Superbugs are invading U.S. healthcare facilities

“Superbugs” are popping up more frequently in hospitals these days, even lasting through drugs of “last resort.” One of these superbugs made headlines this summer after it swept through the National Institute of Health just outside of Washington, DC. NAHAM News reported the story (found here) about staff having to go as far as to rip out plumbing from the walls to stop the spread of bacteria.

These superbugs belong to a string of drug-resistant bacteria known as Carbapenem-Resistant Enterobacteriaceae, or CRE, that has been around in hospitals and nursing homes for almost a decade.

A study by USA Today found that there have been thousands of cases of CRE throughout the country in recent years, affecting 41 states and several cities since the first case was reported in 2001. CRE is not as well-known as other hospital infections such as MRSA or C-Diff, but it is far more deadly. Even worse, there is little chance that an effective treatment for CRE will be developed any time soon.

A challenge for hospitals could be the reporting. There is no Medicare or Medicaid billing code for CRE, and there no reporting requirement so it is impossible to track the superbugs.

The Centers for Disease Control (CDC) has stated that the best way of controlling the spread of CRE may be the old fashioned way. They suggest “rigorous hand cleaning by staff and visitors; isolating infected patients and requiring gowns and gloves for anyone contacting them; cutting antibiotic use to slow the development of resistant bacteria; and limiting use of invasive medical devices, such as catheters, that give bacteria a path into the body.”

In one specific outbreak, a patient was discovered to have two different strains of the CRE bacteria, while other infected patients had a different third strain. All of the patients were linked together, showing that the drug resistant gene could jump between different bacteria, creating new bugs.

In the wake of that news, an important prevention measure because screening patients so that infected individuals can be isolated. However, this poses a challenge to hospitals that may not have the time or resources to screen all of their patients.

Despite the challenges, screening has been proven to work. One Bronx-based medical center started an initiative to cut prevalence rates across its intensive care units.  The initiative tested all intensive-care patients using an experimental, high-speed assay for the bacteria, and carriers were isolated immediately. The initiative eventually grew to all patients in the hospital network. The program controlled the transmission of CRE, but it also found that 40% of infected patients came into the hospital with the superbug already active.

The positive out of all this is that doctors were able to figure out how the drug resistant gene is jumping from strain to strain of the bacteria. Using that as a base, they were able to develop a test that would identify a superbug in days, as opposed to the weeks it was taking before. While this doesn’t help those who are already infected with CRE, it can help stop the spread to new patients.

HHS Press Release on Pre-Existing Conditions and other Affordable Care Act provisions

The Department of Health and Human Services (HHS) issued a press release last week pointing to several new rules proposed by the Obama administration. These rules, three in total, are provisions of the Affordable Care Act designed to make it illegal for insurance companies to discriminate against people with pre-existing conditions.

The Administration proposed a rule that would allow insurance companies to vary premiums based only on age, tobacco use, family size, and geography. The companies would not be allowed to deny coverage or impose higher premiums on individuals with pre-existing or chronic conditions, and would not allow them to consider the individual’s gender, occupation, employer size, or industry

.

A second rule proposed by the Administration outlined policies and standards for coverage of essential health benefits, while giving states more flexibility to implement the health law.

A third rule proposed implementing and expanding employment-based wellness programs in an effort to promote wellness and control health care spending.

For more information, please see the HHS press release here. 

Curbing Medicare Spending begins with Hospital Readmissions

Medicare’s new “Value Based Purchasing Program” levied their first penalties to 2,217 hospitals last month. These hospitals will all receive some form of financial penalty from Medicare, with 307 of them receiving the maximum penalty of a 1% reduction in their Medicare reimbursement rate for the next year.

The program, previously reported by NAHAM News in September (Medicare’s new Value Based Purchasing Program: Enough to Inspire Hospital change?), penalizes hospitals with high readmission rates as part of the Healthcare Reform bill. While a major intent is to get Medicare costs under control (they exceed $550 billion this year), there is also intent to focus more on patient care. The program is expected to save $300 million in reimbursements this year, as well as pressure hospitals to take steps to ensure patient care both before and after they are discharged. Currently, almost 1 in 5 Medicare patients are readmitted to the hospital within a month, costing the government over $17 billion annually.

