Publications by authors named "Karen E Joynt Maddox"

120 Publications

Changes In Non-COVID-19 Emergency Department Visits By Acuity And Insurance Status During The COVID-19 Pandemic.

Health Aff (Millwood) 2021 06;40(6):896-903

Karen E. Joynt Maddox is an assistant professor in the John T. Milliken Department of Internal Medicine, Washington University School of Medicine, and codirector of the Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis.

Prior studies suggest that the COVID-19 pandemic was associated with decreases in emergency department (ED) volumes, but it is not known whether these decreases varied by visit acuity or by demographic and socioeconomic risk factors. In this study of more than one million non-COVID-19 visits to thirteen EDs in a large St. Louis, Missouri, health system, we observed an overall 35 percent decline in ED visits. The decrease in medical and surgical visits ranged from 40 percent to 52 percent across acuity levels, with no statistically significant differences between higher- and lower-acuity visits after correction for multiple comparisons. Mental health visits saw a smaller decrease (-32 percent), and there was no decrease for visits due to substance use. Medicare patients had the smallest decrease in visits (-31 percent) of the insurance groups; privately insured (-46 percent) and Medicaid (-44 percent) patients saw larger drops. There were no observable differences in ED visit decreases by race. These findings can help inform interventions to ensure that people requiring timely ED care continue to seek it and to improve access to lower-risk alternative settings of care where appropriate.
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http://dx.doi.org/10.1377/hlthaff.2020.02464DOI Listing
June 2021

Ambulatory Care Access And Emergency Department Use For Medicare Beneficiaries With And Without Disabilities.

Health Aff (Millwood) 2021 Jun;40(6):910-919

Harold A. Pollack is the Helen Ross Professor in the School of Social Service Administration, University of Chicago, in Chicago, Illinois.

Establishing care with primary care and specialist clinicians is critical for Medicare beneficiaries with complex care needs. However, beneficiaries with disabilities may struggle to access ambulatory care. This study uses the 2015-17 national Medicare Current Beneficiary Survey linked to claims and administrative data to explore these questions. Medicare beneficiaries (ages 21-64) with disabilities were 119 percent more likely to report difficulty accessing care and were 33 percent and 49 percent more likely to lack annual clinician evaluation and management visits for primary and specialty care, respectively, than those without disabilities. Beneficiaries (ages 21-64) with disabilities also had 42 percent, 67 percent, and 77 percent higher likelihood of having all-cause, nonemergent, and preventable emergency department (ED) visits. Furthermore, people with both a disability and a lack of specialist evaluation and management visits also had 21 percent, 48 percent, and 64 percent increased likelihood of all-cause, nonemergent, and preventable ED visits. Barriers to accessing ambulatory care may be a key contributor to the reliance of Americans with disabilities on ED services.
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http://dx.doi.org/10.1377/hlthaff.2020.01891DOI Listing
June 2021

Racial and Ethnic Disparities in Heart and Cerebrovascular Disease Deaths During the COVID-19 Pandemic in the United States.

Circulation 2021 06 18;143(24):2346-2354. Epub 2021 May 18.

Cardiovascular Division, Washington University School of Medicine, Saint Louis, MO (K.E.J.M.).

Background: Cardiovascular deaths increased during the early phase of the COVID-19 pandemic in the United States. However, it is unclear whether diverse racial/ethnic populations have experienced a disproportionate rise in heart disease and cerebrovascular disease deaths.

Methods: We used the National Center for Health Statistics to identify heart disease and cerebrovascular disease deaths for non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic individuals from March to August 2020 (pandemic period), as well as for the corresponding months in 2019 (historical control). We determined the age- and sex-standardized deaths per million by race/ethnicity for each year. We then fit a modified Poisson model with robust SEs to compare change in deaths by race/ethnicity for each condition in 2020 versus 2019.

Results: There were a total of 339 076 heart disease and 76 767 cerebrovascular disease deaths from March through August 2020, compared with 321 218 and 72 190 deaths during the same months in 2019. Heart disease deaths increased during the pandemic in 2020, compared with the corresponding period in 2019, for non-Hispanic White (age-sex standardized deaths per million, 1234.2 versus 1208.7; risk ratio for death [RR], 1.02 [95% CI, 1.02-1.03]), non-Hispanic Black (1783.7 versus 1503.8; RR, 1.19 [95% CI, 1.17-1.20]), non-Hispanic Asian (685.7 versus 577.4; RR, 1.19 [95% CI, 1.15-1.22]), and Hispanic (968.5 versus 820.4; RR, 1.18 [95% CI, 1.16-1.20]) populations. Cerebrovascular disease deaths also increased for non-Hispanic White (268.7 versus 258.2; RR, 1.04 [95% CI, 1.03-1.05]), non-Hispanic Black (430.7 versus 379.7; RR, 1.13 [95% CI, 1.10-1.17]), non-Hispanic Asian (236.5 versus 207.4; RR, 1.15 [95% CI, 1.09-1.21]), and Hispanic (264.4 versus 235.9; RR, 1.12 [95% CI, 1.08-1.16]) populations. For both heart disease and cerebrovascular disease deaths, Black, Asian, and Hispanic populations experienced a larger relative increase in deaths than the non-Hispanic White population (interaction term, <0.001).

