PubMed Articles using Medicare or Medicaid Data

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A statewide effort to reduce high-dose opioid prescribing through coordinated care organizations.

Tue, 05/15/2018 - 6:40am
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A statewide effort to reduce high-dose opioid prescribing through coordinated care organizations.

Addict Behav. 2018 May 01;:

Authors: Hartung DM, Alley L, Leichtling G, Korthuis PT, Hildebran C

Abstract
BACKGROUND: Oregon's Medicaid program is delivered through 16 Coordinated Care Organizations (CCOs) participating in a statewide performance improvement program to reduce high-dose opioid prescribing. CCOs were allowed flexibility to develop their own dose targets and any policies, trainings, guidelines, and/or materials to meet these targets. In this study, we characterize CCO strategies to reduce high-dose opioid prescribing across the 16 CCOs.
METHODS: We reviewed relevant CCO documents and conducted semi-structured interviews with CCO administrators to acquire opioid-related policies, practices, timelines and contextual factors. We applied a systematic coding procedure to develop a comprehensive description of each CCO's strategy. We used administrative data from the state to summarize contextual utilization data for each CCO.
RESULTS: Most CCOs selected a target daily morphine milligram equivalent (MME) dose of 90 mg. Sixteen issued quantity limits related to dose, eight restricted specific drug formulations (short-acting or long-acting), and 11 allowed for time-limited taper plan periods for patients over threshold. Many CCOs also employed provider trainings, feedback reports, and/or onsite technical assistance. Other innovations included incentive measures, electronic health record alerts, and toolkits with materials on local alternative therapy resources and strategies for patient communication. CCOs leveraging collaborations with regional partners appeared to mount a greater intensity of interventions than independently operating CCOs.
CONCLUSIONS: CCOs developed a diversity of interventions to confront high-risk opioid prescribing within their organization. As healthcare systems mount interventions to reduce risky opioid prescribing, it is critical to carefully describe these activities and examine their impact on process and health outcomes.

PMID: 29754987 [PubMed - as supplied by publisher]

The interaction between rural/urban status and dual use status among veterans with heart failure.

Thu, 05/10/2018 - 6:40am
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The interaction between rural/urban status and dual use status among veterans with heart failure.

Rural Remote Health. 2018 May;18(2):4495

Authors: Hunt KJ, Gebregziahber M, Everett CJ, Heidenreich PA, Axon RN

Abstract
INTRODUCTION: Dual healthcare system use is associated with higher rates of healthcare utilization, but the influence of rurality on this phenomenon is unclear. This study aimed to determine the extent to which rurality in the USA modifies the likelihood for acute healthcare use among veterans with heart failure (HF).
METHODS: Using merged Veterans Affairs (VA), Medicare, and state-level administrative data, a retrospective cohort study of 4985 veterans with HF was performed. Negative binomial regression with interaction term for dual use and geographic location was used to estimate and compare the associations between dual use (as compared to VA-only use) and emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions in rural/highly rural veterans versus urban veterans.
RESULTS: The association between dual use compared to VA-only use and ED visits was stronger in rural/highly rural veterans (RR=1.28 (95%CI: 1.21,1.35)) than in urban veterans (rate ratio (RR)=1.17 (95% confidence interval (CI): 1.11,1.22)) (interaction p-value=0.0109), while the association between dual use and all-cause hospitalizations was similar in rural/highly rural veterans (RR=2.00 (95%CI: 1.87, 2.14)) and in urban veterans (RR=1.87 (95%CI: 1.77,1.98)). The association between dual use and all-cause 30-day hospital readmission was also similar in rural/highly rural versus urban veterans.
CONCLUSION: Rurality significantly modifies the likelihood of ED visits for HF, although this effect was not observed for hospitalizations or hospital readmissions. While other patient- or system-level factors may more heavily influence hospitalization and readmission in this population, dual use appears to be a marker for higher healthcare utilization and worse outcomes for both urban and rural veterans.

PMID: 29742355 [PubMed - in process]

Racial/Ethnic Disparities in Readmissions in US Hospitals: The Role of Insurance Coverage.

Tue, 05/08/2018 - 2:41pm
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Racial/Ethnic Disparities in Readmissions in US Hospitals: The Role of Insurance Coverage.

