Person: Jha, Ashish
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Jha
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Ashish
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Jha, Ashish
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Publication Regional health expenditure and health outcomes after out-of-hospital cardiac arrest in Japan: an observational study(BMJ Publishing Group, 2015) Tsugawa, Yusuke; Hasegawa, Kohei; Hiraide, Atsushi; Jha, AshishObjectives: Japan is considering policies to set the target health expenditure level for each region, a policy approach that has been considered in many other countries. The objective of this study was to examine the relationship between regional health expenditure and health outcomes after out-of-hospital cardiac arrest (OHCA), which incorporates the qualities of prehospital, in-hospital and posthospital care systems. Design: We examined the association between prefecture-level per capita health expenditure and patients’ health outcomes after OHCA. Setting: We used a nationwide, population-based registry system of OHCAs that captured all cases with OHCA resuscitated by emergency responders in Japan from 2005 to 2011. Participants: All patients with OHCA aged 1–100 years were analysed. Outcome measures The patients’ 1-month survival rate, and favourable neurological outcome (defined as cerebral performance category 1–2) at 1-month. Results: Among 618 154 cases with OHCA, the risk-adjusted 1-month survival rate varied from 3.3% (95% CI 2.9% to 3.7%) to 8.4% (95% CI 7.7% to 9.1%) across prefectures. The risk-adjusted probabilities of favourable neurological outcome ranged from 1.6% (95% CI 1.4% to 1.9%) to 3.7% (95% CI 3.4% to 3.9%). Compared with prefectures with lowest tertile health expenditure, 1-month survival rate was significantly higher in medium-spending (adjusted OR 1.31, 95% CI 1.03 to 1.66, p=0.03) and high-spending prefectures (adjusted OR 1.30, 95% CI 1.03 to 1.64, p=0.02), after adjusting for patient characteristics. There was no difference in the survival between medium-spending and high-spending regions. We observed similar patterns for favourable neurological outcome. Additional adjustment for regional per capita income did not affect our overall findings. Conclusions: We observed a wide variation in the health outcomes after OHCA across regions. Low-spending regions had significantly worse health outcomes compared with medium-spending or high-spending regions, but no difference was observed between medium-spending and high-spending regions. Our findings suggest that focusing on the median spending may be the optimum that allows for saving money without compromising patient outcomes.Publication Reducing Readmissions: What Might it Take?(Blackwell Publishing Ltd, 2014) Jha, AshishPublication Access, quality, and costs of care at physician owned hospitals in the United States: observational study(BMJ Publishing Group Ltd., 2015) Blumenthal, Daniel; Orav, E John; Jena, Anupam; Dudzinski, David; Le, Sidney T; Jha, AshishObjective: To compare physician owned hospitals (POHs) with non-POHs on metrics around patient populations, quality of care, costs, and payments. Design: Observational study. Setting: Acute care hospitals in 95 hospital referral regions in the United States, 2010. Participants: 2186 US acute care hospitals (219 POHs and 1967 non-POHs). Main outcome measures Proportions of patients using Medicaid and those from ethnic and racial minority groups; hospital performance on patient experience metrics, care processes, risk adjusted 30 day mortality, and readmission rates; costs of care; care payments; and Medicare market share. Results: The 219 POHs were more often small (<100 beds), for profit, and in urban areas. 120 of these POHs were general (non-specialty) hospitals. Compared with patients from non-POHs, those from POHs were younger (77.4 v 78.4 years, P<0.001), less likely to be admitted through an emergency department (23.2% v. 29.0%, P<0.001), equally likely to be black (5.1% v 5.5%, P=0.85) or to use Medicaid (14.9% v 15.4%, P=0.75), and had similar numbers of chronic diseases and predicted mortality scores. POHs and non-POHs performed similarly on patient experience scores, processes of care, risk adjusted 30 day mortality, 30 day readmission rates, costs, and payments for acute myocardial infarction, congestive heart failure, and pneumonia. Conclusion: Although POHs may treat slightly healthier patients, they do not seem to systematically select more profitable or less disadvantaged patients or to provide lower value care.Publication Toward a Common