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Siddique SM, Hettinger G, Dash A, Neuman M, Mitra N, Lewis JD. The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort. Am J Gastroenterol 2024:00000434-990000000-01064. [PMID: 38477470 DOI: 10.14309/ajg.0000000000002755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/07/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes. METHODS This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality. RESULTS Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services. DISCUSSION Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.
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Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gary Hettinger
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anwesh Dash
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Neuman
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nandita Mitra
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James D Lewis
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Knox S, Downer B, Haas A, Ottenbacher KJ. Successful Discharge to Community From Home Health Less Likely for People in Late Stages of Dementia. J Geriatr Phys Ther 2024; 47:77-84. [PMID: 38133896 PMCID: PMC10990837 DOI: 10.1519/jpt.0000000000000383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND PURPOSE Several studies have established the efficacy of home health in meeting the health care needs of people with Alzheimer disease and related dementias (ADRD) and helping them to remain at home. However, transitioning to the community after discharge from home health presents challenges to patient safety and quality of life. The severity of an individual's functional impairments, cognitive limitations, and behavioral and psychological symptoms may compound these challenges. The purpose of this study was to examine the association between dementia severity and successful discharge to community (DTC) from home health. METHODS This was a retrospective study of 142 376 Medicare beneficiaries with ADRD. Successful DTC was defined as having no unplanned hospitalization or death within 30 days of DTC from home health. Successful DTC rates were calculated, and multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC, by dementia severity category, adjusted for patient and clinical characteristics. Six dementia severity categories were identified using a crosswalk between items on the Outcome and Assessment Information Set and the Functional Assessment Staging Tool. RESULTS AND DISCUSSION Successful DTC occurred in 71.2% of beneficiaries. Beneficiaries in the 2 most severe dementia categories had significantly lower risk of successful DTC (category 6: RR = 0.90, 95% CI = 0.889-0.910; category 7: RR = 0.737, 95% CI = 0.704-0.770) than those in the least severe dementia category. The RR of successful DTC for people with ADRD decreased as the level of independence with oral medication management decreased and when there was an overall greater need for caregiver assistance. CONCLUSIONS Patient status at the time of admission to home health is associated with outcomes after discharge from home health. Early identification of people in advanced stages of ADRD provides an opportunity to implement strategies to facilitate successful DTC while people are still receiving home care services. The severity of ADRD and availability of caregiver assistance should be key considerations in planning for successful DTC for people with ADRD.
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Affiliation(s)
- Sara Knox
- Division of Physical Therapy, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Brian Downer
- Department of Nutrition, Metabolism & Rehabilitation Sciences, University of Texas Medical Branch, 301 University Blvd, Galveston, Texas, 77555 United States
| | - Allen Haas
- Department of Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas, United States
| | - Kenneth J. Ottenbacher
- Department of Nutrition, Metabolism & Rehabilitation Sciences, University of Texas Medical Branch, 301 University Blvd, Galveston, Texas, 77555 United States
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Siriwardhana C, Carrazana E, Liow K, Chen JJ. Racial/Ethnic Disparities in the Alzheimer's Disease Link with Cardio and Cerebrovascular Diseases, Based on Hawaii Medicare Data. J Alzheimers Dis Rep 2023; 7:1103-1120. [PMID: 37849625 PMCID: PMC10578323 DOI: 10.3233/adr-230003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 08/22/2023] [Indexed: 10/19/2023] Open
Abstract
Background There is an expanding body of literature implicating heart disease and stroke as risk factors for Alzheimer's disease (AD). Hawaii is one of the six majority-minority states in the United States and has significant racial health disparities. The Native-Hawaiians/Pacific-Islander (NHPI) population is well-known as a high-risk group for a variety of disease conditions. Objective We explored the association of cardiovascular disease with AD development based on the Hawaii Medicare data, focusing on racial disparities. Methods We utilized nine years of Hawaii Medicare data to identify subjects who developed heart failure (HF), ischemic heart disease (IHD), atrial fibrillation (AF), acute myocardial infarction (AMI), stroke, and progressed to AD, using multistate models. Propensity score-matched controls without cardiovascular disease were identified to compare the risk of AD after heart disease and stroke. Racial/Ethnic differences in progression to AD were evaluated, accounting for other risk factors. Results We found increased risks of AD for AF, HF, IHD, and stroke. Socioeconomic (SE) status was found to be critical to AD risk. Among the low SE group, increased AD risks were found in NHPIs compared to Asians for all conditions selected and compared to whites for HF, IHD, and stroke. Interestingly, these observations were found reversed in the higher SE group, showing reduced AD risks for NHPIs compared to whites for AF, HF, and IHD, and to Asians for HF and IHD. Conclusions NHPIs with poor SE status seems to be mostly disadvantaged by the heart/stroke and AD association compared to corresponding whites and Asians.
