PubMed Articles using Medicare or Medicaid Data

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Estimation of the Prevalence of Amyotrophic Lateral Sclerosis in the United States Using National Administrative Healthcare Data from 2002 to 2004 and Capture-Recapture Methodology.

Fri, 08/10/2018 - 5:41am

Estimation of the Prevalence of Amyotrophic Lateral Sclerosis in the United States Using National Administrative Healthcare Data from 2002 to 2004 and Capture-Recapture Methodology.

Neuroepidemiology. 2018 Aug 09;51(3-4):149-157

Authors: Nelson LM, Topol B, Kaye W, Williamson D, Horton DK, Mehta P, Wagner T

Abstract
BACKGROUND: National administrative healthcare data may be used as a case-finding method for prevalence studies of chronic disease in the United States, but the completeness of ascertainment likely varies depending on the disease under study.
METHODS: We used 3 case-finding sources (Medicare, Medicaid, and Veterans Administration data) to estimate the prevalence of amyotrophic lateral sclerosis (ALS) in the United States for 2002-2004, and applied the capture-recapture methodology to estimate the degree of under-ascertainment when relying solely on these sources for case identification.
RESULTS: Case-finding completeness was 76% overall and did not vary by race, but was lower for males (77%) than for females (88%), and lower for patients under age 65 (66%) than patients over age 65 (79%). The uncorrected ALS prevalence ratio was 2.8/100,000 in 2002, 3.3/100,000 in 2003, and 3.7/100,000 in 2004. After correcting for under-ascertainment, the annual prevalence increased by approximately 1 per 100,000 to 3.7/100,000 in 2002 (95% CI 3.66-3.80), 4.4/100,000 in 2003 (95% CI 4.34-4.50), and 4.8/100,000 in 2004 (95% CI 4.76-4.91).
CONCLUSIONS: Federal healthcare claims databases ascertained are a very efficient method for identifying the majority of ALS-prevalent cases in the National ALS Registry, and may be enhanced by having patients self-register through the registry web portal.

PMID: 30092573 [PubMed - as supplied by publisher]

Hospice Care of Veterans in Medicare Advantage and Traditional Medicare: A Risk-Adjusted Analysis.

Fri, 08/10/2018 - 5:41am
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Hospice Care of Veterans in Medicare Advantage and Traditional Medicare: A Risk-Adjusted Analysis.

J Am Geriatr Soc. 2018 Aug 08;:

Authors: Gidwani-Marszowski R, Kinosian B, Scott W, Phibbs CS, Intrator O

Abstract
OBJECTIVES: To compare the quality of end-of-life care in Medicare Advantage (MA) and traditional Medicare (TM), specifically, receipt and length of hospice care.
DESIGN: Retrospective analysis of administrative data.
SETTING: Hospice care.
PARTICIPANTS: Veterans dually enrolled in the Veterans Health Administration (VHA) and MA or TM who died between 2008 and 2013 (N = 1,515,441).
MEASUREMENTS: Outcomes studied included use and duration of hospice care. Use of a VHA-enrolled population allowed for risk adjustment that is otherwise challenging when studying MA.
RESULTS: Adjusted analyses revealed that MA beneficiaries were more likely to receive hospice than TM beneficiaries; results corroborate published non-risk-adjusted analyses. MA beneficiaries had shorter hospice duration; this is an opposite direction of effect than non-risk-adjusted analyses. Results were robust to multiple sensitivity analyses limiting the cohort to individuals in MA and TM who had equal opportunity for their comorbidities to be captured. Removing risk adjustment resulted in results that mirrored those in the existing published literature.
CONCLUSION: Our work provides two important insights regarding MA that are important to consider as enrollment in this insurance mechanism grows. First, MA beneficiaries received poorer-quality end-of-life care than TM beneficiaries, as ascertained by exposure to hospice. Second, any comparisons made between MA and TM require proper risk adjustment to obtain correct directions of effect. We encourage the Centers for Medicare & Medicaid Services to make comorbidity data specific to MA enrollees available to researchers for these purposes.

PMID: 30091240 [PubMed - as supplied by publisher]

Do Medical Homes Improve Quality of Care for Persons with Multiple Chronic Conditions?

Thu, 08/09/2018 - 5:41am
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Do Medical Homes Improve Quality of Care for Persons with Multiple Chronic Conditions?