Inquiry. 2018 Jan-Dec;55:46958018774180

Authors: Basu J, Hanchate A, Bierman A

Abstract
We examine differences in rates of 30-day readmissions across patients by race/ethnicity and the extent to which these differences were moderated by insurance coverage. We use hospital discharge data of patients in the 18 years and above age group for 5 US states, California, Florida, Missouri, New York, and Tennessee for 2009, the latest year prior to the start of Centers for Medicare & Medicaid Services' Hospital Compare program of public reporting of hospital performance on 30-day readmissions. We use logistic regression models by state to estimate the association between insurance status, race, and the likelihood of a readmission within 30 days of an index hospital admission for any cause. Overall in 5 states, non-Hispanic blacks had a slightly higher risk of 30-day readmissions relative to non-Hispanic whites, although this pattern varied by state and insurance coverage. We found higher readmission risk for non-Hispanic blacks, compared with non-Hispanic whites, among those covered by Medicare and private insurance, but lower risk among uninsured and similar risk among Medicaid. Hispanics had lower risk of readmissions relative to non-Hispanic whites, and this pattern was common across subgroups with private, Medicaid, and no insurance coverage. Uninsurance was associated with lower risk of readmissions among minorities but higher risk of readmissions among non-Hispanic whites relative to private insurance. The study found that risk of readmissions by racial ethnic groups varies by insurance status, with lower readmission rates among minorities who were uninsured compared with those with private insurance or Medicare, suggesting that lower readmission rates may not always be construed as a good outcome, because it could result from a lack of insurance coverage and poor access to care, particularly among the minorities.

PMID: 29730971 [PubMed - in process]

Quality of Care for Children with Medical Complexity: an Analysis of Continuity of Care as a Potential Quality Indicator.

Mon, 04/30/2018 - 10:41am
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Quality of Care for Children with Medical Complexity: an Analysis of Continuity of Care as a Potential Quality Indicator.

Acad Pediatr. 2018 Apr 25;:

Authors: Arthur KC, Mangione-Smith R, Burkhart Q, Parast L, Liu H, Elliott MN, McGlynn EA, Schneider EC

Abstract
OBJECTIVE: To examine the relationship between continuity of care for children with medical complexity (CMC) and emergency department (ED) utilization, care coordination quality, and family impact related to care coordination.
METHODS: We measured ED utilization and primary care continuity with the Bice-Boxerman continuity of care index for 1477 CMC using administrative data from Minnesota and Washington state Medicaid agencies. For a subset of 186 of these CMC a caregiver survey was used to measure care coordination quality (using items adapted from the Consumer Assessment of Healthcare Providers and System (CAHPS©) Adult Health Plan Survey) and family impact (using items adapted from the National Survey of Children with Special Health Care Needs). Multivariable regression was used to examine the relationship between continuity, entered as a continuous variable ranging from 0 to 1, and the outcomes.
RESULTS: The median continuity was 0.27 (interquartile range [IQR] 0.12, 0.48) in the administrative data cohort and 0.27 (IQR 0.14, 0.43) in the survey cohort. Compared to children with a continuity score of 0, children with a score of 1 had lower odds of having ≥1 ED visit (OR=0.65, 95% confidence interval [CI], 0.46, 0.93; p=0.017) and their caregivers reported higher scores for the measure of receipt of care coordination (β=35.2 on a 0-100 scale, 95% CI, 11.5, 58.9, p=0.004). There was no association between continuity and family impact.
CONCLUSIONS: Continuity of care holds promise as a quality measure for CMC given its association with lower ED utilization and more frequent receipt of care coordination.

PMID: 29704650 [PubMed - as supplied by publisher]

Does Non-Adherence Increase Treatment Costs in Schizophrenia?

Sat, 04/28/2018 - 6:41am
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Does Non-Adherence Increase Treatment Costs in Schizophrenia?

Pharmacoeconomics. 2018 Apr 26;:

Authors: Pennington M, McCrone P

Abstract
INTRODUCTION: Medication non-adherence is a serious barrier to treatment of schizophrenia. Understanding the impact of non-adherence on costs is essential to the assessment of the cost effectiveness of interventions in which adherence to treatment is a concern.
OBJECTIVES: We undertook a comprehensive review of the available literature on the impact on costs of non-adherence to antipsychotics in the treatment of schizophrenia.
METHODS: We performed a search on multiple databases (MEDLINE, Embase, PsycINFO and Health Management Information Consortium) for any study reporting the impact of adherence to antipsychotics on costs in patients with schizophrenia up to February 2018. We included trials of behavioural interventions but excluded comparisons of different pharmacological therapies. Studies were included if at least one-third of the study population had schizophrenia and costs were reported.
RESULTS: Thirty-four publications on 28 studies met the inclusion criteria. Twenty studies reported analyses of administrative databases, primarily Medicaid. Findings on healthcare costs were mixed but suggested that lower pharmacy costs in non-adherent patients may outweigh increased hospitalisation costs where drug costs are relatively high. A few studies published analysis of prospective cohort data, or trials of behavioural interventions intended to influence adherence, mainly in a European setting. Findings were again mixed but indicate that increasing adherence does not reduce overall costs.
CONCLUSIONS: Inference from analysis of administrative data is limited by the risk of selection bias. Inference from trials is limited by small sample sizes. The literature does not consistently support an assumption that non-adherence increases healthcare costs.

