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The COVID-19 pandemic revealed fundamental problems with the structure of long-term care financing and payment in the United States. The piecemeal system that exists suffers from several key problems, including underfunding, fragmentation across types and sites of care, and substantial variation in payment across states and populations. These problems result in inefficient allocation of resources, limited access to care, substandard quality, and inequities in both access and quality. We propose a new federal benefit for long-term care, most likely as part of the Medicare program. Essential features of this benefit include taxpayer subsidies, along the lines of other Medicare benefits, and coverage across the range of long-term care services, including both residential and home- and community-based care. A new federal benefit has the most potential to break down administrative barriers and improve resource allocation, to ensure adequate payment rates across all states, to expand access to care by spreading risk across the entire Medicare population, and to improve equity by extending coverage to all Medicare beneficiaries who want it. A new federal benefit is politically challenging, requiring bold action by Congress, and entails the risks of administrative challenges and unintended consequences. However, in this case, retaining the status quo remains the far greater risk. [ABSTRACT FROM AUTHOR]

To examine the effect of the COVID-19 pandemic on post-acute care utilization and spending. We used a large national multipayer claims data set from January 2019 through October 2020 to examine trends in posthospital discharge location and spending. We identified and included 975,179 hospital discharges who were aged ≥65 years. We summarized postdischarge utilization and spending in each month of the study: (1) the percentage of patients discharged from the hospital to home for self-care and to the 3 common post-acute care locations: home with home health, skilled nursing facility (SNF), and inpatient rehabilitation; (2) the rate of discharge to each location per 100,000 insured members in our cohort; (3) the total amount spent per month in each post-acute care location; and (4) the percentage of spending in each post-acute care location out of the total spending across the 3 post-acute care settings. The percentage of patients discharged from the hospital to home or to inpatient rehabilitation did not meaningfully change during the pandemic whereas the percentage discharged to SNF declined from 19% of discharges in 2019 to 14% by October 2020. Total monthly spending declined in each of the 3 post-acute care locations, with the largest relative decline in SNFs of 55%, from an average of $42 million per month in 2019 to $19 million in October 2020. Declines in total monthly spending were smaller in home health (a 41% decline) and inpatient rehabilitation (a 32% decline). As a percentage of all post-acute care spending, spending on SNFs declined from 39% to 31%, whereas the percentage of post-acute care spending on home health and inpatient rehabilitation both increased. Changes in posthospital discharge location of care represent a significant shift in post-acute care utilization, which persisted 9 months into the pandemic. These shifts could have profound implications on the future of post-acute care. [ABSTRACT FROM AUTHOR]

To test the association between transesophageal echocardiography (TEE) and incidence of acute kidney injury and length of hospitalization among United States adults undergoing isolated coronary artery bypass graft (CABG) surgery. This was an observational, retrospective cohort analysis. This study used a multicenter claims dataset from a commercially insured population undergoing CABG surgery in the United States between 2004 and 2016. Adults aged 18 years or older with continuous insurance enrollment and an absence of renal-related diagnoses before the index CABG surgery. Receipt of TEE within 1 calendar day of the index CABG surgery date. Of 51,487 CABG surgeries, 5,361 (10.4%; [95% confidence interval [CI]: 10.1-10.7%]) developed acute kidney injury and the mean length of hospitalization was 8.8 days (95% CI: 8.7-8.8). The TEE group demonstrated a greater absolute risk difference (RD) for acute kidney injury by multiple linear regression, overall, (RD=+1.0; [95% CI: 0.4-1.5%]; p < 0.001) and among a low-risk subgroup (RD=+1.0; [95% CI: 0.4-1.6; p = 0.002), but not by instrumental variable analysis (RD=+0.9 [95% CI: –1.1 to 2.9%]; p = 0.362). The TEE group demonstrated a longer length of hospitalization by multiple linear regression, overall (+2.0%; [95% CI: 1.1-2.9%]; p < 0.001), among a low-risk subgroup (+2.2%; [95% CI: 1.2-3.2%]; p < 0.001), and by instrumental variable analysis (+10.3%; [95% CI: 7.0-13.7%]; p < 0.001). TEE monitoring in CABG surgery was not associated with a lower incidence of acute kidney injury or decreased length of hospitalization. These findings highlight the importance of additional work to study the clinical effectiveness of TEE in CABG surgery. [ABSTRACT FROM AUTHOR]

