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

2 hours 21 min ago

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]

Position matters: Validation of medicare hospital claims for myocardial infarction against medical record review in the atherosclerosis risk in communities study.

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

Position matters: Validation of medicare hospital claims for myocardial infarction against medical record review in the atherosclerosis risk in communities study.

Pharmacoepidemiol Drug Saf. 2018 Feb 06;:

Authors: Bush M, Stürmer T, Stearns SC, Simpson RJ, Brookhart MA, Rosamond W, Kucharska-Newton AM

Abstract
PURPOSE: The objectives of this study were to investigate sensitivity and specificity of myocardial infarction (MI) case definitions using multiple discharge code positions and multiple diagnosis codes when comparing administrative data to hospital surveillance data.
METHODS: Hospital surveillance data for ARIC Study cohort participants with matching participant ID and service dates to Centers for Medicare and Medicaid Services (CMS) hospitalization records for hospitalizations occurring between 2001 and 2013 were included in this study. Classification of Definite or Probable MI from ARIC medical record review defined "gold standard" comparison for validation measures. In primary analyses, an MI was defined with ICD9 code 410 from CMS records. Secondary analyses defined MI using code 410 in combination with additional codes.
RESULTS: A total of 25 549 hospitalization records met study criteria. In primary analysis, specificity was at least 0.98 for all CMS definitions by discharge code position. Sensitivity ranged from 0.48 for primary position only to 0.63 when definition included any discharge code position. The sensitivity of definitions including codes 410 and 411.1 were higher than sensitivity observed when using code 410 alone. Specificity of these alternate definitions was higher for women (0.98) than for men (0.96).
CONCLUSION: Algorithms that rely exclusively on primary discharge code position will miss approximately 50% of all MI cases due to low sensitivity of this definition. We recommend defining MI by code 410 in any of first 5 discharge code positions overall and by codes 410 and 411.1 in any of first 3 positions for sensitivity analyses of women.

PMID: 29405474 [PubMed - as supplied by publisher]

Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions.

Thu, 01/25/2018 - 6:42am

Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions.

JAMA Surg. 2018 Jan 24;:e175568

Authors: Loehrer AP, Chang DC, Scott JW, Hutter MM, Patel VI, Lee JE, Sommers BD

Abstract
Importance: Lack of insurance coverage has been associated with delays in seeking care, more complicated diseases at the time of diagnosis, and decreased likelihood of receiving optimal surgical care. The Patient Protection and Affordable Care Act's (ACA) Medicaid expansion has increased coverage among millions of low-income Americans, but its effect on care for common surgical conditions remains unknown.
Objective: To evaluate the association of the ACA's Medicaid expansion with access to timely and recommended care for common and serious surgical conditions.
Design, Setting, and Participants: This quasi-experimental, difference-in-differences study used hospital administrative data to compare patient-level outcomes in expansion vs nonexpansion states before (2010-2013) vs after (2014-2015) expansion. A total of 293 529 patients aged 18 to 64 years with appendicitis, cholecystitis, diverticulitis, peripheral artery disease (PAD), or aortic aneurysm admitted to an academic medical center or affiliated hospital in 27 Medicaid expansion states and 15 nonexpansion states from January 1, 2010, through September 31, 2015, were included in the study. Data analysis was performed from November 1, 2016, to March 3, 2017.
Exposures: State adoption of Medicaid expansion.
Main Outcomes and Measures: Presentation with early uncomplicated disease (diverticulitis without abscess, fistula, or sepsis; nonruptured aortic aneurysm at time of repair; and PAD without ulcerations or gangrene) and receipt of optimal management (cholecystectomy for acute cholecystitis, laparoscopic approach for cholecystectomy or appendectomy, and limb salvage for PAD).
Results: Of the 293 529 study patients (128 392 [43.7%] female and 165 137 [56.3%] male), 225 572 had admissions in Medicaid expansion states and 67 957 had admissions in nonexpansion states. Medicaid expansion was associated with a 7.5-percentage point decreased probability of patients being uninsured (95% CI, -12.2 to -2.9; P = .002) and an 8.6-percentage point increased probability of having Medicaid (95% CI, 6.1-11.1; P < .001). Medicaid expansion was associated with a 1.8-percentage point increase in the probability of early uncomplicated presentation (95% CI, 0.7-2.9; P = .001) and a 2.6-percentage point increase in the probability of receiving optimal management (95% CI, 0.8-4.4; P = .006).
Conclusions and Relevance: The ACA's Medicaid expansion was associated with increased insurance coverage and improved receipt of timely care for 5 common surgical conditions. Health care systems and policymakers should be aware of the influence of insurance coverage expansion (or its repeal) on presentation with and management of surgical disease.