PMID: 29700755 [PubMed - as supplied by publisher]

Evolving Choice Inconsistencies in Choice of Prescription Drug Insurance.

Fri, 04/20/2018 - 11:42am
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Evolving Choice Inconsistencies in Choice of Prescription Drug Insurance.

Am Econ Rev. 2016 08;106(8):2145-2184

Authors: Abaluck J, Gruber J

Abstract
We study choice over prescription insurance plans by the elderly using government administrative data to evaluate how these choices evolve over time. We find large "foregone savings" from not choosing the lowest cost plan that has grown over time. We develop a structural framework to decompose the changes in "foregone welfare" from inconsistent choices into choice set changes and choice function changes from a fixed choice set. We find that foregone welfare increases over time due primarily to changes in plan characteristics such as premiums and out-of-pocket costs; we estimate little learning at either the individual or cohort level.

PMID: 29104294 [PubMed - indexed for MEDLINE]

Understanding Prediabetes in a Medicare Advantage Population Using Data Adaptive Techniques.

Fri, 04/13/2018 - 8:41am

Understanding Prediabetes in a Medicare Advantage Population Using Data Adaptive Techniques.

Popul Health Manag. 2018 Apr 12;:

Authors: Kamble PS, Collins J, Harvey RA, Prewitt T, Kimball E, Deluzio T, Allen E, Bouchard JR

Abstract
The objective was to identify individuals with undiagnosed prediabetes from administrative data using adaptive techniques. The data source was a national Medicare Advantage Prescription Drug (MAPD) plan administrative data set. A retrospective, cross-sectional study developed and evaluated data adaptive logistic regression, decision tree, neural network, and ensemble predictive models for metabolic syndrome and prediabetes using 3 mutually exclusive cohorts (N = 279,903). The misclassification rate (MCR), average squared error (ASE), c-statistics, sensitivity (SN), and false positive (FP) rates were compared to select the final predictive models. MAPD individuals with continuous enrollment from 2013 to 2014 were included. Metabolic syndrome and prediabetes were defined using clinical guidelines, diagnosis, and laboratory data. A total of 512 variables identified through subject matter expertise in addition to utilizing all data available were evaluated for the modeling. The ensemble model demonstrated better discrimination (c-statistics, MCR, and ASE of 0.83, 0.24, and 0.16, respectively), high SN, and low FP rate in predicting metabolic syndrome than the individual data adaptive modeling techniques. Logistic regression demonstrated better discrimination (c-statistics, MCR, and ASE of 0.67, 0.13, and 0.11 respectively), high SN, and low FP rate in predicting prediabetes than the other adaptive modeling techniques or ensemble methods. The scored data predicted prediabetes in 44% of the MAPD population, which is comparable to 2005-2006 National Health and Nutrition Examination Survey prediabetes rates of 41%. The logistic regression model demonstrated good performance in predicting undiagnosed prediabetes in MAPD individuals.

PMID: 29648934 [PubMed - as supplied by publisher]

Influenza Vaccination Coverage Estimates in the Fee-For Service Medicare Beneficiary Population 2006 - 2016: Using Population-Based Administrative Data to Support a Geographic Based Near Real-Time Tool.

Thu, 04/12/2018 - 6:41am

Influenza Vaccination Coverage Estimates in the Fee-For Service Medicare Beneficiary Population 2006 - 2016: Using Population-Based Administrative Data to Support a Geographic Based Near Real-Time Tool.

Hum Vaccin Immunother. 2018 Apr 11;:1-10

Authors: Shen AK, Warnock R, Brereton S, McKean S, Wernecke M, Chu S, Kelman JA

Abstract
Older adults are at great risk of developing serious complications from seasonal influenza. We explore vaccination coverage estimates in the Medicare population through the use of administrative claims data and describe a tool designed to help shape outreach efforts and inform strategies to help raise influenza vaccination rates. This interactive mapping tool uses claims data to compare vaccination levels between geographic (i.e., state, county, zip code) and demographic (i.e., race, age) groups at different points in a season. Trends can also be compared across seasons. Utilization of this tool can assist key actors interested in prevention - medical groups, health plans, hospitals, and state and local public health authorities - in supporting strategies for reaching pools of unvaccinated beneficiaries where general national population estimates of coverage are less informative. Implementing evidence-based tools can be used to address persistent racial and ethnic disparities and prevent a substantial number of influenza cases and hospitalizations.