The previous system paid hospitals a set fee per patient stay, despite the length, so proponents of the new program were concerned that the emphasis was placed more on the number of patients treated, rather than the quality of care. This new system seeks to change that. The penalty is set to double (to 2%) in October of 2013, and will go up to 3% in October 2015.

The program is meeting with resistance from some. Academic medical centers are complaining that the penalties do not take into account the extra challenges posed by extremely sick and low-income patients. This claim is backed up by several studies, including one commissioned by Medicare, that have found that the hospitals with the most poor and African-American patients tended to have higher readmission rates than hospitals with more affluent and Caucasian patients. But these studies also determined that some safety-net hospitals performed better than average, showing that hospitals can overcome the challenges posed by the kinds of patients they treat.

Some researchers also fear that the penalties are too steep. They claim that steep penalties will distract hospitals from other pressing issues, like reducing infections and surgical mistakes, and ensuring patients’ needs are met promptly. There is also a concern that hospitals will try to get around the system, treating patients and sending them home within 24 hours to avoid admission and readmissions.

Overseeing former patients is expensive and time-consuming and many hospitals are relying on financing from community health organizations and foundations. Some may also partner with local organizations to provide follow up care to discharged patients.

No matter the method for reducing readmissions, hospitals will need to adjust to the new system

.

See the full article from the New York Times and Kaiser Health News here. 

HHS Steps up Role in Health Exchanges

While the Obama administration does not yet know the number states that will opt for the federal health insurance exchange option, the fact remains that it will be more than expected. Every state that decides not to implement their own exchange will be one more state that the federal government has responsibility for. As of now, only 17 states (and the District of Columbia) have signaled that they will set up their own system, leaving the federal Department of Health and Human Services (HHS) to step in and set up a system in the remaining 30 or so.

The main challenge in this role will be setting up a national IT infrastructure that can easily communicate with insurers and Medicaid programs throughout different states. Complicating matters is the fact that many of these systems are old and in the midst of an overhaul. The online systems will have to be operational in time for open enrollment in October of 2013, leaving only 11 months for upgrades, development, and implementation. These online systems, according to the health law, will allow people to enroll in different programs and find out about eligibility for subsidies or public assistance.

HHS stepping in also means that the states will be giving up some of the insurance oversight that they have traditionally had. Tasks such as plan certification, staffing call centers, and overseeing the operations would fall to HHS, at least in part, instead of the state counterparts. This could mean that plans, some of which have long-established relationships with state and local regulators, would find it more difficulty to navigate through the federal regulations.

With this short time frame, everyone is wondering if the exchanges will be ready in time to take effect. While no one knows for sure, most are optimistic the come January 1, 2014, the plans will be in effect.

View the article from Politico here. 

NFL Medical Records go Electronic

It turns out that hospitals aren't the only ones who are adopting electronic health records to better serve their patients.

According to reports by Kaiser Health News and Boston.com, the National Football League just signed a deal with Massachusetts based eClinincalWorks to convert the league from paper-based medical records to electronic records.

The records will be completely transportable from hand-held devices to hospitals, and players will also be able to provide the records to their personal physicians. The records will include a player’s medical history, specific injuries, and can even incorporate game footage of specific injuries.  Records will also be able to move with the player, should they be traded.

The system will be phased into use by all 32 teams over a period of 2 seasons. Next season, eight teams (the New England Patriots, New York Jets and Giants, Baltimore Ravens, Pittsburgh Steelers, Houston Texans, San Francisco 49ers and Denver Broncos) will keep their player’s health information electronically. By 2014 the entire league will transition to electronic health records. The NFL estimates that its 10-year contract will cost anywhere between $7 million to $10 million.

The report from KHN can be found here, and the article from Boston.com can be found here. 

Why All of the Deadline Changes?

With the last minute deadline changes and states still undecided on whether or not to set up their own exchanges, some may wonder why this is all coming down to the wire.

The explanation lies in the timing. The Affordable Care Act, or ‘Obamacare’, was signed into law two years ago, and set out a specific implementation time table for states to follow, but most don’t see it as that simple. Over the past two years there have been countless political battles over the law, including a supreme court ruling and a presidential election, all of which could have substantially changed the law and it’s implementation.

Even after the Supreme Court upheld the vast majority of the law in a challenge from 26 states, some of those states held out for the presidential election. Governor Romney vowed to delay or altogether stop the implementation of state health insurance exchanges, if he were to be elected.

