A four-system comparison of patients with chronic illness: the Military Health System, Veterans Health Administration, Medicaid, and commercial plans

Prevalence of Heart Failure Stages in a Universal Health Care System: The Military Health System Experience

BACKGROUND

Morbidity and mortality related to heart failure are increasing and disparities are widening. These alarming trends, often confounded by access to care, are poorly understood. This study evaluates the prevalence of all stages of heart failure by race and socioeconomic status in an environment with no access barrier to care.

METHODS

We conducted a cross-sectional observational study of adult beneficiaries aged 18 to 64 years of the Military Health System (MHS), a model for universal health care for fiscal years 2018-2019. We calculated prevalence of preclinical (stages A/B) or clinical (stages C/D) heart failure stages as defined by professional guidelines. Results were analyzed by age, race, and socioeconomic status (using military rank as a proxy).

RESULTS

Among 5,440,761 MHS beneficiaries aged 18 to 64 years, prevalence of preclinical and clinical heart failure was 18.1% and 2.5%, respectively. Persons with preclinical heart failure were middle aged, with similar proportions of men and women, while those with heart failure were older, mainly men. After multivariable adjustment, male sex (1.35 odds ratio [OR] [preclinical]; 1.95 OR [clinical]), Black race (1.64 OR [preclinical]; 1.88 OR [clinical]) and lower socioeconomic status were significantly associated with large increases in the prevalence of all stages of heart failure.

CONCLUSION

All stages of heart failure are highly prevalent among MHS beneficiaries of working age and, in an environment with no access barrier to care, there are striking disparities by race and socioeconomic status. The high prevalence of preclinical heart failure, particularly notable among Black beneficiaries, delineates a critical time window for prevention.

The Acute Effects of Azithromycin Use on Cardiovascular Mortality as Compared with Amoxicillin-Clavulanate in United States Veterans

PURPOSE

Azithromycin is a common first-line antibiotic for respiratory infection; however, there is conflicting evidence regarding risk of cardiovascular death. We assessed cardiovascular and non-cardiovascular mortality associated with azithromycin versus amoxicillin-clavulanate among United States (US) Veterans treated for non-ear-nose-throat respiratory infection ("respiratory") or ear-nose-throat infection indication.

METHODS

Electronic health record data from the US Veterans Health Administration database was used to identify Veterans (30-74 years) with outpatient dispensings of oral azithromycin versus amoxicillin-clavulanate for respiratory or ear-nose-throat infection (01/01/2000-12/31/2014). Outcomes assessed were risk of cardiovascular death and non-cardiovascular death within 1-5 and 6-10 days post-dispensing. Inverse probability of treatment-weighted proportional hazards models and binomial regression models were used to estimate hazard ratios (HR) and compute risk differences (RD) per million courses of therapy. Cardiac death (subset of cardiovascular death) was assessed in sensitivity analyses.

RESULTS

There were 629,345 azithromycin and 168,429 amoxicillin-clavulanate dispensings for respiratory indications, 143,783 azithromycin, and 203,142 amoxicillin-clavulanate dispensings for ear-nose-throat indications. For respiratory indications, azithromycin was not associated with significantly different risk of cardiovascular death versus amoxicillin-clavulanate within 1-5 days post-dispensing (HR [95% confidence interval (CI)]: 1.12 [0.63-2.00]; RD [95%CI]: 11 [-43 - +64] deaths/million courses of therapy). No elevated risk for azithromycin was found for ear-nose-throat indications. Pooled results for both indications via meta-analysis showed no association between antibiotics and cardiovascular mortality. There was no significant difference in risk of non-cardiovascular or cardiac death between antibiotics post-dispensing.

CONCLUSION

Azithromycin was not associated with elevated risk of cardiovascular or non-cardiovascular death versus amoxicillin-clavulanate among US Veterans. This article is protected by copyright. All rights reserved.

The burden of neuropsychiatric disorders in patients living with HIV-1 treated with antiretroviral therapies-A perspective from US Medicaid data

BACKGROUND

People with human immunodeficiency virus (HIV)-1 face challenges with treatment adherence for various reasons, including consideration of neuropsychiatric disorders and neuropsychiatric adverse reactions associated with antiretroviral therapy (ART).

METHODS

A retrospective cohort study was conducted using administrative claims data from the IBM MarketScan^® Multi-State Medicaid Database (1/1/2014-12/31/2017). Adults (≥18 years) diagnosed with HIV-1 and newly initiated on antiretroviral therapy with continuous health plan enrollment were included. Primary outcome was the 6-month period prevalence of neuropsychiatric events (NPEs) of interest after ART initiation.