Secure Future: Four Global Commissions in the Wake of Ebola(Public Library of Science, 2016) Gostin, Lawrence O.; Tomori, Oyewale; Wibulpolprasert, Suwit; Jha, Ashish; Frenk, Julio; Moon, Suerie; Phumaphi, Joy; Piot, Peter; Stocking, Barbara; Dzau, Victor J.; Leung, Gabriel M.Lawrence Gostin and colleagues offer a set of priorities for global health preparedness and response for future infectious disease threats.Publication Assessing the level of healthcare information technology adoption in the United States: a snapshot(Springer Nature, 2006) Poon, Eric G; Jha, Ashish; Christino, Melissa; Honour, Melissa M; Fernandopulle, Rushika; Middleton, Blackford; Newhouse, Joseph; Leape, Lucian; Bates, David; Blumenthal, David; Kaushal, RainuBackground: Comprehensive knowledge about the level of healthcare information technology (HIT) adoption in the United States remains limited. We therefore performed a baseline assessment to address this knowledge gap. Methods: We segmented HIT into eight major stakeholder groups and identified major functionalities that should ideally exist for each, focusing on applications most likely to improve patient safety, quality of care and organizational efficiency. We then conducted a multi-site qualitative study in Boston and Denver by interviewing key informants from each stakeholder group. Interview transcripts were analyzed to assess the level of adoption and to document the major barriers to further adoption. Findings for Boston and Denver were then presented to an expert panel, which was then asked to estimate the national level of adoption using the modified Delphi approach. We measured adoption level in Boston and Denver was graded on Rogers' technology adoption curve by co-investigators. National estimates from our expert panel were expressed as percentages. Results: Adoption of functionalities with financial benefits far exceeds adoption of those with safety and quality benefits. Despite growing interest to adopt HIT to improve safety and quality, adoption remains limited, especially in the area of ambulatory electronic health records and physician-patient communication. Organizations, particularly physicians' practices, face enormous financial challenges in adopting HIT, and concerns remain about its impact on productivity. Conclusion: Adoption of HIT is limited and will likely remain slow unless significant financial resources are made available. Policy changes, such as financial incentivesto clinicians to use HIT or pay-for-performance reimbursement, may help health care providers defray upfront investment costs and initial productivity loss.Publication Mortality and Readmission After Cervical Fracture from a Fall in Older Adults: Comparison with Hip Fracture Using National Medicare Data(Wiley-Blackwell, 2015) Cooper, Zara; Mitchell, Susan; Lipsitz, Stuart; Harris, Mitchel; Ayanian, John; Bernacki, Rachelle; Jha, AshishBackground Cervical fractures from falls are a potentially lethal injury in older patients. Little is known about their epidemiology and outcomes. Objectives To examine the prevalence of cervical spine fractures after falls among older Americans and show changes in recent years. Further, to compare 12-month outcomes in patients with cervical and hip fracture after falls. Design, Setting, and Participants A retrospective study of Medicare data from 2007–2011 including patients ≥65 with cervical fracture and hip fracture after falls treated at acute care hospitals. Measurements Rates of cervical fracture, 12-month mortality and readmission rates after injury. Results Rates of cervical fracture increased from 4.6/10,000 in 2007 to 5.3/10,000 in 2011, whereas rates of hip fracture decreased from 77.3/10,000 in 2007 to 63.5/10,000 in 2011. Patients with cervical fracture without and with spinal cord injury (SCI) were more likely than patients with hip fracture, respectively, to receive treatment at large hospitals (54.1%, 59.4% vs. 28.1%, p< 0.001), teaching hospitals (40.0%, 49.3% vs. 13.4%, p< 0.001), and regional trauma centers (38.5%, 46.3% vs. 13.0%, p< 0.001). Patients with cervical fracture, particularly those with SCI, had higher risk-adjusted mortality rates at one year than those with hip fracture (24.5%, 41.7% vs. 22.7%, p<0.001). By one year, more than half of patients with cervical and hip fracture died or were readmitted to the hospital (59.5%, 73.4% vs. 59.3%, p<0.001). Conclusion Cervical spine fractures occur in one of every 2,000 Medicare beneficiaries annually and appear to be increasing over time. Patients with cervical fractures had higher mortality than those with hip fractures. Given