Conclusions: During the COVID-19 pandemic in the United States, Black, Hispanic, and Asian populations experienced a disproportionate rise in deaths caused by heart disease and cerebrovascular disease, suggesting that these groups have been most impacted by the indirect effects of the pandemic. Public health and policy strategies are needed to mitigate the short- and long-term adverse effects of the pandemic on the cardiovascular health of diverse populations.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.121.054378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191372PMC
June 2021

Kidney Function and Outcomes in Patients Hospitalized with Heart Failure.

J Am Coll Cardiol 2021 May 4. Epub 2021 May 4.

Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Background: Few contemporary data exist evaluating care patterns and outcomes in HF across the spectrum of kidney function.

Objectives: To characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction.

Methods: We evaluated quality metrics among patients hospitalized with HF at 418 sites in the GWTG-HF registry from 2014-2019 by discharge CKD-EPI-derived eGFR. We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality.

Results: Among 365,494 hospitalizations (age 72±15y, LVEF 43±17%), median discharge eGFR was 51(34-72) mL/min/1.73m, 234,332 (64%) had eGFR<60 mL/min/1.73m, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014-2019. Among 157,439 patients with HFrEF(≤40%), discharge guideline-directed medical therapies, including β-blockers, were lowest in discharge eGFR<30 mL/min/1.73m or dialysis (P<0.001). "Triple therapy" with ACE inhibitor/ARB/ARNI+β-blocker+MRA was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m and dialysis, respectively; P<0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; P<0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger in HFrEF compared with HF with mid-range or preserved EF (P=0.045).

Conclusion: Despite facing elevated risks of mortality, patients with comorbid HFrEF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.
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http://dx.doi.org/10.1016/j.jacc.2021.05.002DOI Listing
May 2021

Predictors of Success in the Bundled Payments for Care Improvement Program.

J Gen Intern Med 2021 May 4. Epub 2021 May 4.

Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.

Background: Hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program were incented to reduce Medicare payments for episodes of care.

Objective: To identify factors that influenced whether or not hospitals were able to save in the BPCI program, how the cost of different services changed to produce those savings, and if "savers" had lower or decreased quality of care.

Design: Retrospective cohort study.

Participants: BPCI-participating hospitals.

Main Measures: We designated hospitals that met the program goal of decreasing costs by at least 2% from baseline in average Medicare payments per 90-day episode as "savers." We used regression models to determine condition-level, patient-level, hospital-level, and market-level characteristics associated with savings.

Key Results: In total, 421 hospitals participated in BPCI, resulting in 2974 hospital-condition combinations. Major joint replacement of the lower extremity had the highest proportion of savers (77.6%, average change in payments -$2235) and complex non-cervical spinal fusion had the lowest (22.2%, average change +$8106). Medical conditions had a higher proportion of savers than surgical conditions (11% more likely to save, P=0.001). Conditions that were mostly urgent/emergent had a higher proportion of savers than conditions that were mostly elective (6% more likely to save, P=0.007). Having higher than median costs at baseline was associated with saving (OR: 3.02, P<0.001). Hospitals with more complex patients were less likely to save (OR: 0.77, P=0.003). Savings occurred across both inpatient and post-acute care, and there were no decrements in clinical care associated with being a saver.

Conclusions: Certain conditions may be more amenable than others to saving under bundled payments, and hospitals with high costs at baseline may perform well under programs which use hospitals' own baseline costs to set targets. Findings may have implications for the BPCI-Advanced program and for policymakers seeking to use payment models to drive improvements in care.
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http://dx.doi.org/10.1007/s11606-021-06820-7DOI Listing
May 2021

Adjusting Quality Measures For Social Risk Factors Can Promote Equity In Health Care.

Health Aff (Millwood) 2021 04;40(4):637-644

Laurent G. Glance is vice chair for research and a professor in the Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, in Rochester, New York.

Risk adjustment of quality measures using clinical risk factors is widely accepted; risk adjustment using social risk factors remains controversial. We argue here that social risk adjustment is appropriate and necessary in defined circumstances and that social risk adjustment should be the default option when there are valid empirical arguments for and against adjustment for a given measure. Social risk adjustment is an important way to avoid exacerbating inequity in the health care system.
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http://dx.doi.org/10.1377/hlthaff.2020.01764DOI Listing
April 2021

The association between state-level abortion restrictions and maternal mortality in the United States, 1995-2017.

Contraception 2021 Mar 26. Epub 2021 Mar 26.