RESULTS

Among 1971 newly treated patients included in the study, mean age (standard deviation [SD]) was 38.5 (12.7) years, and 41.4% were female. During the 6 months after ART initiation, 51.4% of patients had a claim for ≥1 NPE versus 30.3% of matched patients without HIV. Among newly treated patients, the most common (≥10%) NPE claims were for depression (42.2%), anxiety (15.8%), headache (11.9%), and bipolar/manic depression (10.1%). Also in this group, the mean (SD) total all-cause healthcare cost during the 6-month post-ART initiation was $16,632 ($33,928), of which $2914 ($18,233) was NPE-related.

CONCLUSIONS

In summary, in this Medicaid study of people newly initiated on ART, there was a high prevalence of NPEs, and incremental NPE-associated costs were considerable.

CKD Prevalence in the Military Health System: Coded Versus Uncoded CKD

Rationale & Objective

Chronic kidney disease (CKD) is common but often goes unrecorded.

Study Design

Cross-sectional.

Setting & Participants

Military Health System (MHS) beneficiaries aged 18 to 64 years who received care during fiscal years 2016 to 2018.

Predictors

Age, sex, active duty status, race, diabetes, hypertension, and numbers of kidney test results.

Outcomes

We defined CKD by International Classification of Diseases, Tenth Revision (ICD-10) code and/or a positive result on a validated electronic phenotype that uses estimated glomerular filtration rate and measures of proteinuria with evidence of chronicity. We defined coded CKD by the presence of an ICD-10 code. We defined uncoded CKD by a positive e-phenotype result without an ICD-10 code.

Analytical Approach

We compared coded and uncoded populations using 2-tailed t tests (continuous variables) and Pearson χ² test for independence (categorical variables).

Results

The MHS population included 3,330,893 beneficiaries. Prevalence of CKD was 3.2%, based on ICD code and/or positive e-phenotype result. Of those identified with CKD, 63% were uncoded. Compared with beneficiaries with coded CKD, those with uncoded CKD were younger (aged 45 ± 13 vs 52 ± 11 years), more often women (54.4% vs 37.6%) and active duty (20.2% vs 12.5%), and less often of Black race (18.5% vs 31.5%) or with diabetes (23.5% vs 43.5%) or hypertension (46.6% vs 77.1%; P < 0.001). Beneficiaries with coded (vs uncoded) CKD had greater numbers of kidney test results (P < 0.001).

Limitations

Use of cross-sectional administrative data prevents inferences about causality. The CKD e-phenotype may fail to capture CKD in individuals without laboratory data and may underestimate CKD.

Conclusions

The prevalence of CKD in the MHS is ~3.2%. Beneficiaries with well-known CKD risk factors, such as older age, male sex, Black race, diabetes, and hypertension, were more likely to be coded, suggesting that clinicians may be missing CKD in groups traditionally considered lower risk, potentially resulting in suboptimal care.

Association of Health Insurance Payer Type and Outcomes After Durable Left Ventricular Assist Device Implantation: An Analysis of the STS-INTERMACS Registry

BACKGROUND

Due to the high cost of left ventricular assist device (LVAD) therapy, payer type may be an important factor in determining eligibility. How payer type influences outcomes after LVAD implantation is unclear. We, therefore, aimed to study the association of health insurance payer type with outcomes after durable LVAD implantation.

METHODS

Using STS-INTERMACS (Society of Thoracic Surgeons-Interagency Registry for Mechanically Assisted Circulatory Support), we studied nonelderly adults receiving a durable LVAD from 2016 to 2018 and compared all-cause mortality and postindex hospitalization adverse event episode rate by payer type. Multivariable Fine-Gray and generalized linear models were used to compare the outcomes.

RESULTS

Of the 3251 patients included, 26.0% had Medicaid, 24.9% had Medicare alone, and 49.1% had commercial insurance. Compared with commercially insured patients, mortality did not differ for patients with Medicaid (subdistribution hazard ratio, 1.00 [95% CI, 0.75-1.34], P=0.99) or Medicare (subdistribution hazard ratio, 1.09 [95% CI, 0.84-1.41], P=0.52). Medicaid was associated with a significantly lower adjusted incidence rate (incidence rate ratio, 0.88 [95% CI, 0.78-0.99], P=0.041), and Medicare was associated with a significantly higher adjusted incidence rate (incidence rate ratio, 1.16 [95% CI, 1.03-1.30], P=0.011) of adverse event episodes compared with commercially insured patients.

CONCLUSIONS

All-cause mortality after durable LVAD implantation did not differ significantly by payer type. Payer type was associated with the rate of adverse events, with Medicaid associated with a significantly lower rate, and Medicare with a significantly higher rate of adverse event episodes compared with commercially insured patients.