PMID: 29365029 [PubMed - as supplied by publisher]

Acute Myocardial Infarction Readmission Risk Prediction Models: A Systematic Review of Model Performance.

Sat, 01/13/2018 - 5:43am
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Acute Myocardial Infarction Readmission Risk Prediction Models: A Systematic Review of Model Performance.

Circ Cardiovasc Qual Outcomes. 2018 Jan;11(1):e003885

Authors: Smith LN, Makam AN, Darden D, Mayo H, Das SR, Halm EA, Nguyen OK

Abstract
BACKGROUND: Hospitals are subject to federal financial penalties for excessive 30-day hospital readmissions for acute myocardial infarction (AMI). Prospectively identifying patients hospitalized with AMI at high risk for readmission could help prevent 30-day readmissions by enabling targeted interventions. However, the performance of AMI-specific readmission risk prediction models is unknown.
METHODS AND RESULTS: We systematically searched the published literature through March 2017 for studies of risk prediction models for 30-day hospital readmission among adults with AMI. We identified 11 studies of 18 unique risk prediction models across diverse settings primarily in the United States, of which 16 models were specific to AMI. The median overall observed all-cause 30-day readmission rate across studies was 16.3% (range, 10.6%-21.0%). Six models were based on administrative data; 4 on electronic health record data; 3 on clinical hospital data; and 5 on cardiac registry data. Models included 7 to 37 predictors, of which demographics, comorbidities, and utilization metrics were the most frequently included domains. Most models, including the Centers for Medicare and Medicaid Services AMI administrative model, had modest discrimination (median C statistic, 0.65; range, 0.53-0.79). Of the 16 reported AMI-specific models, only 8 models were assessed in a validation cohort, limiting generalizability. Observed risk-stratified readmission rates ranged from 3.0% among the lowest-risk individuals to 43.0% among the highest-risk individuals, suggesting good risk stratification across all models.
CONCLUSIONS: Current AMI-specific readmission risk prediction models have modest predictive ability and uncertain generalizability given methodological limitations. No existing models provide actionable information in real time to enable early identification and risk-stratification of patients with AMI before hospital discharge, a functionality needed to optimize the potential effectiveness of readmission reduction interventions.

PMID: 29321135 [PubMed - in process]

Using State Administrative Data to Identify Social Complexity Risk Factors for Children.

Wed, 01/10/2018 - 6:42am
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Using State Administrative Data to Identify Social Complexity Risk Factors for Children.

Ann Fam Med. 2018 Jan;16(1):62-69

Authors: Arthur KC, Lucenko BA, Sharkova IV, Xing J, Mangione-Smith R

Abstract
PURPOSE: Screening for social determinants of health is challenging but critically important for optimizing child health outcomes. We aimed to test the feasibility of using an integrated state agency administrative database to identify social complexity risk factors and examined their relationship to emergency department (ED) use.
METHODS: We conducted a retrospective cohort study among children younger than 18 years with Washington State Medicaid insurance coverage (N = 505,367). We linked child and parent administrative data for this cohort to identify a set of social complexity risk factors, such as poverty and parent mental illness, that have either a known or hypothesized association with suboptimal health care use. Using multivariate analyses, we examined associations of each risk factor and of number of risk factors with the rate of ED use.
RESULTS: Nine of 11 identifiable social complexity risk factors were associated with a higher rate of ED use. Additionally, the rate increased as the number of risk factors increased from 0 to 5 or more, reaching approximately twice the rate when 5 or more risk factors were present in children aged younger than 5 years (incidence rate ratio = 1.92; 95% CI, 1.85-2.00) and in children aged 5 to 17 years (incidence rate ratio = 2.06; 95% CI, 1.99-2.14).
CONCLUSIONS: State administrative data can be used to identify social complexity risk factors associated with higher rates of ED use among Medicaid-insured children. State agencies could give primary care medical homes a social risk flag or score to facilitate targeted screening and identification of needed resources, potentially preventing future unnecessary ED use in this vulnerable population of children.