Section of Acute and Critical Care Surgery, Division of General Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA. Electronic address:

Objective: To explore the relationship between abortion restrictions and maternal mortality in the United States.

Study Design: This was a retrospective study examining maternal mortality in the United States from 1995 to 2017. We used the Global Health Data Exchange and the Centers for Disease Control and Prevention WONDER databases to extract maternal mortality data for all 50 states for each year from 1995 to 2017. We categorized states as restrictive, neutral, or protective of abortion access according to policy information published by the Guttmacher Institute. We assessed associations between abortion restrictions and maternal mortality ratios (maternal deaths per 100,000 live births).

Results: In 1995, the mean maternal mortality ratios were similar across all groups of states (Restrictive 12.6, 95% CI 11.4-13.6; Neutral 12.2, 95% CI 10.9-13.4; Protective 10.9, 95% CI 9.6-11.9). Maternal mortality ratios increased for each group of states over time and in 2017, the mean maternal mortality ratio was higher in restrictive states than in protective states (Restrictive 28.5, 95% CI 20.7-35.1; Neutral 22.9, 95% CI 16.1-28.6; Protective 15.7, 95% CI 10.7-19.9). Regressions accounting for policy, state and year showed a statistically significant increase in maternal mortality ratios in restrictive states relative to neutral states (1.06, 95% CI 1.01-1.11) and a non-significant decrease associated with protective states (0.89, 95% CI 0.78-1.01).

Conclusions: States that restrict abortion have higher maternal mortality than states that either protect or are neutral towards abortion. Further investigation is needed to determine how abortion restrictions are associated with increased maternal mortality.

Implications: The association between abortion restrictions and maternal mortality may reflect the overall legislative priorities of individual states as restrictive states are less likely to pass proactive legislation demonstrated to improve maternal outcomes.
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http://dx.doi.org/10.1016/j.contraception.2021.03.018DOI Listing
March 2021

Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association.

Circulation 2021 Apr 25;143(17):e875-e891. Epub 2021 Mar 25.

Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.
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http://dx.doi.org/10.1161/CIR.0000000000000967DOI Listing
April 2021

Value-Based Cardiovascular Care: Developing Cost Measures for Percutaneous Coronary Intervention.

Circ Cardiovasc Qual Outcomes 2021 Mar 3;14(3):e007753. Epub 2021 Mar 3.

Department of Health Management and Policy, College for Public Health and Social Justice (K.J.), Saint Louis University, St. Louis, MO.

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http://dx.doi.org/10.1161/CIRCOUTCOMES.121.007753DOI Listing
March 2021

Persistent challenges of COVID-19 in skilled nursing facilities: The administrator perspective.

J Am Geriatr Soc 2021 04 21;69(4):875-878. Epub 2021 Feb 21.

Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1111/jgs.17062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014766PMC
April 2021

Rural-Urban Disparities In All-Cause Mortality Among Low-Income Medicare Beneficiaries, 2004-17.

Health Aff (Millwood) 2021 02;40(2):289-296

Rishi K. Wadhera is an assistant professor of medicine at Harvard Medical School and an investigator at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center.

There is growing concern about the health of older US adults who live in rural areas, but little is known about how mortality has changed over time for low-income Medicare beneficiaries residing in rural areas compared with their urban counterparts. We evaluated whether all-cause mortality rates changed for rural and urban low-income Medicare beneficiaries dually enrolled in Medicaid, and we studied disparities between these groups. The study cohort included 11,737,006 unique dually enrolled Medicare beneficiaries. Between 2004 and 2017 all-cause mortality declined from 96.6 to 92.7 per 1,000 rural beneficiaries (relative percentage change: -4.0 percent). Among urban beneficiaries, declines in mortality were more pronounced (from 86.9 to 72.8 per 1,000 beneficiaries, a relative percentage change of -16.2 percent). The gap in mortality between rural and urban beneficiaries increased over time. Rural mortality rates were highest in East North Central states and increased modestly in West North Central states during the study period. Public health and policy efforts are urgently needed to improve the health of low-income older adults living in rural areas.
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http://dx.doi.org/10.1377/hlthaff.2020.00420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168613PMC
February 2021

Comparing Preventable Acute Care Use of Rural Versus Urban Americans: an Observational Study of National Rates During 2008-2017.

J Gen Intern Med 2021 Jan 28. Epub 2021 Jan 28.

Cardiovascular Division, Washington University School of Medicine , 660 S. Euclid Ave, CB 8086, St. Louis, MO, 63110, USA.

Background: Rural Americans have less access to care than urban Americans. Preventable acute care use is a marker of unmet ambulatory healthcare needs, but little is known about how such utilization has differed between rural and urban areas over time.

Objective: Compare preventable emergency department (ED) visit and hospitalization rates among rural versus urban residents over the past decade.

