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Tsai TC, Brownlee SA, Dai D, Soto M, Rosenthal N, Orav EJ, Frakt AB, Figueroa JF. Disparities in Access to Outpatient Surgery Related to Removal of Procedures from Medicare's Inpatient Only List. Ann Surg 2024:00000658-990000000-00857. [PMID: 38660795 DOI: 10.1097/sla.0000000000006309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE We assessed the shift from inpatient to outpatient surgical care related to changes to the Inpatient Only List in 2020 and 2021 compared to 2019. SUMMARY BACKGROUND DATA The extent to which procedures shift from the inpatient to outpatient setting following removal from Medicare's Inpatient Only List is unknown. Many health systems also encouraged a shift from inpatient to outpatient surgery during the COVID-19 pandemic. Assessing the relative change in outpatient surgical utilization for procedures removed from the Inpatient Only List during COVID-19 would provide empirical data on whether reimbursement policy changes or inpatient capacity needs during the pandemic were more likely to shift care from the inpatient to outpatient setting. METHODS We used administrative data from the PINC AI Healthcare Database across 723 hospitals to determine the within-facility relative change in outpatient vs inpatient procedural volume in 2020 and 2021 compared to 2019 using a multivariable conditional fixed-effects Poisson regression model. We also assessed whether outpatient surgical utilization varied by race and ethnicity. Using a multivariable linear probability model, we assessed the absolute change in risk-adjusted 30-day complication, readmission, and mortality rates for inpatient and outpatient surgical procedures. RESULTS In 2020 and 2021 compared to 2019 respectively, there was a 5.3% (95% CI, 1.4% to 9.5%) and 41.3% (95% CI 33.1% to 50.0%) relative increase in outpatient elective procedural volume. Outpatient procedural volume increased most significantly for hip replacement which was removed from the Inpatient Only List in 2020 (increase in outpatient surgical utilization of 589.3% (95% CI, 524.9% to 660.3%)). The shift to outpatient hip replacement procedures was concentrated among White patients; in 2021, hip replacement procedural volume increased by 271.1% (95% CI, 241.2% and 303.7%) for White patients and 29.5% (95% CI, 24.4% and 34.9%) for Black patients compared to 2019 levels. There were no consistent or large changes in 30-day complication, readmission, or mortality risk in 2020 and 2021 compared to 2019. CONCLUSION There was a modest increase in elective outpatient surgeries and a pronounced increase in outpatient orthopedic surgeries which were removed from the Inpatient Only List during the COVID-19 pandemic. Utilization of outpatient surgical procedures was concentrated among White patients.
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Affiliation(s)
- Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Center for Surgery and Public Health, Boston, MA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sarah A Brownlee
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dannie Dai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Mark Soto
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
| | - Austin B Frakt
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
- VA Boston Healthcare System, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
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Salas RN, Burke LG, Phelan J, Wellenius GA, Orav EJ, Jha AK. Impact of extreme weather events on healthcare utilization and mortality in the United States. Nat Med 2024; 30:1118-1126. [PMID: 38424213 DOI: 10.1038/s41591-024-02833-x] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/25/2024] [Indexed: 03/02/2024]
Abstract
Climate change is intensifying extreme weather events. Yet a systematic analysis of post-disaster healthcare utilization and outcomes for severe weather and climate disasters, as tracked by the US government, is lacking. Following exposure to 42 US billion-dollar weather disasters (severe storm, flood, flood/severe storm, tropical cyclone and winter storm) between 2011 and 2016, we used a difference-in-differences (DID) approach to quantify changes in the rates of emergency department (ED) visits, nonelective hospitalizations and mortality between fee-for-service Medicare beneficiaries in affected compared to matched control counties in post-disaster weeks 1, 1-2 and 3-6. Overall, disasters were associated with higher rates of ED utilization in affected counties in post-disaster week 1 (DID of 1.22% (95% CI, 0.20% to 2.25%; P < 0.020)) through week 2. Nonelective hospitalizations were unchanged. Mortality was higher in affected counties in week 1 (DID of 1.40% (95% CI, 0.08% to 2.74%; P = 0.037)) and persisted for 6 weeks. Counties with the greatest loss and damage experienced greater increases in ED and mortality rates compared to all affected counties. Thus, billion-dollar weather disasters are associated with excess ED visits and mortality in Medicare beneficiaries. Tracking these outcomes is important for adaptation that protects patients and communities, health system resilience and policy.
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Affiliation(s)
- Renee N Salas
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Harvard Global Health Institute, Cambridge, MA, USA.
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Laura G Burke
- Harvard Medical School, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, USA
| | - Jessica Phelan
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Gregory A Wellenius
- Boston University School of Public Health, Center for Climate and Health, Boston, MA, USA
| | - E John Orav
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- Brown University School of Public Health, Providence, RI, USA
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3
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Ma Y, Roberts ET, Johnston KJ, Orav EJ, Figueroa JF. Medicaid Eligibility Loss Among Dual-Eligible Beneficiaries Before and During COVID-19 Public Health Emergency. JAMA Netw Open 2024; 7:e245876. [PMID: 38602676 PMCID: PMC11009828 DOI: 10.1001/jamanetworkopen.2024.5876] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/13/2024] [Indexed: 04/12/2024] Open
Abstract
Importance Medicaid coverage loss can substantially compromise access to and affordability of health care for dual-eligible beneficiaries. The extent to which this population lost Medicaid coverage before and during the COVID-19 public health emergency (PHE) and the characteristics of beneficiaries more at risk for coverage loss are currently not well known. Objective To assess the loss of Medicaid coverage among dual-eligible beneficiaries before and during the first year of the PHE, and to examine beneficiary-level and plan-level factors associated with heightened likelihood of losing Medicaid. Design, Setting, and Participants This repeated cross-sectional study used national Medicare data to estimate annual rates of Medicaid loss among dual-eligible beneficiaries before (2015 to 2019) and during the PHE (2020). Individuals who were dual eligible for Medicare and Medicaid at the beginning of a given year and who continuously received low-income subsidies for Medicare Part D prescription drug coverage were included in the sample. Multivariable regression models were used to examine beneficiary-level and plan-level factors associated with Medicaid loss. Data analyses were conducted between March 2023 and October 2023. Exposure Onset of PHE. Main Outcomes and Measures Loss of Medicaid for at least 1 month within a year. Results Sample included 56 172 736 dual-eligible beneficiary-years between 2015 and 2020. In 2020, most dual-eligible beneficiaries were aged over 65 years (5 984 420 [61.1%]), female (5 868 866 [59.9%]), non-Hispanic White (4 928 035 [50.3%]), full-benefit eligible (6 837 815 [69.8%]), and enrolled in traditional Medicare (5 343 537 [54.6%]). The adjusted proportion of dual-eligible beneficiaries losing Medicaid for at least 1 month increased from 6.6% in 2015 to 7.3% in 2019 and then dropped to 2.3% in 2020. Between 2015 and 2019, dual-eligible beneficiaries who were older (ages 55-64 years: -1.4%; 95% CI, -1.8% to -1.0%; ages 65-74 years: -2.0%; 95% CI, -2.5% to -1.5%; ages 75 and older: -4.5%; 95% CI, -5.0% to -4.0%), disabled (-0.8%; 95% CI, -1.1% to -0.6%), and in integrated care programs were less likely to lose Medicaid. In 2020, the disparities within each of these demographic groups narrowed significantly. Notably, while Black (0.6%; 95% CI, 0.2% to 0.9%) and Hispanic (0.7%; 95% CI, 0.3% to 1.2%) dual-eligible beneficiaries were more likely to lose Medicaid than their non-Hispanic White counterparts between 2015 and 2019, such gap was eliminated for Black beneficiaries and narrowed for Hispanic beneficiaries in 2020. Conclusions and Relevance During the PHE, Medicaid coverage loss declined significantly among dual-eligible beneficiaries, and disparities were mitigated across subgroups. As the PHE unwinds, it is crucial for policymakers to implement strategies to minimize Medicaid coverage disruptions and racial and ethnic disparities, especially given that loss of Medicaid was slightly increasing over time before the PHE.
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Affiliation(s)
- Yanlei Ma
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - E. John Orav
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Chen AC, Epstein AM, Joynt Maddox KE, Grabowski DC, Orav EJ, Barnett ML. Impact of dementia special care units for short-stay nursing home patients. J Am Geriatr Soc 2024; 72:767-777. [PMID: 38041834 PMCID: PMC10947952 DOI: 10.1111/jgs.18708] [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] [Received: 06/21/2023] [Revised: 09/19/2023] [Accepted: 11/14/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Improving quality of care provided to short-stay patients with dementia in nursing homes is a policy priority. However, it is unknown whether dementia-focused care strategies are associated with improved clinical outcomes or lower utilization and costs for short-stay dementia patients. METHODS We performed a national survey of nursing home administrators in 2020-2021, asking about the presence of three dementia-focused care services used for their short-stay patients: (1) a dementia care unit, (2) cognitive deficiency training for staff, and (3) dementia-specific occupational therapy. Using Medicare claims, we identified short-stay episodes for beneficiaries residing in surveyed skilled nursing facilities (SNFs) with and without dementia. We compared clinical, cost, and utilization outcomes for dementia patients in SNFs, which did and did not offer dementia-focused care services. As a counterfactual control, we compared these differences to those for non-dementia patients in the same facilities. Our primary quantity of interest was an interaction term between a patients' dementia status and the presence of a dementia-focused care tool. RESULTS The study population included 102,860 Medicare episodes of care from 377 SNF survey respondents in 2018-2019. In adjusted comparisons of the interaction between dementia status and the presence of each dementia-focused care tool, dementia care units were associated with a 1.5-day increase in healthy days at home in the 90 days following discharge (p = 0.01) and a 3.1% decrease in the likelihood of a subsequent SNF admission (p = 0.001). Cognitive deficiency training was also associated with a 2.0% increase in antipsychotics (p = 0.03), whereas dementia-specific occupational therapy was associated with a 1.2% increase in falls (p = 0.01) per patient episode. CONCLUSIONS Self-reported use of dementia care units for short-stay patients was associated with modestly better performance in some, but not all, outcome measures. This provides hypothesis-generating evidence that dementia care units could be a promising mechanism to improve care delivery in nursing homes.
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Affiliation(s)
- Amanda C Chen
- Harvard Graduate School of Arts and Sciences, Cambridge, Massachusetts, USA
| | - Arnold M Epstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine and Center for Advancing Health Services, Policy and Economics Research, Institute of Public Health at Washington University, St. Louis, Missouri, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Sager R, Gaengler S, Willett WC, Orav EJ, Mattle M, Habermann J, Geiling K, Schimmer RC, Vellas B, Kressig RW, Egli A, Dawson-Hughes B, Bischoff-Ferrari HA. Adherence to the MIND diet and the odds of mild cognitive impairment in generally healthy older adults: The 3-year DO-HEALTH study. J Nutr Health Aging 2024; 28:100034. [PMID: 38320383 DOI: 10.1016/j.jnha.2023.100034] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 12/28/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND The Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet may slow cognitive decline in older adults. A potential mechanism could be possible anti-inflammatory properties of the MIND-diet. OBJECTIVE To examine whether adherence to the MIND diet at baseline is associated with the odds of mild cognitive impairment (MCI) and changes in biomarkers of inflammation (High-sensitivity C-reactive Protein(hsCRP), interleukin-6(IL-6)) over three years in adults ≥70 years. METHODS Adherence to the MIND diet was assessed by food frequency questionnaire (FFQ) at baseline and after three years. Presence of MCI based on the Montreal Cognitive Assessment (MoCA) was defined as <26 (MCI26), or <24 (MCI24). We performed a minimally adjusted model controlling for sex, prior fall, linear spline at age 85, time, treatment and study site. The fully adjusted model also adjusted for education, BMI, physical activity, depression score, daily energy intake, and comorbidity score. To assess the change in inflammatory markers from baseline, we used linear-mixed-effect models adjusted for the same variables plus the respective baseline concentrations. Sensitivity analyses accounting for practice effects of repeated cognitive tests using the reliable change index for both MoCA cut-offs were done. RESULTS We included 2028 of 2157 DO-HEALTH participants (60.5% women; mean age 74.88 years) with complete data. Adherence to the MIND diet at baseline was not associated with cognitive decline over three years, neither at MoCA < 26 (OR (95%CI) = 0.99 (0.94-1.04)) nor at MoCA < 24 (OR (95%CI) = 1.03 (0.96-1.1)). Applying the reliable change index to the two cut-offs confirmed the findings. Further, the MIND diet adherence was not associated with the change in MoCA score from baseline in DO-HEALTH. For inflammatory biomarkers MIND-diet baseline adherence was not associated with changes in hsCRP or IL-6. CONCLUSION Adherence to the MIND-diet was neither associated with the odds of MCI, nor with hsCRP or IL-6 at baseline. Moreover, change in MIND-diet over three years was not associated with changes in hsCRP or IL-6.