Health Serv Res. 2018 Aug 07;:

Authors: Swietek KE, Domino ME, Beadles C, Ellis AR, Farley JF, Grove LR, Jackson C, DuBard CA

Abstract
OBJECTIVE: To examine the association between medical home enrollment and receipt of recommended care for Medicaid beneficiaries with multiple chronic conditions (MCC).
DATA SOURCES/STUDY SETTING: Secondary claims data from fiscal years 2008-2010. The sample included nonelderly Medicaid beneficiaries with at least two of eight target conditions (asthma, chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, seizure disorder, major depressive disorder, and schizophrenia).
STUDY DESIGN: We used linear probability models with person- and year-level fixed effects to examine the association between patient-centered medical home (PCMH) enrollment and nine disease-specific quality-of-care metrics, controlling for selection bias and time-invariant differences between enrollees.
DATA COLLECTION METHODS: This study uses a dataset that links Medicaid claims with other administrative data sources.
PRINCIPAL FINDINGS: Patient-centered medical home enrollment was associated with an increased likelihood of receiving eight recommended mental and physical health services, including A1C testing for persons with diabetes, lipid profiles for persons with diabetes and/or hyperlipidemia, and psychotherapy for persons with major depression and persons with schizophrenia. PCMH enrollment was associated with overuse of short-acting β-agonists among beneficiaries with asthma.
CONCLUSIONS: The PCMH model can improve quality of care for patients with multiple chronic conditions.

PMID: 30088272 [PubMed - as supplied by publisher]

Testing the organizational theory of innovation implementation effectiveness in a community pharmacy medication management program: a hurdle regression analysis.

Thu, 08/02/2018 - 6:40am
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Testing the organizational theory of innovation implementation effectiveness in a community pharmacy medication management program: a hurdle regression analysis.

Implement Sci. 2018 Jul 31;13(1):105

Authors: Turner K, Trogdon JG, Weinberger M, Stover AM, Ferreri S, Farley JF, Ray N, Patti M, Renfro C, Shea CM

Abstract
BACKGROUND: Many state Medicaid programs are implementing pharmacist-led medication management programs to improve outcomes for high-risk beneficiaries. There are a limited number of studies examining implementation of these programs, making it difficult to assess why program outcomes might vary across organizations. To address this, we tested the applicability of the organizational theory of innovation implementation effectiveness to examine implementation of a community pharmacy Medicaid medication management program.
METHODS: We used a hurdle regression model to examine whether organizational determinants, such as implementation climate and innovation-values fit, were associated with effective implementation. We defined effective implementation in two ways: implementation versus non-implementation and program reach (i.e., the proportion of the target population that received the intervention). Data sources included an implementation survey administered to participating community pharmacies and administrative data.
RESULTS: The findings suggest that implementation climate is positively and significantly associated with implementation versus non-implementation (AME = 2.65, p < 0.001) and with program reach (AME = 5.05, p = 0.001). Similarly, the results suggest that innovation-values fit is positively and significantly associated with implementation (AME = 2.17, p = 0.037) and program reach (AME = 11.79, p < 0.001). Some structural characteristics, such as having a clinical pharmacist on staff, were significant predictors of implementation and program reach whereas other characteristics, such as pharmacy type or prescription volume, were not.
CONCLUSIONS: Our study supported the use of the organizational theory of innovation implementation effectiveness to identify organizational determinants that are associated with effective implementation (e.g., implementation climate and innovation-values fit). Unlike broader environmental factors or structural characteristics (e.g., pharmacy type), implementation climate and innovation-values fit are modifiable factors and can be targeted through intervention-a finding that is important for community pharmacy practice. Additional research is needed to determine what implementation strategies can be used by community pharmacy leaders and practitioners to develop a positive implementation climate and innovation-values fit for medication management programs.

PMID: 30064454 [PubMed - in process]

Medicare Advantage Enrollment and Beneficiary Risk Scores: Difference-in-Differences Analyses Show Increases for All Enrollees On Account of Market-Wide Changes.

Sat, 07/28/2018 - 7:40am

Medicare Advantage Enrollment and Beneficiary Risk Scores: Difference-in-Differences Analyses Show Increases for All Enrollees On Account of Market-Wide Changes.

Inquiry. 2018 Jan-Dec;55:46958018788640

Authors: Hayford TB, Burns AL

Abstract
Medicare adjusts payments to Medicare Advantage (MA) insurers using risk scores that summarize the relationship between fee-for-service (FFS) Medicare spending and beneficiaries' demographic characteristics and documented health conditions. Research shows that MA insurers have increasingly documented conditions more thoroughly than traditional Medicare-resulting in higher payments to insurers-but little is known about what factors contribute to diverging risk scores. We apportion that divergence between market-wide increases and increases that vary with length of MA enrollment. We also examine whether effects vary across plan types and whether the enrollment duration effect is contingent upon remaining with the same insurer. Using Medicare administrative data from 2008 to 2013, we employ a difference-in-differences model to compare the growth in risk scores of Medicare beneficiaries who switch from FFS to MA to that of beneficiaries who remain in FFS. We find that the effect of MA enrollment on risk scores increased from 5% in 2009 to 8% in 2012 and that continuous enrollment in MA was associated with an additional 1.2% increase per year, regardless of continuous enrollment with an insurer. Thus, even among those who switched to MA in 2009, enrollment duration comprised less than one-third of the coding intensity difference in 2012. We also find that risk scores grew faster in areas with greater MA penetration and among Health Maintenance Organization enrollees. Overall, our findings suggest that market-wide factors contributed most to the increasing divergence between FFS and MA risk scores.

