By: Saparja Nag  Nov. 13, 2017
Dexur & Harvard Medical School Researchers Submitted Poster
The United States federal government recently declared the opioid epidemic as a national public health emergency. One of the most common uses of opioids is for inpatient post surgical pain management; however, usage of opioids is associated with a number of unfavorable outcomes. Factors that are commonly associated with ORADEs such as respiratory depression, ileus, post operative nausea, and vomiting impact a number of quality outcomes. These quality outcomes include increased length of stay, cost, readmission rates, and mortality. For example, a study by Oderda et al. in 2003 estimated that the common ORADES respiratory depression and urinary retention had a cost of $626 & $777 respectively in selected surgical patients.2
In addition to the implications of ORADEs on patient quality outcomes, value-based purchasing payment programs also motivate hospitals to reduce costs. Furthermore, there are increasingly regulatory guidelines including the Joint Commission Proposed Standards on pain assessment and management that emphasizes safe use of opioids as a key focus area.3 Due to costs associated with opioids, patient quality outcomes, and regulatory guidelines, hospitals are now developing opioid stewardship programs to manage the use of opioids4.
However, despite the strategic need to implement safe use of opioids and manage ORADES, hospitals have found it challenging to implement practical ongoing monitoring programs to operationally measure the outcomes of their initiatives. To address this, a dashboard using Medicare administrative claims was developed to help hospitals evaluate their ORADE incidence rates and the quality impact of these ORADEs on key metrics such as LOS and cost.
The dashboard concept will be presented at ASRA’s 16th Annual Pain Medicine meeting from November 16th to 18th in Orlando, Florida. The American Society of Regional Anesthesia and Pain Medicine (ASRA) is one of the largest subspecialty medical societies in anesthesiology with more than 4,000 members in 60 countries and 6 continents. The abstract won the “Resident/Fellow Best of Meeting Abstracts and Research Travel Award”, which is only awarded to three submissions at the meeting.
Dexur’s research collaborators in this research study included:
Dr. Richard Urman MD, MBA, FASA is an anesthesiologist practicing in Boston, Massachusetts at the Brigham and Women's Hospital. His research interests include pharmacology, health services research, informatics, operating room efficiency, and patient safety. He has published numerous research articles and edited several books, including Pocket Anesthesia, Anesthesiology Student Survival Guide, The MGH Textbook of Anesthetic Equipment and Essential Clinical Anesthesia, Pocket Pain Medicine, Operating Room Leadership and Management, among others. He has lectured nationally and internationally, and he directs the Perioperative Medicine Fellowship and the Center for Perioperative Research.
Dr. Mark Jones is a resident physician training at the Beth Israel Deaconess Medical Center & a Clinical Fellow at the Harvard Medical School. He received his MD from Tulane University and BA from Louisiana State University. His prior publications on opioids have included a review of opioid abuse predictors and strategies to curb opioid abuse.
Dr. Alexander B Stone is a resident physician training at the Brigham and Women's Hospital. He received his MD from Johns Hopkins School of Medicine and BA from Amherst College. His clinical interests include perioperative medicine, quality improvement and enhanced recovery after surgery (ERAS) program implementation and maintenance.
Herzig et al. “Opioid Utilization and Opioid-Related Adverse Events in Non-Surgical Patients in U.S. Hospitals.” Journal of Hospital Medicine. Nov 2014; 9(2): 73-81. DOI: 10.1002/jhm.2102.
Oderda G, et al. “Cost of Opioid-Related Adverse Drug Events in Surgical Patients.” Journal of Pain and Symptom Management. Mar 2003; 25(3): 276-283. DOI: 10.1016/S0885-3924(02)00691-7.