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Affiliation(s)
- Chathura Siriwardhana
- Department of Quantitative Health Sciences, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | - Enrique Carrazana
- Department of Medicine, University of Hawaii John Burns School of Medicine, Honolulu, HI, USA
| | - Kore Liow
- Department of Quantitative Health Sciences, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
- Department of Medicine, University of Hawaii John Burns School of Medicine, Honolulu, HI, USA
- Memory Disorders Center, Stroke & Neurologic Restoration Center, Hawaii Pacific Neuroscience, Honolulu, HI, USA
| | - John J. Chen
- Department of Quantitative Health Sciences, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
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Aswani MS, Roberts ET. Social risk adjustment in the hospital readmission reduction program: Pitfalls of peer grouping, measurement challenges, and potential solutions. Health Serv Res 2023; 58:51-59. [PMID: 35249227 PMCID: PMC9836940 DOI: 10.1111/1475-6773.13969] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 02/04/2022] [Accepted: 02/26/2022] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To examine the limitations of peer grouping and associated challenges measuring social risk in Medicare's Hospital Readmission Reduction Program (HRRP). Under peer grouping, hospitals are divided into quintiles based on the proportion of a hospital's Medicare inpatients with Medicaid ("dual share"). This approach was implemented to address concerns that the HRRP unfairly penalized hospitals that disproportionately serve disadvantaged patients. DATA Public data on hospitals in the HRRP. DESIGN We examined the relationship between hospital dual share and readmission rates within peer groups; changes in hospitals' peer group assignments, readmission rates, and penalties; and the relationship between state Medicaid eligibility rules and peer groups. DATA COLLECTION Public data on hospital characteristics and readmission rates for 3119 hospitals from 2019 to 2020. PRINCIPAL FINDINGS The proportion of dual inpatients among hospitals of the same peer group varied by as much as 69 percentage points (ppt). Within peer groups, a one ppt increase in dual share was associated with a 0.01 ppt increase in the difference from the median readmission rate (p < 0.001). From 2019 to 2020, 8.8% of hospitals switched peer groups. Compared to hospitals that did not switch, those moving to a lower peer group had a higher mean penalty in 2020 (0.096 ppt; p = 0.006); those moving to a higher group had a lower mean penalty (-0.06 ppt; p = 0.079). However, changes in penalties did not correspond to changes in readmission rates. Hospitals in states with higher Medicaid income eligibility limits were more likely to be in higher peer groups. CONCLUSIONS Peer grouping is limited in the extent to which it accounts for differences in hospitals' patient populations, and it may not fully insulate hospitals from penalties linked to changes in patient mix. These problems arise from the construction of peer groups and the measure of social risk used to define them.
