and brand positioning are important factors to consider for high-involvement services such as health-care organizations competing for international patients. These factors become more important in high-involvement service industries because consumers do not have the information needed to evaluate service quality, and the cost to the patient of poor quality is high. Therefore, consumers may rely on country of origin and brand positioning signals more heavily relative to goods or hedonic services. This paper explores the relationship between country of origin and brand positioning in the context of the high-involvement service of health care. An analysis of brand positioning of health-care institutions using promotional materials from a large international health-care conference is presented using a sample of 170 health-care organizations located in 14 countries. The findings indicate that European and Middle Eastern health-care organizations most frequently employ foreign consumer culture positioning, while American institutions tend to use global consumer culture positioning. However, American organizations may be missing an opportunity to capitalize on the appeal of their country and cities and may not be appropriately considering their global competition in their market positioning. The findings are important for hospitals competing globally for patients seeking care abroad.

State Medicaid programs need cost-effective strategies to provide high-quality care that is accessible to individuals with low incomes and limited resources. Integrated delivery systems have been formed to provide care across the continuum, but creating a shared vision for improving community health can be challenging. Medical Home Network was created as a network of primary care providers and hospital systems providing care to Medicaid enrollees, guided by the principles of egalitarian governance, practice-level care coordination, real-time electronic alerts, and pay-for-performance incentives. This analysis of health care utilization and costs included 1,189,195 Medicaid enrollees. After implementation of Medical Home Network, a risk-adjusted increase of $9.07 or 4.3% per member per month was found over the 2 years of implementation compared with an increase of $17.25 or 9.3% per member per month, before accounting for the cost of care management fees and other financial incentives, for Medicaid enrollees within the same geographic area with a primary care provider outside of Medical Home Network. After accounting for care coordination fees paid to providers, the net risk-adjusted cost reduction was $11.0 million.

Best practices that translate the evidence for high dose HM feeding for preterm infants during the NICU hospitalization have been described in multiple studies but their implementation has been compromised largely due to economic and ideologic concerns. Although the rates of “any” HM feeding have increased over the last decade, efforts to help mothers maintain human milk provision through to NICU discharge have remained problematic throughout the world. Special emphasis should be placed on prioritizing the early lactation period of coming to volume so that mothers have sufficient HM volume to achieve their personal HM feeding goals. Finally, donor HM does not provide the same risk reduction as own mothers’ HM for multiple morbidities in preterm infants, providing needed evidence for channeling of limited resources into NICU programs that promote the use of mothers’ own HM.

CONTEXT Incentives to improve quality include paying less for adverse events, including the Centers for Medicare and Medicaid Services' policy to not pay additionally for events classified as hospital-acquired conditions (HACs). This policy is controversial, as variable coding practices at hospitals may lead to differences in the inclusion and position of HACs in the list of codes used for Medicare Severity Diagnosis-Related Group (MS-DRG) assignment. OBJECTIVE Evaluate changes in MS-DRG assignment for patients with an HAC and test the association of the position of an HAC in the list of International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes with change in MS-DRG assignment. DESIGN AND SETTING Retrospective analysis of patients discharged from hospital members of the University HealthSystem Consortium's Clinical Data Base between October 2007 and April 2008. Comparisons were made between the MS-DRG assigned when the HAC was not included in the list of ICD-9 diagnosis codes and the MS-DRG that would have been assigned had the HAC code been included in the assignment. RESULTS Of the 7027 patients with an HAC, 13.8% changed MS-DRG assignment when the HAC was removed. An HAC in the second position versus third position or lower was associated with a 40-fold increase in the likelihood of MS-DRG change. CONCLUSIONS The position of an HAC in the list of diagnosis codes, rather than the presence of an HAC, is associated with a change in MS-DRG assignment. HACs have little effect on reimbursement unless the HAC is in the second position and patients have minor severity of illness. Journal of Hospital Medicine 2014;9:707–713. © 2014 Society of Hospital Medicine

While increasing attention has been given to patients traveling internationally for medical care, hospitals face unique challenges in caring for international patients that may increase hospital length of stay (LOS) and cost of care. The objective of this study was to evaluate whether there are variations in LOS by home region of origin for international patients traveling to the USA. This was a retrospective, cross-sectional study using patient-level discharge data from academic medical center members of University HealthSystems Consortium (UHC). The sample included 4517 international patients discharged between October 2008 and March 2012 from academic medical center members of UHC. Generalized linear regression models were fit to test the association between the LOS and country of home origin, controlling for patient demographic and clinical characteristics. Significant variation in LOS existed across countries of home origin. In the adjusted model, Saudi Arabian and Egyptian home origin were associate...