PMID: 30052104 [PubMed - in process]

Cost Savings in a Surgeon-Directed BPCI Program for Total Joint Arthroplasty.

Sun, 07/22/2018 - 5:40am
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Cost Savings in a Surgeon-Directed BPCI Program for Total Joint Arthroplasty.

Surg Technol Int. 2018 Jul 20;33:

Authors: Siddiqi A, White PB, Murphy W, Terry D, Murphy SB, Talmo CT

Abstract
BACKGROUND: There are few studies available on the savings generated and strategies employed for cost reduction in total joint arthroplasty. In this study, our organization-a group of private practices partnering with a consultant-aimed to analyze the impact of a preoperative protocol on overall cost savings.
MATERIALS AND METHODS: Using administrative data from the Medicare Bundled Payments for Care Improvement (BPCI) initiative, 771 consecutive total joint arthroplasty patients from 2009-2014 were compared with 408 consecutive BPCI patients from 2014-2017. The 30-day episode and Medicare part B total cost of care was analyzed. This included inpatient and post-discharge expenditure, laboratory and imaging costs, physician and ER visits, and readmission.
RESULTS: Average total episode cost declined by $3,174 or 13% from $23,925 to $20,752 (p<0.001) in the BPCI period. Readmission rate was unchanged (p=0.20), and there was a 48% reduction in the percent of patients presenting to the emergency room (p=.03). There was a decline of $2,647 (78%) in skilled nursing cost per case, which represented the majority of savings. Post-discharge imaging, laboratory test claims, postoperative emergency room visits, primary care physician (PCP) visits, and cost per episode all decreased. The decrease in PCP utilization did not result in increased medical complications or readmissions.
CONCLUSION: Our preoperative patient-education protocol has decreased non-home discharge, unnecessary postoperative physician visits, and diagnostic testing resulting in an episode cost savings of 13%. With Advanced BPCI on the horizon, orthopedic surgeon control as the awardee of the bundle, combined with an increasing focus on patient education, will continue to lower costs and improve patient care.

PMID: 30029286 [PubMed - as supplied by publisher]

Association Between Maternal 2nd Trimester Plasma Folate Levels and Infant Bronchiolitis.

Sun, 07/22/2018 - 5:40am
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Association Between Maternal 2nd Trimester Plasma Folate Levels and Infant Bronchiolitis.

Matern Child Health J. 2018 Jul 19;:

Authors: Vereen S, Gebretsadik T, Johnson N, Hartman TJ, Veeranki SP, Piyathilake C, Mitchel EF, Kocak M, Cooper WO, Dupont WD, Tylavsky F, Carroll KN

Abstract
Objectives Viral bronchiolitis is the most common cause of infant hospitalization. Folic acid supplementation is important during the periconceptional period to prevent neural tube defects. An area of investigation is whether higher prenatal folate is a risk factor for childhood respiratory illnesses. We investigated the association between maternal 2nd trimester plasma folate levels and infant bronchiolitis. Methods We conducted a retrospective cohort analysis in a subset of mother-infant dyads (n = 676) enrolled in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study and Tennessee Medicaid. Maternal folate status was determined using 2nd trimester (16-28 weeks) plasma samples. Bronchiolitis diagnosis in the first year of life was ascertained using International Classification of Diagnosis-9 codes from Medicaid administrative data. We used multivariable logistic regression to assess the adjusted association of prenatal folate levels and infant bronchiolitis outcome. Results Half of the women in this lower-income and predominately African-American (84%) study population had high levels of folate (median 2nd trimester level 19.2 ng/mL) and 21% of infants had at least one bronchiolitis healthcare visit. A relationship initially positive then reversing between maternal plasma folate and infant bronchiolitis was observed that did not reach statistical significance (poverall = .112, pnonlinear effect = .088). Additional adjustment for dietary methyl donor intake did not significantly alter the association. Conclusions for Practice Results did not confirm a statistically significant association between maternal 2nd trimester plasma folate levels and infant bronchiolitis. Further work is needed to investigate the role of folate, particularly higher levels, in association with early childhood respiratory illnesses.