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Affiliation(s)
- Monica S. Aswani
- Department of Health Services AdministrationUniversity of Alabama at Birmingham School of Health ProfessionsBirminghamAlabamaUSA
| | - Eric T. Roberts
- Department of Health Policy and ManagementUniversity of Pittsburgh Graduate School of Public HealthPittsburghPennsylvaniaUSA
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Kim J, Jacobs MA, Schmidt S, Brimhall BB, Salazar CI, Wang CP, Wang Z, Manuel LS, Damien P, Shireman PK. Retrospective cohort study comparing surgical inpatient charges, total costs, and variable costs as hospital cost savings measures. Medicine (Baltimore) 2022; 101:e32037. [PMID: 36550805 PMCID: PMC9771214 DOI: 10.1097/md.0000000000032037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
We analyzed differences (charges, total, and variable costs) in estimating cost savings of quality improvement projects using reduction of serious/life-threatening complications (Clavien-Dindo Level IV) and insurance type (Private, Medicare, and Medicaid/Uninsured) to evaluate the cost measures. Multiple measures are used to analyze hospital costs and compare cost outcomes across health systems with differing patient compositions. We used National Surgical Quality Improvement Program inpatient (2013-2019) with charge and cost data in a hospital serving diverse socioeconomic status patients. Simulation was used to estimate variable costs and total costs at 3 proportions of fixed costs (FC). Cases (Private 1517; Medicare 1224; Medicaid/Uninsured 3648) with patient mean age 52.3 years (Standard Deviation = 14.7) and 47.3% male. Medicare (adjusted odds ratio = 1.55, 95% confidence interval = 1.16-2.09, P = .003) and Medicaid/Uninsured (adjusted odds ratio = 1.41, 95% confidence interval = 1.10-1.82, P = .008) had higher odds of complications versus Private. Medicaid/Uninsured had higher relative charges versus Private, while Medicaid/Uninsured and Medicare had higher relative variable and total costs versus Private. Targeting a 15% reduction in serious complications for robust patients undergoing moderate-stress procedures estimated variable cost savings of $286,392. Total cost saving estimates progressively increased with increasing proportions of FC; $443,943 (35% FC), $577,495 (50% FC), and $1184,403 (75% FC). In conclusion, charges did not identify increased costs for Medicare versus Private patients. Complications were associated with > 200% change in costs. Surgical hospitalizations for Medicare and Medicaid/Uninsured patients cost more than Private patients. Variable costs should be used to avoid overestimating potential cost savings of quality improvement interventions, as total costs include fixed costs that are difficult to change in the short term.
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Affiliation(s)
- Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- University Health, San Antonio, TX, USA
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Zhu Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, TX, USA
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
- University Health, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Departments of Primary Care and Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX, USA
- * Correspondence: Paula K. Shireman, Office of the Dean, School of Medicine, Texas A&M Health, 8447 Riverside Parkway, Bryan TX 77807, USA (e-mail: )
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Chatterjee P, Liao JM, Wang E, Feffer D, Navathe AS. Characteristics, utilization, and concentration of outpatient care for dual-eligible Medicare beneficiaries. Am J Manag Care 2022; 28:e370-e377. [PMID: 36252177 PMCID: PMC10084394 DOI: 10.37765/ajmc.2022.89189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To characterize the (1) distribution of outpatient care for dual-eligible Medicare beneficiaries ("duals") and (2) intensity of outpatient care utilization of duals vs non-dual-eligible beneficiaries ("nonduals"). STUDY DESIGN Using data preceding the introduction of several outpatient alternative payment models, as well as Medicaid expansion, we evaluated the distribution of outpatient care across physician practices using a Lorenz curve and compared utilization of different outpatient services between duals and nonduals. METHODS We defined practices that did (high dual) and did not (low dual and no dual) account for the large majority of visits based on the Lorenz curve and then performed descriptive statistics between these groups of practices. Practice-level outcomes included patient demographics, practice characteristics, and county measures of structural disadvantage and population health. Patient-level outcomes included number of outpatient visits and unique outpatient physicians, primary vs subspecialty care visits, and expenditures. RESULTS Nearly 80% of outpatient visits for duals were provided by 35% of practices. Compared with low-dual and no-dual practices, high-dual practices served more patients (1117.6 patients per high-dual practice vs 683.8 patients per low-dual practice and 447.5 patients per no-dual practice; P < .001) with more comorbidities (3.9 mean total Elixhauser comorbidities among patients served by high-dual practices vs 3.6 among low-dual practices and 3.3 among no-dual practices; P < .001). With regard to utilization, duals had 2 fewer outpatient visits per year compared with nonduals (13.3 vs 15.2; P < .001), with particularly fewer subspecialty care visits (6.5 vs 7.9; P < .001) despite having more comorbidities (3.5 vs 2.7; P < .001). CONCLUSIONS Outpatient care for duals was concentrated among a small number of practices. Despite having more chronic conditions, duals had fewer outpatient visits. Duals and the practices that serve them may benefit from targeted policies to promote access and improve outcomes.