Design: Observational study using a validated algorithm to compute age-sex-adjusted rates per 100,000 individuals of preventable ED visits and hospitalizations. Differences in overall, annual, and condition-specific rates for rural versus urban residents were assessed and linear regression was used to assess 10-year trends.

Setting: Nationwide Emergency Department Sample, National Inpatient Sample, and US Census, 2008-2017.

Participants: US adults, an annual average of 241.3 million individuals.

Measurements: Preventable ED visits and hospitalizations.

Results: Compared to urban residents, rural residents had 45% higher rates of preventable ED visits in 2008 (3003 vs. 2070 per 100,000, adjusted difference [AD]: 933; 95% CI: 928-938) and 44% higher rates of preventable ED visits in 2017 (3911 vs. 2708 per 100,000, AD: 1202; 95% CI: 1196-1208). Rural residents had 26% higher rates of preventable hospitalizations in 2008 (2104 vs. 1666 per 100,000, AD: 439; 95% CI: 434-443) and 13% higher rates in 2017 (1634 vs. 1440 per 100,000, AD: 194; 95% CI: 190-199). Preventable ED visits increased more in absolute terms in rural versus urban residents, but the percentage increase was similar (30% vs. 31%) because rural residents started at a higher baseline. Preventable hospitalizations decreased at a faster rate (22% vs. 14%) among rural versus urban residents.

Limitations: Observational study; unable to infer causality.

Conclusions: Rural disparities in acute care use are narrowing for preventable hospitalizations but have persisted for all preventable acute care use, suggesting unmet demand for high-quality ambulatory care in rural areas.
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http://dx.doi.org/10.1007/s11606-020-06532-4DOI Listing
January 2021

Physician Performance in the Medicare Merit-based Incentive Payment System-Reply.

JAMA 2021 01;325(3):309

Washington University Center for Health Economics and Policy, Washington University School of Medicine, St Louis, Missouri.

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http://dx.doi.org/10.1001/jama.2020.22810DOI Listing
January 2021

COVID-19 and Outpatient Parenteral Antimicrobial Therapy.

Ann Intern Med 2021 01;174(1):142

Washington University School of Medicine and Washington University Institute for Public Health, St. Louis, Missouri.

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http://dx.doi.org/10.7326/L20-1347DOI Listing
January 2021

Essential but Undefined - Reimagining How Policymakers Identify Safety-Net Hospitals.

N Engl J Med 2020 Dec 23;383(27):2593-2595. Epub 2020 Dec 23.

From the Department of Medicine, Perelman School of Medicine, and the Leonard Davis Institute of Health Economics, University of Pennsylvania - both in Philadelphia (P.C.); the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, and the Department of Medicine, Brigham and Women's Hospital - both in Boston (B.D.S.); and the Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, and the Center for Health Economics and Policy, Washington University in St. Louis - both in St. Louis (K.E.J.M.).

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http://dx.doi.org/10.1056/NEJMp2030228DOI Listing
December 2020

Sociodemographic differences in utilization and outcomes for temporary cardiovascular mechanical support in the setting of cardiogenic shock.

Am Heart J 2021 Jun 26;236:87-96. Epub 2021 Feb 26.

Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO; Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO. Electronic address:

Background: Temporary mechanical circulatory support (MCS) devices are increasingly used in cardiogenic shock, but whether sociodemographic differences by sex, race and/or ethnicity, insurance status, and neighborhood poverty exist in the utilization of these devices is unknown.

Methods: Retrospective cross-sectional study using the National Inpatient Sample for 2012-2017. Logistic regression models were used to examine predictors of use of temporary MCS devices and for in-hospital mortality, clustering by hospital-year.

Results: Our study population included 109,327 admissions for cardiogenic shock. Overall, 14.3% of admissions received an intra-aortic balloon pump, 4.2% a percutaneous ventricular assist device, and 1.8% extracorporeal membranous oxygenation (ECMO). After adjusting for age, comorbidities, and hospital characteristics, use of temporary MCS was lower in women compared to men (adjusted odds ratio [aOR] = 0.76, P < .001), Black patients compared to white ones (aOR = 0.73, P < .001), those insured by Medicare (aOR = 0.75, P < .001), Medicaid (aOR = 0.74, P < .001), or uninsured (aOR = 0.90, P = .015) compared to privately insured, and those in the lowest income neighborhoods (aOR = 0.94, P = .003) versus other neighborhoods. Women, admissions covered by Medicare, Medicaid, or uninsured, and those from low-income neighborhoods also had higher mortality rates even after adjustment for MCS implantation.

Conclusions: There are differences in the use of temporary MCS in the setting of cardiogenic shock among specific populations within the United States. The growing use of MCS for treating cardiogenic shock highlights the need to better understand its impact on outcomes.
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http://dx.doi.org/10.1016/j.ahj.2020.12.014DOI Listing
June 2021

Association of Stratification by Proportion of Patients Dually Enrolled in Medicare and Medicaid With Financial Penalties in the Hospital-Acquired Condition Reduction Program.