PMID: 30027465 [PubMed - as supplied by publisher]

Validation of body mass index (BMI)-related ICD-9-CM and ICD-10-CM administrative diagnosis codes recorded in US claims data.

Sat, 07/14/2018 - 5:40am
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Validation of body mass index (BMI)-related ICD-9-CM and ICD-10-CM administrative diagnosis codes recorded in US claims data.

Pharmacoepidemiol Drug Saf. 2018 Jul 12;:

Authors: Ammann EM, Kalsekar I, Yoo A, Johnston SS

Abstract
PURPOSE: To quantify the sensitivity and positive predictive value (PPV) of body mass index (BMI)-related ICD-9-CM and ICD-10-CM diagnosis codes in claims data.
METHODS: De-identified electronic health record (EHR) and claims data were obtained from the Optum Integrated Claims-Clinical Database for cross-sections of commercial and Medicare Advantage health plan members age ≥ 20 years in 2013, 2014, and 2016. In each calendar year, health plan members' BMI as coded in the insurance claims data (error-prone measure) was compared with their BMI as recorded in the EHR (gold standard) to estimate the sensitivity and PPV of BMI-related ICD-9-CM and ICD-10-CM diagnosis codes. The unit of analysis was the person-year.
RESULTS: The study sample included 746 763 distinct health plan members who contributed 1 116 283 eligible person-years (median age 56 years; 57% female; 65% commercially insured and 35% with Medicare Advantage). BMI-related diagnoses were coded for 14.6%. The sensitivity of BMI-related diagnoses codes for the detection of underweight, normal weight, overweight, and obesity was 10.1%, 3.7%, 6.0%, and 25.2%, and the PPV was 49.0% for underweight, 89.6% for normal weight, 73.4% for overweight, and 92.4% for obesity, respectively. The sensitivity of BMI-related diagnosis codes was higher in the ICD-10-CM era relative to the ICD-9-CM era.
CONCLUSIONS: The PPV of BMI-related diagnosis codes for normal weight, overweight, and obesity was high (>70%) but the sensitivity was low (<30%). BMI-related diagnoses were more likely to be coded in patients with class II or III obesity (BMI ≥35 kg/m2 ), and in 2016 relative to 2013 or 2014.

PMID: 30003617 [PubMed - as supplied by publisher]

The Association of Inpatient Occupancy with Hospital-Acquired Clostridium difficile Infection.

Tue, 07/03/2018 - 5:40am

The Association of Inpatient Occupancy with Hospital-Acquired Clostridium difficile Infection.

J Hosp Med. 2018 Jun 27;:

Authors: Abir M, Goldstick J, Malsberger R, Setodji CM, Dev S, Wenger N

Abstract
Few studies have evaluated the relationship between high hospital occupancy and hospital-acquired complications. We evaluated the association between inpatient occupancy and hospital-acquired Clostridium difficile infection (CDI) using a novel measure of hospital occupancy. We analyzed administrative data from California hospitals from 2008-2012 for Medicare recipients aged 65 years with a discharge diagnosis of acute myocardial infarction, heart failure, or pneumonia. Using daily census data, we constructed patient-level measures of occupancy on admission day and average occupancy during hospitalization (range: 0-1), which were split into 4 groups. We used logistic regression with cluster standard errors to estimate the adjusted and unadjusted relationship of occupancy with hospital-acquired CDI. Across 327 hospitals, 558,344 discharges met our inclusion criteria. Higher admission day occupancy was associated with significantly lower adjusted likelihood of CDI. Compared to the 0-0.25 occupancy group, patients admitted on a day of 0.51-0.75 occupancy had 0.86 odds of CDI (95% CI 0.75-0.98). The 0.76-1.00 admission occupancy group had 0.87 odds of CDI (95% CI 0.75-1.01). With regard to average occupancy, intermediate levels of occupancy 0.26-0.50 (odds ratio [OR] = 3.04, 95% CI 2.33-3.96) and 0.51-0.75 (OR = 3.28, 95% CI 2.51-4.28) had over 3-fold increased adjusted odds of CDI relative to the low occupancy group; the high occupancy group did not have signifcantly different odds of CDI compared to the low occupancy group (OR = 0.96, 95% CI 0.70-1.31). These findings should prompt exploration of how hospitals react to occupancy changes and how those care processes translate into hospital-acquired complications in order to inform best practices.

PMID: 29964276 [PubMed - as supplied by publisher]

Comparing neighborhood and state contexts for women living with and without HIV: understanding the Southern HIV epidemic.