To describe recent trends in post-acute care provision within nursing homes, focusing specifically on nursing homes' degree of specialization in post-acute care. Retrospective cohort study. All US nursing homes between 2001 and 2017 and all fee-for-service Medicare admissions to nursing homes for post-acute care during that time. We measured post-acute care specialization as annual Medicare admissions per bed for each nursing home and examined changes in the distribution of specialization across nursing homes over the study period. We described the characteristics of nursing homes and the patients they serve based on degree of specialization. The average number of Medicare admissions per bed increased from 1.2 in 2001 to 1.6 in 2017, a relative increase of 41%. This upward trend in the number of Medicare admissions per bed was largest among new nursing homes (those established after 2001), increasing 68% from 2001 to 2017. In contrast, nursing homes that eventually closed during the study period experienced no meaningful growth in the number of admissions per bed. Over time, the number of Medicare admissions per bed increased among highly specialized nursing homes. The number of Medicare admissions per bed grew by 66% at the 95th percentile and by 25% at the 99th percentile. Nursing homes delivering the most post-acute care were more likely to be for-profit or part of a chain, had higher staffing levels, and were less likely to admit patients who were Black, Hispanic, or dually enrolled in Medicare and Medicaid. Over the last 2 decades, post-acute care has become increasingly concentrated in a subset of nursing homes, which tend to be for-profit, part of a chain, and less likely to serve racial and ethnic minorities and persons on Medicaid. Although these nursing homes may benefit financially from higher Medicare payment, it may come at the expense of equitable access and patient care. [ABSTRACT FROM AUTHOR]

Background: Asthma quality assessment often focuses on controller medication use, yet claims-based studies find conflicting associations between this care process and clinical outcomes. Objective: We sought to compare the association between 3 controller-based quality measures and asthma exacerbations to gain better understanding of how processes of care are related to clinical outcomes. Methods: Identifying a cohort of Medicaid beneficiaries with persistent asthma by using Healthcare Effectiveness Data and Information Set (HEDIS) criteria for asthma in 2001–2002 in California and New York, we assessed 3 asthma quality metrics in 2002: (1) the current HEDIS measure of at least 1 controller medication filling; (2) at least 4 controller medication prescription fillings; and (3) a controller-to-total asthma medication ratio of at least 0.5. We calculated the odds of having an asthma exacerbation in 2003 as a function of performance on each quality metric, adjusting for race, sex, age, and prior outpatient and acute care use for asthma. Results: Of 90,909 subjects with persistent asthma in California (48.1%) and New York (51.9%), those who obtained at least 1 or at least 4 controller medications had increased likelihood of poor outcomes (adjusted odds ratios, 1.80 [95% CI, 1.73–1.87] and 1.44 [95% CI 1.40–1.48], respectively). Beneficiaries meeting the controller-to-total asthma medication ratio measure were 23.0% less likely to have exacerbations (adjusted odds ratio, 0.77 [95% CI, 0.75-0.80]). Conclusions: A higher controller medication ratio indicated a lower likelihood of asthma exacerbations, whereas assessing the number of controller medication–dispensing events was associated with a higher odds of exacerbation. [Copyright &y& Elsevier]

The decline in the number of medical students choosing to enter the field of child neurology is a concern. We undertook this study to learn more about the qualities of highly regarded medical schools that may play a role in attracting students to the field of child neurology. We surveyed child neurologists at top U.S. medical schools that were most successful and least successful at attracting students to child neurology to determine what factors influenced the number of students entering the field of child neurology. We determined that the medical schools that produced the most child neurologists had stronger neuroscience curricula, stronger academic reputations, and larger Divisions of Child Neurology. Our findings suggest that our attention should be focused on academic centers that have more resources to create an atmosphere that is appealing to prospective applicants. These schools should implement a curriculum in neuroscience and child neurology that specifically exposes students early and maintains their interest in the field of child neurology. [Copyright &y& Elsevier]

