Payment Source, Quality of Care, and Outcomes in Patients Hospitalized With Heart Failure
ABSTRACT The aim of this study was to analyze the relationship between payment source and quality of care and outcomes in heart failure (HF).
HF is a major cause of morbidity and mortality. There is a lack of studies assessing the association of payment source with HF quality of care and outcomes.
A total of 99,508 HF admissions from 244 sites between January 2005 and September 2009 were analyzed. Patients were grouped on the basis of payer status (private/health maintenance organization, no insurance, Medicare, or Medicaid) with private/health maintenance organization as the reference group.
The no-insurance group was less likely to receive evidence-based beta-blockers (adjusted odds ratio [OR]: 0.73; 95% confidence interval [CI]: 0.62 to 0.86), implantable cardioverter-defibrillator (OR: 0.59; 95% CI: 0.50 to 0.70), or anticoagulation for atrial fibrillation (OR: 0.73; 95% CI: 0.61 to 0.87). Similarly, the Medicaid group was less likely to receive evidence-based beta-blockers (OR: 0.86; 95% CI: 0.78 to 0.95) or implantable cardioverter-defibrillators (OR: 0.86; 95% CI: 0.78 to 0.96). Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers were prescribed less frequently in the Medicare group (OR: 0.89; 95% CI: 0.81 to 0.98). The Medicare, Medicaid, and no-insurance groups had longer hospital stays. Higher adjusted rates of in-hospital mortality were seen in patients with Medicaid (OR: 1.22; 95% CI: 1.06 to 1.41) and in patients with reduced systolic function with no insurance.
Decreased quality of care and outcomes for patients with HF were observed in the no-insurance, Medicaid, and Medicare groups compared with the private/health maintenance organization group.
Full-textDOI: · Available from: Gregg C. Fonarow, Apr 22, 2014
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ABSTRACT: Study Design. The Spine End Results Registry (2003-2004) is a registry of prospectively collected data of all patients undergoing spinal surgery at the University of XXX Medical Center and XXX Medical Center. Insurance data was prospectively collected and used in multivariate analysis to determine risk of perioperative complications.Objective. Given the negative financial impact of surgical site infections and the higher overall complication rates of patients with a Medicaid payer status, we hypothesized that a Medicaid payer status would have a significantly higher surgical site infection rate.Summary of Background Data. The medical literature demonstrates lesser outcomes and increased complication rates in patients that have public insurance as compared to private insurance. No one has shown that patients with a Medicaid payer status as compared to Medicare and privately insured patients have a significantly increased surgical site infection rate for spine surgery.Methods. The prospectively collected Spine End Results Registry provided data for analysis. Surgical site infection was defined as treatment requiring operative debridement. Demographic, social, medical, and the surgical severity index risk factors were assesses against the exposure of payer status for the surgical procedure.Results. The population included Medicare (N = 354), Medicaid (N = 334), the Veterans' Administration (N = 39), private insurers (N = 603), and self-pay (N = 42). Those patients whose insurer was Medicaid had a 2.06 odds (95% CI: 1.19, 3.58, p = 0.01) of having a surgical site infection when compared to the privately insured.Conclusion. The study highlights the increased cost of spine surgeries for Medicaid patients with the passage of the Patient Protection and Affordable Care Act of 2010 (PPACA). The PPACA provisions could cause a reduction in re-imbursement to the hospital for taking care of patients with Medicaid insurance due to their higher complication rates and higher costs. This very issue could inadvertently lead to access limitations.Spine 06/2014; 39(20). DOI:10.1097/BRS.0000000000000496 · 2.45 Impact Factor
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ABSTRACT: Background Observational data in the United States suggests that those without health insurance have a higher mortality and worse health outcomes. A linkage between insurance coverage and outcomes in hospitalized patients has yet to be demonstrated in resource-poor settings. Methods To determine whether uninsured patients admitted to the public medical wards at a Kenyan referral hospital have any difference in in-hospital mortality rates compared to patients with insurance, we performed a retrospective observational study of all inpatients discharged from the public medical wards at Moi Teaching and Referral Hospital in Eldoret, Kenya, over a 3-month study period from October through December 2012. The primary outcome of interest was in-hospital death, and the primary explanatory variable of interest was health insurance status. Results During the study period, 201 (21.3%) of 956 patients discharged had insurance. The National Hospital Insurance Fund was the only insurance scheme noted. Overall, 211 patients (22.1%) died. The proportion who died was greater among the uninsured compared to the insured (24.7% vs. 11.4%, Chi-square=15.6, p<0.001). This equates to an absolute risk reduction of 13.3% (95% CI 7.9–18.7%) and a relative risk reduction of 53.8% (95% CI 30.8–69.2%) of in-hospital mortality with insurance. After adjusting for comorbid illness, employment status, age, HIV status, and gender, the association between insurance status and mortality remained statistically significant (adjusted odds ratio (AOR)=0.40, 95% CI 0.24–0.66) and similar in magnitude to the association between HIV status and mortality (AOR=2.45, 95% CI 1.56–3.86). Conclusions Among adult patients hospitalized in a public referral hospital in Kenya, insurance coverage was associated with decreased in-hospital mortality. This association was comparable to the relationship between HIV and mortality. Extension of insurance coverage may yield substantial benefits for population health.Global Health Action 02/2014; 7:23137. DOI:10.3402/gha.v7.23137 · 1.65 Impact Factor
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ABSTRACT: One of the challenges in treating patients with heart failure (HF) is achieving clinical stability and reducing the hospital readmission rate. A diuretic dose adjustment algorithm developed in the United States (Diuretic Treatment Algorithm, DTA) and later validated for use in Brazil (as the Algoritmo de Ajuste de Diurético, AAD) has proved feasible and readily applicable, but its effect on clinical outcomes has yet to be assessed. This report aims to describe a randomized clinical trial protocol designed to assess the effectiveness of the AAD and of nonpharmacologic management in improving clinical stability and reducing the readmission rate at 90 days in patients with HF. A PROBE (prospective randomized open blinded endpoint) parallel-group design will be used. Adult patients with a diagnosis of reduced ejection fraction HF, who are being treated at a specialized HF clinic are being recruited. Those with indications for loop diuretic dose adjustment during routine clinic visits will be randomized to take part in the trial. Participants in the intervention group (IG) shall have their diuretic doses adjusted in accordance with the AAD and receive four telephone calls (one per week) over 30 days to reinforce guidance on nonpharmacological management (fluid and sodium restriction). Participants in the control group (CG) shall have their diuretic doses adjusted by a physician during the first trial visit and shall not receive any telephone calls. Patients in both groups shall return at 1 month for face-to-face reassessment. The study endpoints shall comprise readmission and/or emergency department visits due to HF decompensation within 90 days and clinical instability. All participants shall be required to have a scale at home (or easy access to one), a telephone number, agree to telephone-based follow-up, and be available to return for a 1-month trial visit. Overall, 135 patients are expected to be enrolled in each group. This trial shall assess the effectiveness of the AAD algorithm and non-pharmacologic management by early identification of clinical deterioration and establishment of a combined intervention to reduce emergency department visits, readmission rate, or a composite endpoint thereof. ClinicalTrials.gov Identifier, NCT02068937 (23 February 2014).Trials 12/2015; 16(1). DOI:10.1186/s13063-015-0559-7 · 2.12 Impact Factor