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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
Hospital Survival Rates for DRG 475 and DRG 483 in New York State
1995-1999
0
0.2
0.4
0.6
0.8
1995 1996 1997 1998 1999
YEAR OF DISCHARGE
SU
RV
IVA
L
RA
TE
S
DRG483
DRG475
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
Pre- and Post-HCRA Survival Rates For DRG 483 MCO and Non-MCO
Patients in New York State
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
MCO Non-MCO
SU
RV
IVA
L R
AT
E
Pre-HCRA ('95-'96)
Post-HCRA ('97-'99)
Pre- and Post-HCRA Survival Rates for DRG 475 MCO and Non-MCO
Patients in New York State
0.58
0.585
0.59
0.595
0.6
0.605
0.61
0.615
0.62
MCO Non-MCO
SU
RV
IVA
L R
AT
ES
Pre-HCRA('95-'96)
Post-HCRA('97-'99)
Skilled Nursing Facility Discharge Rates for DRG 483 and DRG 475 by Year
0
10
20
30
40
50
60
Percent Discharged
1995 1996 1997 1998 1999
Year of Discharge
DRG 483DRG 475
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
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
significant variables
pre
dic
ted
od
ds
BLACK
NYCLOCATION
MEDICARE
MEDICARE/BC
URGENTADMIT
EMERGENCY
FLUIDDISORDER
PNEUMONIA
HCRA
HCRA*MCO
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
0
0.5
1
1.5
2
significant variables
pre
dic
ted
od
ds
NYCLOCATION
MEDICAID
MEDICARE/MEDICAID
URGENTADMIT
EMERGENCY
PLUERISY
TEACHING
HCRA
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
0
0.5
1
1.5
2
2.5
significant variables
pre
dic
ted
od
ds
HISPANIC
NYC LOCATION
FEMALE
URGENT ADMIT
EMERGENCY
FLUID DISORDER
OTHE ANEMIAS
BACTERIALPNEUMONIA
OTHERPNEUMONIA
CHRONIC AIRWAYOBSTRUCTION
PLEURISY
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.
0
0.5
1
1.5
2
2.5
significant variables
pre
dic
ted
od
ds
OTHER ANEMIAS
BACTERIALPNEUMONIA
CHRONIC AIRWAYOBSTRUCTION
TEACHING
MEDICAID
MEDCAID/MEDICARE
COMMERCIAL INS
BLUE CROSS BLUESHIELD
HCRA
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