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Affiliation(s)
- Roman Sager
- Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland.
| | - Stephanie Gaengler
- Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland; Department of Geriatrics and Aging Research, University of Zurich, Zurich, Switzerland.
| | - Walter C Willett
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - E John Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Michele Mattle
- Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland; Department of Geriatrics and Aging Research, University of Zurich, Zurich, Switzerland
| | - Jana Habermann
- University Clinic for Aging Medicine, Zurich City Hospital - Waid, Zurich, Switzerland
| | - Katharina Geiling
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ralph C Schimmer
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Bruno Vellas
- Gérontopôle de Toulouse, Institut du Vieillissement, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France and UMR INSERM 1027, University of Toulouse III, Toulouse, France
| | - Reto W Kressig
- University Department of Geriatric Medicine FELIX PLATTER and University of Basel, Basel, Switzerland
| | - Andreas Egli
- Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland; Department of Geriatrics and Aging Research, University of Zurich, Zurich, Switzerland
| | - Bess Dawson-Hughes
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Heike A Bischoff-Ferrari
- Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland; Department of Geriatrics and Aging Research, University of Zurich, Zurich, Switzerland; Gérontopôle de Toulouse, Institut du Vieillissement, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France and UMR INSERM 1027, University of Toulouse III, Toulouse, France; IHU HealthAge, University Hospital Toulouse, France.
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Milligan M, Erfani P, Orav EJ, Schleicher S, Brooks GA, Lam MB. Practice Consolidation Among US Medical Oncologists, 2015-2022. JCO Oncol Pract 2024:OP2300748. [PMID: 38408291 DOI: 10.1200/op.23.00748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/22/2024] [Indexed: 02/28/2024] Open
Abstract
PURPOSE Health care consolidation has significantly affected cancer care delivery, with oncology practices undergoing substantial consolidation over the past two decades. This study investigates practice consolidation trends among medical oncologists (MOs), factors associated with consolidation, and changes in MO geographic distribution. METHODS Medicare data from 2015 to 2022 were used to assess MO practice consolidation in hospital referral regions (HRRs), linked with regional health care market data and physician demographics. The Herfindahl-Hirschman Index (HHI) was used to measure consolidation, and the Gini coefficient was used to measure MO distribution across counties. Multivariable linear regression explored factors associated with MO practice consolidation. RESULTS Between 2015 and 2022, the number of MOs increased by 14.5% (11,727-13,433), whereas the number of MO practices decreased by 18.0% (2,774-2,276). The mean number of MOs per practice increased by 40% (4.26-5.95; P < .001). The percentage of MOs in small practices decreased, whereas larger practices saw an increase. MO consolidation, as indicated by the HHI, increased by 9% (median HHI, 0.3204-0.3480). HRRs with higher baseline hospital consolidation and more hospital beds per capita were more likely to have MO practice consolidation. Despite MO practice consolidation, the county-level distribution of MOs did not change substantially. CONCLUSION On the basis of Federal Trade Commission classifications, MO practices were highly concentrated in 2015 and consolidated even further by 2022. While distribution of MOs at the county level remained stable, further research is needed to assess the effects of rapid consolidation on cancer care cost, quality, and access. These data have important implications for policymakers and payers as they design programs that ensure high-quality, affordable cancer care.
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Affiliation(s)
- Michael Milligan
- Harvard Radiation Oncology Program, Boston, MA
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Parsa Erfani
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - E John Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | | | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
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Gaengler S, Sadlon A, De Godoi Rezende Costa Molino C, Willett WC, Manson JE, Vellas B, Steinhagen-Thiessen E, Von Eckardstein A, Ruschitzka F, Rizzoli R, da Silva JAP, Kressig RW, Kanis J, Orav EJ, Egli A, Bischoff-Ferrari HA. Effects of vitamin D, omega-3 and a simple strength exercise programme in cardiovascular disease prevention: The DO-HEALTH randomized controlled trial. J Nutr Health Aging 2024; 28:100037. [PMID: 38199870 DOI: 10.1016/j.jnha.2024.100037] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/03/2024] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND The effects of non-pharmaceutical interventions in the prevention of cardiovascular diseases (CVD) in older adults remains unclear. Therefore, the aim was to investigate the effect of 2000 IU/day of vitamin D3, omega-3 fatty acids (1 g/day), and a simple home strength exercise program (SHEP) (3×/week) on lipid and CVD biomarkers plasma changes over 3 years, incident hypertension and major cardiovascular events (MACE). METHODS The risk of MACE (coronary heart event or intervention, heart failure, stroke) was an exploratory endpoint of DO-HEALTH, incident hypertension and change in biomarkers were secondary endpoints. DO-HEALTH is a completed multicentre, randomised, placebo-controlled, 2 × 2 × 2 factorial design trial enrolling 2157 Europeans aged ≥70 years. RESULTS Participants' median age was 74 [72, 77] years, 61.7% were women, 82.5% were at least moderately physically active, and 40.7% had 25(OH)D < 20 ng/mL at baseline. Compared to their controls, omega-3 increased HDL-cholesterol (difference in change over 3 years: 0.08 mmol/L, 95% CI 0.05-0.10), decreased triglycerides (-0.08 mmol/L, (95%CI -0.12 to -0.03), but increased total- (0.15 mmol/L, 95%CI 0.09; 0.2), LDL- (0.11 mmol/L, 0.06; 0.16), and non-HDL-cholesterol (0.07 mmol/L, 95%CI 0.02; 0.12). However, neither omega-3 (adjustedHR 1.00, 95%CI 0.64-1.56), nor vitamin D3 (aHR 1.37, 95%CI 0.88-2.14), nor SHEP (aHR 1.18, 95%CI 0.76-1.84) reduced risk of MACE or incident hypertension compared to control. CONCLUSION Among generally healthy, active, and largely vitamin D replete, older adults, treatment with omega-3, vitamin D3, and/or SHEP had no benefit on MACE prevention. Only omega-3 supplementation changed lipid biomarkers, but with mixed effects. TRIAL REGISTRATION CLINICALTRIALS. GOV IDENTIFIER NCT01745263.
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Affiliation(s)
- Stephanie Gaengler
- Department of Geriatrics and Aging Research, University of Zurich, Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Angélique Sadlon
- Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Caroline De Godoi Rezende Costa Molino
- Department of Geriatrics and Aging Research, University of Zurich, Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Walter C Willett
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - JoAnn E Manson
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Bruno Vellas
- Gérontopôle de Toulouse, Institut du Vieillissement, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; UMR INSERM 1027, University of Toulouse III, Toulouse, France; IHU HealthAge, University Hospital Toulouse, France
| | | | - Arnold Von Eckardstein
- Institute of Clinical Chemistry, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - René Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - José A P da Silva
- Centro Hospitalare Universitário de Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (ICBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Reto W Kressig
- University Department of Geriatric Medicine FELIX PLATTER and University of Basel, Basel, Switzerland
| | - John Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, United Kingdom; Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - E John Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andreas Egli
- Department of Geriatrics and Aging Research, University of Zurich, Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Heike A Bischoff-Ferrari
- Department of Geriatrics and Aging Research, University of Zurich, Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland; Gérontopôle de Toulouse, Institut du Vieillissement, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; UMR INSERM 1027, University of Toulouse III, Toulouse, France; IHU HealthAge, University Hospital Toulouse, France.
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8
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Abstract
BACKGROUND Days spent obtaining health care outside the home can represent not only access to needed care but also substantial time, effort, and cost, especially for older adults and their care partners. Yet, these "health care contact days" have not been characterized. OBJECTIVE To assess composition of, variation and patterns in, and factors associated with contact days among older adults. DESIGN Cross-sectional study. SETTING Nationally representative 2019 Medicare Current Beneficiary Survey data linked to claims. PARTICIPANTS Community-dwelling adults aged 65 years and older in traditional Medicare. MEASUREMENTS Ambulatory contact days (days with a primary care or specialty care office visit, test, imaging, procedure, or treatment) and total contact days (ambulatory days plus institutional days in a hospital, emergency department, skilled-nursing facility, or hospice facility); multivariable mixed-effects Poisson regression to identify patient factors associated with contact days. RESULTS In weighted results, 6619 older adults (weighted: 29 694 084) had means of 17.3 ambulatory contact days (SD, 22.1) and 20.7 total contact days (SD, 27.5) in the year; 11.1% had 50 or more total contact days. Older adults spent most contact days on ambulatory care, including primary care visits (mean [SD], 3.5 [5.0]), specialty care visits (5.7 [9.6]), tests (5.3 [7.2]), imaging (2.6 [3.9]), procedures (2.5 [6.4]), and treatments (5.7 [13.3]). Half of the test and imaging days were not on the same days as office visits (48.6% and 50.1%, respectively). Factors associated with more ambulatory contact days included younger age, female sex, White race, non-Hispanic ethnicity, higher income, higher educational attainment, urban residence, more chronic conditions, and care-seeking behaviors (for example, "go to the doctor…as soon as (I)…feel bad"). LIMITATION Study population limited to those in traditional Medicare. CONCLUSION On average, older adults spent 3 weeks in the year getting care outside the home. These contact days were mostly ambulatory and varied widely not only by number of chronic conditions but also by sociodemographic factors, geography, and care-seeking behaviors. These results show factors beyond clinical need that may drive overuse and underuse of contact days and opportunities to optimize this person-centered measure to reduce patient burdens, for example, via care coordination. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston; and Harvard University, Boston, Massachusetts (I.G., E.J.O.)
| | - Emma D Chant
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (E.D.C.)
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston; and Harvard University, Boston, Massachusetts (I.G., E.J.O.)
| | - Ateev Mehrotra
- Harvard University, Boston; and Beth Israel Deaconess Medical Center, Boston, Massachusetts (A.M.)
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston; and Harvard University, Boston, Massachusetts (C.S.R.)
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9
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Chant ED, Ritchie CS, Orav EJ, Ganguli I. Healthcare contact days among older adults living with dementia. J Am Geriatr Soc 2024. [PMID: 38263877 DOI: 10.1111/jgs.18744] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/03/2023] [Accepted: 12/10/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND For older adults with dementia and their care partners, accessing health care outside the home involves substantial time, direct and indirect costs, and other burdens. While prior studies have estimated days spent by these individuals in or out of hospitals and nursing homes, ambulatory care burdens are likely substantial yet poorly understand. Therefore, we characterized "health care contact days"-days spent receiving ambulatory or institutional care-in this population. METHODS We used 2019 Medicare Current Beneficiary Survey data linked to claims for community-dwelling, ≥65-year-old adults with dementia in Traditional Medicare. We measured contact days including ambulatory days (with an office visit, test, imaging, procedure, or treatment) and institutional days (spent in an emergency department, hospital, skilled nursing facility, or hospice facility). We described variation and patterns in contact days. Using multivariable Poisson regression, we identified sociodemographic and clinical factors associated with contact days. RESULTS In weighted analyses, 887 older adults with dementia (weighted: 2.9 million) had mean (SD) 31.1 (33.7) total contact days/year, of which 21.7 (20.6) were ambulatory. Ten percent had ≥68 contact days in the year. One-third (34%) of ambulatory contact days involved multiple services. In multivariable models, receipt of more ambulatory contact days was associated with younger age (65-74 reference vs. -32.3% [95% CI: -42.2%, -20.7%] for 85+), higher income (>200% Federal Poverty Level [FPL] reference versus -16.6% [95% CI: -26.7%, -5.0%] for ≤200% FPL), and lack of functional impairment (reference versus -14.6% [95% CI: -23.7%, -4.4%]). Each additional chronic condition was associated with 8.2% (95% CI: 6.7%, 9.8%) more ambulatory contact days. CONCLUSIONS Older adults with dementia spent 31 days a year accessing care which was mostly ambulatory. These days varied widely by both clinical and sociodemographic factors. These results highlight the need to reduce patient burden through strategies such as reducing unneeded care, coordinating care, and shifting care to home settings through telemedicine and home care.