the increasing prevalence and the poor outcomes of this population, hospitals need to develop processes to improve care for these vulnerable patients.Publication Effect of Nonpayment for Preventable Infections in U.S. Hospitals(New England Journal of Medicine (NEJM/MMS), 2012) Lee, Grace; Kleinman, Kenneth Paul; Soumerai, Stephen; Tse, Alison; Cole, David; Fridkin, Scott K.; Horan, Teresa; Platt, Richard; Gay, Charlene; Kassler, William; Goldmann, Donald; Jernigan, John; Jha, AshishBackground In October 2008, the Centers for Medicare and Medicaid Services (CMS) discontinued additional payments for certain hospital-acquired conditions that were deemed preventable. The effect of this policy on rates of health care–associated infections is unknown. Methods Using a quasi-experimental design with interrupted time series with comparison series, we examined changes in trends of two health care–associated infections that were targeted by the CMS policy (central catheter–associated bloodstream infections and catheter-associated urinary tract infections) as compared with an outcome that was not targeted by the policy (ventilator-associated pneumonia). Hospitals participating in the National Healthcare Safety Network and reporting data on at least one health care–associated infection before the onset of the policy were eligible to participate. Data from January 2006 through March 2011 were included. We used regression models to measure the effect of the policy on changes in infection rates, adjusting for baseline trends. Results A total of 398 hospitals or health systems contributed 14,817 to 28,339 hospital unit– months, depending on the type of infection. We observed decreasing secular trends for both targeted and nontargeted infections long before the policy was implemented. There were no significant changes in quarterly rates of central catheter– associated bloodstream infections (incidence-rate ratio in the postimplementation vs. preimplementation period, 1.00; P=0.97), catheter-associated urinary tract infections (incidence-rate ratio, 1.03; P=0.08), or ventilator-associated pneumonia (incidence-rate ratio, 0.99; P=0.52) after the policy implementation. Our findings did not differ for hospitals in states without mandatory reporting, nor did it differ according to the quartile of percentage of Medicare admissions or hospital size, type of ownership, or teaching status. Conclusions We found no evidence that the 2008 CMS policy to reduce payments for central catheter–associated bloodstream infections and catheter-associated urinary tract infections had any measurable effect on infection rates in U.S. hospitals.Publication Impact of Medicare's Payment Policy on Mediastinitis Following Coronary Artery Bypass Graft Surgery in US Hospitals(Cambridge University Press (CUP), 2014) Calderwood, Michael S.; Kleinman, Kenneth Paul; Soumerai, Stephen; Jin, Robert; Gay, Charlene; Piatt, Richard; Kassler, William; Goldmann, Donald; Jha, Ashish; Lee, GraceThe Centers for Medicare and Medicaid Services (CMS) implemented a policy in October 2008 to eliminate additional Medicare payment for mediastinitis following coronary artery bypass graft (CABG) surgery. To evaluate the impact of this policy on mediastinitis rates, using Medicare claims and National Healthcare Safety Network (NHSN) prospective surveillance data. We used an interrupted time series design to compare mediastinitis rates before and after the policy, adjusted for secular trends. Billing rates came from Medicare inpatient claims following 638,761 CABG procedures in 1,234 US hospitals (January 2006-September 2010). Prospective surveillance rates came from 151 NHSN hospitals in 29 states performing 94,739 CABG procedures (January 2007-September 2010). Logistic regression mixed-effects models estimated trends for mediastinitis rates. We found a sudden drop in coding for index admission mediastinitis at the time of policy implementation (odds ratio, 0.36 [95% confidence interval (CI), 0.23-0.57]) and a decreasing trend in coding for index admission mediastinitis in the postintervention period compared with the preintervention period (ratio of slopes, 0.83 [95% CI, 0.74-0.95]). However, we saw no impact of the policy on infection rates as measured using NHSN data. Our results were not affected by changes in patient risk over time, heterogeneity in hospital demographics, or timing of hospital participation in NHSN. The CMS policy of withholding additional Medicare payment for mediastinitis on the basis of claims-based evidence of infection was associated with changes in coding for infections but not with changes in actual infection rates during the first 2 years after policy implementation.Publication Have geopolitics influenced decisions on American health foreign assistance efforts during the Obama presidency?