PMID: 29641277 [PubMed - as supplied by publisher]

Access to palliative care by disease trajectory: a population-based cohort of Ontario decedents.

Sun, 04/08/2018 - 6:41am
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Access to palliative care by disease trajectory: a population-based cohort of Ontario decedents.

BMJ Open. 2018 Apr 05;8(4):e021147

Authors: Seow H, O'Leary E, Perez R, Tanuseputro P

Abstract
OBJECTIVES: To examine access to palliative care between different disease trajectories and compare to other geographic areas.
DESIGN: A retrospective population-based decedent cohort study using linked administrative data.
SETTING: Ontario, Canada.
PARTICIPANTS: Ontario decedents between 1 April 2010 and 31 December 2012. Patients were categorised into disease trajectories: terminal illness (eg, cancer), organ failure (eg, chronic heart failure), frailty (eg, dementia), sudden death or other.
INTERVENTIONS: Receipt of palliative care services from institutional and community settings, derived from a validated list of palliative care codes from multiple administrate databases.
OUTCOME MEASURES: Receiving any palliative care services in the last year of life (yes/no), intensity (total days) and time of initiation of palliative care, in hospital and community sectors. Multivariable analysis examined the association between disease trajectory and the receipt of palliative care in the last year of life.
RESULTS: We identified 235 159 decedents in Ontario. In the last year of life, 88% of terminal illness, 44% of organ failure and 32% of frailty decedents accessed at least one palliative care service. Most care was provided during an inpatient hospitalisation. Terminal illness decedents received twice as many palliative care days (mean of 49 days) compared with organ failure and frailty decedents. Patients with terminal illness initiated palliative care median of 107 days before death compared with median of 19 days among those using the US Medicare hospice benefit.
CONCLUSIONS: Terminal illness decedents are more likely to receive any palliative care, with increased intensity and earlier before death than organ failure or frailty decedents. These data serve as a useful comparison for other countries with similar and different healthcare systems and eligibility criteria.

PMID: 29626051 [PubMed - in process]

Does the Number of Pharmacies a Patient Frequents Affect Adherence to Statins?

Wed, 04/04/2018 - 5:40am
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Does the Number of Pharmacies a Patient Frequents Affect Adherence to Statins?

J Popul Ther Clin Pharmacol. 2017 May 06;24(2):e20-e50

Authors: Christie R, Sketris I, Andreou P, Holbrook A, Levy A, Tamim H

Abstract
BACKGROUND: We hypothesized that medication adherence is affected by the number of pharmacies a patient frequents.
OBJECTIVES: The objective was to estimate the strength of association between the number of pharmacies a patient frequents and adherence to statins.
METHODS: Using administrative data from the Nova Scotia Seniors' Pharmacare program, a retrospective cohort study was conducted among subjects aged 65 years and older first dispensed statin between 1998 and 2008. The Usual Provider of Care (UPC), was defined as the number of dispensation days from the most frequented pharmacy divided by the total number of dispensation days. Estimated adherence of over 80% of the Medication Possession Ratio was defined as adherent. Data were analyzed using hierarchical linear regression.
RESULTS: The cohort of 25,641 subjects was 59% female with a mean age of 74 years. During follow-up, subjects filled prescriptions in a median of 2 (mean = 2; standard deviation = 0.88) pharmacies and visited pharmacies a median of 28 (mean = 30) times. During that time, 61% of patients used one pharmacy exclusively. Among subjects using 1 pharmacy, 59% were adherent while 58% using more than one pharmacy were adherent. However, upon adjustment for differences in distributions of age, sex, and other confounders, subjects who used more than one pharmacy had 10% decreased odds of statin adherence (odds ratio: 0.90, 95% confidence interval: 0.86-0.96). These results were robust in sensitivity analyses.
CONCLUSIONS: Among seniors newly starting statin therapy, using a single community pharmacy was modestly associated with adherence.

PMID: 28594479 [PubMed - indexed for MEDLINE]

Using Appendicitis to Improve Estimates of Childhood Medicaid Participation Rates.

Wed, 03/28/2018 - 6:41am
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Using Appendicitis to Improve Estimates of Childhood Medicaid Participation Rates.