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Affiliation(s)
- Emma D Chant
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christine S Ritchie
- Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute Center for Aging and Serious Illness and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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10
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Kantor PF, Shi L, Colan SD, Orav EJ, Wilkinson JD, Hamza TH, Webber SA, Canter CE, Towbin JA, Everitt MD, Pahl E, Ware SM, Rusconi PG, Lamour JM, Jefferies JL, Addonizio LJ, Lipshultz SE. Progressive Left Ventricular Remodeling for Predicting Mortality in Children With Dilated Cardiomyopathy: The Pediatric Cardiomyopathy Registry. J Am Heart Assoc 2024; 13:e022557. [PMID: 38214257 PMCID: PMC10926795 DOI: 10.1161/jaha.121.022557] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 12/08/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Pediatric dilated cardiomyopathy often leads to death or cardiac transplantation. We sought to determine whether changes in left ventricular (LV) end-diastolic dimension (LVEDD), LV end-diastolic posterior wall thickness, and LV fractional shortening (LVFS) over time may help predict adverse outcomes. METHODS AND RESULTS We studied children up to 18 years old with dilated cardiomyopathy, enrolled between 1990 and 2009 in the Pediatric Cardiomyopathy Registry. Changes in LVFS, LVEDD, LV end-diastolic posterior wall thickness, and the LV end-diastolic posterior wall thickness:LVEDD ratio between baseline and follow-up echocardiograms acquired ≈1 year after diagnosis were determined for children who, at the 1-year follow-up had died, received a heart transplant, or were alive and transplant-free. Within 1 year after diagnosis, 40 (5.0%) of the 794 eligible children had died, 117 (14.7%) had undergone cardiac transplantation, and 585 (73.7%) had survived without transplantation. At diagnosis, survivors had higher median LVFS and lower median LVEDD Z scores. Median LVFS and LVEDD Z scores improved among survivors (Z score changes of +2.6 and -1.1, respectively) but remained stable or worsened in the other 2 groups. The LV end-diastolic posterior wall thickness:LVEDD ratio increased in survivors only, suggesting beneficial reverse LV remodeling. The risk for death or cardiac transplantation up to 7 years later was lower when LVFS was improved at 1 year (hazard ratio [HR], 0.83; P=0.004) but was higher in those with progressive LV dilation (HR, 1.45; P<0.001). CONCLUSIONS Progressive deterioration in LV contractile function and increasing LV dilation are associated with both early and continuing mortality in children with dilated cardiomyopathy. Serial echocardiographic monitoring of these children is therefore indicated. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00005391.
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Affiliation(s)
- Paul F. Kantor
- Children’s Hospital Los Angeles and Keck School of Medicine of USCLos AngelesCA
| | - Ling Shi
- New England Research InstitutesWatertownMA
| | | | | | | | | | | | | | | | | | - Elfriede Pahl
- Ann and Robert H. Lurie Children’s Hospital of ChicagoChicagoIL
| | | | | | | | | | | | - Steven E. Lipshultz
- University at Buffalo Jacobs School of Medicine and Biomedical SciencesBuffaloNY
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11
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Burke LG, Burke RC, Orav EJ, Bryan AF, Friend TH, Richardson DA, Jha AK, Tsai TC. Trends in performance of hospital outpatient procedures and associated 30-day costs among Medicare beneficiaries from 2011 to 2018. Healthc (Amst) 2023; 11:100718. [PMID: 37913606 DOI: 10.1016/j.hjdsi.2023.100718] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/20/2023] [Accepted: 09/11/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND United States healthcare has increasingly transitioned to outpatient care delivery. The degree to which Academic Medical Centers (AMCs) have been able to shift surgical procedures from inpatient to outpatient settings despite higher patient complexity is unknown. METHODS This observational study used a 20% sample of fee-for-service Medicare beneficiaries age 65 and older undergoing eight elective procedures from 2011 to 2018 to model trends in procedure site (hospital outpatient vs. inpatient) and 30-day standardized Medicare costs, overall and by hospital teaching status. RESULTS Of the 1,222,845 procedures, 15.9% occurred at AMCs. There was a 2.42% per-year adjusted increase (95% CI 2.39%-2.45%; p < .001) in proportion of outpatient hospital procedures, from 68.9% in 2011 to 85.4% in 2018. Adjusted 30-day standardized costs declined from $18,122 to $14,353, (-$560/year, 95% CI -$573 to -$547; p < .001). Patients at AMCs had more chronic conditions and higher predicted annual mortality. AMCs had a lower proportion of outpatient procedures in all years compared to non-AMCs, a difference that was statistically significant but small in magnitude. AMCs had higher costs compared to non-AMCs and a lesser decline over time (p < .001 for the interaction). AMCs and non-AMCs saw a similar decline in 30-day mortality. CONCLUSIONS There has been a substantial shift toward outpatient procedures among Medicare beneficiaries with a decrease in total 30-day Medicare spending as well as 30-day mortality. Despite a higher complexity population, AMCs shifted procedures to the outpatient hospital setting at a similar rate as non-AMCs. IMPLICATIONS The trend toward outpatient procedural care and lower spending has been observed broadly across AMCs and non-AMCs, suggesting that Medicare beneficiaries have benefited from more efficient delivery of procedural care across academic and community hospitals.
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Affiliation(s)
- Laura G Burke
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; The Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; The Department of Emergency Medicine, Harvard Medical School, Department of Surgery, Brigham and Women's Hospital, USA.
| | - Ryan C Burke
- The Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; The Department of Emergency Medicine, Harvard Medical School, Department of Surgery, Brigham and Women's Hospital, USA
| | - E John Orav
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Tynan H Friend
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Damien A Richardson
- Department of Orthopaedic Surgery, The University of Arizona, College of Medicine, Phoenix, AZ, USA
| | - Ashish K Jha
- Brown University School of Public Health, Providence, RI, USA
| | - Thomas C Tsai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; The Department of Emergency Medicine, Harvard Medical School, Department of Surgery, Brigham and Women's Hospital, USA
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12
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Schiavoni KH, Flom M, Blumenthal KJ, Orav EJ, Hefferon M, Maher E, Boudreau AA, Giuliano CP, Chambers B, Mandell MH, Vienneau M, Mendu ML, Vogeli C. Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management. Pediatrics 2023; 152:e2022058268. [PMID: 38013488 DOI: 10.1542/peds.2022-058268] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis. METHODS Mixed-methods analysis including claims using quasi-stepped-wedge design pre and postenrollment to estimate difference-in-differences, participant survey, and semistructured interviews. Participants included 1321 patients with medical, behavioral, or social needs, high utilization, in Medicaid or commercial ACOs, and enrolled in multidisciplinary, primary care-embedded care management. RESULTS TME significantly declined 1 to 6 months postenrollment and continued through 19 to 24 months (-$645.48 per member per month, P < .001). Emergency department and inpatient utilization significantly decreased 7 to 12 months post-enrollment and persisted through 19 to 24 months (-29% emergency department, P = .012; -82% inpatient, P < .001). Of respondents, 87.2% of survey respondents were somewhat or very satisfied with care coordination, 56.1% received education coordination when needed, and 81.5% had no unmet health needs. Emergency department or inpatient utilization decreases were consistent across payors and care manager disciplines, occurred sooner with behavioral health diagnoses, and were significant among children with above-median risk scores. Satisfaction and experience were equivalent across groups, with more unmet needs and frustration with above-median risk scores. CONCLUSIONS Pediatric care management in multipayor ACOs may effectively reduce TME and utilization and clinically provide high-quality care coordination, including education and family stress, with high participant satisfaction.
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Affiliation(s)
- Katherine H Schiavoni
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Departments of Medicine and Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Megan Flom
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
| | - Karen J Blumenthal
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - E John Orav
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Margaret Hefferon
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
| | - Erin Maher
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
| | - Alexy Arauz Boudreau
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher P Giuliano
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Affiliated Pediatric Practices, Dedham, Massachusetts
- Mass General Brigham Community Physicians Organization, Somerville, Massachusetts
| | - Barbara Chambers
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Mass General Brigham Community Physicians Organization, Somerville, Massachusetts
| | - Mark H Mandell
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Pediatric Associates of Greater Salem, Salem, Massachusetts
| | - Maryann Vienneau
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
| | - Mallika L Mendu
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Renal Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christine Vogeli
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
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13
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Wallis CJ, Jerath A, Ikesu R, Satkunasivam R, Dimick JB, Orav EJ, Maggard-Gibbons M, Li R, Salles A, Klaassen Z, Coburn N, Bass BL, Detsky AS, Tsugawa Y. Association between patient-surgeon gender concordance and mortality after surgery in the United States: retrospective observational study. BMJ 2023; 383:e075484. [PMID: 37993130 PMCID: PMC10664070 DOI: 10.1136/bmj-2023-075484] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE To determine whether patient-surgeon gender concordance is associated with mortality of patients after surgery in the United States. DESIGN Retrospective observational study. SETTING Acute care hospitals in the US. PARTICIPANTS 100% of Medicare fee-for-service beneficiaries aged 65-99 years who had one of 14 major elective or non-elective (emergent or urgent) surgeries in 2016-19. MAIN OUTCOME MEASURES Mortality after surgery, defined as death within 30 days of the operation. Adjustments were made for patient and surgeon characteristics and hospital fixed effects (effectively comparing patients within the same hospital). RESULTS Among 2 902 756 patients who had surgery, 1 287 845 (44.4%) had operations done by surgeons of the same gender (1 201 712 (41.4%) male patient and male surgeon, 86 133 (3.0%) female patient and female surgeon) and 1 614 911 (55.6%) were by surgeons of different gender (52 944 (1.8%) male patient and female surgeon, 1 561 967 (53.8%) female patient and male surgeon). Adjusted 30 day mortality after surgery was 2.0% for male patient-male surgeon dyads, 1.7% for male patient-female surgeon dyads, 1.5% for female patient-male surgeon dyads, and 1.3% for female patient-female surgeon dyads. Patient-surgeon gender concordance was associated with a slightly lower mortality for female patients (adjusted risk difference -0.2 percentage point (95% confidence interval -0.3 to -0.1); P<0.001), but a higher mortality for male patients (0.3 (0.2 to 0.5); P<0.001) for elective procedures, although the difference was small and not clinically meaningful. No evidence suggests that operative mortality differed by patient-surgeon gender concordance for non-elective procedures. CONCLUSIONS Post-operative mortality rates were similar (ie, the difference was small and not clinically meaningful) among the four types of patient-surgeon gender dyads.