Tue, 07/03/2018 - 5:40am

Comparing neighborhood and state contexts for women living with and without HIV: understanding the Southern HIV epidemic.

AIDS Care. 2018 Jul 01;:1-8

Authors: Ludema C, Edmonds A, Cole SR, Eron JJ, Adedimeji AA, Cohen J, Cohen MH, Kassaye S, Konkle-Parker DJ, Metsch LR, Wingood GM, Wilson TE, Adimora AA

Abstract
In the South, people living with HIV experience worse health outcomes than in other geographic regions, likely due to regional political, structural, and socioeconomic factors. We describe the neighborhoods of women (n = 1,800) living with and without HIV in the Women's Interagency HIV Study (WIHS), a cohort with Southern sites in Chapel Hill, NC; Atlanta, GA; Birmingham, AL; Jackson, MS; and Miami, FL; and non-Southern sites in Brooklyn, NY; Bronx, NY; Washington, DC; San Francisco, CA; and Chicago, IL. In 2014, participants' addresses were geocoded and matched to several administrative data sources. There were a number of differences between the neighborhood contexts of Southern and non-Southern WIHS participants. Southern states had the lowest income eligibility thresholds for family Medicaid, and consequently higher proportions of uninsured individuals. Modeled proportions of income devoted to transportation were much higher in Southern neighborhoods (Location Affordability Index of 28-39% compared to 16-23% in non-Southern sites), and fewer participants lived in counties where hospitals reported providing HIV care (55% of GA, 63% of NC, and 76% of AL participants lived in a county with a hospital that provided HIV care, compared to >90% at all other sites). Finally, the states with the highest adult incarceration rates were all in the South (per 100,000 residents: AL 820, MS 788, GA 686, FL 644). Many Southern states opted not to expand Medicaid, invest little in transportation infrastructure, and have staggering rates of incarceration. Resolution of racial and geographic disparities in HIV health outcomes will require addressing these structural barriers.

PMID: 29962235 [PubMed - as supplied by publisher]

Increased Rates of Both Knee and Hip Arthroplasties in Older Patients with Ankylosing Spondylitis.

Tue, 07/03/2018 - 5:40am
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Increased Rates of Both Knee and Hip Arthroplasties in Older Patients with Ankylosing Spondylitis.

J Rheumatol. 2018 Jul 01;:

Authors: Ward MM

Abstract
OBJECTIVE: To determine the risks of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) in older patients with ankylosing spondylitis (AS).
METHODS: We used administrative data from 1999 to 2013 on US Medicare beneficiaries to identify patients (< 75 yrs old) with AS and a comparison group without AS. Rates of primary THA and primary TKA were computed for each group, and standardized for age, sex, and race. We also examined risks of primary TKA among patients with AS by their THA status.
RESULTS: We analyzed 52,568 patients with AS and 4,617,179 patients without AS. Between 1999 and 2013, the standardized incidence of primary THA in patients with AS doubled from 4.5 per 1000 patient-years (PY) to 9.6 per 1000 PY. Rates of primary TKA were higher in patients with AS than controls in all years. In 2013, the standardized incidence of primary TKA in AS was 12.3 per 1000 PY versus 5.7 per 1000 PY in the comparison group (RR 2.14, 95% CI 1.93-2.38). Rates of primary TKA were twice as high among patients with AS and THA than among those without THA (20.4 vs 10.2 per 1000 PY).
CONCLUSION: Rates of THA in older patients with AS doubled over recent years, outpacing the increase in the general population. Rates of TKA were also substantially higher in older patients with AS. The increased risk of TKA in AS may be a consequence of damage from knee inflammation, or alterations in lower extremity biomechanics due to hip arthritis.

PMID: 29961693 [PubMed - as supplied by publisher]

Racial/Ethnic and Socioeconomic Disparities in Total Knee Arthroplasty 30- and 90-Day Readmissions: A Multi-Payer and Multistate Analysis, 2007-2014.

Sat, 06/30/2018 - 6:40am

Racial/Ethnic and Socioeconomic Disparities in Total Knee Arthroplasty 30- and 90-Day Readmissions: A Multi-Payer and Multistate Analysis, 2007-2014.

Popul Health Manag. 2018 Jun 29;:

Authors: Arroyo NS, White RS, Gaber-Baylis LK, La M, Fisher AD, Samaru M

Abstract
Previous studies have addressed racial/ethnic and socioeconomic disparities in total knee arthroplasty (TKA) within the Medicare population. However, there is limited research examining these disparities across racial/ethnic and socioeconomic groups in the general population. This study used administrative data from the State Inpatient Databases from the Healthcare Cost and Utilization Project for the years 2007-2014 from California (2007-2011 only), Florida, New York, and Maryland (2012-2014 only). In all, 739,857 TKA readmission-eligible patients aged ≥8 years were included in the analysis. Black patients and patients with Medicaid had a higher likelihood of 30- and 90-day readmissions compared to white patients and patients with private insurance, respectively. Patients living in higher median income areas and patients treated at higher volume hospitals had lower likelihoods of 30- and 90-day readmissions compared to patients in the lowest median income quartile and patients treated at the lowest volume hospitals, respectively. These results confirmed racial/ethnic and socioeconomic disparities in TKA readmissions across 4 geographically diverse states, identified public insurance status as the salient factor across subpopulations, and raise awareness of the existence of these disparities outside of the Medicare population.

PMID: 29957124 [PubMed - as supplied by publisher]

Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, 2000-2015.

Thu, 06/28/2018 - 6:40am
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Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, 2000-2015.

JAMA. 2018 Jun 25;:

Authors: Teno JM, Gozalo P, Trivedi AN, Bunker J, Lima J, Ogarek J, Mor V

Abstract
Importance: End-of-life care costs are high and decedents often experience poor quality of care. Numerous factors influence changes in site of death, health care transitions, and burdensome patterns of care.
Objective: To describe changes in site of death and patterns of care among Medicare decedents.
Design, Setting, and Participants: Retrospective cohort study among a 20% random sample of 1 361 870 decedents who had Medicare fee-for-service (2000, 2005, 2009, 2011, and 2015) and a 100% sample of 871 845 decedents who had Medicare Advantage (2011 and 2015) and received care at an acute care hospital, at home or in the community, at a hospice inpatient care unit, or at a nursing home.
Exposures: Secular changes between 2000 and 2015.
Main Outcomes and Measures: Medicare administrative data were used to determine site of death, place of care, health care transitions, which are changes in location of care, and burdensome patterns of care. Burdensome patterns of care were based on health care transitions during the last 3 days of life and multiple hospitalizations for infections or dehydration during the last 120 days of life.
Results: The site of death and patterns of care were studied among 1 361 870 decedents who had Medicare fee-for-service (mean [SD] age, 82.8 [8.4] years; 58.7% female) and 871 845 decedents who had Medicare Advantage (mean [SD] age, 82.1 [8.5] years; 54.0% female). Among Medicare fee-for-service decedents, the proportion of deaths that occurred in an acute care hospital decreased from 32.6% (95% CI, 32.4%-32.8%) in 2000 to 19.8% (95% CI, 19.6%-20.0%) in 2015, and deaths in a home or community setting that included assisted living facilities increased from 30.7% (95% CI, 30.6%-30.9%) in 2000 to 40.1% (95% CI, 39.9%-30.3% ) in 2015. Use of the intensive care unit during the last 30 days of life among Medicare fee-for-service decedents increased from 24.3% (95% CI, 24.1%-24.4%) in 2000 and then stabilized between 2009 and 2015 at 29.0% (95% CI, 28.8%-29.2%). Among Medicare fee-for-service decedents, health care transitions during the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) in 2000 to a high of 14.2% (95% CI, 14.0%-14.3%) in 2009 and then decreased to 10.8% (95% CI, 10.6%-10.9%) in 2015. The number of decedents enrolled in Medicare Advantage during the last 90 days of life increased from 358 600 in 2011 to 513 245 in 2015. Among decedents with Medicare Advantage, similar patterns in the rates for site of death, place of care, and health care transitions were observed.
Conclusions and Relevance: Among Medicare fee-for-service beneficiaries who died in 2015 compared with 2000, there was a lower likelihood of dying in an acute care hospital, an increase and then stabilization of intensive care unit use during the last month of life, and an increase and then decline in health care transitions during the last 3 days of life.

PMID: 29946682 [PubMed - as supplied by publisher]

Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data.

Wed, 06/27/2018 - 6:40am

Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data.

PLoS Med. 2018 Jun;15(6):e1002592

Authors: Kumar A, Rahman M, Trivedi AN, Resnik L, Gozalo P, Mor V

Abstract
BACKGROUND: Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees.
METHODS AND FINDINGS: This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation.
CONCLUSIONS: Compared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs.

PMID: 29944655 [PubMed - in process]

Sources of variability in hospital administrative data: Clinical coding of postoperative ileus.

Wed, 06/27/2018 - 6:40am
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Sources of variability in hospital administrative data: Clinical coding of postoperative ileus.