Acad Pediatr. 2018 Mar 23;:

Authors: Silber JH, Zeigler AE, Reiter JG, Hochman LL, Ludwig J, Wang W, Calhoun S, Pati S

Abstract
OBJECTIVE: Administrative data are often used to estimate state Medicaid/CHIP duration of enrollment and insurance continuity, but generally not used to estimate participation (the fraction of eligible children enrolled) because administrative data do not include reasons for disenrollment and cannot observe eligible never-enrolled children, causing estimates of eligible unenrolled to be inaccurate. Analysts are therefore forced to either utilize survey information that is not generally linkable to administrative claims, or rely on duration and continuity measures derived from administrative data and forgo estimating claims-based participation. We introduce "Appendectomy Based Participation" (ABP) to estimate statewide participation rates using claims, by taking advantage of a natural experiment around statewide appendicitis admissions to improve the accuracy of participation rate estimates.
METHODS: Medicaid Analytic eXtract (MAX) from 2008-2010; American Community Survey from 2008-2010, from 43 states to calculate: Appendectomy Based Participation (ABP), the Continuity Ratio (CR), Duration, and participation based on the American Community Survey (ACS).
RESULTS: In the validation study, median participation rates using ABP was 86% versus 87% for ACS-based participation estimates using logical edits, and 84% without logical edits. Correlations between ABP and ACS with or without logical edits was 0.86, P < 0.0001. Using regression, ABP alone was a significant predictor of ACS (P < 0.0001) with or without logical edits, and adding Duration and/or CR did not significantly improve the model.
CONCLUSION: Using the Appendectomy Based Participation Rate derived from administrative claims (MAX) is a valid method to estimate statewide public insurance participation rates in children.

PMID: 29581042 [PubMed - as supplied by publisher]

Prescription Drug Use and Cost Trends Among Medicaid-Enrolled Children with Disruptive Behavioral Disorders.

Sun, 03/25/2018 - 6:42am

Prescription Drug Use and Cost Trends Among Medicaid-Enrolled Children with Disruptive Behavioral Disorders.

J Behav Health Serv Res. 2018 Mar 23;:

Authors: Zhao L, Cross-Barnet C, McClair VL

Abstract
Disruptive behavior disorders (DBDs) are the most common mental health conditions in children. These conditions profoundly affect healthcare utilization and costs. Service use, costs, and diagnostic trends among pediatric Medicaid beneficiaries provide information regarding healthcare quality and potential for smarter spending. Using nationwide Medicaid administrative data, this study investigates diagnoses, prescription drug fills, and payments in 49 states and D.C. from 2006 to 2009 in Medicaid beneficiaries age 20 and under. Psychotherapeutic drug prescriptions and payments were calculated as a proportion of prescription totals. Results were considered by age, gender, race, and state. The results show a trend of increasing DBD diagnosis. Among prescription claims for children with diagnosed DBD, psychotherapeutic drug claims represented 30-40% of prescription claims but over half of prescription costs. This study indicates increasing clinical and financial needs for Medicaid-enrolled children with DBDs. Medicaid could potentially foster reforms in pediatric DBD treatments, particularly regarding medication use.

PMID: 29572707 [PubMed - as supplied by publisher]

Psychotropic Polypharmacy Among Youths With Serious Emotional and Behavioral Disorders Receiving Coordinated Care Services.

Fri, 03/16/2018 - 8:41am

Psychotropic Polypharmacy Among Youths With Serious Emotional and Behavioral Disorders Receiving Coordinated Care Services.

Psychiatr Serv. 2018 Mar 15;:appips201700357

Authors: Wu B, Bruns EJ, Tai MH, Lee BR, Raghavan R, dosReis S

Abstract
OBJECTIVE: The study examined differences in psychotropic polypharmacy among youths with serious emotional and behavioral disorders who received coordinated care services (CCS) that used a wraparound model and a matched sample of youths who received traditional services.
METHODS: A quasi-experimental design compared psychotropic polypharmacy one year before and one year after discharge from CCS. The cohort was youths with serious emotional and behavioral disorders who were enrolled in CCS from December 2009 through May 2014. The comparison group was youths with serious emotional and behavioral disorders who received outpatient mental health services during the same time. Administrative data from Medicaid, child welfare, and juvenile justice services were used. A difference-in-difference analysis with propensity score matching evaluated the CCS intervention by time effect on psychotropic polypharmacy.
RESULTS: In both groups, most youths were male, black, and 10-18 years old, with attention-deficit hyperactivity disorder (54%-55%), mood disorder (39%-42%), depression (26%-27%), and bipolar disorder (25%-26%). About half of each group was taking an antipsychotic. The percentage reduction in polypharmacy from one year before CCS enrollment to one year after discharge was 28% for the CCS group and 29% for the non-CCS group, a nonsignificant difference. CCS youths excluded from the analysis had more complex mental health needs and a greater change in polypharmacy than the CCS youths who were included in the analytic sample.
CONCLUSIONS: Mental health care coordination had limited impact in reducing psychotropic polypharmacy for youths with less complex mental health needs. Further research is needed to evaluate the effect on psychotropic polypharmacy among youths with the greatest mental health needs.

