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Objective: To investigate risk-adjusted, 30-day postdischarge heart failure mortality and readmission rates stratified by hospital teaching intensity. Data Sources and Study Setting: A total of 709 221 Medicare fee-for-service beneficiaries discharged from 3135 US hospitals between 1/1/2013 and 11/30/2014 with a principal diagnosis of heart failure. Study Design: Hospitals were classified as Council of Teaching Hospitals and Health Systems (COTH) major teaching hospitals, non-COTH teaching hospitals, and nonteaching hospitals. Hospital teaching status was linked with MedPAR patient data and FY2016 Hospital Readmission Reduction Program penalties. Index hospitalization survival probabilities were estimated with hierarchical logistic regression and used to stratify index hospitalization survivors into severity deciles. Decile-specific models were estimated for 30-day postdischarge readmission and mortality. Thirty-day postdischarge outcomes were estimated by teaching intensity and penalty categories. Principal Findings: Averaged across deciles, adjusted 30-day COTH hospital readmission rates were, on a relative scale ([COTH minus nonteaching] + nonteaching), 1.63 percent higher (95% CI: 0.89 percent, 2.25 percent) than at nonteaching hospitals, but their average adjusted 30-day postdischarge mortality rates were 11.55 percent lower (95% CI: -13.78 percent, -9.37 percent). Penalized COTH hospitals had the highest readmission rates of all categories (23.99 percent [95% CI: 23.50 percent, 24.49 percent]) but the lowest 30-day postdischarge mortality (8.30 percent [95% CI: 7.99 percent, 8.57 percent] vs 9.84 percent [95% CI: 9.69 percent, 9.99 percent] for nonpenalized, nonteaching hospitals). Conclusions: Heart failure readmission penalties disproportionately impact major teaching hospitals and inadequately credit their better postdischarge survival. KEYWORDS heart failure, mortality, penalties, readmissions, teaching, 1 | BACKGROUND Readmissions are common, costly, variable in frequency across hospitals and regions, and sometimes preventable. (1-6) The Patient Protection and Affordable Care Act of 2010 established the Hospital [...]

Objectives. To investigate the association between hospital safety culture and 30-day risk-adjusted mortality for Medicare patients with acute myocardial infarction (AMI) in a large, diverse hospital cohort. Subjects. The final analytic cohort consisted of 19,357 Medicare AMI discharges (MedPAR data) linked to 257 AHRQ Hospital Survey on Patient Safety Culture surveys from 171 hospitals between 2008 and 2013. Study Design. Observational, cross-sectional study using hierarchical logistic models to estimate the association between hospital safety scores and 30-day risk-adjusted patient mortality. Odds ratios of 30-day, all-cause mortality, adjusting for patient covariates, hospital characteristics (size and teaching status), and several different types of safety culture scores (composite, average, and overall) were determined. Principal Findings. No significant association was found between any measure of hospital safety culture and adjusted AMI mortality. Conclusions. In a large cross-sectional study from a diverse hospital cohort, AHRQ safety culture scores were not associated with AMI mortality. Our study adds to a growing body of investigations that have failed to conclusively demonstrate a safety culture-outcome association in health care, at least with widely used national survey instruments. Key Words. Safety culture, outcomes, mortality, Organizational culture and its association with performance in business and manufacturing have been studied for decades, using a variety of methods, including surveys (Kotter and Heskett 1992; Schein 2010; Waterson [...]