“New and Revised Standards Related to Pain Assessment and Management - Joint Commission Requirements for Accredited Hospitals.” The Official Newsletter of The Joint Commission. Jul 2017; 37(7): 1-3. https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF
Williams C. “Establishment of an Opioid Stewardship Program.” Virginia Society of Health-System Pharmacists. http://www.vshp.org/uploads/6/3/6/0/6360223/williams-opioid_1_per_page.pdf
By: Saparja Nag  Nov. 22, 2017
Inpatient data on super utilizers provide critical insight into how these high-risk patients influence revenue and overall length of stay. A full background and methodology on super utilizer contributions can be read here. Using Medicare inpatient data collected between October 2015 and September 2016, the percentages of discharges, unique patients, revenue, and LOS were determined and compared to state and national values. The top 3 hospitals in Southern California by highest percentage of discharges from super utilizers were also the top 3 highest in the region for super utilizer contributions to revenue and LOS.
Southern California Hospital at Hollywood (SCHH) is a 100-bed acute care facility that emphasizes a commitment to community needs. They are known in the area for their work with the LGBTQ community and specialty in gender confirmation surgery. Centinela Hospital Medical Center is over 3 times the size of SCHH with 369 beds. They have a level II emergency department and have been fully accredited by the Joint Commission. St. Vincent Medical Center was Los Angeles’ first hospital in 1856. It is roughly the same size as CHMC with 366 beds and include a number of speciality clinics.
|Region||% of Unique Patients who are Super Utilizers||% Discharges from Super Utilizers||% Revenue from Super Utilizers||% LOS from Super Utilizers||% 30 Day Readmissions from Super Utilizers|
|Southern California Hospital at Hollywood||37.33||51.99||50.08||54.18||76.96|
|Centinela Hospital Medical Center||23.27||39.76||43.05||42.72||67.46|
|St. Vincent Medical Center||17.99||30.92||33.23||35.58||57.38|
By: Emily Carpintero  Nov. 22, 2017
Skilled nursing facilities (SNF) are optional care facilities for patients discharged from a hospital. Doctors decide on using an SNF according to whether a patient requires medical experts to assist with care and/or the rehabilitation process. Using Medicare inpatient data collected between October 2015 and September 2016, Dexur analysts identified Medicare inpatient discharges, discharges to SNFs, and the percentage of SNF discharges at the national, state, and individual hospital level.
According to Dexur data, the third leading hospital in New York for Medicare inpatient discharge volume between October 2015 and September 2016 was The New York-Presbyterian Hospital in New York City-Weill Cornell Medical Center. The New York-Presbyterian Hospital is one of the most renowned academic medical centers, internationally. They provide high quality, cutting-edge treatments for emergency, primary and specialty care in all departments of medicine. In 2016, New York Magazine’s Best Doctors listed 1,300 top doctors across all specialties, and 282 of these physicians practice at The New York-Presbyterian Hospital.
Looking at the table below, the total number of Medicare inpatient discharges, total number of discharges to SNFs, and percentage of SNF discharges are comparable between the nation, New York state, and The New York-Presbyterian Hospital for October 2015 - September 2016.
|National, State & Hospital Level||Total Discharges||Total SNF Discharges||SNF Discharge Rate %|
|New York State||603,53||131,015||21.71%|
|The New York-Presbyterian Hospital||14,339||2,419||16.87%|
Nationally, there were over 11,000,000 Medicare inpatient discharges and nearly 20% (2,151,089) were discharged to an SNF. Looking at New York’s data regarding Medicare patients during that time period, New York surpassed the national average of SNF discharges by 2.25%. However, The New York-Presbyterian Hospital, serving the greater New York metropolitan area, stayed below both the state and national averages by 4.84% and 2.59%, respectively. This is remarkable considering their high discharge volume of Medicare inpatients at the national and state levels and the array of services they cover. Typically, a patient would prefer being discharged to the comfort of their homes over an SNF; the low rate for SNF discharges by this hospital validates their commitment to quality care.
By: Jeffrey Maser  Nov. 22, 2017
In another Dexur article, we addressed the connection between physician discharge volume and quality metrics. We found that although volume alone does not necessarily imply quality, these two factors have a strong positive correlation. Therefore, it is still valuable to understand which physicians in an area account for a large portion of the community’s healthcare. Similarly, it is valuable to understand which hospitals account for high percentages of a community’s discharges.