Promoting Limb Salvage through Multi-Disciplinary Care of the Diabetic Patient

OPINION STATEMENT

Despite an explosion in the number of options available for helping diabetic patients heal wounds, major amputation remains a critical issue for these persons. Since diabetes prematurely ages tissues and no organ system is immune to its presence, it makes inherent sense that multi-disciplinary team approaches to these patients is necessary to make significant strides forward. Here, we present literature from the fields of podiatric surgery/medicine, vascular and plastic surgery and introduce the successes that a multi-disciplinary limb salvage center can have on the lives and limbs of patients with diabetes.

Mental Health Nursing in Greece: Nursing Diagnoses and Interventions in Major Depression

The aim of the study was to assess nursing diagnoses and nursing interventions that were accordingly implemented during the care of inpatients with major depression in Greece. Twelve nurses working in three major psychiatric hospitals were recruited. Semi-structured interviews were used and audio-recorded data indicated that risk for suicide, social isolation, low self-esteem, sleep problems, and imbalanced nutrition are the nursing diagnoses most commonly reported. Establishing trust and rapport is the primary intervention, followed by specific interventions according to each diagnosis and the individualized care plan. The findings of the study also highlight the need for nursing training in order to teach nurses initial assessment procedures and appropriate evidence-based intervention techniques.

"A room full of chairs around his bed": being present at the death of a loved one in Veterans Affairs Medical Centers

Historically, death took place at home where family held vigil around the dying patient. Today, family presence is an important feature of death and dying in hospital settings. We used hermeneutic phenomenology to explore experiences of being present at the hospital death of a loved one. We conducted in-depth, face-to-face interviews with 78 recently bereaved next-of-kin of veterans who died in 6 Veterans Affairs (VA) Medical Centers in the Southeast United States. Two major themes emerged: 1) "settling in," characteristic of the experiences of wives and daughters in the initial phase of the patient's hospitalization; and 2) "gathering around," characteristic of the experiences of a wider array of family members as the patient neared death. An in-depth understanding of experiences of next-of-kin present at the hospital death of a loved one can increase staff awareness of family's needs and empower staff to develop policies and procedures for supporting family members.

Incidence and prevalence of treated epilepsy among poor health and low-income Americans

OBJECTIVES

To determine the incidence and prevalence of treated epilepsy in an adult Medicaid population.

METHODS

We performed a retrospective, dynamic cohort analysis using Ohio Medicaid claims data between 1992 and 2006. Individuals aged 18-64 years were identified as prevalent cases if they had ≥2 claims of epilepsy (ICD-9-CM: 345.xx) or ≥3 claims of convulsion (ICD-9-CM: 780.3 or 780.39) and ≥2 claims of antiepileptic drugs. Incident cases were required to have no epilepsy or convulsion claims for ≥5 years before epilepsy diagnosis. Subjects were determined as having preexisting disability and/or comorbid conditions, including brain tumor, depression, developmental disorders, migraine, schizophrenia, stroke, and traumatic brain injury, when at least one of these conditions occurred before epilepsy onset.

RESULTS

There were 9,056 prevalent cases of treated epilepsy in 1992-2006 and 1,608 incident cases in 1997-2006. The prevalence was 13.2/1,000 (95% confidence interval, 13.0-13.5/1,000). The incidence was 362/100,000 person-years (95% confidence interval, 344-379/100,000 person-years). The incidence and prevalence were significantly higher in men, in older people, in blacks, and in people with preexisting disability and/or comorbid conditions. The most common preexisting conditions in epilepsy subjects were depression, developmental disorders, and stroke, whereas people with brain tumor, traumatic brain injury, and stroke had the higher risk of developing epilepsy.

CONCLUSIONS

The Medicaid population has a high incidence and prevalence of epilepsy, in an order of magnitude greater than that reported in the US general population. This indigent population carries a disproportionate amount of the epilepsy burden and deserves more attention for its health care needs and support services.

Ten-year trends in quality of care and spending for depression: 1996 through 2005

CONTEXT

During the past decade, the introduction of generic versions of newer antidepressants and the release of Food and Drug Administration warnings regarding suicidality in children, adolescents, and young adults may have had an effect on cost and quality of depression treatment.

OBJECTIVES

To examine longitudinal trends in health service utilization, spending, and quality of care for depression.

DESIGN

Observational trend study.

SETTING

Florida Medicaid enrollees, between July 1, 1996, and June 30, 2006. Patients  Annual cohorts aged 18 to 64 years diagnosed as having depression.

MAIN OUTCOME MEASURES

Mental health care spending (adjusted for inflation and case mix), as well as its components, including inpatient, outpatient, and medication expenditures. Quality-of-care measures included medication adherence, psychotherapy, and follow-up visits.

