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Diane M. Dewar, PhD University at Albany, State University of New York Jean-Paul Hafner, MD, MPH Stratton VA Medical Center and PowerPoint PPT Presentation


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Survival Analysis of Patients Undergoing Mechanical Ventilation with Tracheostomy in New York State 1992-1996: Does Managed Care Influence Outcome for DRG 483? . Diane M. Dewar, PhD University at Albany, State University of New York Jean-Paul Hafner, MD, MPH Stratton VA Medical Center and

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Diane M. Dewar, PhD University at Albany, State University of New York Jean-Paul Hafner, MD, MPH Stratton VA Medical Center and

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Survival Analysis of Patients Undergoing Mechanical Ventilation with Tracheostomy in New York State 1992-1996: Does Managed Care Influence Outcome for DRG 483?

Diane M. Dewar, PhD

University at Albany, State University of New York

Jean-Paul Hafner, MD, MPH

Stratton VA Medical Center and

University at Albany, State University of New York


Critical Care Services’ Impact on Health Care Expenditures

  • Critical care has a significant impact on health care expenditures in the United States

    • 1-1.5% of gross domestic product

    • 7-8% of total health care expenditures nationwide

    • 20-34% of all hospital expenditures

    • 50% of critical care expenditures are allocated to patients with prolonged mechanical ventilation

      • only 10% of critical care unit patients have prolonged mechanical ventilation


High Costs of Mechanical Ventilation

  • Nationwide costs for mechanical ventilation in 1999 were in the range of $45 billion

  • Ventilator dependent patients have costs that are 8-9 times those of medical-surgical floor patients

  • Growth in utilization of mechanical ventilation is due to increased use among elderly with chronic conditions

    • leads to the question whether differential utilization of resources and outcomes are age-specific or due to delivery system changes


How does Delivery System Changes Affect Health Outcomes?

  • Managed care delivery is associated with lower levels of critical care resource utilization than traditional delivery and financing

    • Results are mixed whether reduction is due to financial incentives of managed care organization or severity of illness

    • Which delivery system, managed care or traditional delivery and financing, is more efficient in utilizing these critical care resources?


Study Goals

  • Study investigates the impact of managed care on hospital survival for critically ill patients requiring mechanically ventilation who are discharged under DRG 483 in New York State during 1992-1996.

  • Research Questions:

    • Are improved survival rates among managed care patients due to self-selection or the elimination of ineffective care in the inpatient setting?

    • Do delivery system changes or clinical characteristics have a greater influence over the health outcomes for this subpopulation?


Data Sources

  • Hospital Characteristics from the Bureau of Health Economics, NYS Department of Health

    • Teaching status, number of beds, location

  • State-wide analysis uses New York Statewide Planning and Research Cooperative System (SPARCS) data base for 1992-1996 under all-payer system

    • Demographic, clinical, discharge disposition and payor data collected for population of 1,456 patients managed care adults and 32,337 non-managed care adults aged 19-95 discharged under from hospitals under DRG 483, “tracheostomy except for mouth, larynx and pharynx disorder”


Sample Frame Exclusions

  • Sample does not include patients:

    • With pre-existing tracheostomy

    • Who were over 95 years of age due to small numbers

    • With hospital stay over 90 days

      • Biologically implausible that events occurring at the time of tracheostomy would have longer-lasting effects

    • Discharged after 1996

      • No confounding from affects from competitive reimbursement regime under the NY Health Care Reform Act enacted in 1997.


Preliminary Statistical Analyses

  • All conditions and procedures that were present in more than 3.5% of patients were examined with bivariate analysis (2 x 2 contingency tables) to test for an association with mortality

    • Where possible, similar diagnostic codes were grouped together for the final analysis

    • Comorbid conditions and procedures associated with a 1.5 times greater risk of mortality than the general subpopulation were obtained from ICD-9 codes (principal and secondary)

  • Preliminary inpatient survival assessments using Kaplan-Meier curves

    • Allowed for assessment of proportionality of hazards prior to entry in a multivariate Cox Proportional Hazards Model (PH)


--------Preliminary Statistical Analyses

  • :

    • age: linear, quadratic and cubic forms

    • demographics: dummy variables for race, gender, location

    • clinical risk factors: dummy variables for high frequency and high mortality diagnoses. Disorders of fluid, electrolyte, and acid-based balance, other bacterial pneumonia, pneumonia, organism unspecified, and pleurisy

    • admission type: dummy variable for emergency, urgent admission

    • payer classes: dummy variables for payment source (i.e., selfpay, various insurance combinations)

    • MCO: dummy variable for managed care participation, % MCO in hospital of discharge

    • HCRA: dummy variable competitive regime enactment

    • Length of stay

    • Teaching: teaching status of hospital of discharge


Profile of DRG 483 and DRG 475 Hospital Survivors in 1995-1999 in New York State

  • DRG 483 survivors are more likely to be male, have more elective admissions, and have long hospital stays averaging 63 days.

