Association Between Medicare Expenditures and Adverse Events for Patients With Acute Myocardial Infarction, Heart Failure, or Pneumonia in the United States

Affiliations

PMID: 32259263
PMCID: PMC7139276
DOI: 10.1001/jamanetworkopen.2020.2142

Abstract

Importance: Studies have shown that adverse events are associated with increasing inpatient care expenditures, but contemporary data on the association between expenditures and adverse events beyond inpatient care are limited.

Objective: To evaluate whether hospital-specific adverse event rates are associated with hospital-specific risk-standardized 30-day episode-of-care Medicare expenditures for fee-for-service patients discharged with acute myocardial infarction (AMI), heart failure (HF), or pneumonia.

Design, setting, and participants: This cross-sectional study used the 2011 to 2016 hospital-specific risk-standardized 30-day episode-of-care expenditure data from the Centers for Medicare & Medicaid Services and medical record-abstracted in-hospital adverse event data from the Medicare Patient Safety Monitoring System. The setting was acute care hospitals treating at least 25 Medicare fee-for-service patients for AMI, HF, or pneumonia in the United States. Participants were Medicare fee-for-service patients 65 years or older hospitalized for AMI, HF, or pneumonia included in the Medicare Patient Safety Monitoring System in 2011 to 2016. The dates of analysis were July 16, 2017, to May 21, 2018.

Main outcomes and measures: Hospitals' risk-standardized 30-day episode-of-care expenditures and the rate of occurrence of adverse events for which patients were at risk.

Results: The final study sample from 2194 unique hospitals included 44 807 patients (26.1% AMI, 35.6% HF, and 38.3% pneumonia) with a mean (SD) age of 79.4 (8.6) years, and 52.0% were women. The patients represented 84 766 exposures for AMI, 96 917 exposures for HF, and 109 641 exposures for pneumonia. Patient characteristics varied by condition but not by expenditure category. The mean (SD) risk-standardized expenditures were $22 985 ($1579) for AMI, $16 020 ($1416) for HF, and $16 355 ($1995) for pneumonia per hospitalization. The mean risk-standardized rates of occurrence of adverse events for which patients were at risk were 3.5% (95% CI, 3.4%-3.6%) for AMI, 2.5% (95% CI, 2.5%-2.5%) for HF, and 3.0% (95% CI, 2.9%-3.0%) for pneumonia. An increase by 1 percentage point in the rate of occurrence of adverse events was associated with an increase in risk-standardized expenditures of $103 (95% CI, $57-$150) for AMI, $100 (95% CI, $29-$172) for HF, and $152 (95% CI, $73-$232) for pneumonia per discharge.

Conclusions and relevance: Hospitals with high adverse event rates were more likely to have high 30-day episode-of-care Medicare expenditures for patients discharged with AMI, HF, or pneumonia.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Metersky reported working on various quality improvement and patient safety projects with Qualidigm, the Centers for Medicare & Medicaid Services (CMS), and the Agency for Healthcare Research and Quality (AHRQ) (his employer received remuneration for all). Dr Normand reported having a US patent pending (201810345624.5). Drs Bernheim, Normand, and Krumholz reported working under contract with the CMS to develop and maintain performance measures. Dr Krumholz reported working under contract with the CMS to support quality measurement programs; receiving a research grant through Yale University from Medtronic and the US Food and Drug Administration to develop methods for postmarket surveillance of medical devices; receiving a research grant from Johnson & Johnson through Yale University to support clinical trial data sharing; receiving a research agreement through Yale University from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion; collaborating with the National Center for Cardiovascular Diseases in Beijing, China; receiving payment from the Arnold & Porter Law Firm for work related to the Sanofi clopidogrel litigation, from the Martin Baughman Law Firm for work related to the Cook Celect inferior vena cava filter litigation, and from the Siegfried and Jensen Law Firm for work related to Vioxx litigation; being chair of a cardiac scientific advisory board for UnitedHealth; being a member of the IBM Watson Health life sciences board; being a member of the advisory board for Element Science, the advisory board for Facebook, and the physician advisory board for Aetna; and being cofounder of Hugo Health, a personal health information platform, and cofounder of Refactor Health, an enterprise health care artificial intelligence–augmented data management company. No other disclosures were reported.