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Thirty-Day Re-observation, Chronic Re-observation, and Neighborhood Disadvantage

  • Ann M. Sheehy
    Correspondence
    Correspondence: Address to Ann M. Sheehy, MD, MS, Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, K4/484, Madison, WI, 53792.
    Affiliations
    Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI
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  • W. Ryan Powell
    Affiliations
    Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI

    Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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  • Farah A. Kaiksow
    Affiliations
    Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI

    Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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  • William R. Buckingham
    Affiliations
    Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI

    Applied Population Laboratory, University of Wisconsin, Madison, WI
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  • Christie M. Bartels
    Affiliations
    Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI

    Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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  • Jen Birstler
    Affiliations
    Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI
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  • Menggang Yu
    Affiliations
    Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI
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  • Andrea Gilmore Bykovskyi
    Affiliations
    Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI

    School of Nursing, University of Wisconsin, Madison, WI
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  • Fangfang Shi
    Affiliations
    Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI

    Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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  • Amy J.H. Kind
    Affiliations
    Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI

    Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI

    Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, WI
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      Abstract

      Objective

      To determine whether neighborhood socioeconomic disadvantage, as determined by the Area Deprivation Index, increases 30-day hospital re-observation risk.

      Participants and Methods

      This retrospective study of 20% Medicare fee-for-service beneficiary observation stays from January 1, 2014, to November 30, 2014, included 319,980 stays among 273,308 beneficiaries. We evaluated risk for a 30-day re-observation following an index observation stay for those living in the 15% most disadvantaged compared with the 85% least disadvantaged neighborhoods.

      Results

      Overall, 4.5% (270,600 of 6,080,664) of beneficiaries had index observation stays, which varied by disadvantage (4.3% [232,568 of 5,398,311] in the least disadvantaged 85% compared with 5.6% [38,032 of 682,353] in the most disadvantaged 15%). Patients in the most disadvantaged neighborhoods had a higher 30-day re-observation rate (2857 of 41,975; 6.8%) compared with least disadvantaged neighborhoods (13,543 of 278,005; 4.9%); a 43% increased risk (unadjusted odds ratio [OR], 1.43; 95% CI, 1.31 to 1.55). After adjustment, this risk remained (adjusted OR, 1.13; 95% CI, 1.04 to 1.22). Discharge to a skilled nursing facility reduced 30-day re-observation risk (OR, 0.63; 95% CI, 0.57 to 0.69), whereas index observation length of stay of 4 or more days (3 midnights) conferred increased risk (OR, 1.29; 95% CI, 1.09 to 1.52); those living in disadvantaged neighborhoods were less likely to discharge to skilled nursing facilities and more likely to have long index stays. Beneficiaries with more than one 30-day re-observation (chronic re-observation) had progressively greater disadvantage by number of stays (adjusted incident rate ratio, 1.08; 95% CI, 1.02 to 1.14). Observation prevalence varied nationally.

      Conclusion

      Thirty-day re-observation, especially chronic re-observation, is highly associated with socioeconomic neighborhood disadvantage, even after accounting for factors such as race, disability, and Medicaid eligibility. Beneficiaries least able to pay are potentially most vulnerable to costs from serial re-observations and challenges of Medicare observation policy, which may discourage patients from seeking necessary care.

      Abbreviations and Acronyms:

      ADI (Area Deprivation Index), C-APC (Comprehensive Ambulatory Payment Classification), CMS (Centers for Medicare & Medicaid Services), COPD (chronic obstructive pulmonary disease), ED (emergency department), OR (odds ratio), Q (quartile), SNF (skilled nursing facility)
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