Health Inf Manag. 2018 Jan 01;:1833358318781106

Authors: Resslar MA, Ivanitskaya LV, Perez MA, Zikos D

Abstract
BACKGROUND: Multiple studies have questioned the validity of clinical codes in hospital administrative data. We examined variability in reporting a postoperative ileus (POI).
OBJECTIVE: We aimed to analyse sources of coding variations to understand how clinical coding professionals arrive at POI coding decisions and to verify existing knowledge that current clinical coding practices lack standardised applications of regulatory guidelines.
METHOD: Two medical records (cases 1 and 2) were provided to 15 clinical coders employed by a midsize nonprofit hospital in the northwest region of the United States. After coding these cases, the study participants completed a survey, reported on the application of guidelines, and participated in a focus group led by a health information management regulatory compliance expert.
RESULTS: Only 5 of the 15 clinical coders correctly indicated no POI complication in case 1 where the physician documentation did not establish a link between the POI as a complication of care and the surgery. In contrast, 13 of the 15 study participants correctly coded case 2, which included clear physician documentation and contained the clinical parameters for the coding of the POI as a complication of care. Clinical coder education, credentials, certifications, and experience did not relate to the coding performance. The clinical coders inconsistently prioritised coding rules and valued experience more than education.
CONCLUSION AND IMPLICATIONS: The application of International Classification of Diseases, Ninth Revision, Clinical Modification; coding conventions; Centers for Medicare and Medicaid Services coding guidelines; and American Hospital Association coding clinic advice was subject to the clinical coders' interpretation; they perceived them as conflicting guidance. Their reliance on subjective experience in dealing with this conflicting guidance may limit the accuracy of reporting outcomes of clinical performance.

PMID: 29940796 [PubMed - as supplied by publisher]

The Role of Big Data in the Development and Evaluation of US Dialysis Care.

Thu, 06/21/2018 - 9:40am
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The Role of Big Data in the Development and Evaluation of US Dialysis Care.

Am J Kidney Dis. 2018 Jun 16;:

Authors: Erickson KF, Qureshi S, Winkelmayer WC

Abstract
Rapid growth in electronic communications and digitalization, combined with advances in data management, analysis, and storage, have led to an era of "Big Data." The Social Security Amendments of 1972 turned end-stage renal disease (ESRD) care into a single-payer system for most patients requiring dialysis in the United States. As a result, there are few areas of medicine that have been as influenced by Big Data as dialysis care, for which Medicare's large administrative data sets have had a central role in the evaluation and development of public policy for several decades. In the 1970/1980s, Medicare data helped identify concerning trends in costs, access to dialysis care, and quality of care delivered. As the research community and policymakers made Medicare's administrative data increasingly accessible for investigation, analyses of Medicare claims have had a large role in facilitating policy synthesis and refinement. Efforts to address the skyrocketing cost of injectable drugs in the 1990s and 2000s exemplify this expanded role of Big Data. Although there are opportunities for large government and nongovernmental administrative data sets to continue serving a critical role in the evaluation and development of ESRD policies, it is important to understand challenges and limitations associated with their use.

PMID: 29921451 [PubMed - as supplied by publisher]

Receipt of other routinely recommended vaccines relative to receipt of seasonal influenza vaccines: Trends from medicare administrative data, 2013-2015.

Mon, 06/18/2018 - 5:40am
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Receipt of other routinely recommended vaccines relative to receipt of seasonal influenza vaccines: Trends from medicare administrative data, 2013-2015.

Vaccine. 2018 Jun 13;:

Authors: Shen AK, Warnock R, Chu S, Kelman JA

Abstract
Annual influenza vaccination campaigns emphasize the importance of getting vaccinated against influenza. These campaigns offer potential opportunities to raise awareness of all vaccines. We explored the peak timing of the receipt of influenza and other routinely recommended vaccinations. We examined administrative claims data of 31 million Medicare fee-for-service beneficiaries, eligible to receive vaccinations administered from 2013 to 2015 from Medicare Part B (medical insurance) and Medicare Part D (prescription drug benefit). From 2013 to 2015, 88% of over 50 million influenza vaccination claims occurred in September, October, and November. Claims for pneumococcal (42%), herpes zoster (36%), and tetanus-containing (32%) vaccines were also concentrated during these months. For pneumococcal vaccines, this concentration occurred across various provider settings, including traditional doctor's offices, pharmacies, and hospitals. Herpes zoster (92%) and tetanus-containing (72%) vaccines were largely administered in the pharmacy. Annual influenza vaccination efforts offer additional opportunities to assess, recommend, and administer other recommended vaccinations.

PMID: 29909132 [PubMed - as supplied by publisher]

Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans.

Thu, 06/14/2018 - 6:40am
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Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans.

