Steven D. Culler

Background: The majority of recent estimates on the direct medical cost attributable to hospital-onset infections (HOIs) has focused on device- or procedure-associated HOIs. The attributable costs of HOIs that are not associated with device use or procedures have not been extensively studied. Objective: We developed simulation models of attributable cost for 16 HOIs and estimated the total direct medical cost, including nondevice-related HOIs in the USA for 2011 and 2015. Data and Methods: We used total discharge costs associated with HOI-related hospitalization from the National Inpatient Sample and applied an analogy costing methodology to develop simulation models of the costs attributable to HOIs. The mean attributable cost estimate from the simulation analysis was then multiplied by previously published estimates of the number of HOIs for 2011 and 2015 to generate national estimates of direct medical costs. Results: After adjusting all estimates to 2017 US dollars, attributable cost estimates for select nondevice-related infections attributable cost estimates ranged from $7661 for ear, eye, nose, throat, and mouth (EENTM) infections to $27,709 for cardiovascular system infections in 2011; and from $8394 for EENTM to $26,445 for central nervous system infections in 2016 (based on 2015 incidence data). The national direct medical costs for all HOIs were $14.6 billion in 2011 and $12.1 billion in 2016. Nondevice- and nonprocedure-associated HOIs comprise approximately 26−28% of total HOI costs. Conclusion: Results suggest that nondevice- and nonprocedure-related HOIs result in considerable costs to the healthcare system.

Background: Although electronic health information sharing is expanding nationally, it is unclear whether electronic health information sharing improves patient outcomes, particularly for patients who are at the highest risk of communication challenges, such as older adults with Alzheimer disease. Objective: To determine the association between hospital-level health information exchange (HIE) participation and in-hospital or postdischarge mortality among Medicare beneficiaries with Alzheimer disease or 30-day readmissions to a different hospital following an admission for one of several common conditions. Methods: This was a cohort study of Medicare beneficiaries with Alzheimer disease who had one or more 30-day readmissions in 2018 following an initial admission for select Hospital Readmission Reduction Program conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, and pneumonia) or common reasons for hospitalization among older adults with Alzheimer disease (dehydration, syncope, urinary tract infection, or behavioral issues). Using unadjusted and adjusted logistic regression, we examined the association between electronic information sharing and in-hospital mortality during the readmission or mortality in the 30 days following the readmission. Results: A total of 28,946 admission-readmission pairs were included. Beneficiaries with same-hospital readmissions were older (aged 81.1, SD 8.6 years) than beneficiaries with readmissions to different hospitals (age range 79.8-80.3 years, P<.001). Compared to admissions and readmissions to the same hospital, beneficiaries who had a readmission to a different hospital that shared an HIE with the admission hospital had 39% lower odds of dying during the readmission (adjusted odds ratio [AOR] 0.61, 95% CI 0.39-0.95). There were no differences in in-hospital mortality observed for admission-readmission pairs to different hospitals that participated in different HIEs (AOR 1.02, 95% CI 0.82-1.28) or to different hospitals where one or both hospitals did not participate in HIE (AOR 1.25, 95% CI 0.93-1.68), and there was no association between information sharing and postdischarge mortality. Conclusions: These results indicate that information sharing between unrelated hospitals via a shared HIE may be associated with lower in-hospital, but not postdischarge, mortality for older adults with Alzheimer disease. In-hospital mortality during a readmission to a different hospital was higher if the admission and readmission hospitals participated in different HIEs or if one or both hospitals did not participate in an HIE. Limitations of this analysis include that HIE participation was measured at the hospital level, rather than at the provider level. This study provides some evidence that HIEs can improve care for vulnerable populations receiving acute care from different hospitals.

BACKGROUND Although electronic health information sharing is expanding nationally, it is unclear whether electronic health information sharing improves patient outcomes, particularly for patients who are at the highest risk of communication challenges, such as older adults with Alzheimer disease. OBJECTIVE To determine the association between hospital-level health information exchange (HIE) participation and in-hospital or postdischarge mortality among Medicare beneficiaries with Alzheimer disease or 30-day readmissions to a different hospital following an admission for one of several common conditions. METHODS This was a cohort study of Medicare beneficiaries with Alzheimer disease who had one or more 30-day readmissions in 2018 following an initial admission for select Hospital Readmission Reduction Program conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, and pneumonia) or common reasons for hospitalization among older adults with Alzheimer disease (dehydration, syncope, urinary tract infection, or behavioral issues). Using unadjusted and adjusted logistic regression, we examined the association between electronic information sharing and in-hospital mortality during the readmission or mortality in the 30 days following the readmission. RESULTS A total of 28,946 admission-readmission pairs were included. Beneficiaries with same-hospital readmissions were older (aged 81.1, SD 8.6 years) than beneficiaries with readmissions to different hospitals (age range 79.8-80.3 years, P<.001). Compared to admissions and readmissions to the same hospital, beneficiaries who had a readmission to a different hospital that shared an HIE with the admission hospital had 39% lower odds of dying during the readmission (adjusted odds ratio [AOR] 0.61, 95% CI 0.39-0.95). There were no differences in in-hospital mortality observed for admission-readmission pairs to different hospitals that participated in different HIEs (AOR 1.02, 95% CI 0.82-1.28) or to different hospitals where one or both hospitals did not participate in HIE (AOR 1.25, 95% CI 0.93-1.68), and there was no association between information sharing and postdischarge mortality. CONCLUSIONS These results indicate that information sharing between unrelated hospitals via a shared HIE may be associated with lower in-hospital, but not postdischarge, mortality for older adults with Alzheimer disease. In-hospital mortality during a readmission to a different hospital was higher if the admission and readmission hospitals participated in different HIEs or if one or both hospitals did not participate in an HIE. Limitations of this analysis include that HIE participation was measured at the hospital level, rather than at the provider level. This study provides some evidence that HIEs can improve care for vulnerable populations receiving acute care from different hospitals.