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Affiliation(s)
- Christopher Jd Wallis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
- Division of Urology, Department of Surgery, University Health Network, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Ryo Ikesu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
- Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, USA
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Ruixin Li
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Arghavan Salles
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Zachary Klaassen
- Division of Urology, Medical College of Georgia-Augusta University, Augusta, GA, USA
| | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Barbara L Bass
- George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Allan S Detsky
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, ON, Canada
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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14
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Vissing CR, Axelsson Raja A, Day SM, Russell MW, Zahka K, Lever HM, Pereira AC, Colan SD, Margossian R, Murphy AM, Canter C, Bach RG, Wheeler MT, Rossano JW, Owens AT, Benson L, Mestroni L, Taylor MRG, Patel AR, Wilmot I, Thrush P, Soslow JH, Becker JR, Seidman CE, Lakdawala NK, Cirino AL, McMurray JJV, MacRae CA, Solomon SD, Bundgaard H, Orav EJ, Ho CY. Cardiac Remodeling in Subclinical Hypertrophic Cardiomyopathy: The VANISH Randomized Clinical Trial. JAMA Cardiol 2023; 8:1083-1088. [PMID: 37672268 PMCID: PMC10483382 DOI: 10.1001/jamacardio.2023.2808] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/23/2023] [Indexed: 09/07/2023]
Abstract
Importance Valsartan has shown promise in attenuating cardiac remodeling in patients with early-stage sarcomeric hypertrophic cardiomyopathy (HCM). Genetic testing can identify individuals at risk of HCM in a subclinical stage who could benefit from therapies that prevent disease progression. Objective To explore the potential for valsartan to modify disease development, and to characterize short-term phenotypic progression in subclinical HCM. Design, Setting, and Participants The multicenter, double-blind, placebo-controlled Valsartan for Attenuating Disease Evolution in Early Sarcomeric Hypertrophic Cardiomyopathy (VANISH) randomized clinical trial was conducted from April 2014 to July 2019 at 17 sites in 4 countries (Brazil, Canada, Denmark, and the US), with 2 years of follow-up. The prespecified exploratory VANISH cohort studied here included sarcomere variant carriers with subclinical HCM and early phenotypic manifestations (reduced E' velocity, electrocardiographic abnormalities, or an increased left ventricular [LV] wall thickness [LVWT] to cavity diameter ratio) but no LV hypertrophy (LVH). Data were analyzed between March and December 2022. Interventions Treatment with placebo or valsartan (80 mg/d for children weighing <35 kg, 160 mg/d for children weighing ≥35 kg, or 320 mg/d for adults aged ≥18 years). Main Outcomes and Measures The primary outcome was a composite z score incorporating changes in 9 parameters of cardiac remodeling (LV cavity volume, LVWT, and LV mass; left atrial [LA] volume; E' velocity and S' velocity; and serum troponin and N-terminal prohormone of brain natriuretic peptide levels). Results This study included 34 participants, with a mean (SD) age of 16 (5) years (all were White). A total of 18 participants (8 female [44%] and 10 male [56%]) were randomized to valsartan and 16 (9 female [56%] and 7 male [44%]) were randomized to placebo. No statistically significant effects of valsartan on cardiac remodeling were detected (mean change in composite z score compared with placebo: -0.01 [95% CI, -0.29 to 0.26]; P = .92). Overall, 2-year phenotypic progression was modest, with only a mild increase in LA volume detected (increased by 3.5 mL/m2 [95% CI, 1.4-6.0 mL/m2]; P = .002). Nine participants (26%) had increased LVWT, including 6 (18%) who developed clinically overt HCM. Baseline LA volume index (LAVI; 35 vs 28 mL/m2; P = .01) and average interventricular septum thickness (8.5 vs 7.0 mm; P = .009) were higher in participants who developed HCM. Conclusions and Relevance In this exploratory cohort, valsartan was not proven to slow progression of subclinical HCM. Minimal changes in markers of cardiac remodeling were observed, although nearly one-fifth of patients developed clinically overt HCM. Transition to disease was associated with greater baseline interventricular septum thickness and LAVI. These findings highlight the importance of following sarcomere variant carriers longitudinally and the critical need to improve understanding of factors that drive disease penetrance and progression. Trial Registration ClinicalTrials.gov Identifier: NCT01912534.
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Affiliation(s)
- Christoffer Rasmus Vissing
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anna Axelsson Raja
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sharlene M. Day
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | | | | | | | - Alexandre C. Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Steven D. Colan
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Renee Margossian
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Anne M. Murphy
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles Canter
- Washington University School of Medicine, St Louis, Missouri
| | - Richard G. Bach
- Washington University School of Medicine, St Louis, Missouri
| | - Matthew T. Wheeler
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Anjali T. Owens
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Lee Benson
- Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Amit R. Patel
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville
| | - Ivan Wilmot
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Philip Thrush
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | - Jason R. Becker
- Division of Cardiology, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, Pennsylvania
| | - Christine E. Seidman
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Howard Hughes Medical Institute, Chevy Chase, Maryland
| | - Neal K. Lakdawala
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Allison L. Cirino
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - John J. V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Calum A. MacRae
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott D. Solomon
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Henning Bundgaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - E. John Orav
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carolyn Y. Ho
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Atlas SJ, Tosteson ANA, Wright A, Orav EJ, Burdick TE, Zhao W, Hort SJ, Wint AJ, Smith RE, Chang FY, Aman DG, Thillaiyapillai M, Diamond CJ, Zhou L, Haas JS. A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial. JAMA 2023; 330:1348-1358. [PMID: 37815566 PMCID: PMC10565610 DOI: 10.1001/jama.2023.18755] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/31/2023] [Indexed: 10/11/2023]
Abstract
Importance Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results. Objective To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results. Design, Setting, and Participants Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021. Intervention Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment. Main Outcomes and Measures The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk. Results Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result. Conclusions and Relevance A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer. Trial Registration ClinicalTrials.gov Identifier: NCT03979495.
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Affiliation(s)
- Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Anna N. A. Tosteson
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Dartmouth Cancer Center, Dartmouth Health and Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
- Department of Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Timothy E. Burdick
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
- SYNERGY Research Informatics, Dartmouth Health, Lebanon, New Hampshire
- Department of Biomedical Data Science, Dartmouth Health, Lebanon, New Hampshire
| | - Wenyan Zhao
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Shoshana J. Hort
- Department of Medicine, Dartmouth Health, Lebanon, New Hampshire
- SYNERGY Research Informatics, Dartmouth Health, Lebanon, New Hampshire
| | - Amy J. Wint
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Rebecca E. Smith
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Frank Y. Chang
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David G. Aman
- Research Computing, Dartmouth College, Lebanon, New Hampshire
| | | | - Courtney J. Diamond
- Department of Biomedical Informatics, Irving Medical Center, Columbia University, New York, New York
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer S. Haas
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
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16
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Shashikumar SA, Zheng J, Orav EJ, Epstein AM, Joynt Maddox KE. Changes in Cardiovascular Spending, Care Utilization, and Clinical Outcomes Associated With Participation in Bundled Payments for Care Improvement - Advanced. Circulation 2023; 148:1074-1083. [PMID: 37681315 PMCID: PMC10540757 DOI: 10.1161/circulationaha.123.065109] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/03/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Bundled Payments for Care Improvement - Advanced (BPCI-A) is a Medicare initiative that aims to incentivize reductions in spending for episodes of care that start with a hospitalization and end 90 days after discharge. Cardiovascular disease, an important driver of Medicare spending, is one of the areas of focus BPCI-A. It is unknown whether BPCI-A is associated with spending reductions or quality improvements for the 3 cardiovascular medical events or 5 cardiovascular procedures in the model. METHODS In this retrospective cohort study, we conducted difference-in-differences analyses using Medicare claims for patients discharged between January 1, 2017, and September 30, 2019, to assess differences between BPCI-A hospitals and matched nonparticipating control hospitals. Our primary outcomes were the differential changes in spending, before versus after implementation of BPCI-A, for cardiac medical and procedural conditions at BPCI-A hospitals compared with controls. Secondary outcomes included changes in patient complexity, care utilization, healthy days at home, readmissions, and mortality. RESULTS Baseline spending for cardiac medical episodes at BPCI-A hospitals was $25 606. The differential change in spending for cardiac medical episodes at BPCI-A versus control hospitals was $16 (95% CI, -$228 to $261; P=0.90). Baseline spending for cardiac procedural episodes at BPCI-A hospitals was $37 961. The differential change in spending for cardiac procedural episodes was $171 (95% CI, -$429 to $772; P=0.58). There were minimal differential changes in physicians' care patterns such as the complexity of treated patients or in their care utilization. At BPCI-A versus control hospitals, there were no significant differential changes in rates of 90-day readmissions (differential change, 0.27% [95% CI, -0.25% to 0.80%] for medical episodes; differential change, 0.31% [95% CI, -0.98% to 1.60%] for procedural episodes) or mortality (differential change, -0.14% [95% CI, -0.50% to 0.23%] for medical episodes; differential change, -0.36% [95% CI, -1.25% to 0.54%] for procedural episodes). CONCLUSIONS Participation in BPCI-A was not associated with spending reductions, changes in care utilization, or quality improvements for the cardiovascular medical events or procedures offered in the model.
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Affiliation(s)
- Sukruth A. Shashikumar
- Department of Medicine (S.A.S.), Brigham and Women’s Hospital, Boston, MA
- Center for Advancing Health Services, Policy & Economics Research, Washington University, St. Louis, MO (S.A.S., K.E.J.M.)
| | - Jie Zheng
- Department of Health Policy and Management (J.Z., A.M.E.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine (E.J.O., A.M.E.), Brigham and Women’s Hospital, Boston, MA
- Department of Biostatistics (E.J.O.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Arnold M. Epstein
- Division of General Internal Medicine and Primary Care, Department of Medicine (E.J.O., A.M.E.), Brigham and Women’s Hospital, Boston, MA
- Department of Health Policy and Management (J.Z., A.M.E.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Karen E. Joynt Maddox
- Center for Advancing Health Services, Policy & Economics Research, Washington University, St. Louis, MO (S.A.S., K.E.J.M.)
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (K.E.J.M.)
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Burke LG, Burke RC, Duggan CE, Figueroa JF, John Orav E, Marcantonio ER. Trends in healthy days at home for Medicare beneficiaries using the emergency department. J Am Geriatr Soc 2023; 71:3122-3133. [PMID: 37300394 PMCID: PMC10592590 DOI: 10.1111/jgs.18464] [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] [Received: 02/07/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status. METHODS We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status. RESULTS We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD. CONCLUSIONS Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - E. John Orav
- Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
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Gagesch M, Wieczorek M, Abderhalden LA, Lang W, Freystaetter G, Armbrecht G, Kressig RW, Vellas B, Rizzoli R, Blauth M, Orav EJ, Egli A, Bischoff-Ferrari HA. Grip strength cut-points from the Swiss DO-HEALTH population. Eur Rev Aging Phys Act 2023; 20:13. [PMID: 37543639 PMCID: PMC10403936 DOI: 10.1186/s11556-023-00323-6] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND While grip strength (GS) is commonly assessed using a Dynamometer, the Martin Vigorimeter was proposed as an alternative method especially in older adults. However, its reference values for Swiss older adults are missing. We therefore aimed to derive sex- and age-specific GS cut-points for the dominant and non-dominant hand (DH; NDH) using the Martin Vigorimeter. Additionally, we aimed to identify clinically relevant weakness and assess convergent validity with key markers of physical function and sarcopenia in generally healthy Swiss older adults. METHODS This cross-sectional analysis includes baseline data from Swiss participants enrolled in DO-HEALTH, a 3-year randomized controlled trial in community-dwelling adults age 70 + . For both DH and NDH, 4 different definitions of weakness to derive GS cut-points by sex and age category (≤ 75 vs. > 75 years) were used: i) GS below the median of the 1st quintile, ii) GS below the upper limit of the 1st quintile, iii) GS below 2-standard deviation (SD) of the sex- and age-specific mean in DO-HEALTH Swiss healthy agers (i.e. individuals without major chronic diseases, disabilities, cognitive impairment or mental health issues) and iv) GS below 2.5-SD of the sex- and age-specific mean in DO-HEALTH Swiss healthy agers. To assess the proposed cut-points' convergent validity, we assessed their association with gait speed, time to complete the 5 Times Sit-To-Stand (5TSTS) test, and present sarcopenia. RESULTS In total, 976 participants had available GS at the DH (mean age 75.2, 62% women). According to the 4 weakness definitions, GS cut-points at the DH ranged from 29-42 and 25-39 kPa in younger and older women respectively, and from 51-69 and 31-50 kPa in younger and older men respectively. Overall, weakness prevalence ranged from 2.0% to 19.3%. Definitions of weakness using the median and the upper limit of the 1st GS quintile were most consistently associated with markers of physical performance. Weak participants were more likely to have lower gait speed, longer time to complete the 5TSTS, and sarcopenia, compared to participants without weakness. CONCLUSIONS In generally healthy Swiss older adults, weakness defined by the median or the upper limit of the 1st GS quintile may serve as reference to identify clinically relevant weakness. Additional research is needed in less healthy populations in order to derive representative population-based cut-points. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01745263.