Obama’s election victory and the continuation of a Democratic Party majority in the Senate guaranteed the survival of his health care law, however, and sent some states scrambling to meet deadlines less than two weeks away. According to the law, states were required to tell the Department of Health and Human Services (HHS) if they intended to operate their own exchanges, and to give specifics on how they would run those exchanges by November 16, 2012.

HHS first issued a letter after the election that maintained the November 16^th deadline for states to report their intent, but pushed back the deadline to report specifics .Then, responding to a request from the Republican Governors Association, HHS on Thursday pushed back the deadline for states to report intent to match specific plan deadline on December 14^th.

This gives time for the Obama administration to issue details on how a federally run insurance exchange would work before states make up their mind. Those details were also on hold until after the election.

Although the public remains divided about the health care law, the idea of states running the new insurance markets is popular, especially with Republicans and political independents. A recent AP poll found that 63 percent of Americans would prefer states to run the exchanges, with 32 percent favoring federal control.

The breakdown among Republicans was 81 percent to 17 percent in favor of state control, while independents lined up 65-28 percent in favor of states taking the lead. Democrats were almost evenly divided, with a slim majority favoring state control.

This article was written with information from a Washington Post article, found here. 

States Given More Time to Work on Health Exchanges

In a confusing week for the healthcare industry, the newly re-elected Obama administration has twice changed the insurance exchange deadline, giving states extra time to work on their health insurance exchange plan.

Kathleen Sebelius, Secretary of the Department of Health and Human Services (HHS), sent a letter to Governors on November 9^th stating that the administration still expected states to declare whether they intend to operate their own exchanges, or opt for the federal government to set up their exchange, by Friday, November 16^th.  The letter further stated, however, that states now had until December 14^th to file blueprints showing specifically how they would operate the marketplaces. These dates are according to a Reuters report found here.

Sec. Sebelius then sent another letter late on Thursday, the day before the declaration deadline, pushing that deadline back to December 14^th as well. The article by Kaiser Health News can be found here.

The decision was in response to the Republican Governors Association (RGA) request Wednesday to extend the deadlines until HHS publishes rules detailing how the exchanges would work. A slew of regulations are expected to be published in the next few weeks. In a statement last night, the RGA thanked the agency for its response.

As previously written by NAHAM News, the health insurance exchanges (known as HIX or HEX) are a key part of the Obama Healthcare Law, also known as Obamacare. The law sets up these exchanges to allow millions of individuals to shop for insurance coverage and find out if they are eligible for government subsidies or Medicaid.

The law allows (and encourages) states to set up their own exchanges, and requires the federal government to step in to build and operate exchanges in states that choose not to set up their own.

As of Thursday, 17 states and the District of Columbia had committed to setting up their own exchanges. Those states are California, Oregon, Minnesota, Washington, Nevada, New Mexico, Utah, Colorado, Kentucky, West Virginia, New York, Vermont, Connecticut, Massachusetts, Mississippi, Rhode Island and Hawaii.

Seven states remain undecided on whether to build state-based exchanges. The undecided states are Tennessee, Pennsylvania, Idaho, New Jersey, Oklahoma, Arizona and Wisconsin.

The remaining states will most likely chose the third option, allowing those states to develop their exchanges in partnership with the federal government. States that chose the partnership option will have until February 15^th, 2013 to declare their intentions and prepare the paperwork.

Previous letters have strongly stated that no matter what option states chose, or when they declare their intentions, consumers in all 50 states and the District of Columbia will need to have access to insurance through these new marketplaces on January 1, 2014.

Patient Identification Pitfalls Plague HIE Networks

As NAHAM members well know, managing patient identities is one of the hidden problems of health information exchange (HIE) and electronic health record (EHR) technology.  Every patient needs a single and unique identifier tied to his records, and a simple typo or a misspoken birthday can leave a patient with duplicate records, potentially compromising his care. 

Many hospitals use their own master patient indexes (MPIs) to check if patients have an existing record, but the emergence of HIE means new challenges in ensuring accuracy across multiple providers for millions of new patients. Unique identifiers must be the same across the entire HIE for the network to function, and NAHAM has been working to provide a toolkit to members to assist with that goal.

According to a white paper on EHR Intelligence, establishing a unique identifier can also be accomplished with the help of a system-wide enterprise MPI (EMPI).  An EMPI provides its own identifier that spans the entire network, requiring accurate and complete data across every department or healthcare provider contributing to a patient’s care.