(Edinburgh University Global Health Society, 2018) Gupta, Vin; Tsai, Alexander; Mason-Sharma, Alexandre; Goosby, Eric P; Jha, Ashish; Kerry, Vanessa BBackground: This study sought to characterize the possible relationship between US geopolitical priorities and annual decisions on health foreign assistance among recipient nations between 2009 and 2016. Methods: Data on total planned United States (US) foreign aid and health aid were collected for the 194 member nations of the World Health Organization (WHO) from publicly available databases. Trends in per-capita spending were examined between 2009 and 2016 across the six regions of the WHO (Africa, Americas, Eastern Mediterranean, Europe, Southeast Asia, and the Western Pacific). Data on US national security threats were obtained from the Council on Foreign Relations’ annual Preventive Priorities Survey. Multivariable regression models were fitted specifying planned health aid as the dependent variable and threat level of a recipient aid nation as the primary independent variable. Results: Across the aggregate 80 planned recipient countries of US health aid over the duration of the study period, cumulative planned per-capita spending was stable (US$ 0.65 in both 2009 and 2016). The number of annual planned recipients of this aid declined from 74 in 2009 to 56 in 2016 (24.3% decline), with planned allocations decreasing in the Americas, Eastern Mediterranean, and Europe; corresponding increases were observed in Africa, Southeast Asia, and the Western Pacific. Regression analyses demonstrated a dose-response, whereby higher levels of threat were associated with larger declines in planned spending (critical threat nations: b = -3.81; 95% confidence interval (CI) -5.84 to -1.78, P ≤ 0.001) and one-year lagged (critical threat nations: b = -3.91; 95% CI, -5.94 to -1.88, P ≤ 0.001) analyses. Conclusions: Higher threat levels are associated with less health aid. This is a novel finding, as prior studies have demonstrated a strong association between national security considerations and decisions on development aid.Publication Does the Computerized Display of Charges Affect Inpatient Ancillary Test Utilization?(American Medical Association (AMA), 1997-11-24) Bates, David; Kuperman, Gilad J.; Jha, Ashish; Teich, Jonathan; Orav, Endel; Ma'luf, Nell; Onderdonk, Andrew; Pugatch, Robert; Wybenga, Donald; Winkelman, James; Brennan, Troyen; Komaroff, Anthony; Tanasijevic, MilenkoBackground: The computerized display of charges for ancillary tests in outpatients has been found to affect physician-ordering behavior, but this issue has not been studied in inpatients. Objective: To assess whether the computerized display of charges for clinical laboratory or radiological tests affected physician-ordering behavior. Patients and methods: Two prospective controlled trials, randomized by patient, were performed. Each trial included all medical and surgical inpatients at 1 large teaching hospital during 4 and 7 months: 3536 intervention and 3554 control inpatients in the group with clinical laboratory tests, and 8728 intervention and 8653 control inpatients in the group with radiological tests. The intervention consisted of the computerized display of charges for tests at the time of ordering. Main outcome measures: The number of clinical laboratory and radiological tests ordered per admission and the charges for these tests. Results: For the clinical laboratory tests, during a 4-month study period, patients in the intervention group had 4.5% fewer tests ordered, and the total charges for these tests were 4.2% lower, although neither difference was statistically significant. Compared with historical controls from the same 4-month period a year before, the charges for the tests per admission had decreased 13.3%, but the decrease was temporally correlated with a restriction of future ordering of tests, and not with the introduction of the display of charges. For the radiological tests, during a 7-month period, the intervention group had almost identical numbers of tests ordered and charges for these tests. Conclusions: The computerized display of charges had no statistically significant effect on the number of clinical laboratory tests or radiological procedures ordered or performed, although small trends were present for clinical laboratory tests. More intensive interventions may be needed to affect physician test utilization.