PMID: 29311178 [PubMed - in process]

Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: An Opportunity for Improvement?

Sun, 01/07/2018 - 5:43am

Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: An Opportunity for Improvement?

Circulation. 2018 Jan 05;:

Authors: Beatty AL, Truong M, Schopfer DW, Shen H, Bachmann JM, Whooley MA

Abstract
Background -Cardiac rehabilitation is strongly recommended after myocardial infarction (MI), percutaneous coronary intervention (PCI), or coronary artery bypass surgery (CABG), but is historically underused. We sought to evaluate variation in cardiac rehabilitation participation across the United States. Methods -From administrative data from the Veterans Affairs (VA) healthcare system and a 5% Medicare sample, we used ICD-9 codes to identify patients hospitalized for MI, PCI, or CABG from 2007-2011. After excluding patients who died within 30 days of hospitalization, we calculated the percent of patients who participated in one or more outpatient visits for cardiac rehabilitation during the 12 months after hospitalization. We estimated adjusted and standardized rates of participation in cardiac rehabilitation by state using hierarchical logistic regression models. Results -Overall, participation in cardiac rehabilitation was 16.3% (23,403/143,756) in Medicare and 10.3% (9,123/88,826) in VA. However, participation rates varied widely across states, ranging from 3.2% to 41.8% in Medicare and 1.2% to 47.6% in VA. Similar regional variation was observed in both populations. Patients in the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) had the highest participation, while those in the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) had the lowest participation in both Medicare (33.7% vs. 10.6%) and VA (16.6% vs. 5.1%) populations. Significant hospital-level variation was also present, with participation ranging from 3-75% in Medicare and 1-43% in VA. Conclusions -Cardiac rehabilitation participation remains low overall in both Medicare and VA populations. However, there is remarkably similar regional variation, with some regions and hospitals achieving high rates of participation in both populations. This provides an opportunity to identify best practices from higher-performing hospitals and regions that could be used to improve cardiac rehabilitation participation in lower-performing hospitals and regions.

PMID: 29305529 [PubMed - as supplied by publisher]

Untapped Potential: Using the HRS-Medicare Linked Files to Study the Changing Nursing Home Population.

Thu, 01/04/2018 - 6:42am

Untapped Potential: Using the HRS-Medicare Linked Files to Study the Changing Nursing Home Population.

Med Care. 2018 Jan 02;:

Authors: Lima JC, Ogarek J, Mor V

Abstract
BACKGROUND: Nursing home (NH) care in the United States now includes many short-term admissions to skilled nursing facilities (SNFs) for postacute care.
OBJECTIVE: To demonstrate the potential of the Health and Retirement Study (HRS) linked to administrative data to study this group.
RESEARCH DESIGN: Descriptive retrospective panel study.
SUBJECTS: HRS respondents between 2002 and 2010 linked to administrative data from the Centers for Medicare and Medicaid Services (CMS).
MEASURES: NH use was defined in 3 ways: by survey responses, Medicare SNF claims, and mandatory NH assessments.
RESULTS: In total, 8.5% of observation periods (ie, time between 2 consecutive survey dates or 2 years before initial survey) reported by the survey and 26.0% reported by administrative data indicated some NH use. There was 98% agreement between survey responses and administrative data when there was no indication of a NH observation in the administrative data. However, there was only 33% agreement between survey responses and administrative data when a NH stay was indicated in the administrative data. NH stays associated with SNF care were responsible for the discrepancy-they were not consistently captured by the HRS survey. Rates of agreement were highest when a proxy respondent was used, and lowest among respondents who rated themselves in excellent overall health. Rates of agreement were higher later in the decade than earlier.
CONCLUSIONS: The HRS-Medicare linked files enhance the ability of the HRS to examine the growing use of NH for postacute care as well as offer a more comprehensive view of who uses NHs.