Quality control during the admissions process is the first step towards ensuring accuracy, but staff performing the data entry is often under conditions that require them to be as speedy as possible: mishearing the spelling of a surname or transposing a letter in a street address can accidentally create an entirely new record and identification number for a patient who may have visited the facility before. Without consulting the patient, it’s nearly impossible to tell if the original data is correct or if a mistake was made previously and the new input is the proper information.  Implementing safeguards in patient record software to prevent these small mistakes may seem like an easy task, but human error will always find a way to defy technology. 

HIE vendors are trying to work around these problems with a variety of innovative ideas such as biometric data or cloud-base solutions, but patient records are continually developing collections of changeable data.  The goal of HIE and EHR is to manage this data cleanly, effectively, and with the maximum benefit to the patient, but the margin for error only grows wider as more and more providers try to collaborate and share information. 

HIE systems must be capable of preventing mistakes caused by duplication or accidental deletion of records, but healthcare providers themselves are ultimately responsible for being certain that the patient in front of them matches the information on their computer screen.

The Obama Win and Healthcare Reforms could Benefit Hospitals

Hospital stocks reacted with optimism to the news that President Barack Obama had won a second term, making the fate of the healthcare reform law even more certain – this according to a Bloomberg report.

The Affordable Care Act, or “Obamacare”, is the biggest change to the U.S. health-care system since Medicare and Medicaid began providing taxpayer-funded services in 1965.

That enthusiasm for hospitals seems to be a repeat.  Traders bought hospital stocks and sold off commercial insurers after Obama’s overhaul passed Congress in 2010, and again when the law survived a challenge at the Supreme Court.

Romney said in June that he disagreed with the Supreme Court’s decision to uphold the constitutionality of the plan, and that he would repeal the law on his “first day if elected president.” This caused investors to be unsure as some agencies planning for implementation slowed or even stopped preparation until after the election.

The law’s survival represents the status quo, however, and means that the industry will undergo significant change and new regulations beginning in 2014. With the status quo, comes renewed optimism in hospital stock.

While share prices of the largest insurers declined, shares rose for companies that focus largely on Medicaid.

Preservation of the overhaul helps most hospitals, which had already started moving ahead with implementing aspects of the law despite the election. Romney’s plans would have pressed hospitals to find new ways to deliver care at a lower cost.

Up to now, hospitals have been paid each time they do a procedure, in arrangements known as “fee for service.” This law shifts them to incentive systems where the focus is on more efficient care. They may get a set amount of dollars to spend on a patient, for example, and can keep surplus if they can provide care for less.

While exact implementation plans for healthcare reform remain unclear, confidence in hospital stocks is expected to remain high. 

Obamacare Is Here To Stay – But In What Form?

President Obama's re-election, and the retention of a Democratic majority in the Senate, means that repeal of the Affordable Care Act is not likely, but no one is quite sure what implementation will look like. An NPR article discusses some possibilities.

January 1, 2014, is the date that major parts of the law, like the new insurance policies available to individuals and small businesses, are supposed to become available. The full timeline can be found here.

That doesn’t leave a lot of time to get ready, however. Many states and some key parts of the health care industry delayed gearing up much of this past year. Some say they assumed either the Supreme Court would rule the law unconstitutional, or Mitt Romney and a Republican Congress would be elected and make the law go away. Neither of those options happened.

In fact, there is a key deadline just days away.  By November 14, states must decide whether they want to run their own insurance exchanges, or whether they want to let the federal government do it for them.

Insurance exchanges are where people will go to shop for insurance coverage. They are also where people will get help paying for that coverage if they qualify for subsidies from the federal government. So far, only 13 states and Washington, D.C., have said they plan to set up their own exchange. If states decide not to set up their own exchanges, the federal government will step in and do it instead. But federal officials still haven't spelled out exactly how that will work.

Meanwhile, opponents of the law say that there are some problems with the underlying statute. The problem goes back to those subsidies that will help people afford coverage starting in 2014. The law authorizes subsidies for state-sponsored exchanges, but not for the exchanges picked up by the feds.  This raises concerns in some quarters that the health insurance markets are going to collapse and health insurance premiums are going to skyrocket because the subsidies are available only through state, and not federal, insurance exchanges.

Other experts contend that is not true. They point to cross-references within the statute that make it clear that the subsidies are meant to be available to everyone based on their income. This means the subsidies should be available whether the insurance exchanges are run by states or by the federal government.