Health Serv Res. 2018 Jun 12;:

Authors: Vaughan Sarrazin M, Rosenthal GE, Turvey CL

Abstract
OBJECTIVE: Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care.
METHODS: The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset.
RESULTS: Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA.
CONCLUSIONS: VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.

PMID: 29896771 [PubMed - as supplied by publisher]

Exploring the Healthcare Value of Percutaneous Coronary Intervention: Appropriateness, Outcomes, and Costs in Michigan Hospitals.

Sat, 06/02/2018 - 5:40am
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Exploring the Healthcare Value of Percutaneous Coronary Intervention: Appropriateness, Outcomes, and Costs in Michigan Hospitals.

Circ Cardiovasc Qual Outcomes. 2018 Jun;11(6):e004328

Authors: Alyesh DM, Seth M, Miller DC, Dupree JM, Syrjamaki J, Sukul D, Dixon S, Kerr EA, Gurm HS, Nallamothu BK

Abstract
BACKGROUND: Assessments of healthcare value have largely focused on measuring outcomes of care at a given level of cost with less attention paid to appropriateness. However, understanding how appropriateness relates to outcomes and costs is essential to determining healthcare value.
METHODS AND RESULTS: In a retrospective cohort study design, administrative data from fee-for-service Medicare patients undergoing percutaneous coronary intervention (PCI) in Michigan hospitals between June 30, 2010, and December 31, 2014, were linked with clinical data from a statewide PCI registry to calculate hospital-level measures of (1) appropriate use criteria scores, (2) 90-day risk-standardized readmission and mortality rates, and (3) 90-day risk-standardized episode costs. We then used Spearman correlation coefficients to assess the relationship between these measures. A total of 29 839 PCIs were performed at 33 PCI hospitals during the study period. A total of 13.3% were for ST-segment-elevation myocardial infarction, 25.0% for non-ST-segment-elevation myocardial infarction, 47.1% for unstable angina, 9.8% for stable angina, and 4.7% for other. The overall hospital-level mean appropriate use criteria score was 8.4±0.2. Ninety-day risk-standardized readmission occurred in 23.7%±3.7% of cases, 90-day risk-standardized mortality in 4.3%±0.6%, and mean risk-standardized episode costs were $26 159±$1074. Hospital-level appropriate use criteria scores did not correlate with 90-day readmission, mortality, or episode costs.
CONCLUSIONS: Among Medicare patients undergoing PCI in Michigan, we found hospital-level appropriate use criteria scores did not correlate with 90-day readmission, mortality, or episode costs. This finding suggests that a comprehensive understanding of healthcare value requires multidimensional consideration of appropriateness, outcomes, and costs.

PMID: 29853465 [PubMed - in process]

Preoperative Patient Profile in Total Hip and Knee Arthroplasty Predictive of Increased Medicare Payments in a Bundled Payment Model.

Tue, 05/29/2018 - 1:40pm
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Preoperative Patient Profile in Total Hip and Knee Arthroplasty Predictive of Increased Medicare Payments in a Bundled Payment Model.

J Arthroplasty. 2018 Apr 09;:

Authors: Karas V, Kildow BJ, Baumgartner BT, Green CL, Attarian DE, Bolognesi MP, Seyler TM

Abstract
BACKGROUND: The shift toward value-based bundled payment models in total joint arthroplasty highlights the need for identification of modifiable risk factors for increased spending as well as opportunities to mitigate perioperative treatment of chronic disease. The purpose of this study was to identify preoperative comorbidities that result in an increased financial burden using institutional data at a single institution.
METHODS: We conducted a retrospective review of total joint arthroplasty patients and collected payment data from the Center for Medicare and Medicaid Services for each patient up to 90 days after surgery in accordance with the regulations of the Comprehensive Care for Joint Replacement initiative. Statistical analysis and comparison of preoperative profile and Medicare payments as a surrogate for cost were completed.
RESULTS: Six hundred ninety-four patients were identified over a 4-year time period who underwent surgery before adoption of the Comprehensive Care for Joint Replacement but that met criteria for inclusion. The median total payment per patient episode of care was $20,048. Preoperative diagnosis of alcoholism, anemia, diabetes, and obesity was found to have a statistically significant effect on total payments. The model predicted a geometric mean increase from $1425 to $9308 for patients bearing these comorbidities.
CONCLUSION: With Medicare payments as a surrogate for cost, we demonstrate that specific patient comorbidities and a cumulative increase in comorbidities predict increased costs. This study was based on institutional data rather than administrative data to gain actionable information on an institutional level and highlight potential flaws in research based on administrative data.

PMID: 29793850 [PubMed - as supplied by publisher]

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