The Impact of Enhanced Critical Care Training and 24/7 (tele-ICU) - PowerPoint PPT Presentation

The Impact of Enhanced Critical Care Training and 24/7 (tele-ICU) Support on Medicare Spending and Post-Discharge Utilization Patterns June 27, 2017 Matthew Trombley (Abt Associates), Andrea Hassol (Abt Associates), Jennifer Lloyd (Center for Medicare & Medicaid Services), Timothy Buchman (Emory Critical Care Center), Allison Marier (Abt Associates), Alan White (Abt Associates), Erin Colligan (Center for Medicare & Medicaid Services) The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Background  Hospital intensive care units (ICUs) treat the most critically ill patients, requiring highly trained staff and sophisticated resources  Use of intensivist physicians associated with better quality intensive care  Only 37% of all ICU patients in US are currently covered by intensivist physicians  In many ICUs there are no intensivist physicians present on-site at night or on weekends Abt Associates | pg 2 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Background  Integrating physicians’ assistants and nurse practitioners into the ICU team is demonstrably cost-effective and may maintain or decrease length of stay (LOS) and mortality  Electronic ICUs (tele-ICUs) allow continuous remote monitoring of patients, including nights and weekends  Tele-ICU implementation is correlated with reductions in ICU and hospital LOS and mortality  Recent research has identified potentially large savings to hospitals  Prior literature did not consider post-discharge patient outcomes or potential benefits to payers Abt Associates | pg 3 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Program Background  Emory University Hospital received Healthcare Innovation Award from CMS in the summer of 2012  Award funded joint program targeting care in ICU setting  Critical care residency for physicians’ assistants and nurse practitioners  Tele-ICU to provide remote support to ICUs Abt Associates | pg 4 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Program Background  Three participating hospitals  Emory University  Emory University Midtown  St. Joseph’s Hospital  Eight participating ICU/coronary care units  2 medical/surgical ICUs  2 CCUs  4 cardiothoracic surgery ICUs Source: Google Maps Abt Associates | pg 5 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Program Background  Critical care residency training program for non-physician practitioners placed first graduates January 2013, 15 months before the tele-ICU became operational  6-12 month residency  Practical skills, focusing on ICU procedures  Leadership training Source: Emory University Abt Associates | pg 6 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Program Background  Tele-ICU coverage started April-May 2014  Audio-visual connection; telemetry data feed; physiologic alert  Staffed 24/7 by experienced critical care nurses, monitoring telemetry  Staffed by intensivist physicians Source: Emory University nights and weekends Abt Associates | pg 7 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Evaluation Design  Difference-in-difference evaluation design – Allows us to estimate program impacts despite non- experimental program design – Before and after program start date, at participating hospitals and matched comparisons – Intervention group: Medicare fee-for-service beneficiaries with relevant ICU/CCU stay at one of participating hospitals – Comparison group: Medicare fee-for-service beneficiaries at one of 9 comparison hospitals located in Atlanta Hospital Referral Region with at least 250 beds Abt Associates | pg 8 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Intent to Treat Sample Selection  Emory provided a registry of all patients treated in ICUs covered by tele-ICU  Linked registry data to Medicare claims  ICU revenue codes alone insufficiently sensitive/specific to define the intervention population for purposes of drawing a matched comparison sample  Added ICD-9 codes for permutations of primary and secondary diagnoses present on claims from patients in the registry, to improve accuracy in defining intervention population  Definition of intervention population applied to patients in comparison hospitals to define comparable group using same criteria Abt Associates | pg 9 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Intent to Treat Sample Selection  Example:  Emory registry included beneficiaries with primary diagnosis heart failure and secondary diagnosis sepsis; but none with primary sepsis and secondary heart failure  All inpatient stays with ICU code 0200 or 021X, and primary diagnosis of heart failure, and secondary diagnosis of sepsis, included in analytic sample  Inpatient stays with primary diagnosis sepsis and secondary diagnosis heart failure not included Abt Associates | pg 10 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Intent to Treat Sample Selection  All ICU stays meeting  Episode of care includes these criteria initiated inpatient stay and subsequent an “episode of care” if: 60 days post-discharge  The beneficiary did not Final Sample of Episodes die in the hospital Emory Comparison  The beneficiary had not had an episode of care Baseline Period 6,129 17,136 in the prior 120 days 1/1/10 - 4/24/14  Beneficiaries could be in Intervention Period 3,093 4,002 sample multiple times if 4/24/14 - 6/30/15 episodes of ICU care were separated by at least 120 days Abt Associates | pg 11 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Cost and Utilization Measures  Total Part A and B Medicare payments per 60-day episode (inpatient hospitalization through 60 days post-discharge)  All-cause inpatient readmissions within 30 or 60 days after discharge  ED visits within 30 or 60 days after discharge  Inpatient length of stay  Discharge destination  Home, Home Health, Institutional post-acute care facility, “other” Abt Associates | pg 12 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Statistical Analyses Outcome Statistical Model Total Medicare Spending OLS Inpatient Readmissions Logit ED Visits Logit Length of Stay Negative Binomial Discharge Destination Multinomial Logit  Regression-adjusted difference-in-difference  Quarter and hospital fixed effects  Controls for  patient demographics  prior health status  Major Diagnostic Category (MDC) Abt Associates | pg 13 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Descriptive Analysis – Independent Variables Emory Baseline Comparison Difference in Differential Period Baseline Period Baseline Change (N=6,129) (N=17,136) Period Female (%) 44.4 49.4 5.1*** -2.3* Nonwhite (%) 41.0 28.5 12.5*** -0.5*** Age 70.2 + 14.0 72.2 + 12.8 -2.0*** 0.0 Hierarchical Condition Category Score 2.9 + 3.1 2.7 + 2.7 0.3*** 0.3*** Medicaid (%) 64.1 66.8 -2.7*** 0.0 Non-disabled (%) 63.5 64.8 -0.1* 0.2 Hospital Transfer (%) 22.2 6.8 15.4*** -8.7*** Other Health Transfer (%) 3.3 5.4 -2.1*** 5.0*** Charlson Comorbidity Index Score 3.1 + 2.1 2.9 + 1.9 0.2*** -0.2*** *p<0.10 **p<0.05 ***p<0.01 + indicates standard deviation for continuous measures Differential changes for (%) measures are reported as percentage point changes. Abt Associates | pg 14 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.