Heart failure and respiratory failure are among the most common causes of hospitalization and death in the United States. In fact, primary or secondary diagnoses of respiratory failure and heart failure accounted for roughly 16% and 25%, respectively, of traditional Medicare hospitalizations in 2018. For most of these hospitalizations, respiratory failure appears as a secondary condition (90.1%) as does heart failure (97.9%). While heart failure and respiratory failure are chronic conditions, patients may be hospitalized with acute exacerbations of these conditions, described as “acute on chronic” conditions. While risk adjustment models to assess provider performance on quality used by the Centers for Medicare & Medicaid Services (CMS) control for respiratory and heart failure, these models do not differentiate acute on chronic from chronic (non-acute).
To better understand similarities and differences in patients with and without acute on chronic conditions, we compared length of stays in a short-term acute care hospital (STACH) and post-STACH use patterns between two groups of patient with heart failure or respiratory failure: (1) Medicare beneficiaries hospitalized with a principal or secondary diagnosis of acute on chronic heart or respiratory failure; (2) Medicare beneficiaries hospitalized with a principal or secondary diagnosis of chronic (non-acute) respiratory or heart failure but without an acute on chronic diagnosis. Our analysis was completed using the 2018 100% Medicare Inpatient Standard Analytic File.
Acute on chronic cases accounted for 34.6% of all heart failure cases in STACHs and 26.0% of respiratory failure cases. Within these cases, acute on chronic hospital stays grouped into a smaller number of MS-DRGs. The majority (75.8%) of all acute on chronic heart failure cases were grouped into 15 MS-DRGs, while roughly a third (35.5%) of chronic (non-acute) heart failure cases fell into the same MS-DRGs. Similarly, 81.5% of all acute on chronic respiratory failure cases fell into 15 MS-DRGs, while 56.2% of chronic (non-acute) respiratory failure cases were grouped to the same MS-DRGs.
Hospital resource use and outcomes for acute on chronic patients also differed from their (non-acute) chronic counterparts. Acute on chronic respiratory failure cases had an average length of stay of 7.5 days compared to 7.0 days for chronic (non-acute) respiratory failure cases (8% difference). Acute on chronic heart failure cases had an average length of stay of 6.6 days compared to 5.4 days for chronic (non-acute) heart failure cases (23% difference).
Discharge disposition also varies across chronic condition types. Our findings show 4.5% of all acute on chronic heart failure cases were discharged to a long-term care hospital (LTCH) compared to 3.6% of all chronic (non-acute) heart failure cases. The difference in LTCH discharges was greater between acute on chronic and chronic (non-acute) patients in the respiratory failure cohort, with 11.2% of acute on chronic respiratory failure cases discharged to LTCHs compared to 7.6% chronic (non-acute) respiratory failure cases. While cases discharged to an LTCH were more likely to be acute on chronic than chronic (non-acute), the reverse pattern was observed for skilled nursing facilities (Heart failure: 60.6% of all acute on chronic vs. 64.1% chronic; Respiratory Failure: 58.8% of all acute on chronic vs. 59.8% chronic) and inpatient rehabilitation facilities (Heart failure: 7.3% of all acute on chronic vs. 9.2% chronic; Respiratory Failure: 6.3% of all acute on chronic vs. 9.4% chronic).
The differences in resource utilization and patient outcomes, identified in this study, suggest that risk adjustment models used to assess provider performance may be improved by distinguishing between these types of heart failure and respiratory failure patients.
Comparison of Average Length of Stay (Days) by Acute on Chronic vs. Chronic (Non-acute) Diagnosis
Source: KNG Health analysis of 2018 and 2019 Standard Analytic File.
Services : Blog, Health Economics & Outcomes Research, Practice Area - Evaluation and Health Economics Expertise: health economics, Quality Measurement and Provider Performance
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Ori Nevo is a Research Associate in the Healthcare Reform and Payment Innovation Practice. Mr. Nevo specializes in biostatistics and epidemiology with a focus in behavioral health outcomes and has managed quantitative analysis on a range of topics including substance use, osteoporotic fracture recovery, as well as conducted client and staff engagement in healthcare settings. Prior to joining KNG, Mr. Nevo worked as Data Analysis and Outcomes Manager, leading in-house research for an organization that provides behavioral health services throughout Massachusetts. His work provided analysis regarding inpatient care outcomes, residential and day clinic programs, child services, and substance use program management. In this role he assessed the efficiency and efficacy of these programs in managing client care as well as the relationship between environmental effects on health outcomes. Mr. Nevo also brings direct care experience in the area of behavioral health care, having worked as a mental health specialist for individuals living with mental illness for five years. Mr. Nevo earned his Master’s in Public Health at Boston University School of Public Health, and his BS in Psychology and BA in Music Composition from Brandeis University. |
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Marie Steele-Adjognon is a Research Director in the Evaluation and Health Economics Practice at KNG Health. She has formal training and experience in conducting quasi-experimental analyses, simulation models, demand projections, econometric analysis of both cross-sectional and panel data, and instrumental variable techniques. Dr. Steele-Adjognon conducts episode-based analysis, following patients’ episodes of care starting from admission to the short-term acute care hospital to the post-acute care (PAC) setting and then for a period of time following the post-acute care treatment. Common health outcomes she evaluates are mortality rates, readmission rates, and total healthcare spending. Examples of her work include evaluating how well different risk adjustment methods are able to capture variations in health outcomes; monitoring health outcomes, as well as PAC utilization, over time as different policies and programs change; simulating how new potential health care policy ideas might affect the number of people insured and how they are insured (through employer, public resources, etc.); and evaluating how individual hospitals compare to others in terms of market share and health outcomes within their geographic proximity using Medicare claims files. One specific project she is working on is evaluating how Maryland’s unique All Payer system affects discharge rates, length of stay and Medicare and Medicaid charges at short term acute hospitals in addition to post-acute care settings throughout Maryland for the dual eligible population. Dr. Steele-Adjognon earned her BS in Mathematics and Financial Economics from University of Maryland Baltimore County and her PhD in Agricultural, Food and Resource Economics from Michigan State University. |
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Lane Koenig is President and Founder of KNG Health Consulting and Director of the Healthcare Reform and Payment Innovation Practice. He is a healthcare economist with over 20 years’ experience in the public and private sectors. As President of KNG Health Consulting, Dr. Koenig has overall responsibility for the quality and direction of KNG Health’s research. He serves as Project Director and Principal Investigator for many studies, particularly those related to healthcare reform proposals, healthcare provider payments, value-based purchasing, and delivery system innovations. With expertise on hospital and post-acute care payment and quality issues, his work regularly assesses the potential impact on hospitals and other providers of proposed legislation or regulations. He has assisted both industry and Federal and state governments in the development and assessment of healthcare provider payment policies and value-base purchasing initiatives. Prior to founding KNG Health in 2007, Dr. Koenig was the senior economist in the Office of Policy at the Centers for Medicare & Medicaid Services (CMS). Before joining CMS, Dr. Koenig was a Senior Scientist in the healthcare finance practice at The Lewin Group. Dr. Koenig has led over 100 quantitative and qualitative health policy and health economic studies and has published over 20 peer-reviewed studies in journals, such as Health Affairs, Health Services Research, and Medical Care. He graduated with Honors from the University of Florida, Gainesville and earned his PhD in Economics from the University of Maryland, College Park. |
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