John D Birkmeyer's research while affiliated with Geisel School of Medicine at Dartmouth and other places

Background: Black and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access. Objective: To examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19. Design: Retrospective cohort analysis of manually abstracted electronic medical records. Patients: 7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020 MAIN MEASURES: Advance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR). Key results: Adjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9-1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6-1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)). Conclusions: Hospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.

Background: We sought to determine whether dementia is associated with treatment intensity and mortality in patients hospitalized with COVID-19. Methods: Review of the medical records for patients > 60 years of age (n=5,394) hospitalized with COVID-19 from 132 community hospitals between March and June, 2020. We examined the relationships between dementia and treatment intensity (including intensive care unit admission (ICU) and mechanical ventilation (MV) and care processes that may influence them, including advance care planning (ACP) billing and do-not-resuscitate (DNR) orders) and in-hospital mortality adjusting for age, sex, race/ethnicity, comorbidity, month of hospitalization, and clustering within hospital. We further explored the effect of ACP conversations on the relationship between dementia and outcomes, both at the individual patient level (effect of having ACP) and at the hospital level (effect of being treated at a hospital with low: <10%, medium 10-20%, or high >20% ACP rates). Results: Ten percent (n=522) of the patients had documented dementia. Dementia patients were older (> 80yo: 60% vs. 27%, p< 0.0001), had a lower burden of comorbidity (3+ comorbidities: 31% vs. 38%, p=0.003), were more likely to have ACP (28% vs. 17%, p<0.0001) and a DNR order (52% vs. 22%, p<0.0001), had similar rates of ICU admission (26% vs. 28%, p=0.258), were less likely to receive MV (11% vs. 16%, p=0.001), and more likely to die (22% vs. 14%, p<0.0001). Differential treatment intensity among patients with dementia was concentrated in hospitals with low, dementia-biased ACP billing practices (risk-adjusted ICU use: 21% vs 30%, OR=0.6, p=0.016; risk-adjusted MV use: 6% vs 16%, OR=0.3, p<0.001). Conclusions: Dementia was associated with lower treatment intensity and higher mortality in patients hospitalized with COVID-19. Differential treatment intensity was concentrated in low-ACP billing hospitals suggesting an interplay between provider bias and "preference-sensitive" care for COVID-19.

Hospital admissions in the US fell dramatically with the onset of the coronavirus disease 2019 (COVID-19) pandemic. However, little is known about differences in admissions patterns among patient groups or the extent of the rebound. In this study of approximately 1 million medical admissions from a large nationally representative hospitalist group, we found that declines in non-COVID-19 admissions from February to April 2020 were generally similar across patient demographic subgroups and exceeded 20% for all primary admission diagnoses. By late June/early July 2020, overall non-COVID-19 admissions had rebounded to 16% below pre-pandemic baseline volume (8% including COVID-19 admissions). Non-COVID-19 admissions were substantially lower for patients residing in majority-Hispanic neighborhoods (32% below baseline) and remained well below baseline for patients with pneumonia (-44%), COPD/asthma (-40%), sepsis (-25%), urinary tract infection (-24%) and acute ST-elevation myocardial infarction (STEMI), -22%). Health system leaders and public health authorities should focus on efforts to ensure that patients with acute medical illnesses can obtain hospital care as needed during the pandemic to avoid adverse outcomes. [Editor's Note: This Fast Track Ahead Of Print article is the accepted version of the peer-reviewed manuscript. The final edited version will appear in an upcoming issue of Health Affairs.].