With the election over, overturn of the Affordable Healthcare Act is unlikely, and attention now turns to implementation.   The healthcare law is here to stay, but it’s not clear what it will look like.

Hospitals Gamble on Urgent Care Clinics to Keep Patients Healthy

Some doctors are referring patients to urgent care clinics over primary care appointments or emergency room visits, according to an NPR article. The clinics are all about speedy service; some even feature a timer outside of every exam room so the staff knows how long a patient has been waiting. With the expanded use of electronic health records, clinics can pull up electronic health records to determine medicine allergies or if the patient is due for any other care.

Hospitals already own more than a quarter of the nearly 9,000 urgent care clinics in the U.S. that are drawing patients away from emergency rooms.  But this trend is in its “early stages” according to the NPR report.

But industry watchers say it is unclear whether hospitals will actually be successful at managing urgent care centers. They say that hospitals tend to be good at providing high-quality care, but patients may prefer clinics from a customer service perspective.

As an example from the NPR report, within the MedStar Health system, hospitals make money for every patient the clinic refers to a MedStar facility for follow-up care, like a CT scan or an appointment with an orthopedist. Patients who don't yet have a regular source of health care can be referred to a MedStar primary care doctor.

There appears to be a future for this model. Insurers and Medicare are starting to pay providers to keep patients healthy. Providers get a bonus if they manage to lower the cost of the medical services their patients need. These clinics could be a key part of this strategy for hospitals.

How the Health Law Might be Changed Under the Next President

After reviewing what each candidate has been saying on the campaign trail, Kaiser Health News has published an article on how Obama and Romney might change the health law in the years ahead. The article is based on interviews with health policy experts, and can be found here.

OBAMA'S CHALLENGES

President Barack Obama has asked voters to re-elect him so that he can put the law fully into effect. But some analysts predict the mounting pressures to reduce federal spending will complicate that plan.  And others note that in a second term, Obama may be more open to working with Congress to tweak provisions of the law that have raised concerns. Leading up to this tight election, Obama and Democrats have been reluctant to make modifications to the law, known as the Affordable Care Act (ACA) or Obamacare.

Scale Back Subsidies: As part of that effort to reduce federal spending, there could be pressure to scale back the health law’s subsidies that help low-income residents afford coverage. People who earn up to 400 percent of poverty – currently about $92,000 for a family of four – are eligible to get financial help in purchasing coverage.  Another big-ticket item is the expansion of Medicaid coverage to anyone up to 133 percent of the poverty level, or about $30,656 for a family of four.

Change in Age Rating Bands: The ACA prohibits insurers from charging more than three times as much for a policy sold to an older person than to a younger person. Some say this creates a problem where coverage become more affordable for the elderly but more expensive for the young people – an important demographic that needs to be able to get coverage.

Medical Device Tax Cut: Of the many taxes in the health law, one has come under strong criticism: a 2.3 percent tax on the sale of any taxable medical device. Medical device manufacturers have loudly opposed the tax and won some key congressional support. Legislation to repeal the tax passed the House in June with 37 Democrats joining Republicans to support the measure, although it is unlikely to receive Senate consideration this year. 

ROMNEY'S CHALLENGES

Gov. Mitt Romney has promised a full-scale repeal of the ACA.. Short of Republicans controlling both chambers of Congress however, he would have to rely on the federal regulatory process to stop funding and give states wide latitude to implement – or ignore -- the law.

Slowing Down Implementation: The health law gives significant power to the secretary of Health and Human Services to implement the health law, and a Romney administration could use that power to slow the rulemaking process.

If Republicans win control of the Senate, they could also use the reconciliation process—which requires only a majority instead of the 60 votes usually needed to pass a measure -- to strip out sections of the law that relate to the federal budget. Reconciliation can be a cumbersome and difficult process, and it only applies to budget measures, so not all of the law would be subject to Reconciliation. And changes made under the process can’t increase the deficit.

Waivers: Romney has said he would allow states to opt-out of the health law by using a waiver process. He could also use the process to give states wide latitude to implement provisions, like health insurance exchanges, that differ from requirements in the ACA. But there are many rules that govern the waiver process, so there may be limitations on what the president could do through waivers.

If Romney opted not to move forward on the law, the administration could also be sued by individuals and groups. That litigation could take months – maybe years – to be resolved.