Background & Aims Gastrointestinal bleeding results in significant morbidity, mortality, and healthcare costs in the United States. The Center for Medicare and Medicaid Services' payment reform programs assess quality and value based on rates of hospital readmission for patients with gastrointestinal bleeding, but they identify these patients using Medicare Severity Diagnosis Related Groups (MS-DRGs), which include many types of gastrointestinal bleeding and do not account for the clinical heterogeneity among these patients. We aimed to characterize heterogeneity in outcomes of subgroups of patients with gastrointestinal bleeding. Methods We performed was a cross-sectional, claims-based retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding in 2014 (159,000 hospitalizations). The primary outcome was unplanned readmission within 30 days of discharge from the hospital (30-day readmission). Secondary outcomes included length of stay, inpatient mortality, and death within 30 days of admission to the hospital (30-day mortality). Analyses were adjusted for age, sex, race, and Elixhauser comorbidities using logistic and Poisson regression, adjusting for clustering within hospitals. Results The 30-day readmission rate was 16.0%. Readmission rates varied among patients with different types of gastrointestinal bleeding, ranging from 13.5% for diverticular bleeding to 18.6% for small bowel bleeding. The mean length of stay was 4.2 days and 30-day mortality was 6.9% (ranging from 3.4% for diverticular bleeding to 12.1% for upper gastrointestinal bleeding not otherwise specified). When hospitalizations were stratified by MS-DRGs, the main source of variation in rates of readmission and mortality was MS-DRGs. Conclusions In a retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding, we found that 16% of these patients are readmitted to the hospital. Rates of hospital readmission, length of stay, and mortality vary with type of gastrointestinal bleeding, but MS-DRGs account for the largest source of variation. Policies focused on quality and value should account for this heterogeneity. [ABSTRACT FROM AUTHOR]

Increasing recognition of the adverse events older adults experience in post-acute care in skilled nursing facilities (SNFs) has led to multiple efforts to improve care integration between hospitals and SNFs. We sought to measure current care integration activities between hospitals and SNFs. Cross-sectional survey. A total of 500 randomly selected Medicare-certified SNFs in the United States in 2019. The survey inquired about 12 care integration activities with the 2 highest volume referring hospitals for each SNF. We collapsed survey responses into 5 categories of integration based on high correlations between the individual measures. These were: (1) formal integration (co-location or co-ownership); (2) informal integration (eg, formal affiliation, participation in SNF collaborative, shared pay for performance, or clinical leadership meetings between hospital and SNF); (3) shared quality/safety activities (eg, initiatives to improve medication safety or reduce hospital admission); (4) shared care coordinators; and/or (5) shared supervising clinicians. We then conducted multivariate regressions to examine associations between different care integration activities and hospital/SNF characteristics. Our overall response rate was 53.0%, including 265 SNFs that represented 487 SNF-hospital pairs. Informal integration was most common (in 53.3% of pairs), whereas shared clinicians (43.0%), care coordinators (36.5%), shared quality/safety activities (35.1%), and formal integration (7.4%) were present in a minority. Hospital-SNF pairs had lower odds of being formally integrated if the SNF was for-profit compared with not-for-profit [odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03–0.42, adjusted P =.04)] and higher odds of sharing quality improvement activities in metropolitan rather than rural areas (OR 4.06, 95% CI 1.80–9.17, adjusted P =.02) and in the Midwest compared with West (OR 2.95, 95% CI 1.44–6.06, adjusted P =.049). These findings raise important questions about what is driving variability in hospital-SNF integration activities, and which activities may be most effective for improving transitional care outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Little is known about how patient–clinician communication leads to better outcomes. Among patients with diabetes, we describe patient-reported use of collaborative goal setting and evaluate whether perceived competency and physician trust mediate the association between collaborative goal setting and glycemic control. Methods: Data from a patient survey administered in 2008 to a cohort of insured patients aged 18+ years with diabetes who initiated oral mono-therapy between 2000 and 2005 were joined with pharmaceutical claims data for the prior 12 months and laboratory data for the prior and subsequent 12 months (N =1065). A structural equation model (SEM) was used to test mediation models controlling for baseline HbA1c. Results: The hypothesized mediation model was supported. Patient-reported use of more collaborative goal setting was associated with greater perceived self-management competency and increased level of trust in the physician (p <0.05). In turn, both greater perceived competence and increased trust were associated with increased control (p <0.05). Conclusions: Findings indicate that engaging patients in collaborative goal setting during clinical encounters has potential to foster a trusting patient–clinician relationship as well as enhance patient perceived competence, thereby improving clinical control. Practice implications: Fostering collaborative goal setting may yield payoffs in improved clinical outcomes among patients with diabetes. [Copyright &y& Elsevier]