PMID: 29298176 [PubMed - as supplied by publisher]

Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes.

Tue, 01/02/2018 - 5:42am
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Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes.

Neurosurg Focus. 2018 Jan;44(1):E5

Authors: O'Connell C, Azad TD, Mittal V, Vail D, Johnson E, Desai A, Sun E, Ratliff JK, Veeravagu A

Abstract
OBJECTIVE Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs. METHODS A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug-use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs. RESULTS The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17-1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95-0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03-1.25), revision fusions (OR 1.15, 95% CI 1.05-1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04-1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84-1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively. CONCLUSIONS Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.

PMID: 29290135 [PubMed - in process]

Preoperative Scale to Determine All-Cause Readmission after Coronary Artery Bypass Surgery.

Sun, 12/31/2017 - 6:42am
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Preoperative Scale to Determine All-Cause Readmission after Coronary Artery Bypass Surgery.

Ann Thorac Surg. 2017 Dec 27;:

Authors: Zywot A, Lau CS, Glass N, Bonne S, Hwang F, Goodman K, Mosenthal A, Paul S

Abstract
BACKGROUND: Coronary artery bypass graft (CABG) surgery is associated with all-cause readmission rates of approximately 15%. In attempts to reduce readmission rates, the Hospital Readmission Reduction Program expanded to include CABG surgeries in 2015. The aim of this study was therefore to develop a predictive readmission scale that would identify patients at higher risk of readmission after CABG using commonly available administrative data.
METHODS: Data on 126,519 patients from California and New York (derivation cohort) and 94,318 patients from Florida and Washington (validation cohort) were abstracted from the State Inpatient Database (2006-2011). The readmission after CABG scale was developed to predict 30-day readmission risk and was validated against a separate cohort.
RESULTS: Thirty-day CABG readmission rates were 23% in the derivation cohort and 21% in the validation cohort. Predictive factors included: older age, female gender (odds ratio (OR) 1.34), ethnicity (African American (OR 1.13), and Medicare or Medicaid insurance, as well as comorbidities including renal failure (OR 1.56) and congestive heart failure (OR 2.82). These were independently predictive of increased readmission rates (p<0.01). The readmission scale was then created with these preoperative factors. When applied to the validation cohort, it explained 98% of the readmission variability.
CONCLUSIONS: The readmission after CABG scale reliably predicts a patient's 30-day CABG readmission risk. By identifying patients at high-risk for readmission prior to their procedure, risk reduction strategies can be implemented to reduce readmissions and healthcare expenditures.

PMID: 29288658 [PubMed - as supplied by publisher]

Hospice Admission and Survival following 18F-Fluoride PET Performed for Evaluation of Osseous Metastatic Disease in the National Oncologic PET Registry.

Sat, 12/30/2017 - 8:43am
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Hospice Admission and Survival following 18F-Fluoride PET Performed for Evaluation of Osseous Metastatic Disease in the National Oncologic PET Registry.

J Nucl Med. 2017 Dec 28;:

Authors: Gareen IF, Hillner BE, Hanna L, Makineni R, Duan F, Shields AF, Subramaniam RM, Siegel B