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Affiliation(s)
- Michael Gagesch
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland.
| | - Maud Wieczorek
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Lauren A Abderhalden
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Wei Lang
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Gregor Freystaetter
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Gabriele Armbrecht
- Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Reto W Kressig
- University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| | - Bruno Vellas
- UMR INSERM 1027, Gérontopôle, Toulouse University Hospital, University of Toulouse, Toulouse, France
- IHU HealthAge, University Hospital Toulouse, Toulouse, France
| | - René Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - E John Orav
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Andreas Egli
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Heike A Bischoff-Ferrari
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
- IHU HealthAge, University Hospital Toulouse, Toulouse, France
- University Clinic for Acute Geriatric Care, City Hospital Waid and Triemli, Zurich, Switzerland
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Beckman AL, Tietschert M, Old A, Orav EJ, Singer SJ, Figueroa JF. High-performing primary care clinics across high-need, high-cost Medicare populations. BMJ Open Qual 2023; 12:e002271. [PMID: 37491105 PMCID: PMC10373721 DOI: 10.1136/bmjoq-2023-002271] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND To reduce spending and improve quality, some primary care clinics in the USA have focused on high-need, high-cost (HNHC) Medicare beneficiaries, which include clinically distinct subpopulations: older adults with frailty, adults under 65 years with disability and beneficiaries with major complex chronic conditions. Nationally, the extent to which primary care clinics are high-performing 'Bright Spots'-clinics that achieve favourable outcomes at lower costs across HNHC beneficiary subpopulations-is not known. OBJECTIVE To determine the prevalence of primary care clinics that perform highly on commonly used cost or quality measures for HNHC subpopulations. DESIGN AND PARTICIPANTS Cross-sectional study using Medicare claims data from 2014 to 2015. MAIN MEASURES Annual spending, avoidable hospitalisations for ambulatory care-sensitive conditions, treat-and-release emergency department visits, all-cause 30-day unplanned hospital readmission rates and healthy days at home. Clinics were high performing when they ranked in the top quartile of performance for ≥4 measures for an HNHC subpopulation. 'Bright Spot' clinics were in the top quartile of performance for ≥4 measures across all the HNHC subpopulations. KEY RESULTS A total of 2770 primary care clinics cared for at least 10 beneficiaries from each of the three HNHC subpopulations (adults under 65 with disability, older adults with frailty and beneficiaries with major complex chronic conditions). Less than 4% of clinics were high performing for each HNHC subpopulation; <0.5% of clinics were in the top quartile for all five measures for a given subpopulation. No clinics met the definition of a primary care 'Bright Spot'. CONCLUSIONS High-performing primary care clinics that achieved favourable health outcomes or lower costs across subpopulations of HNHC beneficiaries in the Medicare programme in 2015 were rare. Efforts are needed to support primary care clinics in providing optimal care to HNHC subpopulations.
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Affiliation(s)
- Adam L Beckman
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Andrew Old
- Ministry of Health New Zealand, Wellington, New Zealand
| | - E John Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard University TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Sara J Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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20
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Ulyte A, Waken RJ, Epstein AM, Orav EJ, Barnett ML, Joynt Maddox KE, Grabowski DC. Medicare Skilled Nursing Facility Use and Spending Before and After Introduction of the Public Health Emergency Waiver During the COVID-19 Pandemic. JAMA Intern Med 2023; 183:637-645. [PMID: 37093607 PMCID: PMC10126940 DOI: 10.1001/jamainternmed.2023.0770] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/16/2023] [Indexed: 04/25/2023]
Abstract
Importance In response to the COVID-19 pandemic, Medicare introduced a public health emergency (PHE) waiver in March 2020, removing a 3-day hospitalization requirement before fee-for-service beneficiaries could receive skilled nursing facility (SNF) care benefits. Objective To assess whether there were changes in SNF episode volume and Medicare spending on SNF care before and during the PHE among long-term care (LTC) residents and other Medicare beneficiaries. Design, Setting, and Participants This retrospective cohort study used Medicare fee-for-service claims and the Minimum Data Set for Medicare beneficiaries who were reimbursed for SNF care episodes from January 2018 to September 2021 in US SNFs. Exposures The prepandemic period (January 2018-February 2020) vs the PHE period (March 2020-September 2021). Main Outcomes and Measures The main outcomes were SNF episode volume, characteristics, and costs. Episodes were defined as standard (with a preceding 3-day hospitalization) or waiver (with other or no acute care use). Results Skilled nursing facility care was provided to 4 299 863 Medicare fee-for-service beneficiaries. Medicare beneficiaries had on average 130 400 monthly SNF episodes in the prepandemic period (mean [SD] age of beneficiaries, 78.9 [11.0] years; 59% female) and 108 575 monthly episodes in the PHE period (mean [SD] age of beneficiaries, 79.0 [11.1] years; 59% female). All waiver episodes increased from 6% to 32%, and waiver episodes without preceding acute care increased from 3% to 18% (from 4% to 49% among LTC residents). Skilled nursing facility episodes provided for LTC residents increased by 77% (from 15 538 to 27 537 monthly episodes), primarily due to waiver episodes provided for residents with COVID-19 in 2020 and early 2021 (62% of waiver episodes without preceding acute care). Skilled nursing facilities in the top quartile of waiver episodes were more often for-profit (80% vs 68%) and had lower quality ratings (mean [SD] overall star rating, 2.7 [1.4] vs 3.2 [1.4]; mean [SD] staffing star rating, 2.5 [1.1] vs 3.0 [1.2]) compared with SNFs in the other quartiles. Monthly Medicare spending on SNF care was $2.1 billion before the pandemic and $2.0 billion during the PHE. For LTC residents, monthly SNF spending increased from $301 million to $585 million while spending on hospitalizations remained relatively stable. Conclusions and Relevance This cohort study found that the PHE waiver for SNF care was associated with a marked increase in the prevalence of SNF episodes without a preceding hospitalization, especially in the first year of the COVID-19 pandemic. The waiver was used primarily among certain types of facilities and for LTC residents with COVID-19. Although the effect of the waiver cannot be differentiated from that of the pandemic, overall SNF care costs did not increase substantially; for LTC residents, the waiver was applied primarily for COVID-19 care, suggesting the waiver's successful implementation.
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Affiliation(s)
- Agne Ulyte
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - R. J. Waken
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Arnold M. Epstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Center for Health Economics & Policy, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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21
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Figueroa JF, Dai D, Feyman Y, Garrido MM, Tsai TC, Orav EJ, Frakt AB. Use of High-Risk Medications Among Older Adults Enrolled in Medicare Advantage Plans vs Traditional Medicare. JAMA Netw Open 2023; 6:e2320583. [PMID: 37368399 DOI: 10.1001/jamanetworkopen.2023.20583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Importance Limiting the use of high-risk medications (HRMs) among older adults is a national priority to provide a high quality of care for older beneficiaries of both Medicare Advantage and traditional fee-for-service Medicare Part D plans. Objective To evaluate the differences in the rate of HRM prescription fills among beneficiaries of traditional Medicare vs Medicare Advantage Part D plans and to examine the extent to which these differences change over time and the patient-level factors associated with higher rates of HRMs. Design, Setting, and Participants This cohort study used a 20% sample of Medicare Part D data on filled drug prescriptions from 2013 to 2017 and a 40% sample from 2018. The sample comprised Medicare beneficiaries aged 66 years or older who were enrolled in Medicare Advantage or traditional Medicare Part D plans. Data were analyzed between April 1, 2022, and April 15, 2023. Main Outcomes and Measures The primary outcome was the number of unique HRMs prescribed to older Medicare beneficiaries per 1000 beneficiaries. Linear regression models were used to model the primary outcome, adjusting for patient characteristics and county characteristics and including hospital referral region fixed effects. Results The sample included 5 595 361 unique Medicare Advantage beneficiaries who were propensity score-matched on a year-by-year basis to 6 578 126 unique traditional Medicare beneficiaries between 2013 and 2018, resulting in 13 704 348 matched pairs of beneficiary-years. The traditional Medicare vs Medicare Advantage cohorts were similar in age (mean [SD] age, 75.65 [7.53] years vs 75.60 [7.38] years), proportion of males (8 127 261 [59.3%] vs 8 137 834 [59.4%]; standardized mean difference [SMD] = 0.002), and predominant race and ethnicity (77.1% vs 77.4% non-Hispanic White; SMD = 0.05). On average in 2013, Medicare Advantage beneficiaries filled 135.1 (95% CI, 128.4-142.6) unique HRMs per 1000 beneficiaries compared with 165.6 (95% CI, 158.1-172.3) HRMs per 1000 beneficiaries for traditional Medicare. In 2018, the rate of HRMs had decreased to 41.5 (95% CI, 38.2-44.2) HRMs per 1000 beneficiaries in Medicare Advantage and to 56.9 (95% CI, 54.1-60.1) HRMs per 1000 beneficiaries in traditional Medicare. Across the study period, Medicare Advantage beneficiaries received 24.3 (95% CI, 20.2-28.3) fewer HRMs per 1000 beneficiaries per year compared with traditional Medicare beneficiaries. Female, American Indian or Alaska Native, and White populations were more likely to receive HRMs than other groups. Conclusion and Relevance Results of this study showed that HRM rates were consistently lower among Medicare Advantage than traditional Medicare beneficiaries. Higher use of HRMs among female, American Indian or Alaska Native, and White populations is a concerning disparity that requires further attention.
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Affiliation(s)
- Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dannie Dai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yevgeniy Feyman
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Melissa M Garrido
- Boston University School of Public Health, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Thomas C Tsai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Boston, Massachusetts
| | - E John Orav
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Austin B Frakt
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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22
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Velasquez DE, Orav EJ, Figueroa JF. Enrollment And Characteristics Of Dual-Eligible Medicare And Medicaid Beneficiaries In Integrated Care Programs. Health Aff (Millwood) 2023; 42:683-692. [PMID: 37126757 DOI: 10.1377/hlthaff.2022.01321] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Integrated care programs (ICPs) are meant to make Medicare and Medicaid coverage for dual-eligible beneficiaries work more seamlessly. Evidence is limited on ICP enrollment trends and the characteristics of dual-eligible beneficiaries who enroll in these programs-specifically, the Program of All-Inclusive Care for the Elderly, Medicare Advantage (MA) Fully Integrated Dual-Eligible Special Needs Plans, and state demonstration Medicare-Medicaid plans. Using national data, we evaluated changes in ICP enrollment between 2013 and 2020 and compared the demographic characteristics of beneficiaries in these programs relative to the characteristics of beneficiaries not in them. The proportion of dual-eligible beneficiaries in ICPs increased from 2.0 percent in 2013 to 9.4 percent in 2020. However, nonintegrated or partially integrated coordination-only MA plans experienced the plurality of growth in enrollment of dual-eligible beneficiaries. Relative to non-ICP fee-for-service Medicare, beneficiaries in ICPs were more likely to be Black and Hispanic versus White and were less likely to be rural, younger, or disabled. Policy makers should diligently monitor growth in ICPs and less integrated dual-eligible plans in MA while also evaluating their impact on equity, spending, and quality of care.
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Affiliation(s)
| | - E John Orav
- E. John Orav, Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
| | - José F Figueroa
- José F. Figueroa , Harvard University and Brigham and Women's Hospital
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23
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Kim Y, Mastali M, Van Eyk JE, Orav EJ, Vissing CR, Day SM, Raja AA, Russell MW, Zahka K, Lever HM, Pereira AC, Murphy AM, Canter C, Bach RG, Wheeler MT, Rossano JW, Owens AT, Bundgaard H, Benson L, Mestroni L, Taylor MRG, Patel AR, Wilmot I, Thrush P, Soslow JH, Becker JR, Seidman CE, Ho CY. Transforming Growth Factor-β Analysis of the VANISH Trial Cohort. Circ Heart Fail 2023; 16:e010314. [PMID: 36999957 PMCID: PMC10121916 DOI: 10.1161/circheartfailure.122.010314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Affiliation(s)
- Yuri Kim
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA, USA
| | - Mitra Mastali
- Advanced Clinical Biosystems Research Institute, The Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer E. Van Eyk
- Advanced Clinical Biosystems Research Institute, The Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - E. John Orav
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Christoffer R. Vissing
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA, USA
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Sharlene M. Day
- Division of Cardiovascular Medicine Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Anna Axelsson Raja
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mark W. Russell
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Kenneth Zahka
- Department of Pediatric Cardiology, Cleveland Clinic Children’s, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Harry M. Lever
- Department of Pediatric Cardiology, Cleveland Clinic Children’s, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alexandre C. Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Anne M. Murphy
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles Canter
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard G. Bach
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew T. Wheeler
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph W. Rossano
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anjali T. Owens
- Division of Cardiovascular Medicine Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Henning Bundgaard
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lee Benson
- The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Luisa Mestroni
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew R. G. Taylor
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Amit R. Patel
- Division of Cardiology, University of Virginia, Charlottesville, VA, USA
| | - Ivan Wilmot
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Philip Thrush
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Jonathan H. Soslow
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason R. Becker
- Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christine E. Seidman
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA, USA
- Howard Hughes Medical Institute, Chevy Chase, MD, USA
| | | | - Carolyn Y. Ho
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA, USA
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Oseran AS, Wadhera RK, Orav EJ, Figueroa JF. Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings. Ann Intern Med 2023; 176:480-488. [PMID: 36972544 DOI: 10.7326/m22-3165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown. OBJECTIVE To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures. DESIGN Cross-sectional. SETTING Population-based. PARTICIPANTS Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. MEASUREMENTS Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated. RESULTS Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings. LIMITATION Hospital performance measurement and risk adjustment differed slightly from those used by Medicare. CONCLUSION Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. PRIMARY FUNDING SOURCE Laura and John Arnold Foundation.
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Affiliation(s)
- Andrew S Oseran
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts (A.S.O.)
| | - Rishi K Wadhera
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.K.W.)
| | - E John Orav
- Harvard T.H. Chan School of Public Health and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (E.J.O., J.F.F.)
| | - Jose F Figueroa
- Harvard T.H. Chan School of Public Health and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (E.J.O., J.F.F.)
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Chen AC, Epstein AM, Joynt Maddox KE, Grabowski DC, Orav EJ, Barnett ML. Care delivery approaches and perceived barriers to improving quality of care: A national survey of skilled nursing facilities. J Am Geriatr Soc 2023. [PMID: 36918371 PMCID: PMC10363227 DOI: 10.1111/jgs.18331] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/08/2023] [Accepted: 02/12/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Nursing home quality of care is a persistent challenge, with recent reports calling for increased reforms to improve quality and safety. Less is known about the clinical approaches currently used and the barriers perceived by skilled nursing facilities (SNFs) to provide care for their short-stay residents. METHODS We conducted a nationally representative survey of SNFs from October 2020 to May 2021 to understand their care delivery approaches and perceived barriers. Our primary outcomes were the reported number of 23 separate care delivery approaches and the reported number of 12 separate barriers to reduce spending or improve care for SNF short-stay residents. We also performed stratified analyses by facility participation in bundled payments and other SNF characteristics. RESULTS We received 377 responses from 693 SNFs contacted (response rate = 54%). SNFs reported an average of 16.8 care delivery approaches and an average of 5.0 barriers. While there were some differences observed in SNF characteristics, such as by bundled payments participation or ownership type, there were common care delivery approaches and barriers shared by most facilities. Care management practices, including reviewing the patient census and medication reconciliation on discharge, were the most common delivery approaches reported. SNFs were less likely to ensure the completion of a follow-up appointment with a primary care provider or track repeat emergency room visits. Issues concerning staffing, such as staff turnover and/or burnout, and lack of resources to provide patients social support, mental health, and substance use services, were the most cited barriers to care delivery. CONCLUSIONS Nationally, SNFs implemented a wide array of care delivery approaches, but challenges with staffing and limited resources to address patients' social and mental health needs were dominant. Individual SNFs may have limited ability to address these key barriers, so the involvement of many stakeholders across the entire healthcare system may be necessary.
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Affiliation(s)
- Amanda C Chen
- Harvard Graduate School of Arts and Sciences, Boston, Massachusetts, USA
| | - Arnold M Epstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Karen E Joynt Maddox
- Center for Economics and Policy, Institute of Public Health at Washington University, St. Louis, Missouri, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Ganguli I, Orav EJ, Hailu R, Lii J, Rosenthal MB, Ritchie CS, Mehrotra A. Patient Characteristics Associated With Being Offered or Choosing Telephone vs Video Virtual Visits Among Medicare Beneficiaries. JAMA Netw Open 2023; 6:e235242. [PMID: 36988958 PMCID: PMC10061240 DOI: 10.1001/jamanetworkopen.2023.5242] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Importance After the rapid expansion of telemedicine during the COVID-19 pandemic, there is debate about the role and reimbursement of telephone vs video visits. Missing is an understanding of what type of virtual visits clinicians may offer or patients may choose when given the option. Objective To evaluate characteristics of Medicare beneficiaries associated with practices and clinicians offering telephone visits only and patients receiving telephone visits only, when both telephone and video were available. Design, Setting, and Participants This survey study used 2019-2020 nationally representative Medicare Current Beneficiary Survey data. Participants included community-dwelling Medicare beneficiaries with a usual source of medical care who attended a practice offering telemedicine. Data were analyzed from May 3 to August 23, 2022. Main Outcomes and Measures Multivariable regression analysis was used to identify patient sociodemographic (age, sex, race, ethnicity, educational level, income, English proficiency, housing type, and number living at home), clinical (dementia, mental illness, self-rated health, hearing impairment, and vision impairment), and technology (technology access and prior use of video visits) factors associated with respondents' report of (1) practices offering telephone virtual visits only, (2) being offered telephone visits only when both video and telephone visits were available, and (3) receiving telephone visits only when both video and telephone visits were offered. Results Of 4691 respondents (representing 27 887 642 Medicare beneficiaries; mean [SD] age, 71.3[8.1] years; 55.0% female) reporting that their practice offered telemedicine, 1234 (23.3% weighted) reported that their practices offered telephone virtual visits only; factors associated with being in a practice offering telephone only included older age (adjusted odds ratio [aOR], 1.62 [95% CI, 1.10-2.39] for those aged ≥85 years vs 18-64 years), male sex (aOR, 1.36 [95% CI, 1.12-1.64]), Hispanic ethnicity (aOR, 1.41 [95% CI, 1.03-1.95]), lower income (aOR, 1.89 [95% CI, 1.43-2.49] for those with income ≤100% vs >200% of the federal poverty level), poor self-rated health (aOR, 1.25 [95% CI, 1.01-1.56]), and less technology access (aOR, 2.05 [95% CI, 1.61-2.60] for those with low vs high access). Of the 1593 patients in practices offering both video and telephone visits, 297 (16.7% weighted) were themselves offered telephone visits only; factors associated with being offered telephone only included Hispanic ethnicity (aOR, 1.96 [95% CI, 1.13-3.41]), limited English proficiency (aOR, 3.05 [95% CI, 1.28-7.31]), and less technology access (aOR, 1.68 [95% CI, 1.00-2.81] for those with low vs high access). Finally, of the 711 respondents who were themselves offered both video and telephone visits, 304 (43.1% weighted) had a telephone visit; factors associated with receiving telephone visits only were older age (aOR, 2.68 [95% CI, 1.21-5.92] for those aged 75-84 years vs 18-64 years) and less technology access (aOR, 2.65 [95% CI, 1.12-6.25] for those with moderate vs high access]). Among those who used video calls in other settings and were offered a choice, 122 (28.5%, weighted) chose telephone visits. Conclusions and Relevance In this survey study of Medicare beneficiaries, respondents often reported being offered or choosing telephone visits even when video visits were available. Study findings suggest that policy makers and clinical leaders should support the use of telephone visits to the extent that telephone is appropriate, while addressing both practice-level and patient-level barriers to video visits.
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Affiliation(s)
- Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ruth Hailu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Joyce Lii
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Meredith B Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Christine S Ritchie
- Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Beckman AL, Frakt AB, Duggan C, Zheng J, Orav EJ, Tsai TC, Figueroa JF. Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare. JAMA Health Forum 2023; 4:e225530. [PMID: 36826828 PMCID: PMC9958527 DOI: 10.1001/jamahealthforum.2022.5530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Importance Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care-sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges. Objective To determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare. Design, Setting, and Participants Cross-sectional study of US Medicare Advantage vs traditional Medicare beneficiaries from January 1 to December 31, 2018. Poisson regression models were used to compare risk-adjusted rates of Medicare Advantage vs traditional Medicare, controlling for patient demographic characteristics and clinical risk and including county fixed-effects. Data were analyzed between April 2021 and November 2022. Main Outcomes and Measures Hospitalizations, observation stays, and ED direct discharges for ACSCs. Results The study sample comprised 2 665 340 Medicare Advantage patients (mean [SD] age, 72.7 [9.8] years; 1 504 519 [56.4%] women; 1 859 067 [69.7%] White individuals) and 7 981 547 traditional Medicare patients (mean [SD] age, 71.2 [11.8] years; 4 232 201 [53.0%] women; 6 176 239 [77.4%] White individuals). Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94; 95% CI, 0.93-0.95), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44; 95% CI, 1.43-1.45) and observation stays (RR, 2.38; 95% CI, 2.34-2.41) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30; 95% CI, 1.30-1.31). Within the Medicare Advantage population, patients in health maintenance organizations (HMOs) were at lower risk of ACSC-related hospitalization compared with patients in its preferred provider organizations (RR, 0.96; 95% CI, 0.95-0.98); however, those in the HMOs had a higher risk of ED direct discharge (RR, 1.08; 95% CI, 1.07-1.09) and observation stay (overall RR, 1.10; 95% CI, 1.02-1.12). Conclusions and Relevance The findings of this cross-sectional study of Medicare Advantage and traditional Medicare patients with ACSCs indicate that apparent gains in lowering rates of potentially avoidable acute care have been associated with shifting inpatient care to settings such as ED direct discharges and observation stays.