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Affiliation(s)
- Paula Chatterjee
- Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Rm 1318, Philadelphia, PA 19104.
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Holcomb J, Oliveira LC, Highfield L, Hwang KO, Giancardo L, Bernstam EV. Predicting health-related social needs in Medicaid and Medicare populations using machine learning. Sci Rep 2022; 12:4554. [PMID: 35296719 PMCID: PMC8927567 DOI: 10.1038/s41598-022-08344-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/03/2022] [Indexed: 01/02/2023] Open
Abstract
Providers currently rely on universal screening to identify health-related social needs (HRSNs). Predicting HRSNs using EHR and community-level data could be more efficient and less resource intensive. Using machine learning models, we evaluated the predictive performance of HRSN status from EHR and community-level social determinants of health (SDOH) data for Medicare and Medicaid beneficiaries participating in the Accountable Health Communities Model. We hypothesized that Medicaid insurance coverage would predict HRSN status. All models significantly outperformed the baseline Medicaid hypothesis. AUCs ranged from 0.59 to 0.68. The top performance (AUC = 0.68 CI 0.66–0.70) was achieved by the “any HRSNs” outcome, which is the most useful for screening prioritization. Community-level SDOH features had lower predictive performance than EHR features. Machine learning models can be used to prioritize patients for screening. However, screening only patients identified by our current model(s) would miss many patients. Future studies are warranted to optimize prediction of HRSNs.
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Affiliation(s)
- Jennifer Holcomb
- Department of Management, Policy, and Community Health, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, 1200 Pressler St, Houston, TX, 77030, USA.,Sinai Urban Health Institute, 1500 South Fairfield Avenue, Chicago, IL, 60608, USA
| | - Luis C Oliveira
- The University of Texas Health Science Center at Houston (UTHealth) School of Biomedical Informatics, 7000 Fannin, Houston, TX, 77030, USA.,Houston Methodist Academic Institute, 6670 Bertner Ave, Houston, TX, 77030, USA
| | - Linda Highfield
- Departments of Management, Policy, and Community Health and Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, 1200 Pressler St, Houston, TX, 77030, USA.,Department of Internal Medicine, The University of Texas Health Science Center at Houston (UTHealth) John P and Katherine G McGovern Medical School, 6410 Fannin, Houston, TX, 77030, USA
| | - Kevin O Hwang
- Center for Healthcare Quality and Safety at UTHealth/Memorial Hermann, The University of Texas Health Science Center at Houston (UTHealth) John P and Katherine G McGovern Medical School, 6410 Fannin, Houston, TX, 77030, USA
| | - Luca Giancardo
- Center for Precision Health, The University of Texas Health Science Center at Houston (UTHealth) School of Biomedical Informatics, 7000 Fannin, Houston, TX, 77030, USA
| | - Elmer Victor Bernstam
- The University of Texas Health Science Center at Houston (UTHealth) School of Biomedical Informatics, 7000 Fannin, Houston, TX, 77030, USA. .,Department of Internal Medicine, The University of Texas Health Science Center at Houston (UTHealth) John P and Katherine G McGovern Medical School, 6410 Fannin, Houston, TX, 77030, USA.
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Abstract
IMPORTANCE Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. OBJECTIVE To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022. EXPOSURES Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other. MAIN OUTCOMES AND MEASURES Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke. RESULTS Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke. CONCLUSIONS AND RELEVANCE In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.