Objective. To determine whether (a) quality in schizophrenia care varies by race/ ethnicity and over time and (b) these patterns differ across counties within states. Data Sources. Medicaid claims data from California, Florida, New York, and North Carolina during 2002-2008. Study Design. We studied black, Latino, and white Medicaid beneficiaries with schizophrenia. Hierarchical regression models, by state, quantified person and county effects of race/ethnicity and year on a composite quality measure, adjusting for person-level characteristics. Principal Findings. Overall, our cohort included 164,014 person-years (41-61 percent non-whites), corresponding to 98,400 beneficiaries. Relative to whites, quality was lower for blacks in every state and also lower for Latinos except in North Carolina. Temporal improvements were observed in California and North Carolina only. Within each state, counties differed in quality and disparities. Between-county variation in the black disparity was larger than between-county variation in the Latino disparity in California, and smaller in North Carolina; Latino disparities did not vary by county in Florida. In every state, counties differed in annual changes in quality; by 2008, no county had narrowed the initial disparities. Conclusions. For Medicaid beneficiaries living in the same state, quality and disparities in schizophrenia care are influenced by county of residence for reasons beyond patients' characteristics. Key Words. Medicaid, schizophrenia, quality of care, racial/ethnic disparities, geographic variation, Medicaid is one of the largest components of state spending, accounting for nearly a quarter of total spending (National Association of State Budget Officers 2013). In response to recession-driven growth [...]

Objective. To characterize hospitals based on patterns of their combined financial and clinical outcomes for heart failure hospitalizations longitudinally. Data Source. Detailed cost and administrative data on hospitalizations for heart failure from 424 hospitals in the 2005-2011 Premier database. Study Design. Using a mixture modeling approach, we identified groups of hospitals with distinct joint trajectories of risk-standardized cost (RSC) per hospitalization and risk-standardized in-hospital mortality rate (RSMR), and assessed hospital characteristics associated with the distinct patterns using multinomial logistic regression. Principal Findings. During 2005-2011, mean hospital RSC decreased from $12,003 to $10,782, while mean hospital RSMR declined from 3.9 to 3.2 percent. We identified five distinct hospital patterns: highest cost and low mortality (3.2 percent of the hospitals), high cost and low mortality (20.4 percent), medium cost and low mortality (34.6 percent), medium cost and high mortality (6.2 percent), and low cost and low mortality (35.6 percent). Longer hospital stay and greater use of intensive care unit and surgical procedures were associated with phenotypes with higher costs or greater mortality. Conclusions. Hospitals vary substantially in the joint longitudinal patterns of cost and mortality, suggesting marked difference in value of care. Understanding determinants of the variation will inform strategies for improving the value of hospital care. Key Words. Cost, mortality, value of care, trajectory, heart failure, Hospital care is the most expensive component of the national health expenditure in the United States, totaling $814.0 billion in 2010 (Martin et al. 2012). Hospital cost per inpatient stay [...]

Objective. To examine racial/ethnic disparities in quality of schizophrenia care and assess the size of observed disparities across states and over time. Data Sources. Medicaid claims data from CA, FL, NY, and NC. Study Design. Observational repeated cross-sectional panel cohort study of white, black, and Latino fee-for-service adult beneficiaries with schizophrenia. Main outcome was the relationship of race/ethnicity and year with a composite measure of quality of schizophrenia care derived from 14 evidence-based quality indicators. Principal Findings. Quality was assessed for 325,373 twelve-month person-episodes between 2002 and 2008, corresponding to 123,496 Medicaid beneficiaries. In 2002, quality was lowest for blacks in all states. With the exception of FL, quality was lower for Latinos than whites. In CA, blacks had about 43 percent of the individual indicators met compared to 58 percent for whites. Quality improved annually for all groups in CA, NY, and NC. While in CA the improvement was slightly larger for Latinos, in FL quality improved for blacks but declined for Latinos and whites. Conclusions. Quality of schizophrenia care is poor and racial/ethnic disparities exist among Medicaid beneficiaries from four states. The size of the disparities varied across the states, and most of the initial disparities were unchanged by 2008. Key Words. Racial/ethnic disparities, schizophrenia, quality of care, trends, Medicaid, It has been a decade since the Institute of Medicine published its report Unequal Treatment on racial/ethnic disparities in health in the United States (Smedley, Stith, and Nelson 2003). Substantial [...]