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Affiliation(s)
- Adam L. Beckman
- Harvard Medical School, Boston, Massachusetts,Harvard Business School, Boston, Massachusetts
| | - Austin B. Frakt
- US Department of Veterans Affairs, Boston Healthcare System, Boston University School of Public Health, Boston, Massachusetts,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Ciara Duggan
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas C. Tsai
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Burke LG, Burke RC, Orav EJ, Duggan CE, Figueroa JF, Jha AK. Association of Academic Medical Center Presence With Clinical Outcomes at Neighboring Community Hospitals Among Medicare Beneficiaries. JAMA Netw Open 2023; 6:e2254559. [PMID: 36723939 PMCID: PMC9892959 DOI: 10.1001/jamanetworkopen.2022.54559] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Studies suggest that academic medical centers (AMCs) have better outcomes than nonteaching hospitals. However, whether AMCs have spillover benefits for patients treated at neighboring community hospitals is unknown. OBJECTIVE To examine whether market-level AMC presence is associated with outcomes for patients treated at nonteaching hospitals within the same markets. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based cohort study assessed traditional Medicare beneficiaries aged 65 years and older discharged from US acute care hospitals between 2015 and 2017 (100% sample). Data were analyzed from August 2021 to December 2022. EXPOSURES The primary exposure was market-level AMC presence. Health care markets (ie, hospital referral regions) were categorized by AMC presence (percentage of hospitalizations at AMCs) as follows: no presence (0%), low presence (>0% to 20%), moderate presence (>20% to 35%), and high presence (>35%). MAIN OUTCOMES AND MEASURES The primary outcomes were 30-day and 90-day mortality and healthy days at home (HDAH), a composite outcome reflecting mortality and time spent in facility-based health care settings. RESULTS There were 22 509 824 total hospitalizations, with 18 865 229 (83.8%) at non-AMCs. The median (IQR) age of patients was 78 (71-85) years, and 12 568 230 hospitalizations (55.8%) were among women. Of 306 hospital referral regions, 191 (62.4%) had no AMCs, 61 (19.9%) had 1 AMC, and 55 (17.6%) had 2 or more AMCs. Markets characteristics differed significantly by category of AMC presence, including mean population, median income, proportion of White residents, and physicians per population. Compared with markets with no AMC presence, receiving care at a non-AMC in a market with greater AMC presence was associated with lower 30-day mortality (9.5% vs 10.1%; absolute difference, -0.7%; 95% CI, -1.0% to -0.4%; P < .001) and 90-day mortality (16.1% vs 16.9%; absolute difference, -0.8%; 95% CI, -1.2% to -0.4%; P < .001) and more HDAH at 30 days (16.49 vs 16.12 HDAH; absolute difference, 0.38 HDAH; 95% CI, 0.11 to 0.64 HDAH; P = .005) and 90 days (61.08 vs 59.83 HDAH; absolute difference, 1.25 HDAH; 95% CI, 0.58 to 1.92 HDAH; P < .001), after adjustment. There was no association between market-level AMC presence and mortality for patients treated at AMCs themselves. CONCLUSIONS AND RELEVANCE AMCs may have spillover effects on outcomes for patients treated at non-AMCs, suggesting that they have a broader impact than is traditionally recognized. These associations are greatest in markets with the highest AMC presence and persist to 90 days.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ashish K. Jha
- Brown University School of Public Health, Providence, Rhode Island
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Ganguli I, Orav EJ, Lii J, Mehrotra A, Ritchie CS. Which Medicare Beneficiaries Have Trouble Getting Places Like the Doctor's Office, and How Do They Do It? J Gen Intern Med 2023; 38:245-248. [PMID: 35469357 PMCID: PMC9849509 DOI: 10.1007/s11606-022-07615-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/12/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Ishani Ganguli
- Brigham and Women's Hospital, Division of General Internal Medicine and Primary Care, 1620 Tremont Street, 3rd Floor, Boston, MA, 02120, USA.
- Harvard Medical School, Boston, MA, USA.
| | - E John Orav
- Brigham and Women's Hospital, Division of General Internal Medicine and Primary Care, 1620 Tremont Street, 3rd Floor, Boston, MA, 02120, USA
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Joyce Lii
- Harvard Medical School, Boston, MA, USA
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Milligan MG, Orav EJ, Lam MB. Determinants of Commercial Prices for Common Radiation Therapy Procedures. Int J Radiat Oncol Biol Phys 2023; 115:23-33. [PMID: 36309073 DOI: 10.1016/j.ijrobp.2022.04.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Using hospital-reported price data, we analyzed whether various market factors including radiation oncology practice consolidation were associated with higher commercial prices for radiation therapy (RT). METHODS AND MATERIALS We evaluated commercial prices paid by private insurers for 4 common RT procedures-intensity modulated RT (IMRT) planning, IMRT delivery, 3-dimensional RT (3D-RT) planning, and 3D-RT delivery-reported among the 2096 hospitals in the United States that deliver RT according to the Medicare Provider of Service file. To assess price variation within hospitals, we evaluated the ratio of the 90th percentile price to the 10th percentile price among different private insurers. To assess regional variation, we similarly compared median commercial prices at the 90th and 10th percentile hospitals in each Hospital Referral Region. We generated multivariable models to test the association of various hospital, health system, regional, and market factors on median hospital commercial prices. RESULTS A total of 1004 hospitals (47.9%) reported at least 1 commercial price for any of the 4 RT procedures considered in this study. National median commercial prices for IMRT planning and IMRT delivery were $4073 (interquartile ratio [IQR], $2242-$6305) and $1666 (IQR, $1014-$2619), respectively. Prices for 3D-RT planning and 3D-RT delivery were $2824 (IQR, $1339-$4738) and $616 (IQR, $419-877), respectively. Within hospitals, the 90th percentile price paid by a private insurer was 2.3 to 2.5 times higher on average than the 10th percentile price, depending on the procedure. Within each Hospital Referral Region, the median price at the 90th percentile hospital was between 2.4 and 3.2 times higher than at the 10th percentile hospital. On multivariable analysis, higher prices were generally observed at hospitals with for-profit ownership, teaching status, and affiliation with large health systems. Levels of radiation oncology practice consolidation were not significantly associated with any prices. CONCLUSIONS Commercial prices for common RT procedures vary by more than a factor of 2 depending on a patient's private insurer and hospital of choice. Higher prices were more likely to be found at for-profit hospitals, teaching hospitals, and hospitals affiliated with large health systems.
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Affiliation(s)
- Michael G Milligan
- Harvard Radiation Oncology Program, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - E John Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
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de Godoi Rezende Costa Molino C, Woll L, Wieczorek M, Abderhalden LA, Lanz P, Schaer DJ, Spahn DR, Orav EJ, Egli A, Bischoff-Ferrari HA. Association between iron deficiency and hospitalization rate in community-dwelling older adults: A 3-year prospective observational study of DO-HEALTH. Am J Clin Nutr 2023; 117:12-21. [PMID: 36789930 DOI: 10.1016/j.ajcnut.2022.11.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/31/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Iron deficiency (ID) is associated with negative health outcomes in older adults. However, data on the impact of ID on the number of hospitalizations and length of hospital stay (LOS) is lacking. OBJECTIVE To explore the associations between baseline ID and the number of hospitalizations and between baseline ID and at least one LOS ≥5 days in community-dwelling older adults. METHODS This is a secondary observational analysis of a randomized controlled trial including 2157 community-dwelling adults aged ≥70 years without major diseases at baseline. The main exposure was defined as ID (soluble transferrin receptor [sTfR] concentrations >28.1 nmol/L) at baseline. The primary outcome was the number of hospitalizations over a 3-year follow-up. The secondary outcome was having at least one LOS ≥5 days over the study period among individuals with one or more hospitalizations. Interaction between ID and anemia (hemoglobin <130 g/L for men and <120 g/L for women) was also investigated. RESULTS Baseline sTfR concentration was determined in 2141 participants (median age 74.0 years). At 3 year, 1497 hospitalizations were reported with an incidence rate of hospitalization of 0.26 per person-year (95% CI: 0.24, 0.28). Overall, baseline ID was associated with a 24% increased incidence rate of hospitalization (incidence rate ratio: 1.24; 95% CI: 1.05, 1.45) over 3 years. This association was independent of anemia status at baseline since the interaction between ID and anemia at baseline was not significant. Moreover, ID was not significantly associated with having a LOS ≥5 days (OR: 1.40; 95% CI: 1.00, 1.97) among participants with at least one hospitalization over 3 years. CONCLUSIONS ID is associated with increased hospitalization rate and not associated with LOS ≥5 days among generally healthy older adults. Efforts to minimize ID in older adults may improve overall health and optimize healthcare costs.
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Affiliation(s)
- Caroline de Godoi Rezende Costa Molino
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Laurence Woll
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Maud Wieczorek
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lauren A Abderhalden
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patricia Lanz
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dominik J Schaer
- Clinic for Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - E John Orav
- Department of Biostatistics, Harvard School of Public Health, Boston, USA
| | - Andreas Egli
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Heike A Bischoff-Ferrari
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland; University Clinic for Aging Medicine, Zurich City Hospital-Waid, Zurich, Switzerland.
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Hammond G, Orav EJ, Zheng J, Epstein AM, Joynt Maddox KE. Changes in Racial Equity Associated With Participation in the Bundled Payments for Care Improvement Advanced Program. JAMA Netw Open 2022; 5:e2244959. [PMID: 36469318 PMCID: PMC9855294 DOI: 10.1001/jamanetworkopen.2022.44959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The Medicare alternative payment models are designed to incentivize cost reduction and quality improvement, but there are no requirements established for evaluating the outcomes of the Medicare populations. OBJECTIVE To examine whether participation in the Medicare Bundled Payments for Care Improvement Advanced (BPCI-A) program was associated with narrowing or widening of Black and White racial inequities in outcomes and access. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort alternative payment models on equity and quality for disadvantaged populations were studied between April 6, 2021, and August 28, 2022, in US hospitals. Black and White Medicare beneficiaries admitted for any of the 29 inpatient conditions in the BPCI-A program between January 1, 2017, and September 31, 2019, were included. EXPOSURES BPCI-A participation implemented in 2018. MAIN OUTCOMES AND MEASURES Ninety-day readmission and mortality, healthy days at home, and proportion of Black patients hospitalized. Segmented regression models were used to examine quarterly changes in slopes for each outcome. RESULTS The sample included 6 690 336 episodes (6 019 359 White patients, 670 977 Black patients). The population comprised approximately 43% men, 57% women, 17% individuals younger than 65 years, 47% between ages 65 and 80 years, and 36% older than 80 years. Prior to implementation of the BPCI-A program, compared with episodes for White patients, Black patients had higher 90-day readmissions (36.3% vs 29.6%), similar 90-day mortality (12.3% vs 13.3%), and fewer healthy days at home (mean, 68.5 vs 69.5 days). BPCI-A participation was not associated with significant changes in the racial gap in readmissions but was associated with a greater gain in heathy days at home (differences by race, -0.07 days per quarter; 95% CI, -0.12 to -0.01 days per quarter). Among Black patients admitted to BPCI-A hospitals vs controls, healthy days at home increased by 0.09 more days/episode per quarter (95% CI, 0.02-0.17 days/episode per quarter). The proportion of Black patients decreased similarly at BPCI-A and control hospitals. CONCLUSIONS AND RELEVANCE In this cohort study, BPCI-A participation was not associated with improvements in racial inequities in clinical outcomes. Black patients in BPCI-A had a slight gain in healthy days at home; there were no changes in access. The findings of this study suggest that more needs to be done if payment policy reform is going to be part of the efforts to address glaring racial inequities in health care quality and outcomes. These findings support a need for payment policy reform specifically targeting equity-enhancing programs.
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Affiliation(s)
- Gmerice Hammond
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - E. John Orav
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston Massachusetts
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Arnold M. Epstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
- Institute for Public Health at Washington University, St. Louis, Missouri
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Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Medicare’s Bundled Payments For Care Improvement Advanced Model: Impact On High-Risk Beneficiaries. Health Aff (Millwood) 2022; 41:1661-1669. [DOI: 10.1377/hlthaff.2022.00138] [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] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - E. John Orav
- E. John Orav, Harvard University and Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Arnold M. Epstein
- Arnold M. Epstein, Harvard University and Brigham and Women’s Hospital
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Figueroa JF, Duggan C, Toledo-Cornell C, Zheng J, Orav EJ, Tsai TC. Assessment of Strategies Used in US Hospitals to Address Social Needs During the COVID-19 Pandemic. JAMA Health Forum 2022; 3:e223764. [PMID: 36269339 PMCID: PMC9587473 DOI: 10.1001/jamahealthforum.2022.3764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This survey study uses 2020 American Hospital Association data to assess strategies of US hospitals serving vulnerable populations in addressing social needs during the COVID-19 pandemic.
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Affiliation(s)
- Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts,Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ciara Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Jie Zheng
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Thomas C. Tsai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts,Brigham and Women’s Hospital, Boston, Massachusetts
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Lam MB, Friend TH, Erfani P, Orav EJ, Jha AK, Figueroa JF. ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study. J Gen Intern Med 2022; 37:3275-3282. [PMID: 35022958 PMCID: PMC9550919 DOI: 10.1007/s11606-021-07183-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN Retrospective analysis of Medicare claims. PATIENTS We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.
