JAMA Internal Medicine

doi: 10.1001/jamainternmed.2019.0115pmid: 31380915

doi: 10.1001/jamainternmed.2018.5491pmid: 31380916

doi: 10.1001/jamainternmed.2018.5492pmid: 31380917

Greenland, Philip; Hassan, Shahzeb

doi: 10.1001/jamainternmed.2019.0142pmid: 30882848

This Viewpoint discusses the potential overstatement of findings in 2 studies that used predictive risk scores to draw conclusions about precision preventive medicine and suggests that improvements to predictive methods are necessary before being more widely applied.

Blum, Lawrence D.

doi: 10.1001/jamainternmed.2019.0428pmid: 30958511

This Viewpoint discusses how physician burnout, depression, and suicide can arise from guilt feelings that physicians have sublimated into their work.

Foote, Michael B.

doi: 10.1001/jamainternmed.2019.0234pmid: 30907947

This Perspective describes the physician’s role in caring for survivors of domestic abuse.

Fleegler, Eric

doi: 10.1001/jamainternmed.2019.0578pmid: 30933239

This article discusses the high frequency of mass shootings in the United States and outlines potential legislative solutions.

Redberg, Rita F.

doi: 10.1001/jamainternmed.2019.0508pmid: 30907921

Mor, Vincent

doi: 10.1001/jamainternmed.2019.0232pmid: 30855642

Werner, Rachel M.; Coe, Norma B.; Qi, Mingyu; Konetzka, R. Tamara

doi: 10.1001/jamainternmed.2018.7998pmid: 30855652

ImportanceUse of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care. ObjectiveTo investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility. Design, Setting, and ParticipantsA retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary’s home zip code and the closest home health agency and the closest skilled nursing facility as an instrument. ExposuresReceipt of postacute care at home vs in a skilled nursing facility. Main Outcomes and MeasuresReadmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode. ResultsA total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean [SD] age, 80.5 [7.9] years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P = .02). There were no significant differences in 30-day mortality rates (−2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (−1.9 percentage points; 95% CI, –12.0 to 8.2; P = .71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility (−$5384; 95% CI, –$6932 to –$3837; P < .001), as was total Medicare payment within the first 60 days after admission (−$4514; 95% CI, –$6932 to –$3837; P < .001). Conclusions and RelevanceAmong Medicare beneficiaries eligible for postacute care at home or in a skilled nursing facility, discharge to home with home health care was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments.