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. 2018 Oct 5;1(6):e183519.
doi: 10.1001/jamanetworkopen.2018.3519.

Variation in and Hospital Characteristics Associated With the Value of Care for Medicare Beneficiaries With Acute Myocardial Infarction, Heart Failure, and Pneumonia

Nihar R Desai  1   2 , Lesli S Ott  1   3 , Elizabeth J George  1 , Xiao Xu  1 , Nancy Kim  1   4 , Shengfan Zhou  1 , Angela Hsieh  1   5 , Sudhakar V Nuti  6 , Zhenqiu Lin  1 , Susannah M Bernheim  1   4 , Harlan M Krumholz  1   2
Affiliations

Variation in and Hospital Characteristics Associated With the Value of Care for Medicare Beneficiaries With Acute Myocardial Infarction, Heart Failure, and Pneumonia

Nihar R Desai et al. JAMA Netw Open. .

Abstract

Importance: Payers and policy makers have advocated for transitioning toward value-based payment models. However, little is known about what is the extent of hospital variation in the value of care and whether there are any hospital characteristics associated with high-value care.

Objectives: To investigate the association between hospital-level 30-day risk-standardized mortality rates (RSMRs) and 30-day risk-standardized payments (RSPs) for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PNA); to characterize patterns of value in care; and to identify hospital characteristics associated with high-value care (defined by having lower than median RSMRs and RSPs).

Design, setting, and participants: This national cross-sectional study applied weighted linear correlation to investigate the association between hospital RSMRs and RSPs for AMI, HF, and PNA between July 1, 2011, and June 30, 2014, among all hospitals; examined correlations in subgroups of hospitals based on key characteristics; and assessed the proportion and characteristics of hospitals delivering high-value care. The data analysis was completed in October 2017. The setting was acute care hospitals. Participants were Medicare fee-for-service beneficiaries discharged with AMI, HF, or PNA.

Main outcomes and measures: Hospital-level 30-day RSMRs and RSPs for AMI, HF, and PNA.

Results: The AMI sample consisted of 4339 hospitals with 487 141 hospitalizations for mortality and 462 905 hospitalizations for payment. The HF sample included 4641 hospitals with 960 960 hospitalizations for mortality and 903 721 hospitalizations for payment. The PNA sample contained 4685 hospitals with 952 022 hospitalizations for mortality and 901 764 hospitalizations for payment. The median (interquartile range [IQR]) RSMRs and RSPs, respectively, was 14.3% (IQR, 13.8%-14.8%) and $21 620 (IQR, $20 966-$22 567) for AMI, 11.7% (IQR, 11.0%-12.5%) and $15 139 (IQR, $14 310-$16 118) for HF, and 11.5% (IQR, 10.6%-12.6%) and $14 220 (IQR, $13 342-$15 097) for PNA. There were statistically significant but weak inverse correlations between the RSMRs and RSPs of -0.08 (95% CI, -0.11 to -0.05) for AMI, -0.21 (95% CI, -0.24 to -0.18) for HF, and -0.07 (95% CI, -0.09 to -0.04) for PNA. The largest shared variance between the RSMRs and RSPs was only 4.4% (for HF). The correlations between the RSMRs and RSPs did not differ significantly across teaching status, safety-net status, urban/rural status, or the proportion of patients with low socioeconomic status. Approximately 1 in 4 hospitals (20.9% for AMI, 23.0% for HF, and 23.9% for PNA) had both lower than median RSMRs and RSPs.

Conclusions and relevance: These findings suggest that there is significant potential for improvement in the value of AMI, HF, and PNA care and also suggest that high-value care for these conditions is attainable across most hospital types.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors except Mr Nuti reported working under contract with the Centers for Medicare & Medicaid Services (CMS) to develop and maintain performance measures. Drs Desai and Krumholz reported being recipients of a research agreement from Johnson & Johnson, through Yale University, to develop methods of clinical trial data sharing. Dr Xu reported receiving support from the CMS in the form of a contract agreement to develop and maintain performance measures during the conduct of the study. Dr Hsieh reported receiving grants from the CMS during the conduct of the study. Dr Bernheim reported receiving support from the CMS outside of the present work in the form of a contract agreement to develop and maintain performance measures. Dr Krumholz reported receiving a grant from the US Food and Drug Administration (FDA) to develop methods for postmarket surveillance of medical devices; reported chairing a cardiac scientific advisory board for UnitedHealth; reported being a participant in/participant representative of the IBM Watson Health Life Sciences Board; reported being a member of the Advisory Board for Element Science and the Physician Advisory Board for Aetna; reported being the founder of Hugo, a personal health information platform; reported receiving other support from the CMS during the conduct of the study; reported receiving grants from Johnson & Johnson, Medtronic, and the FDA; and reported receiving personal fees from UnitedHealth, IBM Watson Health, Element Science, and Aetna. No other disclosures were reported.

Figures

Figure.
Figure.. Scatterplot of Hospital-Level RSMRs and RSPs
Values are inflation adjusted to 2013 US dollars. Blue lines show the cubic spline smooth regression lines, with risk-standardized mortality rates (RSMRs) as the dependent variable and risk-standardized payments (RSPs) as the independent variable. Tinted areas around the cubic spline regression lines show the 95% CIs. The Pearson product moment correlation coefficients are −0.08 (95% CI, −0.11 to −0.05) for acute myocardial infarction (n = 4339) (A), −0.21 (95% CI, −0.24 to −0.18) for heart failure (n = 4641) (B), and −0.07 (95% CI, −0.09 to −0.04) for pneumonia (n = 4685) (C). The horizontal and vertical dotted lines indicate the median RSMR and RSP, respectively.
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References

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