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Affiliation(s)
- Pamela R. Bosch
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
| | - Amol M. Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond
- Sheltering Arms Institute, Richmond, Virginia
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff
| | - Corey R. Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Marcus Institute for Aging Research, Boston, Massachusetts
| | - Robert E. Burke
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Amit Kumar
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
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Rethorn ZD, Rethorn TJ, Cook CE, Sharpe JA, Hastings SN, Allen KD. Association of Burden and Prevalence of Arthritis With Disparities in Social Risk Factors, Findings From 17 US States. Prev Chronic Dis 2022; 19:E08. [PMID: 35175917 PMCID: PMC8880108 DOI: 10.5888/pcd19.210277] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Social risks previously have been associated with arthritis prevalence and costs. Although social risks often cluster among individuals, no studies have examined associations between multiple social risks within the same individual. Our objective was to determine the association between individual and multiple social risks and the prevalence and burden of arthritis by using a representative sample of adults in 17 US states. Methods Data are from the 2017 Behavioral Risk Factor Surveillance System. Respondents were 136,432 adults. Social risk factors were food insecurity, housing insecurity, financial insecurity, unsafe neighborhoods, and health care access hardship. Weighted χ2 and logistic regression analyses, controlling for demographic characteristics, measures of socioeconomic position, and other health conditions examined differences in arthritis prevalence and burden by social risk factor and by a social risk index created by summing the social risk factors. Results We observed a gradient in the prevalence and burden of arthritis. Compared with those reporting 0 social risk factors, respondents reporting 4 or more social risk factors were more likely to have arthritis (adjusted odds ratio [AOR], 1.92; 95% CI, 1.57–2.36) and report limited usual activities (AOR, 2.97; 95% CI, 2.20–4.02), limited work (AOR, 2.72; 95% CI, 2.06–3.60), limited social activities (AOR, 3.10; 95% CI, 2.26–4.26), and severe joint pain (AOR, 1.86; 95% CI, 1.44–2.41). Conclusion Incremental increases in the number of social risk factors were independently associated with higher odds of arthritis and its burden. Intervention efforts should address the social context of US adults to improve health outcomes.
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Affiliation(s)
- Zachary D. Rethorn
- Doctor of Physical Therapy Division, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Veterans Affairs Health Care System, Durham, North Carolina
| | - Timothy J. Rethorn
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio
| | - Chad E. Cook
- Doctor of Physical Therapy Division, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
| | - Jason A. Sharpe
- Center of Innovation to Accelerate Discovery and Practice Transformation, Veterans Affairs Health Care System, Durham, North Carolina
| | - S. Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Health Care System, Durham, North Carolina
- Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina
| | - Kelli D. Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Veterans Affairs Health Care System, Durham, North Carolina
- Department of Medicine and Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, North Carolina
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Sterling RS. Insurance Type and Patient-Reported Outcome Measures: Can Insurance Type Be a Good Proxy for Risk Stratification?: Commentary on an article by Brady D. Greene, BS, et al.: "Correlation Between Patient-Reported Outcome Measures and Health Insurance Provider Types in Patients with Hip Osteoarthritis". J Bone Joint Surg Am 2021; 103:e66. [PMID: 34406141 DOI: 10.2106/jbjs.21.00660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Robert S Sterling
- Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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Khullar D, Schpero WL, Bond AM, Qian Y, Casalino LP. Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System. JAMA 2020; 324:975-983. [PMID: 32897345 PMCID: PMC7489811 DOI: 10.1001/jama.2020.13129] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The US Merit-based Incentive Payment System (MIPS) is a major Medicare value-based payment program aimed at improving quality and reducing costs. Little is known about how physicians' performance varies by social risk of their patients. OBJECTIVE To determine the relationship between patient social risk and physicians' scores in the first year of MIPS. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of physicians participating in MIPS in 2017. EXPOSURES Physicians in the highest quintile of proportion of dually eligible patients served; physicians in the 3 middle quintiles; and physicians in the lowest quintile. MAIN OUTCOMES AND MEASURES The primary outcome was the 2017 composite MIPS score (range, 0-100; higher scores indicate better performance). Payment rates were adjusted -4% to 4% based on scores. RESULTS The final sample included 284 544 physicians (76.1% men, 60.1% with ≥20 years in practice, 11.9% in rural location, 26.8% hospital-based, and 24.6% in primary care). The mean composite MIPS score was 73.3. Physicians in the highest risk quintile cared for 52.0% of dually eligible patients; those in the 3 middle risk quintiles, 21.8%; and those in the lowest risk quintile, 6.6%. After adjusting for medical complexity, the mean MIPS score for physicians in the highest risk quintile (64.7) was lower relative to scores for physicians in the middle 3 (75.4) and lowest (75.9) risk quintiles (difference for highest vs middle 3, -10.7 [95% CI, -11.0 to -10.4]; highest vs lowest, -11.2 [95% CI, -11.6 to -10.8]; P < .001). This relationship was found across specialties except psychiatry. Compared with physicians in the lowest risk quintile, physicians in the highest risk quintile were more likely to work in rural areas (12.7% vs 6.4%; difference, 6.3 percentage points [95% CI, 6.0 to 6.7]; P < .001) but less likely to care for more than 1000 Medicare beneficiaries (9.4% vs 17.8%; difference, -8.3 percentage points [95% CI, -8.7 to -8.0]; P < .001) or to have more than 20 years in practice (56.7% vs 70.6%; difference, -13.9 percentage points [95% CI, -14.4 to -13.3]; P < .001). For physicians in the highest risk quintile, several characteristics were associated with higher MIPS scores, including practicing in a larger group (mean score, 82.4 for more than 50 physicians vs 46.1 for 1-5 physicians; difference, 36.2 [95% CI, 35.3 to 37.2]; P < .001) and reporting through an alternative payment model (mean score, 79.5 for alternative payment model vs 59.9 for reporting as individual; difference, 19.7 [95% CI, 18.9 to 20.4]; P < .001). CONCLUSIONS AND RELEVANCE In this cross-sectional analysis of physicians who participated in the first year of the Medicare MIPS program, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with other physicians. Further research is needed to understand the reasons underlying the differences in physician MIPS scores by levels of patient social risk.
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Affiliation(s)
- Dhruv Khullar
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
- NewYork-Presbyterian Hospital, New York, New York
| | - William L. Schpero
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Amelia M. Bond
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Yuting Qian
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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Keohane LM, Stevenson DG, Stewart L, Thapa S, Freed S, Buntin MB. Risk adjusting for Medicaid participation in Medicare Advantage. Am J Manag Care 2020; 26:e258-e263. [PMID: 32835468 DOI: 10.37765/ajmc.2020.44076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Determining appropriate capitated payments has important access implications for dual-eligible Medicare Advantage (MA) members. In 2017, MA plans began receiving higher capitated payments for beneficiaries with full vs partial Medicaid when payments started being risk adjusted for level of Medicaid benefits instead of any Medicaid participation. This approach could favor MA plans in states with more generous Medicaid programs where more beneficiaries qualify for full Medicaid and thus a higher capitated payment. To understand this issue, we examined adjusted Medicare spending for dual-eligible beneficiaries across states with differing Medicaid eligibility criteria. STUDY DESIGN Retrospective analysis of 2007-2015 traditional Medicare data for dual-eligible beneficiaries 65 years and older. METHODS We compared predicted per-beneficiary spending levels after adjusting for any Medicaid participation and for level of Medicaid benefits across states with varying Medicaid eligibility requirements. RESULTS States with the most generous Medicaid requirements had more dual-eligible beneficiaries with full Medicaid compared with the most restrictive states (median, 82% vs 55%). Nationally, Medicare spending levels were 1.3 times greater for full vs partial Medicaid participants (range across states, 0.8-1.7). When per-beneficiary spending was adjusted for level of Medicaid benefits, rather than any Medicaid participation, states with more generous Medicaid eligibility had larger gains in predicted spending per dual-eligible beneficiary than states with less generous Medicaid coverage (1.7% vs 1.3% increase). CONCLUSIONS Distinguishing between partial and full Medicaid in MA payments may disproportionately increase MA payments in states that have more full Medicaid beneficiaries due to more generous Medicaid eligibility.
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Affiliation(s)
- Laura M Keohane
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Ste 1200, Nashville, TN 37203-8684.
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Roberts ET, Mellor JM, McInerney M, Sabik LM. State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment. Health Serv Res 2019; 54:1233-1245. [PMID: 31576563 DOI: 10.1111/1475-6773.13205] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. DATA SOURCE 2010-2013 Medicare Current Beneficiary Survey. STUDY DESIGN Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. PRINCIPAL FINDINGS Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. CONCLUSIONS Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.
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Affiliation(s)
- Eric T Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | | | | | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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