PMID: 29540121 [PubMed - as supplied by publisher]

Impact of a New York City Supportive Housing Program on Housing Stability and Preventable Health Care among Homeless Families.

Wed, 03/14/2018 - 5:41am

Impact of a New York City Supportive Housing Program on Housing Stability and Preventable Health Care among Homeless Families.

Health Serv Res. 2018 Mar 12;:

Authors: Lim S, Singh TP, Hall G, Walters S, Gould LH

Abstract
OBJECTIVE: To assess the impact of a New York City supportive housing program on housing stability and preventable emergency department (ED) visits/hospitalizations among heads of homeless families with mental and physical health conditions or substance use disorders.
DATA SOURCES: Multiple administrative data from New York City and New York State for 966 heads of families eligible for the program during 2007-12.
STUDY DESIGN: We captured housing events and health care service utilization during 2 years prior to the first program eligibility date (baseline) and 2 years postbaseline. We performed sequence analysis to measure housing stability and compared housing stability and preventable ED visits and hospitalizations between program participants (treatment group) and eligible applicants not placed in the program (comparison group) via marginal structural modeling.
DATA COLLECTION/EXTRACTION METHODS: We matched electronically collected data.
PRINCIPAL FINDINGS: Eighty-seven percent of supportive housing tenants experienced housing stability in 2 years postbaseline. Compared with unstably housed heads of families in the comparison group, those in the treatment group were 0.60 times as likely to make preventable ED visits postbaseline (95% CI = 0.38, 0.96).
CONCLUSIONS: Supportive housing placement was associated with improved housing stability and reduced preventable health care visits among homeless families.

PMID: 29532478 [PubMed - as supplied by publisher]

Colonoscopy and Colorectal Cancer Mortality in the Veterans Affairs Health Care System: A Case-Control Study.

Wed, 03/14/2018 - 5:41am

Colonoscopy and Colorectal Cancer Mortality in the Veterans Affairs Health Care System: A Case-Control Study.

Ann Intern Med. 2018 Mar 13;:

Authors: Kahi CJ, Pohl H, Myers LJ, Mobarek D, Robertson DJ, Imperiale TF

Abstract
Background: Colonoscopy is widely used in the Veterans Affairs (VA) health care system for colorectal cancer (CRC) prevention, but its effect on CRC mortality is unknown.
Objective: To determine whether colonoscopy is associated with decreased CRC mortality in veterans and whether its effect differs by anatomical location of CRC.
Design: Case-control study.
Setting: VA-Medicare administrative data.
Participants: Case patients were veterans aged 52 years or older who were diagnosed with CRC between 2002 and 2008 and died of the disease by the end of 2010. Case patients were matched to 4 control patients without prior CRC on the basis of age, sex, and facility. Conditional logistic regression was performed to calculate odds ratios (ORs) for exposure to colonoscopy, with adjustment for race, Charlson Comorbidity Index score, selected chronic conditions, nonsteroidal anti-inflammatory drug use, and family history of CRC.
Measurements: Exposure to colonoscopy was determined from 1997 to 6 months before CRC diagnosis in case patients and to a corresponding date in control patients. Subgroup analysis was performed for patients who had undergone screening colonoscopy.
Results: A total of 4964 case patients and 19 856 control patients were identified. Case patients were significantly less likely to have undergone any colonoscopy (OR, 0.39 [95% CI, 0.35 to 0.43]). Colonoscopy was associated with reduced mortality for left-sided cancer (OR, 0.28 [CI, 0.24 to 0.32]) and right-sided cancer (OR, 0.54 [CI, 0.47 to 0.63]). The results were similar for patients who had undergone screening colonoscopy (overall OR, 0.30 [CI, 0.24 to 0.38]). Sensitivity analyses that varied the interval between CRC diagnosis and colonoscopy exposure did not affect the primary findings.
Limitation: Unmeasured confounding.
Conclusion: In this study using national VA-Medicare data, colonoscopy was associated with significant reductions in CRC mortality among veterans and was associated with greater benefit for left-sided cancer than right-sided cancer.
Primary Funding Source: U.S. Department of Veterans Affairs.

PMID: 29532085 [PubMed - as supplied by publisher]

The Effect of Medicaid on Management of Depression: Evidence From the Oregon Health Insurance Experiment.