Abstract
We have previously reported that positron emission tomography using 18F-fluoride (NaF-PET) for assessment of osseous metastatic disease was associated with substantial changes in intended management in Medicare beneficiaries participating in the National Oncologic PET Registry (NOPR). Here, we use Medicare administrative data to examine the association between NaF-PET results and hospice claims within 180 days and 1-year survival. Methods: We classified NOPR NaF-PET results linked to Medicare claims by imaging indication [initial staging (IS); detection of suspected first osseous metastasis (FOM); suspected progression of osseous metastasis (POM); or treatment monitoring (TM)] and type of cancer (prostate, lung, breast or other). Results were classified as definitely positive versus probably positive versus negative scan findings for osseous metastasis for IS and FOM; more extensive versus no change/less extensive disease for POM; and worse versus no change/better prognosis for TM, based on the post-scan assessment. Our study included 21,167 scans performed from 2011-2014 of consenting NOPR participants 65 years and older. Results: Relative risk of hospice claims within 180 days of NaF-PET scan ranged from 2.0 to 7.5 times higher for patients with evidence of new or progressing osseous metastasis, compared with those without, depending on indication and cancer type (all p<0.008). The percent difference in hospice claims for those with a finding of new or more advanced osseous disease ranged from 3.9% for IS prostate patients to 28% for FOM lung. Six-month survival was also associated with evidence of new or increased osseous disease; risk of death was 1.8 to 5.1 times as likely (all p<0.0001), with percent differences of approximately 30% comparing positive and negative scans in patients with lung cancer imaged for IS or FOM. Conclusion: Our analyses demonstrate that NaF-PET scan results are highly associated with subsequent hospice claims and, ultimately, with patient survival. NaF-PET provides important information on the presence of osseous metastasis and prognosis, to assist patients and their physicians when making decisions on whether to select palliative care and transition to hospice, or continue treatment.

PMID: 29284672 [PubMed - as supplied by publisher]

Geographic Region and Profit Status Drive Variation in Hospital Readmission Outcomes among Inpatient Rehabilitation Facilities in the United States.

Mon, 12/25/2017 - 6:42am
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Geographic Region and Profit Status Drive Variation in Hospital Readmission Outcomes among Inpatient Rehabilitation Facilities in the United States.

Arch Phys Med Rehabil. 2017 Dec 21;:

Authors: Daras LC, Ingber MJ, Deutsch A, Hefele JG, Perloff J

Abstract
OBJECTIVE: To examine whether there are differences in inpatient rehabilitation facilities (IRFs') all-cause, 30-day post-discharge hospital readmission rates by organizational characteristics and geographic regions.
DESIGN: Observational study.
SETTING AND PARTICIPANTS: We analyzed Medicare claims and administrative data sources for Medicare fee-for-service beneficiaries discharged from all IRFs nationally (N=1,166) in 2013 and 2014.
MAIN OUTCOME MEASURE: We applied specifications for an existing quality measure adopted by CMS for public reporting that assesses all-cause unplanned hospital readmissions for 30 days post-discharge from inpatient rehabilitation. We estimated facility-level observed and risk-standardized readmission rates and then examined variation by several organizational characteristics (facility type, profit status, teaching status, proportion of low-income patients, size) and geographic factors (rural/urban, census division, and state).
RESULTS: The mean IRF risk-standardized hospital readmission rate was 13.00 percent (SD 0.77). After controlling for organizational characteristics and practice patterns, we found substantial variation in IRFs' readmission rates: for-profit IRFs had significantly higher readmission rates compared to not-for-profit IRFs (p<0.001). We also found geographic variation: IRFs in the South Atlantic and South Central census regions had the highest hospital readmission rates compared to IRFs in New England that had the lowest rates.
CONCLUSIONS: Our findings point to variation in the quality of care, as measured by risk-standardized hospital readmission rates following IRF discharge. Thus, monitoring of readmission outcomes is important to encourage quality improvement in discharge care planning, care transitions and follow-up.

PMID: 29274725 [PubMed - as supplied by publisher]

Medicaid program choice, inertia and adverse selection.

Tue, 12/19/2017 - 5:42am
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Medicaid program choice, inertia and adverse selection.

J Health Econ. 2017 Dec;56:292-316

Authors: Marton J, Yelowitz A, Talbert JC

Abstract
In 2012, Kentucky implemented Medicaid managed care statewide, auto-assigned enrollees to three plans, and allowed switching. Using administrative data, we find that the state's auto-assignment algorithm most heavily weighted cost-minimization and plan balancing, and placed little weight on the quality of the enrollee-plan match. Immobility - apparently driven by health plan inertia - contributed to the success of the cost-minimization strategy, as more than half of enrollees auto-assigned to even the lowest quality plans did not opt-out. High-cost enrollees were more likely to opt-out of their auto-assigned plan, creating adverse selection. The plan with arguably the highest quality incurred the largest initial profit margin reduction due to adverse selection prior to risk adjustment, as it attracted a disproportionate share of high-cost enrollees. The presence of such selection, caused by differential degrees of mobility, raises concerns about the long run viability of the Medicaid managed care market without such risk adjustment.

