Turning readmission reduction policies into results: some lessons from a multistate initiative to reduce readmissions.

Efforts are under way nationally to reduce avoidable hospital readmissions by changing payments to hospitals, but it is unclear how well or how quickly these policy changes will produce widespread reductions in hospital readmissions. To examine some of the challenges to implementing such approaches, the authors analyzed the early experiences of 3 statewide programs to reduce preventable readmissions that began in 2009. Based on interviews with program participants in 2011, the authors identified 3 key obstacles to progress: the difficulty of developing collaborative relationships across care settings, gaps in evidence for effective interventions, and deficits in quality improvement capabilities among some organizations.

Does admission to a teaching hospital affect acute myocardial infarction survival?

Purpose: Previous studies have found that teaching hospitals produce better acute myocardial infarction (AMI) outcomes than nonteaching hospitals. However, these analyses generally excluded patients transferred out of nonteaching hospitals and did not study outcomes by patient risk level. The objective of this study was to determine whether admission to a teaching hospital was associated with greater survival after accounting for patient transfers and patient severity.

Are the healthy behaviors of US high-deductible health plan enrollees driven by people who chose these plans? Smoking as a case study.

Purpose: To determine whether negative associations between enrollment in a high-deductible health plan (HDHP) and one exemplar unhealthy behavior--daily smoking--are found only among people who chose these plans.

Design: Cross-sectional analysis of nationally-representative data.

Setting: United States from 2007 to 2008.

Default options in advance directives influence how patients set goals for end-of-life care.

Although decisions regarding end-of-life care are personal and important, they may be influenced by the ways in which options are presented. To test this hypothesis, we randomly assigned 132 seriously ill patients to complete one of three types of advance directives. Two types had end-of-life care options already checked-a default choice-but one of these favored comfort-oriented care, and the other, life-extending care.

The impact of profitability of hospital admissions on mortality.

Background: Fiscal constraints faced by Medicare are leading to policies designed to reduce expenditures. Evidence of the effect of reduced reimbursement on the mortality of Medicare patients discharged from all major hospital service lines is limited.

Methods: We modeled risk-adjusted 30-day mortality of patients discharged from 21 hospital service lines as a function of service line profitability, service line time trends, and hospital service line and year-fixed effects.

Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial.

Context: A 2009 Institute of Medicine report recommended protected sleep periods for medicine trainees on extended overnight shifts, a position reinforced by new Accreditation Council for Graduate Medical Education requirements.

Objective: To evaluate the feasibility and consequences of protected sleep periods during extended duty.

Design, Setting, And Participants: Randomized controlled trial conducted at the Philadelphia VA Medical Center medical service and Oncology Unit of the Hospital of the University of Pennsylvania (2009-2010).

The impact of price discounts and calorie messaging on beverage consumption: a multi-site field study.

Objectives: To examine the efficacy of alternative approaches for shifting consumers toward zero calorie beverages. We examined the effect of price discounts and novel presentations of calorie information on sales of beverages.

Methods: This prospective interrupted time-series quasi-experiment included three sites in Philadelphia, PA, Evanston, IL, and Detroit, MI.

On the Way to Health.

Information technology (IT) has fundamentally changed the way we work, bank, and communicate. Its impact on health care and health research, however, has been limited by the lack of a comprehensive infrastructure to connect patients, providers, and researchers. As we learn more about how to address the unhealthy behaviors that underlie many chronic conditions, researchers are seeking IT solutions to connect to patients in scalable ways.

Randomized trial of lottery-based incentives to improve warfarin adherence.

Background: Poor adherence to medications is a major cause of morbidity and inadequate drug effectiveness. Efforts to improve adherence have typically been either ineffective or too complex to implement in clinical practice. Lottery-based incentive interventions could be a scalable approach to improving adherence.

Teaching hospital financial status and patient outcomes following ACGME duty hour reform.

Objective: To examine whether hospital financial health was associated with differential changes in outcomes after implementation of 2003 ACGME duty hour regulations.

Data Sources/study Setting: Observational study of 3,614,174 Medicare patients admitted to 869 teaching hospitals from July 1, 2000 to June 30, 2005.

Study Design: Interrupted time series analysis using logistic regression to adjust for patient comorbidities, secular trends, and hospital site.

Can behavioural economics make us healthier?

Behavioural economics is becoming increasingly popular as a way to improve public health. George Loewenstein and colleagues point out some of the pitfalls and warn that it cannot be used as a substitute for conventional policies to tackle fundamental problems.

Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors.

Purpose: To assess internal medicine (IM) and surgery program directors' views of the likely effects of the 2011 Accreditation Council for Graduate Medical Education duty hours regulations.

Method: In fall 2010, investigators surveyed IM and surgery program directors, assessing their views of the likely impact of the 2011 duty hours standards on learning environment, workload, education opportunities, program administration, and patient outcomes.

Results: Of 381 IM program directors, 287 (75.

Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009.

Purpose: To gauge internal medicine (IM) trainees' perceptions regarding aspects of their inpatient rotations, including supervision, educational opportunities, the perceived effect of duty hours regulations on quality of patient care, the causes of medical errors, and sleep.

Method: The authors analyzed the results of questionnaires administered to trainees following the October 2009 in-training examinations (ITE).

Results: Of the 21,768 IM trainees in postgraduate years 1 through 3 who took the IM-ITE, 18,272 (83.

Leveraging insights from behavioral economics to increase the value of health-care service provision.

United States health expenditures continue to escalate at unsustainable rates. A recent movement around increasing price transparency has been suggested as a way of reducing the rate of increase in expenditures, with legislative efforts taking place at both the state and federal level. While this seems on the surface like a good idea, simply providing information on prices to physicians, particularly trainees, may not achieve the type of large changes in practice patterns that proponents expect.

Application of the RE-AIM framework to evaluate the impact of a worksite-based financial incentive intervention for smoking cessation.

Objective: To apply the RE-AIM framework to examine factors that may have influenced the impact of a financial incentive smoking cessation intervention delivered at General Electric (GE) worksites.

Methods: Intervention reach and efficacy were examined alone and in combination across worksites. Telephone interviews were conducted with worksite staff to explore organizational-level factors that may have influenced program adoption, implementation, and maintenance.

A longitudinal analysis of the impact of hospital service line profitability on the likelihood of readmission.

Quality of care may be linked to the profitability of admissions in addition to level of reimbursement. Prior policy reforms reduced payments that differentially affected the average profitability of various admission types. The authors estimated a Cox competing risks model, controlling for the simultaneous risk of mortality post discharge, to determine whether the average profitability of hospital service lines to which a patient was admitted was associated with the likelihood of readmission within 30 days.

Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial.

Background: Compared with white persons, African Americans have a greater incidence of diabetes, decreased control, and higher rates of microvascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes.

Objective: To determine whether peer mentors or financial incentives are superior to usual care in helping African American veterans decrease their hemoglobin A(1c) (HbA(1c)) levels.

Empirical observations on longer-term use of incentives for weight loss.

Behavioral economic-based interventions are emerging as powerful tools to help individuals accomplish their own goals, including weight loss. Deposit contract incentive systems give participants the opportunity to put their money down toward losing weight, which they forfeit if they fail to lose weight; lottery incentive systems enable participants to win money if they attain weight loss goals. In this paper, we pool data from two prior studies to examine a variety of issues that unpublished data from those studies allow us to address.