JAMA Intern Med 2021 Mar;181(3):330-338

Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri.

Importance: The Hospital-Acquired Condition Reduction Program (HACRP) is a value-based payment program focused on safety events. Prior studies have found that the program disproportionately penalizes safety-net hospitals, which may perform more poorly because of unmeasured severity of illness rather than lower quality. A similar program, the Hospital Readmissions Reduction Program, stratifies hospitals into 5 peer groups for evaluation based on the proportion of their patients dually enrolled in Medicare and Medicaid, but the effect of stratification on the HACRP is unknown.

Objective: To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification.

Design, Setting, And Participants: This economic evaluation used publicly available data on HACRP performance and penalties merged with hospital characteristics and cost reports. A total of 3102 hospitals participating in the HACRP in fiscal year 2020 (covering data from July 1, 2016, to December 31, 2018) were studied.

Exposures: Hospitals were divided into 5 groups based on the proportion of patients dually enrolled, and penalties were assigned to the lowest-performing quartile of hospitals in each group rather than the lowest-performing quartile overall.

Main Outcomes And Measures: Penalties in the prestratification vs poststratification schemes.

Results: The study identified 3102 hospitals evaluated by the HACRP. Safety-net hospitals received $111 333 384 in penalties before stratification compared with an estimated $79 087 744 after stratification-a savings of $32 245 640. Hospitals less likely to receive penalties after stratification included safety-net hospitals (33.6% penalized before stratification vs 24.8% after stratification, Δ = -8.8 percentage points [pp], P < .001), public hospitals (34.1% vs 30.5%, Δ = -3.6 pp, P = .003), hospitals in the West (26.8% vs 23.2%, Δ = -3.6 pp, P < .001), hospitals in Medicaid expansion states (27.3% vs 25.6%, Δ = -1.7 pp, P = .003), and hospitals caring for the most patients with disabilities (32.2% vs 28.3%, Δ = -3.9 pp, P < .001) and from racial/ethnic minority backgrounds (35.1% vs 31.5%, Δ = -3.6 pp, P < .001). In multivariate analyses, safety-net status and treating patients with highly medically complex conditions were associated with higher odds of moving from penalized to nonpenalized status.

Conclusions And Relevance: This economic evaluation suggests that stratification of hospitals would be associated with a narrowing of disparities in penalties and a marked reduction in penalties for safety-net hospitals. Policy makers should consider adopting stratification for the HACRP.
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http://dx.doi.org/10.1001/jamainternmed.2020.7386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754078PMC
March 2021

Building a Better Clinician Value-Based Payment Program in Medicare.

JAMA 2021 Jan;325(2):129-130

Washington University Center for Health Economics and Policy, Washington University School of Medicine in St Louis, St Louis, Missouri.

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http://dx.doi.org/10.1001/jama.2020.22924DOI Listing
January 2021

Trends in Diagnosis Related Groups for Inpatient Admissions and Associated Changes in Payment From 2012 to 2016.

JAMA Netw Open 2020 12 1;3(12):e2028470. Epub 2020 Dec 1.

Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.

Importance: Hospitals are reimbursed based on Diagnosis Related Groups (DRGs), which are defined, in part, by patients having 1 or more complications or comorbidities within a given DRG family. Hospitals have made substantial investment in efforts to document these complications and comorbidities.

Objective: To examine temporal trends in DRGs with a major complication or comorbidity, compare these findings with 2 alternative measures of disease severity, and estimate associated changes in payment.

Design, Setting, And Participants: This retrospective cohort study used data from the all-payer National Inpatient Sample for admissions assigned to 1 of the top 20 reimbursed DRG families at US acute care hospitals from January 1, 2012, to December 31, 2016. Data were analyzed from July 10, 2018, to May 29, 2019.

Exposures: Quarter year of hospitalization.

Main Outcomes And Measures: The primary outcome was the proportion of DRGs with a major complication or comorbidity. Secondary outcomes were comorbidity scores, risk-adjusted mortality rates, and estimated payment. Changes in assigned DRGs, comorbidity scores, and risk-adjusted mortality rates were analyzed by linear regression. Payment changes were estimated for each DRG by calculating the Centers for Medicare & Medicaid Services weighted payment using 2012 and 2016 case mix and hospitalization counts.

Results: Between 2012 and 2016, there were 62 167 976 hospitalizations for the 20 highest-reimbursed DRG families; the sample was 32.9% male and 66.8% White, with a median age of 57 years (interquartile range, 31-73 years). Within 15 of these DRG families (75%), the proportion of DRGs with a major complication or comorbidity increased significantly over time. Over the same period, comorbidity scores were largely stable, with a decrease in 6 DRG families (30%), no change in 10 (50%), and an increase in 4 (20%). Among 19 DRG families with a calculable mortality rate, the risk-adjusted mortality rate significantly decreased in 8 (42%), did not change in 9 (47%), and increased in 2 (11%). The observed DRG shifts were associated with at least $1.2 billion in increased payment.

