111 Misaligned Incentives for Lumbar Spine Surgery in the Bundled Payment for Care Initiative

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 223-223
Author(s):  
Joseph E Tanenbaum ◽  
Dominic Pelle ◽  
Edward C Benzel ◽  
Michael P Steinmetz ◽  
Thomas Mroz
Keyword(s):  
Acute Care ◽  
Lumbar Fusion ◽  
Hospital Costs ◽  
Care Facility ◽  
Thoracolumbar Fracture ◽  
Acute Care Facility ◽  
Patient Demographics ◽  
Episode Of Care ◽  
Hospital Characteristics ◽  
Post Acute Care

Abstract INTRODUCTION Under the Bundled Payments for Care Initiative (BPCI), Medicare reimburses for lumbar fusion without adjusting for the patient's underlying pathology. We compared the hospital resource use of two lumbar fusion cohorts that BPCI groups into the same payment bundle: patients with spondylolisthesis and patients with thoracolumbar fracture. METHODS With BPCI, hospitals are reimbursed for a lumbar fusion episode of care if patients are assigned diagnosis related group (DRG) 459 or 460. Vertebroplasty and kyphoplasty use different DRGs. National Inpatient Sample data from 2013 were queried to identify all patients that underwent lumbar fusion to treat a primary diagnosis of thoracolumbar fracture or spondylolisthesis and that were assigned DRG 459 or 460. Multivariable linear and logistic regression were used to compare length of hospital stay (LOS), direct hospital costs, and odds of discharge to a post-acute care facility for thoracolumbar fracture patients and spondylolisthesis patients. All models adjusted for patient demographics, 29 comorbidities, and hospital characteristics. The complex survey design of the NIS was taken into account in all models. RESULTS >After adjusting for patient demographics, insurance status, hospital characteristics, and 29 comorbidities, spondylolisthesis patients had a mean LOS that was 36% shorter (95% CI 26% - 44%, P< 0.0001), a mean cost that was 13% less (95% CI 3.7% - 21%, P< 0.0001), and had 3.6 times greater odds of being discharged home (95% CI 2.5 5.4, P< 0.0001) than thoracolumbar fracture patients. CONCLUSION Under the proposed DRG-based BPCI, hospitals would be reimbursed the same amount for lumbar fusion regardless of whether a patient had spondylolisthesis or thoracolumbar fracture. However, compared with fusion for spondylolisthesis, fusion for thoracolumbar fracture was associated with longer LOS, greater direct hospital costs, and increased likelihood of being discharged to a post-acute care facility. Our findings suggest that the BPCI episode of care for lumbar fusion dis-incentivizes treating trauma patients.

DRG-based bundled reimbursement for lumbar fusion: implications for patient selection

2019 ◽  
Vol 31 (4) ◽  
pp. 542-547
Author(s):  
Philina Yee ◽  
Joseph E. Tanenbaum ◽  
Dominic W. Pelle ◽  
Don Moore ◽  
Edward C. Benzel ◽  
...  
Keyword(s):  
Vertebral Fracture ◽  
Acute Care ◽  
Resource Use ◽  
Lumbar Fusion ◽  
Hospital Costs ◽  
Care Facility ◽  
Hospital Resource ◽  
Acute Care Facility ◽  
Patient Demographics ◽  
Lumbar Vertebral Fracture

OBJECTIVEUnder the Bundled Payments for Care Improvement (BPCI) initiative, Medicare reimburses for lumbar fusion without adjusting for underlying pathology. However, lumbar fusion is a widely used technique that can treat both degenerative and traumatic pathologies. In other surgical cohorts, significant heterogeneity exists in resource use when comparing procedures for traumatic versus degenerative pathologies. If the same were true for lumbar fusion, BPCI would create a financial disincentive to treat specific patient populations. The goal of this study was to compare hospital resource use for lumbar fusion between 2 patient populations: patients with spondylolisthesis and patients with lumbar vertebral fracture.METHODSThe authors compared the hospital resource use of two lumbar fusion cohorts that BPCI groups into the same payment bundle for lumbar fusion: patients with spondylolisthesis and patients with lumbar vertebral fracture. National Inpatient Sample data from 2013 were queried for patients who underwent lumbar fusion for lumbar vertebral fracture or spondylolisthesis. Hospital resource use was measured using length of stay (LOS), direct hospital costs, and odds of discharge to a post-acute care facility and compared using multivariable linear and logistic regression. All models adjusted for patient demographics, 29 comorbidities, and hospital characteristics.RESULTSAfter adjusting for patient demographics, insurance status, hospital characteristics, and 29 comorbidities, spondylolisthesis patients had a mean LOS that was 36% shorter (95% CI 26%–44%, p < 0.0001), a mean cost that was 13% less (95% CI 3.7%–21%, p < 0.0001), and 3.2 times greater odds of being discharged home (95% CI 2.5–5.4, p < 0.0001) than lumbar vertebral fracture patients.CONCLUSIONSUnder the proposed DRG (diagnosis-related group)–based BPCI, hospitals would be reimbursed the same amount for lumbar fusion regardless of the diagnosis. However, compared with fusion for spondylolisthesis, fusion for lumbar vertebral fracture was associated with longer LOS, greater direct hospital costs, and increased likelihood of being discharged to a post-acute care facility. These findings suggest that the BPCI episode of care for lumbar fusion dis-incentivizes treatment of trauma patients.