What Might Stay: Romney has said that he expects insurers to keep coverage that allows adult children to stay on a parent’s health insurance policy until age 26, although it’s unclear if he would support legislation or regulations to make that happen. He also has expressed support for states to set up health insurance exchanges and high-risk pools to cover the uninsured. 

Insurers nervous over prospect of Romney victory

With the election just around the corner, NAHAM News is taking a look at the healthcare side of the rhetoric. This article from the Associated Press reports that although the insurance industry dislikes parts of President Barack Obama's health care law, major outfits such as UnitedHealth Group and BlueCross Blue Shield also stand to rake in billions of dollars from new customers who'll get health insurance under the law.

The companies already have invested tens of millions to carry it out. Were Romney elected, insurers would be in for months of uncertainty as his administration tries to make good on his promise repeal Obama's law. Simultaneously, federal and state bureaucrats and the health care industry would face a rush of legal deadlines for putting into place the major pieces of "Obamacare."

The Romney campaign has not provided specifics on how the candidate would carry out his repeal promise, other than to say the push would begin on his first day in office. Romney has hinted that he wants to help people with medical conditions, but doesn't say what parts of the health care law he would keep.  Rather than an overall repeal, most assume he will try to reduce scope or coverage.  A lot would depend on what Congress is willing to go along with – if anything.  For its part, the insurance industry has three items in particular it wants stripped out: 1) cuts to Medicare Advantage private insurance plans; 2) a requirement that insurers spend 80 percent of premiums on medical care or rebate the difference to their customers; and 3) new taxes on insurance companies.

There is also no consensus among Republicans in Congress on how to replace Obamacare, much less anything like a bipartisan middle ground on health care. This would be a necessity if the House retains its GOP majority and the Senate remains in Democratic hands.

In contrast, Obamacare is starting to look more and more like a tangible business opportunity. In a little over a year, some 30 million uninsured people will start getting coverage through a mix of subsidized private insurance for middle-class households and expanded Medicaid for low-income people. Many of the new Medicaid recipients would get signed up in commercial managed care companies.

At a time when employer coverage has been eroding, government programs such as Medicare, Medicaid, and now Obamacare are becoming the growth engines for the industry's bottom line. 

Are social factors tied to hospital readmissions?

With hospital readmission rates being tied into reimbursement under the Healthcare law, there is new scrutiny of the causes behind readmission. Reuters recently published an article looking at non-medical causes for readmission. They report that  there may be several non-medical factors outside of hospitals' control that are linked to how heart and pneumonia patients fare once they're discharged, according to a fresh look at past research. The full article can be found here.

In the new study, published in the Journal of General Internal Medicine, researchers analyzed data from 72 previous papers examining the reasons people died after being released from the hospital, or were readmitted to the hospital, and found that age, race, employment status, living situation, education and income levels are just some of the factors that may play a role.

Researchers say they still don’t know how to accurately measure these factors.  The study’s lead author, Dr. Linda Calvillo-King, an assistant professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas, and her colleagues gathered research that examined social factors and hospital readmissions in heart and pneumonia patients over about 30 years. Overall, the researchers were able to pull information from 20 studies looking at pneumonia and 52 looking at heart failure.

For pneumonia patients, among the factors linked to the risk of being readmitted to the hospital were being older and not white. Having a low level of education, low income and being unemployed were also tied to a higher risk of going back into the hospital.

Being older and being a man were each associated with a greater chance of dying within the 30 days after being released from a hospital, as was being a nursing home resident.

For heart failure patients, the risk of being readmitted to a hospital was tied to being elderly, African American or Hispanic.

The type of insurance a person had, their marital status and economic status were also among the factors tied to heart patients' risk of being readmitted to a hospital - as were risky behaviors, such as smoking and cocaine use.

Many of the same factors were linked both to a heart failure patient's risk of death after being hospitalized and the risk of readmission to the hospital.

Some studies also found that living far away from a hospital and feeling cold at home were linked to an increased risk of dying for heart failure patients.

The studies reviewed varied in sample size, demographics and social factors.  The researchers say future studies should focus on which factors are the most important, how they should be accounted for and how to address them

Particularly since CMS compares hospitals "according to 30-day readmission and mortality rates," the researchers write, identifying the social factors that affect patient outcomes and yet are beyond a hospital's control could make assessments of the care patients actually do get in the hospital more accurate.