Conclusions And Relevance: In this cohort study, between 2012 and 2016, the proportion of admissions assigned to a DRG with major complication or comorbidity increased for 15 of the top 20 reimbursed DRG families. This change was not accompanied by commensurate increases in disease severity but was associated with increased payment.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.28470DOI Listing
December 2020

Severe Maternal Morbidity, Race, and Rurality: Trends Using the National Inpatient Sample, 2012-2017.

J Womens Health (Larchmt) 2021 Jun 19;30(6):837-847. Epub 2020 Nov 19.

Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.

Severe maternal morbidity is related to maternal mortality and an important measure of maternal health outcomes. Our objective was to evaluate differences in rates of severe maternal morbidity and mortality (SMM&M) by rurality and race, and examine these trends over time. It involves the retrospective cohort study of delivery hospitalizations from January 1, 2012 to December 31, 2017 from the National Inpatient Sample. We identified delivery hospitalizations using International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis and procedure codes and diagnosis-related groups. We used hierarchical regression models controlling for insurance status, income, age, comorbidities, and hospital characteristics to model odds of SMM&M. The eligible cohort contained 4,494,089 delivery hospitalizations. Compared with women from small cities, women in the most urban and most rural areas had higher odds of SMM&M (urban adjusted odds ratio [aOR] 1.09, 95% confidence interval [1.04-1.14]; noncore rural aOR 1.24 [1.18-1.31]). Among White women, the highest odds of SMM&M were in noncore rural counties (aOR 1.20 [1.12-1.27]), while among Black women the highest odds were in urban (aOR 1.21 [1.11-1.31]) and micropolitan areas (aOR 1.36 [1.19-1.57]). Findings were similar for Hispanic, Native American, and other race women. Rates of SMM&M increased from 2012 to 2017, especially among urban patients. Women in the most urban and most rural counties experienced higher odds of SMM&M, and these relationships differed by race. These findings suggest particular areas for clinical leaders and policymakers to target to reduce geographic and racial disparities in maternal outcomes.
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http://dx.doi.org/10.1089/jwh.2020.8606DOI Listing
June 2021

Applicability of US Food and Drug Administration Labeling for Dapagliflozin to Patients With Heart Failure With Reduced Ejection Fraction in US Clinical Practice: The Get With the Guidelines-Heart Failure (GWTG-HF) Registry.

JAMA Cardiol 2020 Nov 13. Epub 2020 Nov 13.

Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles.

Importance: In May 2020, dapagliflozin was approved by the US Food and Drug Administration (FDA) as the first sodium-glucose cotransporter 2 inhibitor for heart failure with reduced ejection fraction (HFrEF), based on the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial. Limited data are available characterizing the generalizability of dapagliflozin to US clinical practice.

Objective: To evaluate candidacy for initiation of dapagliflozin based on the FDA label among contemporary patients with HFrEF in the US.

Design, Setting, And Participants: This cohort study included 154 714 patients with HFrEF (left ventricular ejection fraction ≤40%) hospitalized at 406 sites in the Get With the Guidelines-Heart Failure (GWTG-HF) registry admitted between January 1, 2014, and September 30, 2019. Patients who left against medical advice, transferred to an acute care facility or to hospice, or had missing data were excluded. The FDA label (which excluded patients with an estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2, those undergoing dialysis, and those with type 1 diabetes) was applied to the GWTG-HF registry sample. Data analyses were conducted from April 1 to June 30, 2020.

Main Outcomes And Measures: The proportion of patients hospitalized with HFrEF who would be candidates for dapagliflozin under the FDA label.

Results: Among 154 714 patients hospitalized with HFrEF, 125 497 (81.1%; 83 481 men [66.5%]; mean [SD] age, 68 [15] years) would be candidates for dapagliflozin according to the FDA label. Across 355 sites with patients with 10 or more hospitalizations, the median proportion of candidates for dapagliflozin according to the FDA label was 81.1% (interquartile range, 77.8%-84.6%) at each site. This proportion was similar across all study years (interquartile range, 80.4%-81.7%) and was higher among those without type 2 diabetes than with type 2 diabetes (85.5% vs 75.6%). Among GWTG-HF participants, the most frequent reason for not meeting the FDA label criteria was eGFR less than 30 mL/min/1.73 m2 at discharge (18.5%). Among 75 654 patients with available paired admission and discharge data, 14.2% had an eGFR less than 30 mL/min/1.73 m2 at both time points, while 3.8% developed an eGFR less than 30 mL/min/1.73 m2 by discharge. Although there were more older adults, women, and Black patients in the GWTG-HF registry than in the DAPA-HF trial, most clinical characteristics were qualitatively similar between the 2 groups. Compared with the DAPA-HF trial cohort, there was lower use of evidence-based HF therapies among patients in GWTG-HF.