PMID: 29248057 [PubMed - in process]

Trends in Health Insurance Coverage of Title X Family Planning Program Clients, 2005-2015.

Thu, 12/14/2017 - 5:43am

Trends in Health Insurance Coverage of Title X Family Planning Program Clients, 2005-2015.

J Womens Health (Larchmt). 2017 Dec 13;:

Authors: Decker EJ, Ahrens KA, Fowler CI, Carter M, Gavin L, Moskosky S

Abstract
BACKGROUND: The federal Title X Family Planning Program supports the delivery of family planning services and related preventive care to 4 million individuals annually in the United States. The implementation of the 2010 Affordable Care Act's (ACA's) Medicaid expansion and provisions expanding access to health insurance, which took effect in January 2014, resulted in higher rates of health insurance coverage in the U.S. population; the ACA's impact on individuals served by the Title X program has not yet been evaluated.
METHODS: Using administrative data we examined changes in health insurance coverage among Title X clinic patients during 2005-2015.
RESULTS: We found that the percentage of clients without health insurance decreased from 60% in 2005 to 48% in 2015, with the greatest annual decrease occurring between 2013 and 2014 (63% to 54%). Meanwhile, between 2005 and 2015, the percentage of clients with Medicaid or other public health insurance increased from 20% to 35% and the percentage of clients with private health insurance increased from 8% to 15%.
CONCLUSIONS: Although clients attending Title X clinics remained uninsured at substantially higher rates compared with the national average, the increase in clients with health insurance coverage aligns with the implementation of ACA-related provisions to expand access to affordable health insurance.

PMID: 29237143 [PubMed - as supplied by publisher]

Correlates of second-line type 2 diabetes medication selection in the USA.

Tue, 12/12/2017 - 6:43am
Related Articles

Correlates of second-line type 2 diabetes medication selection in the USA.

BMJ Open Diabetes Res Care. 2017;5(1):e000421

Authors: Ackermann RT, Wallia A, O'Brien MJ, Kang R, Cooper A, Moran MR, Liss DT

Abstract
Objective: Past research provides insufficient evidence to inform second-line diabetes medication prescribing when metformin is no longer sufficient. We evaluated patient, prescriber, and health plan characteristics associated with selection of second-line diabetes medications in the USA.
Research design and methods: We used a multiple case-comparison study design to identify characteristics associated with the probability of starting each of six second-line diabetes medication alternatives within 77 744 adults enrolled in commercial or Medicare Advantage health plans from 2011 to 2015. National administrative data were provided by a large commercial health payer. Multinomial logistic regression models were used to identify characteristics independently associated with selecting each diabetes drug class.
Results: From 2011 to 2015, sulfonylureas still represented 47% of all second-line drug starts, with proportionately higher use in patients ≥75 years of age (63% of drug starts). Basal insulin was more likely to be selected when a past A1c test result was >10% (13.0% vs 4.5% for those with A1c <8%; p<0.001). Initiation of a glucagon-like peptide-1 receptor agonist was associated with being female (10.1% vs 6.0% for male; p<0.001) and having a diagnosis code for obesity (10.8% vs 6.9% for no diagnosis; p<0.001). For all drug classes, the recent prescribing behavior of the provider was a strong correlate of subsequent second-line drug selection.
Conclusions: Sulfonylureas continue to represent almost half of second-line diabetes medication starts in the USA. This could reflect overuse for some groups such as older adults, for whom some alternatives may be safer, although more costly and potentially less effective. Future research should compare outcomes of medication choices and conditions under which particular classes are most effective.

PMID: 29225892 [PubMed]

Hospital Readmissions Reduction Program: Intended and Unintended Effects.