Delirium among elderly patients admitted to a post-acute care facility and 3-months outcome

2015 ◽  
Vol 16 (5) ◽  
pp. 586-592 ◽  
Author(s):  
Doris Ka Ying Miu ◽  
Ching Wai Chan ◽  
Ching Kok
Keyword(s):  
Elderly Patients ◽  
Acute Care ◽  
Care Facility ◽  
Acute Care Facility ◽  
Post Acute Care

scholarly journals Hospital to Post-Acute Care Facility Transfers: Identifying Targets for Information Exchange Quality Improvement

2017 ◽  
Vol 18 (1) ◽  
pp. 70-73 ◽  
Author(s):  
Christine D. Jones ◽  
Ethan Cumbler ◽  
Benjamin Honigman ◽  
Robert E. Burke ◽  
Rebecca S. Boxer ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Acute Care ◽  
Information Exchange ◽  
Care Facility ◽  
Acute Care Facility ◽  
Post Acute Care

scholarly journals A predictive score to identify hospitalized patients' risk of discharge to a post-acute care facility

2008 ◽  
Vol 8 (1) ◽  
Author(s):  
Martine Louis Simonet ◽  
Michel P Kossovsky ◽  
Pierre Chopard ◽  
Philippe Sigaud ◽  
Thomas V Perneger ◽  
...  
Keyword(s):  
Acute Care ◽  
Care Facility ◽  
Hospitalized Patients ◽  
Predictive Score ◽  
Acute Care Facility ◽  
Post Acute Care

scholarly journals Outcomes of Patients Who Have Do Not Resuscitate Status prior to Being Admitted to an Intensive Care Unit

Scientifica ◽  
2016 ◽  
Vol 2016 ◽  
pp. 1-3 ◽  
Author(s):  
Debjit Saha ◽  
Carlos Moreno ◽  
Marc Csete ◽  
Elizabeth Kury Perez ◽  
Luigi Cubeddu ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Acute Care ◽  
Care Facility ◽  
Limited Resources ◽  
Apache Ii Score ◽  
Do Not Resuscitate ◽  
Acute Care Facility ◽  
Intensive Intervention ◽  
Post Acute Care

Admission of patients who have do not resuscitate (DNR) status to an intensive care unit (ICU) is potentially a misallocation of limited resources to patients who may neither need nor want intensive care. Yet, patients who have DNR status are often admitted to the ICU. This is a retrospective review of patients who had a valid DNR status at the time that they were admitted to an ICU in a single hospital over an eighteen-month period. Thirty-five patients met the criteria for inclusion in the study. The primary reasons for admission to the ICU were respiratory distress (54.2%) and sepsis (45.7%). Sixteen (45.7%) of the patients died, compared to a 5.4% mortality rate for all patients admitted to our ICU during this period (p<0.001). APACHE II score was a significant predictor of mortality (18.5 ± 1.3 alive and 23.4 ± 1.4 dead;p=0.038). Of the 19 patients discharged alive, 9 were discharged home, 5 to hospice, and 4 to a post-acute care facility.Conclusions.Patients who have DNR status and are admitted to the ICU have a higher mortality than other ICU patients. Those who survive have a high likelihood of being discharged to hospice or a post-acute care facility. The value of intensive intervention for these patients is not supported by these results. Only a minority of patients were seen by palliative care and chaplain teams, services which the literature supports as valuable for DNR patients. Our study supports the need for less expensive and less intensive but more appropriate resources for patients and families who have chosen DNR status.