Conclusions And Relevance: These data from a large, contemporary US registry of patients hospitalized with heart failure suggest that 4 of 5 patients with HFrEF (with or without type 2 diabetes) would be candidates for initiation of dapagliflozin, supporting its broad generalizability to US clinical practice.
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http://dx.doi.org/10.1001/jamacardio.2020.5864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666432PMC
November 2020

Association of Skilled Nursing Facility Participation in a Bundled Payment Model With Institutional Spending for Joint Replacement Surgery.

JAMA 2020 11;324(18):1869-1877

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: Medicare recently concluded a national voluntary payment demonstration, Bundled Payments for Care Improvement (BPCI) model 3, in which skilled nursing facilities (SNFs) assumed accountability for patients' Medicare spending for 90 days from initial SNF admission. There is little evidence on outcomes associated with this novel payment model.

Objective: To evaluate the association of BPCI model 3 with spending, health care utilization, and patient outcomes for Medicare beneficiaries undergoing lower extremity joint replacement (LEJR).

Design, Setting, And Participants: Observational difference-in-difference analysis using Medicare claims from 2013-2017 to evaluate the association of BPCI model 3 with outcomes for 80 648 patients undergoing LEJR. The preintervention period was from January 2013 through September 2013, which was 9 months prior to enrollment of the first BPCI cohort. The postintervention period extended from 3 months post-BPCI enrollment for each SNF through December 2017. BPCI SNFs were matched with control SNFs using propensity score matching on 2013 SNF characteristics.

Exposures: Admission to a BPCI model 3-participating SNF.

Main Outcomes And Measures: The primary outcome was institutional spending, a combination of postacute care and hospital Medicare-allowed payments. Additional outcomes included other categories of spending, changes in case mix, admission volume, home health use, length of stay, and hospital use within 90 days of SNF admission.

Results: There were 448 BPCI SNFs with 18 870 LEJR episodes among 16 837 patients (mean [SD] age, 77.5 [9.4] years; 12 173 [72.3%] women) matched with 1958 control SNFs with 72 005 LEJR episodes among 63 811 patients (mean [SD] age, 77.6 [9.4] years; 46 072 [72.2%] women) in the preintervention and postintervention periods. Seventy-nine percent of matched BPCI SNFs were for-profit facilities, 85% were located in an urban area, and 85% were part of a larger corporate chain. There were no systematic changes in patient case mix or episode volume between BPCI-participating SNFs and controls during the program. Institutional spending decreased from $17 956 to $15 746 in BPCI SNFs and from $17 765 to $16 563 in matched controls, a differential decrease of 5.6% (-$1008 [95% CI, -$1603 to -$414]; P < .001). This decrease was related to a decline in SNF days per beneficiary (from 26.2 to 21.3 days in BPCI SNFs and from 26.3 to 23.4 days in matched controls; differential change, -2.0 days [95% CI, -2.9 to -1.1]). There was no significant change in mortality or 90-day readmissions.

Conclusions And Relevance: Among Medicare patients undergoing lower extremity joint replacement from 2013-2017, the BPCI model 3 was significantly associated with a decrease in mean institutional spending on episodes initiated by admission to SNFs. Further research is needed to assess bundled payments in other clinical contexts.
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http://dx.doi.org/10.1001/jama.2020.19181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656279PMC
November 2020

Paying for Performance Improvement in Quality and Outcomes of Cardiovascular Care: Challenges and Prospects.

Methodist Debakey Cardiovasc J 2020 Jul-Sep;16(3):225-231

WASHINGTON UNIVERSITY SCHOOL OF MEDICINE, ST. LOUIS, MISSOURI.

Over the past two decades, Medicare and other payers have been looking at ways to base payment for cardiovascular care on the quality and outcomes of care delivered. Public reporting of hospital performance on a series of quality measures began in 2004 with basic processes of care such as aspirin use and influenza vaccination, and it expanded in later years to include outcomes such as mortality and readmission rates. Following the passage of the Affordable Care Act in March 2010, Medicare and other payers moved forward with pay-for-performance programs, more commonly referred to as value-based purchasing (VBP) programs. These programs are largely based on an underlying fee-for-service payment infrastructure and give hospitals and clinicians bonuses or penalties based on their performance. Another new payment mechanism, called alternative payment models (APMs), aims to move towards episode-based or global payments to improve quality and efficiency. The two most relevant APMs for cardiovascular care include Accountable Care Organizations and bundled payments. Both VBP programs and APMs have challenges related to program efficacy, accuracy, and equity. In fact, despite over a decade of progress in measuring and incentivizing high-quality care delivery within cardiology, major limitations remain. Many of the programs have had little benefit in terms of clinical outcomes yet have led to marked administrative burden for participants. However, there are several encouraging prospects to aid the successful implementation of value-based high-quality cardiovascular care, such as more sophisticated data science to improve risk adjustment and flexible electronic health records to decrease administrative burden. Furthermore, payment models designed specifically for cardiovascular care could incentivize innovative care delivery models that could improve quality and outcomes for patients. This review provides an overview of current efforts, largely at the federal level, to pay for high-quality cardiovascular care and discusses the challenges and prospects related to doing so.
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http://dx.doi.org/10.14797/mdcj-16-3-225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587319PMC
November 2020

Incorporating Patient Preferences Into Hospital Quality Metrics for Heart Failure.