Dexur data analysts studied hospital discharge volume on national, statewide, and countywide levels for every therapeutic area and specific DRG and the top 10 hospitals for orthopedic discharge volume nationwide for the time period of October 2015 - September 2016 are given below.
|Rank||Hospital Name||City||State / U.S. Territory||Total Medicare Inpatient Orthopedic Discharges||% Of National Discharges|
|All U.S. Hospitals||1,364,880||100.00|
|1||Hospital for Special Surgery||New York||New York||5,524||0.40|
|2||Florida Hospital, Orlando||Orlando||Florida||3,902||0.29|
|3||Beaumont Hospital - Royal Oak||Royal Oak||Michigan||3,657||0.27|
|4||Mayo Clinic Hospital, Saint Mary's Campus||Rochester||Minnesota||3,643||0.27|
|6||New England Baptist Hospital||Roxbury Crossing||Massachusetts||2,713||0.20|
|7||Cedars-Sinai Medical Center||Los Angeles||California||2,557||0.19|
|8||Morristown Medical Center||Morristown||New Jersey||2,542||0.19|
|9||New Hanover Regional Medical Center||Wilmington||North Carolina||2,512||0.18|
|10||Virtua Voorhees Hospital||Voorhees||New Jersey||2,412||0.18|
As indicated by the above table, between October 2015 - September 2016, Hospital for Special Surgery (HSS) in New York, New York saw over 1,500 more orthopedic discharges more than the next leading hospital in orthopedic discharge volume. The 5,524 discharges from HSS was 41.6% higher than the 3,902 discharges from Florida Hospital, Orlando, which is the next highest volume hospital for orthopedics discharges. Out of the 1,364,880 orthopedics discharges from U.S. Medicare enrollees during the aforementioned timeframe, the discharges from Hospital for Special Surgery accounted for 0.40% of these discharges. With over 5,000 inpatient facilities in the U.S., 0.40% of discharges makes up a significant portion of the market share.
When we look more specifically at the rankings for orthopedic discharge volume for the state of New York alone, these market share values are inherently going to be substantially higher. Between October 2015 - September 2016, Hospital for Special Surgery accounted for nearly 6% of all orthopedic discharges from New York residents enrolled in Medicare. With over 200 hospitals in New York alone, this is a very impressive statistic. For reference, the next highest volume hospital in New York state for orthopedic discharges is North Shore University Hospital, where the discharges there accounted for nearly 3% of New York Medicare enrollees’ orthopedic discharges.
|Orthopedic Inpatient Discharge Volume Rank||Hospital Name||City||State||Total Medicare Orthopedic Inpatient Discharges||% Of New York’s Orthopedic Discharges|
|All New York Hospitals||66,270||100.00|
|1||Hospital for Special Surgery||New York||New York||3,760||5.67|
|2||North Shore University Hospital||Manhasset||New York||1,958||2.95|
|3||Tisch Hospital||New York||New York||1,911||2.88|
|4||St. Joseph's Hospital Health Center||Syracuse||New York||1,214||1.83|
|5||Montefiore Medical Center||Bronx||New York||1,191||1.80|
|6||St. Peter's Hospital||Albany||New York||1,126||1.70|
|7||Long Island Jewish Medical Center||New Hyde Park||New York||1,094||1.65|
|8||NewYork-Presbyterian/Weill Cornell Medical Center||New York||New York||1,073||1.62|
|9||Albany Medical Center||Albany||New York||1,069||1.61|
|10||Staten Island University Hospital||Staten Island||New York||1,058||1.60|
When we take the number of national orthopedics discharges (5,524) for Hospital for Special Surgery and subtract the number of discharges from New York residents (3,760), we are left with 1,764, which represents the number of discharges at Hospital for Specialty Surgery that came from Medicare enrollees living outside of New York. This means that if only the orthopedic discharges at HSS from out-of-state residents accounted for the hospital’s discharge volume, the hospital would still rank 39th in orthopedic discharge volume.