  • DRG 475 survivors are more likely to be female, Hispanic, have more emergency admissions, and have moderate hospital stays of 17 days

  • No statistically significant differences between DRG 483 and DRG 475 survivors in managed care coverage and commercial/self-insurance class, upstate location, and most frequent age range of 36-50


Profile of Survivors in DRG 483 and DRG 475 Pre- and Post-NYS Health Care Reform Enactment of 1996

  • Pre-HCRA enactment

    • DRG 483 survivors are equally likely to be MCO and non-MCOs, with 30% of survivors discharged to SNFs

    • DRG 475 survivors are more likely to be in MCO, with 16% of survivors discharged to SNFs

  • Post-HCRA enactment

    • DRG 483 survivors are more likely to be in MCO, with 44% of survivors discharged to SNFs

      • The greatest proportion of survivors occurs in 1999

      • Regardless of MCO status, more survivors are seen post-HCRA

    • DRG 475 survivors are more likely to be in non-MCO, with 25% of survivors discharged to SNFs

      • The greatest proportion of survivors occurs in 1997-1999


Skilled Nursing Facility Discharge Rates for DRG 483 and DRG 475 by Year


Competitive Hospital Reimbursements and Payer Status are Major Determinants of Hospital Survival for DRG 483

  • Increased likelihood of survival seen for:

    • Competitive reimbursement regime

    • MCO discharges under HCRA

  • Decreased likelihood of survival seen for:

    • Medicare payment

    • Non-elective admissions

  • Statistically significant predictors but do not contribute to increased risk of survival:

    • MCO status

    • Hospital teaching status

    • Length of stay


Competitive Hospital Reimbursements and Payer Status are Major Determinants of Discharges to Skilled Nursing Facilities for DRG483

  • Results of two-stage probit model predicting likelihood of SNF discharges for survivors:

    • Significant increases in likelihood of SNF discharges for:

      • Competitive reimbursement regime

      • Medicaid payment

      • NYC location

    • Statistically significant predictors but do not contribute to increased risk of discharge location:

      • MCO status

      • Length of stay

      • Est. survival likelihood


Clinical Factors are Major Determinants of Hospital Survival for DRG 475

  • Increased likelihood of survival seen for:

    • Non-elective admissions

    • Chronic airway obstruction

  • Decreased likelihood of survival seen for:

    • Most other high-risk diagnose

    • Statistically significant predictors but do not contribute to increased risk of survival:

      • Competitive reimbursement regime

      • MCO status

      • Hospital teaching status

      • Length of stay


Competitive Hospital Regime and Payer Status are Major Determinants of Discharges to Skilled Nursing Facilities for DRG 475 Survivors

  • Results of two-stage probit estimation predicting likelihood of SNF discharges for survivors:

    • Increases in SNF discharges seen for:

      • Competitive reimbursement regime

      • Medicaid payment

      • Hospital volume

      • Most high-risk diagnoses

    • Statistically significant predictors but do not contribute to increased risk of discharge location:

      • MCO status

      • Length of stay

      • Est. survival prob.


Discussion

  • Models fit the data well and indicate that competitive hospital market leads to increased shifting to other venues of care for high-cost critical care patients

  • State-level administrative data can provide indication of impact of system changes on management of patients

  • Limitations include:

    • Lack of information concerning specific changes in reimbursement rates by payer under competition

    • Lack of information concerning intervention by case management and social work to facilitate discharge planning

      • Unclear what proportion of discharges to other venues are clinically appropriate or due to cost pressures


Clinical Excellence must be Combined with Cost Control

  • Managed care does not uniquely impact the likelihood of survival nor skilled nursing facility discharges for survivors among DRG 483 and DRG 475 discharges

    • No unique evidence that managed care preferentially selects patients nor favorably manages discharges on the state-level

  • Competitive reimbursement regime under HCRA of 1996 indicates trends of increased hospital survival and increased cost-shifting to skilled nursing facilities for survivors among both DRGs

    • Differential reimbursements under Medicare for hospital and skilled nursing facilities may lead to increased discharges for LTC settings under competition

  • Critical care services delivered to older persons with chronic illness are facing greater scrutiny but clinical outcomes also need to be considered

    • more emphasis should be placed on multidisciplinary management teams


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