JAMA Cardiol 2021 Feb;6(2):177-178

Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.

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http://dx.doi.org/10.1001/jamacardio.2020.4964DOI Listing
February 2021

Evaluation of Hospital Performance Using the Excess Days in Acute Care Measure in the Hospital Readmissions Reduction Program.

Ann Intern Med 2021 01 13;174(1):86-92. Epub 2020 Oct 13.

Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (R.K.W., B.E.L., C.S., R.W.Y.).

The Hospital Readmissions Reduction Program (HRRP) has penalized hospitals with higher 30-day readmission rates more than $3 billion to date. Clinicians and policy experts have raised concerns that the 30-day readmission measure used in this program provides an incomplete picture of performance because it does not capture all hospital encounters that may occur after discharge. In contrast, the excess days in acute care (EDAC) measure, which currently is not used in the HRRP, captures the full spectrum of hospital encounters (emergency department, observation stay, inpatient readmission) and their associated lengths of stay within 30 days of discharge. This study of 3173 hospitals that participated in the HRRP in fiscal year 2019 compared performance on the readmission and EDAC measures and evaluated whether using the EDAC measure would change hospitals' penalty status for 3 conditions targeted by the HRRP. Overall, only moderate agreement was found on hospital performance rankings by using the readmission and EDAC measures (weighted κ statistic: heart failure, 0.45 [95% CI, 0.42 to 0.47]; acute myocardial infarction [AMI], 0.37 [CI, 0.35 to 0.40]; and pneumonia, 0.50 [CI, 0.47 to 0.52]). Under the HRRP, the penalty status of 769 (27.0%) of 2845 hospitals for heart failure, 581 (28.3%) of 2055 for AMI, and 724 (24.9%) of 2911 for pneumonia would change if the EDAC measure were used instead of the readmission measure to evaluate performance. Fewer small and rural hospitals would receive penalties. The Centers for Medicare & Medicaid Services should consider using the EDAC measure, which provides a more comprehensive picture of postdischarge hospital use, rather than the 30-day readmission measure to evaluate health care system performance under federal quality, reporting, and value-based programs.
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http://dx.doi.org/10.7326/M20-3486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165741PMC
January 2021

CMS Quality Measure Development-Reply.

JAMA 2020 09;324(12):1214-1215

Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2020.12073DOI Listing
September 2020

Utilization of Social Determinants of Health ICD-10 Z-Codes Among Hospitalized Patients in the United States, 2016-2017.

Med Care 2020 12;58(12):1037-1043

Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, MO.

Background: The inclusion of Z-codes for social determinants of health (SDOH) in the 10th revision of the International Classification of Diseases (ICD-10) may offer an opportunity to improve data collection of SDOH, but no characterization of their utilization exists on a national all-payer level.

Objective: To examine the prevalence of SDOH Z-codes and compare characteristics of patients with and without Z-codes and hospitals that do and do not use Z-codes.

Research Design: Retrospective cohort study using 2016 and 2017 National Inpatient Sample.

Participants: Total of 14,289,644 inpatient hospitalizations.

Measures: Prevalence of SDOH Z-codes (codes Z55-Z65) and descriptive statistics of patients and hospitals.

Results: Of admissions, 269,929 (1.9%) included SDOH Z-codes. Average monthly SDOH Z-code use increased across the study period by 0.01% per month (P<0.001). The cumulative number and proportion of hospitals that had ever used an SDOH Z-code also increased, from 1895 hospitals (41%) in January 2016 to 3210 hospitals (70%) in December 2017. Hospitals that coded at least 1 SDOH Z-code were larger, private not-for-profit, and urban teaching hospitals. Compared with admissions without an SDOH Z-code, admissions with them were for patients who were younger, more often male, Medicaid recipients or uninsured. A higher proportion of admissions with SDOH Z-codes were for mental health (44.0% vs. 3.3%, P<0.001) and alcohol and substance use disorders (9.6% vs. 1.1%, P<0.001) compared with those without.

Conclusions: The uptake of SDOH Z-codes has been slow, and current coding is likely poorly reflective of the actual burden of social needs experienced by hospitalized patients.
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http://dx.doi.org/10.1097/MLR.0000000000001418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666017PMC
December 2020