Background: Patients undergoing complex pediatric cardiac surgery remain at considerable risk of mortality and morbidity, and variation in outcomes exists across hospitals. The Pediatric Cardiac Critical Care Consortium (PC4) was formed to improve the quality of care for these patients through transparent data sharing and collaborative learning between participants. Objectives: The purpose of this study was to determine whether outcomes improved over time within PC4. Methods: The study analyzed 19,600 hospitalizations (18 hospitals) in the PC4 clinical registry that included cardiovascular surgery from August 2014 to June 2018. The primary exposure was 2 years of PC4 participation; this provided adequate time for hospitals to accrue data and engage in collaborative learning. Aggregate case mix-adjusted outcomes were compared between the first 2 years of participation (baseline) and all months post-exposure. We also evaluated outcomes from the same era in a cohort of similar, non-PC4 hospitals. Results: During the baseline period, there was no evidence of improvement. We observed significant improvement in the post-exposure period versus baseline for post-operative intensive care unit mortality (2.1% vs. 2.7%; 22% relative reduction [RR]; p = 0.001), in-hospital mortality (2.5% vs. 3.3%; 24% RR; p = 0.001), major complications (10.1% vs. 11.5%; 12% RR; p < 0.001), intensive care unit length of stay (7.3 days vs. 7.7 days; 5% RR; p < 0.001), and duration of ventilation (61.3 h vs. 70.6 h; 13% RR; p = 0.01). Non-PC4 hospitals showed no significant improvement in mortality, complications, or hospital length of stay. Conclusions: This analysis demonstrates improving cardiac surgical outcomes at children's hospitals participating in PC4. This change appears unrelated to secular improvement trends, and likely reflects PC4's commitment to transparency and collaboration.

Background: There is widespread interest in reducing use of postacute care (ie, care after hospital discharge) following major surgery, provided that such reductions do not worsen quality outcomes such as readmission rates. Objectives: To describe the association between changes in skilled nursing facility (SNF) use and changes in readmission rates after surgery. Research design: This was a observational study. Subjects: Fee-for-service Medicare beneficiaries undergoing coronary artery bypass grafting (CABG) or total hip replacement (THR) from 2008 to 2013. Measures: Primary exposure was risk-adjusted SNF use initiated 0-2 days after hospital discharge, and the primary outcome was risk-adjusted readmission rates from 3 to 30 days after discharge. Results: Among 176,994 patients who underwent CABG at 804 hospitals and 233,955 patients who underwent THR at 1220 hospitals, hospital-level SNF utilization increased after CABG (16.4%-19.0%, P=0.001) and THR (40.8%-45.5%, P<0.001), from 2008 to 2013. Hospital readmission rates decreased for CABG (14.7%-12.7%, P<0.001) but did not change for THR (4.9%-4.8%, P=0.55), from 2008 to 2013. However, there was wide variation in hospital-level change in readmission rates. After adjusting for hospital characteristics and baseline readmission rates, there was no statistically significant association between change in SNF use and change in readmission rates (0.017 and 0.011 percentage point increase in SNF use for every one percentage point increase in readmission rates for CABG and THR respectively, P=0.58 and 0.32). Conclusions: Changes in use of postacute care after THR and CABG have not been associated with changes in readmission rates.

Importance: As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions. Objective: To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions. Design, setting, and participants: This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period. Exposure: Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers. Main outcomes and measures: Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care. Results: A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period. Conclusions and relevance: Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.

The rising popularity of episode-based payment models for surgery underscores the need to better understand the drivers of variability in spending on postacute care. Examining postacute care spending for fee-for-service Medicare beneficiaries after three common surgical procedures in the period 2009-12, we found that it varied widely between hospitals in the lowest versus highest spending quintiles for postacute care, with differences of 129 percent for total hip replacement, 103 percent for coronary artery bypass grafting (CABG), and 82 percent for colectomy. Wide variation persisted after we adjusted for the intensity of postacute care. However, the variation diminished considerably after we adjusted instead for postacute care setting (home health care, outpatient rehabilitation, skilled nursing facility, or inpatient rehabilitation facility): It decreased to 16 percent for hip replacement, 4 percent for CABG, and 21 percent for colectomy. Health systems seeking to improve surgical episode efficiency should collaborate with patients to choose the highest-value postacute care setting. © 2017 Project HOPE-The People-to-People Health Foundation, Inc.