scholarly journals “Self-care index” (SPI) and “Post-acute care discharge score” (PACD) to predict transfer of adult medical inpatients to a post-acute care facility: study protocol for a multicentre validation study (Preprint)

2020 ◽  
Author(s):  
Antoinette Conca ◽  
Daniel Koch ◽  
Katharina Regez ◽  
Alexander Kutz ◽  
Ciril Baechli ◽  
...  
Keyword(s):  
Acute Care ◽  
Study Protocol ◽  
Negative Impact ◽  
External Validation ◽  
Self Care ◽  
Care Facility ◽  
The Self ◽  
Acute Care Facility ◽  
Care Index ◽  
Post Acute Care

BACKGROUND Delays in patient discharge can not only lead to deterioration especially among geriatric patients, but also incorporates unnecessary resources at the hospital level. Many of these delays and their negative impact may be preventable by early focused screening to identify patients at risk for transfer to a post-acute care facility. Early interprofessional discharge planning is crucial in order to fit the appropriate individual discharge destination. As prediction of discharge to a post-acute care facility using post-acute care discharge score, the self-care index and a combination of both has been shown in a single centre pilot study, an external validation is still missing. OBJECTIVE This paper outlines the study protocol and methodology currently being used to replicate the previous pilot findings whether the post-acute care discharge score, the self-care index or the combination of both can reliably identify patients requiring transfer to post-acute care facilities. METHODS This study will use prospective data involving all phases of the quasi-experimental study “In-HospiTOOL” conducted at seven Swiss hospitals in urban and rural areas. During a 18-month period consecutive adult medical patients admitted to the hospitals through the emergency department will be included. This data will enable a prospective external validation of the prediction instruments. RESULTS We expect to gain more insight into the predictive capability of the above mentioned prediction instruments. This approach will allow us to get important information about the generalizability of the three different models. CONCLUSIONS This study will provide evidence on prognostic properties, comparative performance, reliability of scorings, and suitability of the instruments for screening purpose in order to be able to recommend application in clinical practice.

scholarly journals Association of Nutritional Support With Clinical Outcomes in Malnourished Cancer Patients: A Population-Based Matched Cohort Study

2021 ◽  
Vol 7 ◽  
Author(s):  
Nina Kaegi-Braun ◽  
Philipp Schuetz ◽  
Beat Mueller ◽  
Alexander Kutz
Keyword(s):  
Cohort Study ◽  
Hospital Mortality ◽  
Cancer Patients ◽  
Acute Care ◽  
Nutritional Support ◽  
Care Facility ◽  
Population Based ◽  
Main Diagnosis ◽  
Acute Care Facility ◽  
Post Acute Care

Malnutrition is prevalent in hospitalized cancer patients and has been associated with poor therapy response and unfavorable clinical outcome. While recent studies have shown a survival benefit through nutritional support in a hospitalized malnourished medical population including cancer patients, we aimed to investigate the association of nutritional support with in-hospital mortality and other clinical outcomes in a nationwide inpatient cancer population. In this population-based cohort study, using a large Swiss administrative claims database from April 2013 to December 2018, we created two cohorts of malnourished cancer patients on medical wards. We generated two pairwise cohorts of malnourished patients who received nutritional support by 1:1 propensity-score matching to patients not receiving nutritional support. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were 30-days all-cause hospital readmission and discharge to a post-acute care facility. To account for disease activity, we stratified patients either admitted for cancer as main diagnosis or admitted with cancer as comorbidity. Among 1,851,498 hospitalizations on medical ward, we identified a total of 32,038 malnourished cancer patients. After matching, 11,906 (37%) cases were included in the “cancer main diagnosis cohort” and 5,954 (18.6%) in the “cancer comorbidity cohort.” Patients prescribed a nutritional support showed a lower in-hospital mortality in both cohorts as compared to their respective matched controls not receiving nutritional support [cancer main diagnosis cohort: 15.4 vs. 19.4 %, OR 0.76 (95% CI 0.69–0.83); cancer comorbidity cohort: 7.4 vs. 10.2%, OR 0.71 (95% CI 0.59–0.85)]. While we found no difference in 30-days readmission rates, discharge to a post-acute care facility was less frequent in the nutritional support group of both cohorts. In this large cohort study, nutritional support in hospitalized patients with either cancer as main diagnosis or comorbidity was associated with a lower risk of in-hospital mortality and discharge to a post-acute care facility.

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