Tue, 03/06/2018 - 5:41am
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The Effect of Medicaid on Management of Depression: Evidence From the Oregon Health Insurance Experiment.

Milbank Q. 2018 Mar;96(1):29-56

Authors: Baicker K, Allen HL, Wright BJ, Taubman SL, Finkelstein AN

Abstract
Policy Points: We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage on mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression. Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications and reduced the share of respondents reporting unmet mental health care needs by almost 40%. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations.
CONTEXT: Expanding Medicaid to previously uninsured adults has been shown to increase detection and reduce the prevalence of depression, but the ways that Medicaid affects mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression remain unclear.
METHODS: We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage using a randomized-controlled design, drawing on both primary and administrative data sources.
FINDINGS: Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications frequently prescribed to treat depression and related mental health conditions and reduced the share of respondents reporting unmet mental health care needs by almost 40%. The share of respondents screening positive for depression dropped by 9.2 percentage points overall, and by 13.1 for those with preexisting depression diagnoses, with greatest relief in symptoms seen primarily in feeling down or hopeless, feeling tired, and trouble sleeping-consistent with the increase observed not just in medications targeting depression but also in those targeting sleep.
CONCLUSIONS: Medicaid coverage had significant effects on the diagnosis, treatment, and outcomes of a population with substantial unmet mental health needs. Coverage increased access to care, reduced the prevalence of untreated and undiagnosed depression, and substantially improved the symptoms of depression. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations.

PMID: 29504203 [PubMed - in process]

Maryland Multipayor Patient-centered Medical Home Program: A 4-Year Quasiexperimental Evaluation of Quality, Utilization, Patient Satisfaction, and Provider Perceptions.

Wed, 02/21/2018 - 6:42am

Maryland Multipayor Patient-centered Medical Home Program: A 4-Year Quasiexperimental Evaluation of Quality, Utilization, Patient Satisfaction, and Provider Perceptions.

Med Care. 2018 Feb 16;:

Authors: Marsteller JA, Hsu YJ, Gill C, Kiptanui Z, Fakeye OA, Engineer LD, Perlmutter D, Khanna N, Rattinger GB, Nichols D, Harris I

Abstract
OBJECTIVE: To evaluate impact of the Maryland Multipayor Patient-centered Medical Home Program (MMPP) on: (1) quality, utilization, and costs of care; (2) beneficiaries' experiences and satisfaction with care; and (3) perceptions of providers.
DESIGN: 4-year quasiexperimental design with a difference-in-differences analytic approach to compare changes in outcomes between MMPP practices and propensity score-matched comparisons; pre-post design for patient-reported outcomes among MMPP beneficiaries.
SUBJECTS: Beneficiaries (Medicaid-insured and privately insured) and providers in 52 MMPP practices and 104 matched comparisons in Maryland.
INTERVENTION: Participating practices received unconditional financial support and coaching to facilitate functioning as medical homes, membership in a learning collaborative to promote education and dissemination of best practices, and performance-based payments.
MEASURES: Sixteen quality, 20 utilization, and 13 cost measures from administrative data; patient-reported outcomes on care delivery, trust in provider, access to care, and chronic illness management; and provider perceptions of team operation, team culture, satisfaction with care provided, and patient-centered medical home transformation.
RESULTS: The MMPP had mixed impact on site-level quality and utilization measures. Participation was significantly associated with lower inpatient and outpatient payments in the first year among privately insured beneficiaries, and for the entire duration among Medicaid beneficiaries. There was indication that MMPP practices shifted responsibility for certain administrative tasks from clinicians to medical assistants or care managers. The program had limited effect on measures of patient satisfaction (although response rates were low) and on provider perceptions.
CONCLUSIONS: The MMPP demonstrated mixed results of its impact and indicated differential program effects for privately insured and Medicaid beneficiaries.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/.

PMID: 29462077 [PubMed - as supplied by publisher]

Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study.

Tue, 02/13/2018 - 2:42pm

Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study.

Am J Kidney Dis. 2018 Feb 08;:

Authors: Woodside KJ, Bell S, Mukhopadhyay P, Repeck KJ, Robinson IT, Eckard AR, Dasmunshi S, Plattner BW, Pearson J, Schaubel DE, Pisoni RL, Saran R

