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      Association between comprehensive geriatric assessment and short-term outcomes among older adult patients with stroke: A nationwide retrospective cohort study using propensity score and instrumental variable methods

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          Abstract

          Background

          Comprehensive geriatric assessment (CGA) is a multidimensional and multidisciplinary method to identify geriatric conditions among older patients. The aim of the present study was to examine the associations between CGA and short-term outcomes among older adult inpatients with stroke.

          Methods

          The study was a nationwide, retrospective cohort study. We used the Diagnosis Procedure Combination database, a national Japanese inpatient database, to identify older adult stroke patients from 2014 to 2017. The associations between CGA and in-hospital mortality, length of hospital stay, readmission rate, rehabilitation intervention, and introduction of home health care were evaluated using propensity score matching and instrumental variable analysis.

          Findings

          We identified 338,720 patients, 21·3% of whom received CGA. A propensity score-matched analysis of 53,861 pairs showed that in-hospital mortality was significantly lower in the CGA group than in the non-CGA group (3·6% vs. 4·1%, p < 0·001). The rate of long-term hospitalization (> 60 days) was significantly lower in the CGA group than in the non-CGA group (8·7% vs. 10·1%, p < 0·001), and the rates of rehabilitation intervention (30·3% vs. 24·9%, p < 0·001) and home health care (8·3% vs. 7·6%, p = 0·001) were both higher in the CGA group than in the non-CGA group. Instrumental variable analysis showed similar results.

          Interpretation

          CGA was significantly associated with the examined short-term outcomes. These findings from Japan, one of the most aged countries worldwide, highlight the possible benefits of CGA for short-term outcomes and can be of use for health policy in other international contexts.

          Funding

          This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141).

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          Two-stage residual inclusion estimation: addressing endogeneity in health econometric modeling.

          Joseph V Terza, Anirban Basu, Paul Rathouz (2008)
          The paper focuses on two estimation methods that have been widely used to address endogeneity in empirical research in health economics and health services research-two-stage predictor substitution (2SPS) and two-stage residual inclusion (2SRI). 2SPS is the rote extension (to nonlinear models) of the popular linear two-stage least squares estimator. The 2SRI estimator is similar except that in the second-stage regression, the endogenous variables are not replaced by first-stage predictors. Instead, first-stage residuals are included as additional regressors. In a generic parametric framework, we show that 2SRI is consistent and 2SPS is not. Results from a simulation study and an illustrative example also recommend against 2SPS and favor 2SRI. Our findings are important given that there are many prominent examples of the application of inconsistent 2SPS in the recent literature. This study can be used as a guide by future researchers in health economics who are confronted with endogeneity in their empirical work.
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            Comparing paired vs non-paired statistical methods of analyses when making inferences about absolute risk reductions in propensity-score matched samples

            Peter C Austin (2011)
            Propensity-score matching allows one to reduce the effects of treatment-selection bias or confounding when estimating the effects of treatments when using observational data. Some authors have suggested that methods of inference appropriate for independent samples can be used for assessing the statistical significance of treatment effects when using propensity-score matching. Indeed, many authors in the applied medical literature use methods for independent samples when making inferences about treatment effects using propensity-score matched samples. Dichotomous outcomes are common in healthcare research. In this study, we used Monte Carlo simulations to examine the effect on inferences about risk differences (or absolute risk reductions) when statistical methods for independent samples are used compared with when statistical methods for paired samples are used in propensity-score matched samples. We found that compared with using methods for independent samples, the use of methods for paired samples resulted in: (i) empirical type I error rates that were closer to the advertised rate; (ii) empirical coverage rates of 95 per cent confidence intervals that were closer to the advertised rate; (iii) narrower 95 per cent confidence intervals; and (iv) estimated standard errors that more closely reflected the sampling variability of the estimated risk difference. Differences between the empirical and advertised performance of methods for independent samples were greater when the treatment-selection process was stronger compared with when treatment-selection process was weaker. We recommend using statistical methods for paired samples when using propensity-score matched samples for making inferences on the effect of treatment on the reduction in the probability of an event occurring. Copyright © 2011 John Wiley & Sons, Ltd.
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              Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences

              Tacara Soones, Linda V DeCherrie, Bruce Leff … (2018)
              This case-control study compares the patient outcomes and ratings of care between patients who received hospital-at-home care bundled with a 30-day postacute transitional care period vs traditional inpatient care. Question What is the association of providing hospital-at-home care bundled with a 30-day postacute period of home-based transitional care with clinical outcomes and patients’ experiences compared with traditional inpatient care? Findings This case-control study with 507 participants found that compared with patients receiving inpatient care, patients receiving hospital-at-home care had shorter length of stay; lower rates of 30-day hospital readmission, emergency department visits, and skilled nursing facility admissions; and better ratings of care. There were no differences in the rates of adverse events. Meaning Hospital-at-home care bundled with a 30-day episode of postacute transitional care may be a safe and effective alternative to inpatient care for some patients. Importance Hospital-at-home (HaH) care provides acute hospital-level care in a patient’s home as a substitute for traditional inpatient care. In September 2017, the Physician-Focused Payment Model Technical Advisory Committee recommended implementation of an alternative payment model for a new model of HaH that bundles the acute episode with 30 days of postacute transitional care. Objective To report outcomes of this new payment model for HaH care. Design, Setting, and Participants Case-control study of HaH care patients with a concurrent control group of hospital inpatients recruited from emergency departments (EDs) and residences in New York City from November 18, 2014, to August 31, 2017. HaH patients were 18 years or older with fee-for-service Medicare and acute medical illness requiring inpatient-level care. Control patients met HaH eligibility but refused participation or were seen in the ED when a HaH admission could not be initiated. Exposures HaH care or inpatient care. Main Outcomes and Measures Primary outcomes were acute period length of stay (LOS), all-cause 30-day hospital readmissions and ED visits, admissions to skilled nursing facilities (SNFs), referral to a certified home health care agency, and patient experiences with care. Analyses accounted for nonrandom selection using inverse probability weighting. Results Among the 507 patients enrolled (mean [SD] age, 74.6 [15.7] years; 68.6% women), data were available on all patients 30 days postdischarge. HaH patients (n = 295) were older than controls (n = 212) and more likely to have a preacute functional impairment. HaH patients had shorter LOS (3.2 days vs 5.5 days; difference, −2.3 days; 95% CI, −1.8 to −2.7 days; weighted P  < .001); lower rates of readmissions (8.6% [25] vs 15.6% [32]; difference, −7.0%; 95% CI, −12.9% to −1.1%; weighted P  < .001), ED revisits (5.8% [17] vs 11.7% [24]; difference, −5.9%; 95% CI, −11.0% to −0.7%; weighted P  < .001), and SNF admissions (1.7% [5] vs 10.4% [22]; difference, −8.7%; 95% CI, −13.0% to −4.3%; weighted P  < .001); and were also more likely to rate their hospital care highly (68.8% [119] vs 45.3% [67]; difference, 23.5%; 95% CI, 12.9% to 34.1%; weighted P  < .001). There were no differences in referrals to certified home health agencies. Conclusions and Relevance HaH care bundled with a 30-day postacute transitional care episode was associated with better patient outcomes and ratings of care compared with inpatient hospitalization. This model warrants consideration for addition to Medicare’s current portfolio of shared savings programs.
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                Author and article information

                Contributors
                Sumito Ogawa
                Journal
                Journal ID (nlm-ta): EClinicalMedicine
                Journal ID (iso-abbrev): EClinicalMedicine
                Title: EClinicalMedicine
                Publisher: Elsevier
                ISSN (Electronic): 2589-5370
                Publication date PMC-release: 15 June 2020
                Publication date Collection: June 2020
                Publication date (Electronic): 15 June 2020
                Volume: 23
                Electronic Location Identifier: 100411
                Affiliations
                [a ]Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
                [b ]Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
                [c ]Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
                [d ]Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
                Author notes
                [* ]Corresponding author. suogawa-tky@ 123456umin.ac.jp
                Article
                Publisher ID: S2589-5370(20)30155-3 Publisher ID: 100411
                DOI: 10.1016/j.eclinm.2020.100411
                PMC ID: 7298723
                PubMed ID: 32566923
                SO-VID: ef780766-7bb0-4ac6-b0fa-54cdbc4825bb
                Copyright © © 2020 The Author(s)
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 5 December 2019
                Date revision received : 21 May 2020
                Date accepted : 22 May 2020
                Categories
                Subject: Research paper

                Keywords: japanese diagnosis procedure combination database,geriatrics,stroke,comprehensive geriatric assessment,mortality,length of stay
                Data availability:
                Keywords: japanese diagnosis procedure combination database, geriatrics, stroke, comprehensive geriatric assessment, mortality, length of stay

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