Tue, 12/05/2017 - 5:43am

Hospital Readmissions Reduction Program: Intended and Unintended Effects.

Med Care Res Rev. 2017 Dec 01;:1077558717744611

Authors: Chen M, Grabowski DC

Abstract
This study examines whether the Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals with excess readmissions for certain conditions, has reduced hospital readmissions and led to unintended consequences. Our analyses of Florida hospital administrative data between 2008 and 2014 find that the HRRP resulted in a reduction in the likelihood of readmissions by 1% to 2% for traditional Medicare (TM) beneficiaries with heart failure, pneumonia, or chronic obstructive pulmonary disease. Readmission rates for Medicare Advantage (MA) beneficiaries and privately insured patients with heart attack and heart failure decreased even more than TM patients with the same target condition (e.g., for heart attack, the likelihood for TM beneficiaries to be remitted is 2.2% higher than MA beneficiaries and 2.3% higher than privately insured patients). We do not find any evidence of cost-shifting, delayed readmission, or selection on discharge disposition or patient income. However, the HRRP reduced the likelihood of Hispanic patients with target conditions being admitted by 2% to 4%.

PMID: 29199504 [PubMed - as supplied by publisher]

Impact of a Usual Source of Care on Health Care Use, Spending, and Quality Among Adults With Mental Health Conditions.

Fri, 12/01/2017 - 6:42am

Impact of a Usual Source of Care on Health Care Use, Spending, and Quality Among Adults With Mental Health Conditions.

Adm Policy Ment Health. 2017 Nov 30;:

Authors: Fullerton CA, Witt WP, Chow CM, Gokhale M, Walsh CE, Crable EL, Naeger S

Abstract
Physical comorbidities associated with mental health conditions contribute to high health care costs. This study examined the impact of having a usual source of care (USC) for physical health on health care utilization, spending, and quality for adults with a mental health condition using Medicaid administrative data. Having a USC decreased the probability of inpatient admissions and readmissions. It decreased expenditures on emergency department visits for physical health, 30-day readmissions, and behavioral health inpatient admissions. It also had a positive effect on several quality measures. Results underscore the importance of a USC for physical health and integrated care for adults with mental health conditions.

PMID: 29189994 [PubMed - as supplied by publisher]

The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities.

Wed, 11/29/2017 - 5:43am
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The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities.

Ann Intern Med. 2017 Nov 28;:

Authors: Roberts ET, Zaslavsky AM, McWilliams JM

Abstract
Background: When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average.
Objective: To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients.
Design: Exploiting the phase-in of the VM on the basis of practice size, regression discontinuity analysis and 2014 Medicare claims were used to estimate differences in practice performance associated with exposure of practices with 100 or more clinicians to full VM incentives (bonuses and penalties) and exposure of practices with 10 or more clinicians to partial incentives (bonuses only). Analyses were repeated with 2015 claims to estimate performance differences associated with a second year of exposure above the threshold of 100 or more clinicians. Performance differences were assessed between practices serving higher- and those serving lower-risk patients after standard Medicare adjustments versus adjustment for additional patient characteristics.
Setting: Fee-for-service Medicare.
Patients: Random 20% sample of beneficiaries.
Measurements: Hospitalization for ambulatory care-sensitive conditions, all-cause 30-day readmissions, Medicare spending, and mortality.
Results: No statistically significant discontinuities were found at the threshold of 10 or more or 100 or more clinicians in the relationship between practice size and performance on quality or spending measures in either year. Adjustment for additional patient characteristics narrowed performance differences by 9.2% to 67.9% between practices in the highest and those in the lowest quartile of Medicaid patients and Hierarchical Condition Category scores.
Limitation: Observational design and administrative data.
Conclusion: The VM was not associated with differences in performance on program measures. Performance differences between practices serving higher- and those serving lower-risk patients were affected considerably by additional adjustments, suggesting a potential for Medicare's pay-for-performance programs to exacerbate health care disparities.
Primary Funding Source: The Laura and John Arnold Foundation and National Institute on Aging.

PMID: 29181511 [PubMed - as supplied by publisher]

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