RESULTS

Mental health care spending increased from a mean of $2802 per enrollee to $3610 during this period (29% increase). This increase occurred despite a mean decrease in inpatient spending from $641 per enrollee to $373 and was driven primarily by an increase in pharmacotherapy spending (up 110%), the bulk of which was due to spending on antipsychotics (949% increase). The percentage of enrollees with depression who were hospitalized decreased from 9.1% to 5.1%, and the percentage who received psychotherapy decreased from 56.6% to 37.5%. Antidepressant use increased from 80.6% to 86.8%, anxiety medication use was unchanged at 62.7% and 64.4%, and antipsychotic use increased from 25.9% to 41.9%. Changes in quality of care were mixed, with antidepressant use improving slightly, psychotherapy utilization fluctuating, and follow-up visits decreasing.

CONCLUSIONS

During a 10-year period, spending for Medicaid enrollees with depression increased substantially, with minimal improvements in quality of care. Antipsychotic use contributed significantly to the increase in spending, while contributing little to traditional measures of quality of care.

Suicide among veterans in 16 states, 2005 to 2008: comparisons between utilizers and nonutilizers of Veterans Health Administration (VHA) services based on data from the National Death Index, the National Violent Death Reporting System, and VHA administrative records

OBJECTIVES

We sought to compare suicide rates among veterans utilizing Veterans Health Administration (VHA) services versus those who did not.

METHODS

Suicide rates from 2005 to 2008 were estimated for veterans in the 16 states that fully participated in the National Violent Death Reporting System (NVDRS), using data from the National Death Index, NVDRS, and VHA records.

RESULTS

Between 2005 and 2008, veteran suicide rates differed by age and VHA utilization status. Among men aged 30 years and older, suicide rates were consistently higher among VHA utilizers. However, among men younger than 30 years, rates declined significantly among VHA utilizers while increasing among nonutilizers. Over these years, an increasing proportion of male veterans younger than 30 years received VHA services, and these individuals had a rising prevalence of diagnosed mental health conditions.

CONCLUSIONS

The higher rates of suicide for utilizers of VHA among veteran men aged 30 and older were consistent with previous reports about which veterans utilize VHA services. The increasing rates of mental health conditions in utilizers younger than 30 years suggested that the decreasing relative rates in this group were related to the care provided, rather than to selective enrollment of those at lower risk for suicide.

Cost-effectiveness of implementing the chronic care model for diabetes care in a military population

BACKGROUND

Applying the chronic care model (CCM) for diabetes management helps improve health outcomes and patient care. The CCM was implemented at U.S. Air Force Wilford Hall Medical Center through the Diabetes Outreach Clinic (DOC) in 2006, but its cost-effectiveness in this setting is unknown.

METHODS

We constructed a Markov decision model to estimate DOC cost-effectiveness compared with usual care (UC) over a 20-year period. Based on empirical, post-intervention demographic and clinical data, we applied United Kingdom Prospective Diabetes Study risk equations to predict long-term probabilities of developing microvascular or macrovascular complications. Health care system and societal perspectives were considered, discounting costs and benefits at 3% annually. Intervention costs and outcomes were obtained from military data, while other costs, disease progression data, and utilities were drawn from published literature.

RESULTS

From a health care system perspective, the DOC cost $45,495 per quality-adjusted life-year (QALY) compared with UC; from a societal perspective, the DOC compared with UC cost $42,051/QALY (when the model started with the uncomplicated diabetes cohort), $61,243/QALY (when starting with the DOC cohort), or $61,813/QALY (when starting with the UC cohort). In one-way sensitivity analyses, results were most sensitive to yearly costs for specialty care visits. In probabilistic sensitivity analysis, the DOC was favored in 51% of model iterations using an acceptability threshold of $50,000/QALY and in 72% at a threshold of $100,000/QALY.

CONCLUSIONS

The DOC strategy for diabetes care, performed with the CCM methodology in a military population, appears to be economically reasonable compared with UC.

The effect of group clinics in the control of diabetes

OBJECTIVES

Novel interventions are needed for long-term maintenance of diabetes control. We studied the effects of a group diabetes clinic (GDC) on diabetes control when compared to usual care with primary care providers (PCP).

RESEARCH DESIGN/METHODS

Data from the electronic medical records of 56 patients were collected. Twenty-nine patients were in the group diabetes clinic (GDC) while 27 patients followed with their PCP. Outcome variables, A1c, LDL, and blood pressure (BP) were measured at baseline and every 6 months for a 2 year period.

RESULTS

A1c, LDL and BP were no different at the end of 2 years in the GDC cohort and the PCP cohort. Slight upward trend in time was detected for A1c in both groups, but more so in the PCP group.

CONCLUSION

GDC can lead to maintenance of diabetes control in a population with difficult to manage diabetes as effectively as and more efficiently than usual care.