Hospital for Special Surgery is known as one of the top orthopedic hospitals in the nation and, according to commentary from HSS Surgeon-in-Chief Emeritus, Dr. Thomas Peter Sculco, is the oldest orthopedic hospital in the United States. With that in mind, it is not surprising that a hospital with such an esteemed reputation ranks highest in the U.S. for orthopedic discharge volume among Medicare enrollees.
By: Emily Carpintero  Nov. 21, 2017
North Carolina had the 11th highest volume of Medicare inpatient discharges in the nation, accounting for 3.22% of discharges between October 2015 and September 2016. Along with total Medicare inpatient discharge volume, Dexur analysts identified total Medicare inpatient payments, total percentage of revenue contributed from 30 day readmissions and the percentage of total days from length of stay (LOS) contributing to 30 day readmissions. You can read about 30 day readmission contribution to revenue and percentage of days from length of stay contributing to 30 day readmissions, as well as how this data is calculated here.
According to Dexur data, the leading hospital in North Carolina for Medicare inpatient discharge volume between October 2015 and September 2016 was New Hanover Regional Medical Center in Wilmington. The hospital was founded in 1967 and currently holds several accreditations and national awards. New Hanover Regional Medical Center has accomplished a five-star rating for knee-replacements every year for over a decade. It has also been noted that they have high quality care for cardiac arrest patients; they treat these patients 40 minutes faster than the national average.
Looking at the table below, Dexur analysts identified the percentage of revenue contributed from 30 day readmissions from Medicare inpatients and the percentage of days from length of stay (LOS) contributing to 30 day admissions from Medicare inpatients at the national, state, and hospital level between October 2015 and September 2016.
|Hospital Name||Total Medicare Inpatient Discharges||Total Medicare Inpatient Payments||30 Day Readmission Medicare Inpatient Revenue Contribution %||30 Day Readmission Medicare Inpatient LOS Contribution %|
|New Hanover Regional Medical Center||17,168||$188,166,677||20.57%||23.26%|
The national hospitals’ average percentage of revenue contribution from 30 day readmissions of Medicare inpatients is 22.48% lower than the national average at 23.24%. New Hanover Regional Medical Center is below the national and state average for both revenue contribution from 30 day readmissions and the average percentage of days from LOS from 30 day readmissions that contributed to revenue from Medicare inpatients. Its average is 5.15% less than the national average for revenue contributed by 30 day readmissions and 2.67% less than the state average. New Hanover Regional Medical Center also has a small gap of only 2.66% between their revenue contributed by 30 day readmissions and the average percentage of days from LOS from 30 day readmissions that contributed to revenue. New Hanover Regional Medical Center was able to treat a high volume and array of patients, while successfully keeping below the national and state averages and minimizing cost for care.
By: Saparja Nag  Nov. 21, 2017
30 day readmission rates to index hospitals are commonly used to measure the continuity of care that patients receive. The metric is often utilized in hospital comparisons to explain differences in quality of care. The state of Connecticut had the highest proportion of readmissions admitted to the index hospital in the country based on Medicare data between October 2015 and September 2016. Dexur’s analysis revealed the 3 Connecticut hospitals with the highest readmission rates to index hospitals were Danbury Hospital, Stamford Hospital, and Yale-New Haven Hospital. A primer on 30 day readmissions to index and non-index hospitals can be found here.
Danbury Hospital, a member of the Western Connecticut Health Network, is a non-profit community hospital. They had 8,007 Medicare discharges between October 2015 and September 2016 while also contributing $143 million to the community. Stamford Hospital is a Level II trauma center that serves Fairfield county, CT and Westchester county, NY, treating 4,453 Medicare discharges during this data time period. Yale-New Haven Hospital is the highest volume hospital in Connecticut with 22,191 Medicare inpatient discharges. They are nationally recognized for patient care, clinical research, and healthcare equality.
|Region||Total Medicare Inpatient Discharges||% Readmission Rate to Index Hospital|
|Yale-New Haven Hospital||22,191||82.76|