Abstract
BACKGROUND: Arteriovenous fistulas (AVFs) are the preferred form of hemodialysis vascular access, but maturation failures occur frequently, often resulting in prolonged catheter use. We sought to characterize AVF maturation in a national sample of prevalent hemodialysis patients in the United States.
STUDY DESIGN: Nonconcurrent observational cohort study.
SETTING & PARTICIPANTS: Prevalent hemodialysis patients having had at least 1 new AVF placed during 2013, as identified using Medicare claims data in the US Renal Data System.
PREDICTORS: Demographics, geographic location, dialysis vintage, comorbid conditions.
OUTCOMES: Successful maturation following placement defined by subsequent use identified using monthly CROWNWeb data.
MEASUREMENTS: AVF maturation rates were compared across strata of predictors. Patients were followed up until the earliest evidence of death, AVF maturation, or the end of 2014.
RESULTS: In the study period, 45,087 new AVFs were placed in 39,820 prevalent hemodialysis patients. No evidence of use was identified for 36.2% of AVFs. Only 54.7% of AVFs were used within 4 months of placement, with maturation rates varying considerably across end-stage renal disease (ESRD) networks. Older age was associated with lower AVF maturation rates. Female sex, black race, some comorbid conditions (cardiovascular disease, peripheral artery disease, diabetes, needing assistance, or institutionalized status), dialysis vintage longer than 1 year, and catheter or arteriovenous graft use at ESRD incidence were also associated with lower rates of successful AVF maturation. In contrast, hypertension and prior AVF placement at ESRD incidence were associated with higher rates of successful AVF maturation.
LIMITATIONS: This study relies on administrative data, with monthly recording of access use.
CONCLUSIONS: We identified numerous associations between AVF maturation and patient-level factors in a recent national sample of US hemodialysis patients. After accounting for these patient factors, we observed substantial differences in AVF maturation across some ESRD networks, indicating a need for additional study of the provider, practice, and regional factors that explain AVF maturation.

PMID: 29429750 [PubMed - as supplied by publisher]

Disaster impacts on cost and utilization of Medicare.

Fri, 02/09/2018 - 6:42am

Disaster impacts on cost and utilization of Medicare.

BMC Health Serv Res. 2018 Feb 07;18(1):89

Authors: Rosenheim N, Grabich S, Horney JA

Abstract
BACKGROUND: To estimate changes in the cost and utilization of Medicare among beneficiaries over age 65 who have been impacted by a natural disaster, we merged publically available county-level Medicare claims for the years 2008-2012 with Federal Emergency Management Agency (FEMA) data related to disasters in each U.S. County from 2007 to 2012.
METHODS: Fixed-effects generalized linear models were used to calculate change in per capita costs standardized by region and utilization per 1000 beneficiaries at the county level. Aggregate county demographic characteristics of Medicare participants were included as predictors of change in county-level utilization and cost. FEMA data was used to determine counties that experienced no, some, high, and extreme hazard exposure. FEMA data was merged with claims data to create a balanced panel dataset from 2008 to 2012.
RESULTS: In general, both cost and utilization of Medicare services were higher in counties with more hazard exposure. However, utilization of home health services was lower in counties with more hazard exposure.
CONCLUSIONS: Additional research using individual-level data is needed to address limitations and determine the impacts of the substitution of services (e.g., inpatient rehabilitation for home health) that may be occurring in disaster affected areas during the post-disaster period.

PMID: 29415716 [PubMed - in process]

Evaluation of a Methodological Approach to Define An Inception Cohort of Rheumatoid Arthritis Patients Using Administrative Data.

Wed, 02/07/2018 - 5:42am

Evaluation of a Methodological Approach to Define An Inception Cohort of Rheumatoid Arthritis Patients Using Administrative Data.

Arthritis Care Res (Hoboken). 2018 Feb 06;:

Authors: Curtis JR, Xie F, Chen L, Greenberg JD, Zhang J

Abstract
BACKGROUND/PURPOSE: Identifying incident rheumatoid arthritis (RA) is desirable to create inception cohorts. We evaluated an approach to identify incident RA in health plan claims data.
METHODS: Both Medicare and commercial claims data was linked to Corrona, a U.S. RA registry. We evaluated accuracy of year of RA onset in the registry (gold standard) versus different claims algorithms, varying ICD-9 codes for RA/arthritis, duration of health plan enrollment preceding diagnosis (minimum of 1 vs. 2 years) and use of RA medications. Results were reported as positive predictive values (PPVs) of the claims-based algorithm for incident RA.
RESULTS: Depending on algorithm tested and whether patients were enrolled in Medicare or the commercial health plan, the PPVs for incident RA ranged from 68%-81%. A 2 year clean period free of all RA-related diagnoses and RA medications was somewhat more optimal, although by comparison, a 1 year clean period yielded similar PPVs and retained approximately 90% more RA patients for analysis.
CONCLUSION: Claims-based algorithms can accurately identify incident RA. This article is protected by copyright. All rights reserved.

PMID: 29409118 [PubMed - as supplied by publisher]

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