Background: Medicare has a voluntary episodic payment model for Medicare beneficiaries that bundles payment for the index acute myocardial infarction ( AMI ) hospitalization and all post‐discharge services for a 90‐day follow‐up period. The purpose of this study is to report on the types and frequency of readmissions and identify demographic and clinical factors associated with readmission of Medicare beneficiaries that survived their AMI hospitalization. Methods and Results: This retrospective study used the Inpatient Standard Analytical File for 2014. There were 143 286 Medicare beneficiaries with AMI who were discharged alive from 3619 hospitals. All readmissions occurring in any hospital within 90 days of the index AMI discharge date were identified. Of 143 286 Medicare beneficiaries discharged alive from their index AMI hospitalization, 28% (40 145) experienced at least 1 readmission within 90 days and 8% (11 477) had >1 readmission. Readmission rates were higher among Medicare beneficiaries who did not undergo a percutaneous coronary intervention in their index AMI admission (34%) compared with those that underwent a percutaneous coronary intervention (20.2%). Using all Medicare beneficiary's index AMI , 27 comorbid conditions were significantly associated with the likelihood of a Medicare beneficiary having a readmission during the follow‐up period. The strongest clinical characteristics associated with readmissions were dialysis dependence, type 1 diabetes mellitus, and heart failure. Conclusions: This study provides benchmark information on the types of hospital readmissions Medicare beneficiaries experience during a 90‐day AMI bundle. This paper also suggests that interventions are needed to alleviate the need for readmissions in high‐risk populations, such as, those managed medically and those at risk of heart failure.

Purpose: This study reports resource utilization during a Medicare Beneficiary’s (MBs) Transcatheter Aortic Valve Replacement (TAVR) index hospitalization and all subsequent encounters for 12 months and compares data between MBs who did or did not receive a pacemaker implantation (PPM) during their index hospitalization. Method: This retrospective study examined Medicare hospital claims from January 1, 2014 through June 30, 2015. 15,533 MBs who survived for 365 days were studied. Information from all encounters during the study period was combined to compare hospital resource utilization and outcomes. Results: 14.8% of MBs had a PPM during the index hospitalization. 46.0% of MBs had at least one readmission to a hospital during the 365-day follow-up period. 54.6% of MB’s first hospital readmission occurred within 90 days of their TAVR discharge date. Average total Medicare reimbursement for all hospitalizations was $60,638 ± $28,974 associated with average total hospital length of stay of 11.2 ± 11.7 days. After adjusting for demographics and 47 comorbid conditions, MBs receiving a PPM during the index TAVR had significantly higher estimated Medicare reimbursement ($5,132) and longer total length of stay (1.8 days) for the entire study period than MBs not receiving a PPM. Conclusion: Total Medicare reimbursement and hospital LOS were significantly higher among MBs that had a PPM implantation during their index admission; however, there were no significant differences in readmission rates, readmission length of stay, or days to first readmission during the follow-up period between the two study cohorts.

Economic evaluations of interventions to prevent healthcare-associated infections in the United States rarely take the societal perspective and thus ignore the potential benefits of morbidity and mortality risk reductions. Using new Department of Health and Human Services guidelines for regulatory impact analysis, we developed a cost-benefit analyses of a national multifaceted, in-hospital Clostridioides difficile infection prevention program (including staffing an antibiotic stewardship program) that incorporated value of statistical life estimates to obtain economic values associated with morbidity and mortality risk reductions. We used a net present value model to assess costs and benefits associated with antibiotic stewardship programs. Model inputs included treatment costs, intervention costs, healthcare-associated Clostridioides difficile infection cases, attributable deaths, and the value of statistical life which was used to estimate the economic value of morbidity and mortality risk reductions. From 2015 to 2020, total net benefits of the intervention to the healthcare system range from $300 million to $7.6 billion when values for morbidity and mortality risk reductions are ignored. Including these values, the net social benefits of the intervention range from $21 billion to $624 billion with the annualized net benefit of $25.5 billion under our most likely outcome scenario. Incorporating the economic value of morbidity and mortality risk reductions in economic evaluations of healthcare-associated infections will significantly increase the benefits resulting from prevention.