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Affiliation(s)
- Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Radiation Oncology, Brigham and Women's Hospital / Dana Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, MA, Boston, USA.
| | - Tynan H Friend
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - E John Orav
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- School of Public Health, Brown University, Providence, RI, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, MA, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Angelo J, Soto M, Dai D, Spector D, Orav EJ, Tavakkoli A, Tsai TC. Impact of the COVID-19 Pandemic on Inpatient and Outpatient Utilization of Bariatric Surgery. Surg Endosc 2022:10.1007/s00464-022-09655-3. [PMID: 36167873 PMCID: PMC9514883 DOI: 10.1007/s00464-022-09655-3] [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: 05/02/2022] [Accepted: 09/13/2022] [Indexed: 11/21/2022]
Abstract
Background During the COVID-19 pandemic, deferral of inpatient elective surgical procedures served as a primary mechanism to increase surge inpatient capacity. Given the benefit of bariatric surgery on treating obesity and associated comorbidities, decreased access to bariatric surgery may have long-term public health consequences. Understanding the extent of the disruption of the COVID-19 pandemic to bariatric surgery will help health systems plan for appropriate access. Materials and methods This is an observational cohort study using the PINC AI Healthcare Database from 1/1/2019–6/31/2021. A Poisson regression model with patient characteristics and hospital-fixed effects was used to assess the relative monthly within-hospital reduction in surgical encounters, variations by race and ethnicity, and shift from inpatient to outpatient procedures. A multivariate linear probability model was used to assess the change in 30-day readmissions from 2020 and 2021 compared to 2019. Results Among 309 hospitals, there were 46,539 bariatric procedures conducted in 2019 with a 14.8% reduction in volume to 39,641 procedures in 2020. There were 22,642 bariatric procedures observed from January to June of 2021. The most pronounced decrease in volume occurred in April with an 89.7% relative reduction from 2019. Black and Hispanic patients were more likely to receive bariatric surgery after the height of the pandemic compared to white patients. A clinically significant shift from inpatient to outpatient bariatric surgical procedures was not observed. Relative to 2019, there were no significant differences in bariatric surgical readmission rates. Conclusion During the pandemic there was a sizable decrease in bariatric surgical volume. There did not appear to be disparities in access to bariatric surgery for minority patients. We did not observe a meaningful shift toward outpatient bariatric surgical procedures. Post-pandemic, monitoring is needed to assess if hospitals have been able to meet the demand for bariatric surgical procedures. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09655-3.
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Affiliation(s)
- Jillian Angelo
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Mark Soto
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Dannie Dai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - David Spector
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Ali Tavakkoli
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA. .,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA. .,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.
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Barnett ML, Waken RJ, Zheng J, Orav EJ, Epstein AM, Grabowski DC, Joynt Maddox KE. Changes in Health and Quality of Life in US Skilled Nursing Facilities by COVID-19 Exposure Status in 2020. JAMA 2022; 328:941-950. [PMID: 36036916 PMCID: PMC9425288 DOI: 10.1001/jama.2022.15071] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE During the COVID-19 pandemic, the US federal government required that skilled nursing facilities (SNFs) close to visitors and eliminate communal activities. Although these policies were intended to protect residents, they may have had unintended negative effects. OBJECTIVE To assess health outcomes among SNFs with and without known COVID-19 cases. DESIGN, SETTING, AND PARTICIPANTS This retrospective observational study used US Medicare claims and Minimum Data Set 3.0 for January through November in each year beginning in 2018 and ending in 2020 including 15 477 US SNFs with 2 985 864 resident-years. EXPOSURES January through November of calendar years 2018, 2019, and 2020. COVID-19 diagnoses were used to assign SNFs into 2 mutually exclusive groups with varying membership by month in 2020: active COVID-19 (≥1 COVID-19 diagnosis in the current or past month) or no-known COVID-19 (no observed diagnosis by that month). MAIN OUTCOMES AND MEASURES Monthly rates of mortality, hospitalization, emergency department (ED) visits, and monthly changes in activities of daily living (ADLs), body weight, and depressive symptoms. Each SNF in 2018 and 2019 served as its own control for 2020. RESULTS In 2018-2019, mean monthly mortality was 2.2%, hospitalization 3.0%, and ED visit rate 2.9% overall. In 2020, among active COVID-19 SNFs compared with their own 2018-2019 baseline, mortality increased by 1.60% (95% CI, 1.58% to 1.62%), hospitalizations decreased by 0.10% (95% CI, -0.12% to -0.09%), and ED visit rates decreased by 0.57% (95% CI, -0.59% to -0.55%). Among no-known COVID-19 SNFs, mortality decreased by 0.15% (95% CI, -0.16% to -0.13%), hospitalizations by 0.83% (95% CI, -0.85% to -0.81%), and ED visits by 0.79% (95% CI, -0.81% to -0.77%). All changes were statistically significant. In 2018-2019, across all SNFs, residents required assistance with an additional 0.89 ADLs between January and November, and lost 1.9 lb; 27.1% had worsened depressive symptoms. In 2020, residents in active COVID-19 SNFs required assistance with an additional 0.36 ADLs (95% CI, 0.34 to 0.38), lost 3.1 lb (95% CI, -3.2 to -3.0 lb) more weight, and were 4.4% (95% CI, 4.1% to 4.7%) more likely to have worsened depressive symptoms, all statistically significant changes. In 2020, residents in no-known COVID-19 SNFs had no significant change in ADLs (-0.06 [95% CI, -0.12 to 0.01]), but lost 1.8 lb (95% CI, -2.1 to -1.5 lb) more weight and were 3.2% more likely (95% CI, 2.3% to 4.1%) to have worsened depressive symptoms, both statistically significant changes. CONCLUSIONS AND RELEVANCE Among skilled nursing facilities in the US during the first year of the COVID-19 pandemic and prior to the availability of COVID-19 vaccination, mortality and functional decline significantly increased at facilities with active COVID-19 cases compared with the prepandemic period, while a modest statistically significant decrease in mortality was observed at facilities that had never had a known COVID-19 case. Weight loss and depressive symptoms significantly increased in skilled nursing facilities in the first year of the pandemic, regardless of COVID-19 status.
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Affiliation(s)
- Michael L. Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - R. J. Waken
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, Missouri
- Center for Health Economics and Policy, Institute of Public Health at Washington University in St Louis, Missouri
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Arnold M. Epstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, Missouri
- Center for Health Economics and Policy, Institute of Public Health at Washington University in St Louis, Missouri
- Associate Editor, JAMA
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Bruch JD, Nair-Desai S, Orav EJ, Tsai TC. Private Equity Acquisitions Of Ambulatory Surgical Centers Were Not Associated With Quality, Cost, Or Volume Changes. Health Aff (Millwood) 2022; 41:1291-1298. [PMID: 36067436 DOI: 10.1377/hlthaff.2021.01904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ambulatory surgical centers (ASCs) are increasingly being acquired by private equity firms, yet the implications for patients remain understudied. In this study we employed a quasi-experimental difference-in-differences design within an event study framework to assess changes in outcomes associated with the acquisition of ASCs by private equity entities. Using a two-way fixed effects model, we assessed the baseline probability of an unplanned hospital visit, total costs, and total encounters three years preacquisition compared with three years postacquisition in ASCs acquired by private equity versus those acquired by non-private equity entities. We identified ninety-one ASCs acquired by private equity and fifty-seven ASCs acquired by non-private equity entities during the period 2011-14. There was no statistically significant observed change in the probability of an unplanned hospital visit, total costs, or total encounters after acquisition by private equity relative to acquisition by non-private equity entities. When we compared private equity-acquired ASCs with matched ASCs that were never acquired, we also found no statistically significant relative change in the probability of an unplanned hospital visit, total costs, or total encounters. Regulators should ensure that data on private equity acquisitions are transparent and that data are available to track the long-term quality and financial implications of these acquisitions.
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Affiliation(s)
| | | | - E John Orav
- E. John Orav, Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
| | - Thomas C Tsai
- Thomas C. Tsai , Harvard University and Brigham and Women's Hospital
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Figueroa JF, Phelan J, Newton H, Orav EJ, Meara ER. ACO Participation Associated With Decreased Spending For Medicare Beneficiaries With Serious Mental Illness. Health Aff (Millwood) 2022; 41:1182-1190. [PMID: 35914206 DOI: 10.1377/hlthaff.2022.00096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Serious mental illness (SMI) is a major source of suffering among Medicare beneficiaries. To date, limited evidence exists evaluating whether Medicare accountable care organizations (ACOs) are associated with decreased spending among people with SMI. Using national Medicare data from the period 2009-17, we performed difference-in-differences analyses evaluating changes in spending and use associated with enrollment in the Medicare Shared Savings Program (MSSP) among beneficiaries with SMI. After five years, participation in MSSP ACOs was associated with small savings for beneficiaries with SMI (-$233 per person per year) in total health care spending, primarily related to savings from chronic medical conditions (excluding mental health; -$227 per person per year) and not from savings related to mental health services (-$6 per person per year). Savings were driven by reductions in acute and postacute care for medical conditions. Further work is needed to ensure that Medicare ACOs invest in strategies to reduce potentially unnecessary care related to mental health disorders and to improve health outcomes.
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Affiliation(s)
- José F Figueroa
- José F. Figueroa , Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Helen Newton
- Helen Newton, Yale University, New Haven, Connecticut
| | - E John Orav
- E. John Orav, Harvard University and Brigham and Women's Hospital
| | - Ellen R Meara
- Ellen R. Meara, Harvard University; Dartmouth College, Lebanon, New Hampshire; and National Bureau of Economic Research, Cambridge, Massachusetts
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Abstract
This cross-sectional study assesses whether the increase in adult and pediatric and neonatal mechanical ventilators in US hospitals in response to the COVID-19 pandemic varied across hospital structural features, region, and safety-net status.
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Affiliation(s)
- Thomas C. Tsai
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ashish K. Jha
- Brown University School of Public Health, Providence, Rhode Island
| | - Jose F. Figueroa
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Levine DM, Paz M, Burke K, Beaumont R, Boxer RB, Morris CA, Britton KA, Orav EJ, Schnipper JL. Remote vs In-home Physician Visits for Hospital-Level Care at Home: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2229067. [PMID: 36040741 PMCID: PMC9428739 DOI: 10.1001/jamanetworkopen.2022.29067] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
IMPORTANCE Home hospital care is the substitutive provision of home-based acute care services usually associated with a traditional inpatient hospital. Many home hospital models require a physician to see patients at home daily, which may hinder scalability. Whether remote physician visits can safely substitute for most in-home visits is unknown. OBJECTIVE To compare remote and in-home physician care. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial assessed 172 adult patients at an academic medical center and community hospital who required hospital-level care for select acute conditions, including infection, heart failure, chronic obstructive pulmonary disease, and asthma, between August 3, 2019, and March 26, 2020; follow-up ended April 26, 2020. INTERVENTIONS All patients received acute care at home, including in-home nurse or paramedic visits, intravenous medications, remote monitoring, and point-of-care testing. Patients were randomized to receive physician care remotely (initial in-home visit followed by daily video visit facilitated by the home hospital nurse) vs in-home care (daily in-home physician visit). In the remote care group, the physician could choose to see the patient at home beyond the first visit if it was felt to be medically necessary. MAIN OUTCOMES AND MEASURES The primary outcome was the number of adverse events, compared using multivariable Poisson regression at a noninferiority threshold of 10 events per 100 patients. Adverse events included a fall, pressure injury, and delirium. Secondary outcomes included the Picker Patient Experience Questionnaire 15 score (scale of 0-15, with 0 indicating worst patient experience and 15 indicating best patient experience) and 30-day readmission rates. RESULTS A total of 172 patients (84 receiving remote care and 88 receiving in-home physician care [control group]) were randomized; enrollment was terminated early because of COVID-19. The mean (SD) age was 69.3 (18.0) years, 97 patients (56.4%) were female, 77 (45.0%) were White, and 42 (24.4%) lived alone. Mean adjusted adverse event count was 6.8 per 100 patients for remote care patients vs 3.9 per 100 patients for control patients, for a difference of 2.8 (95% CI, -3.3 to 8.9), supporting noninferiority. For remote care vs control patients, the mean adjusted Picker Patient Experience Questionnaire 15 score difference was -0.22 (95% CI, -1.00 to 0.56), supporting noninferiority. The mean adjusted 30-day readmission absolute rate difference was 2.28% (95% CI, -3.23% to 7.79%), which was inconclusive. Of patients in the remote group, 16 (19.0%) required in-home visits beyond the first visit. CONCLUSIONS AND RELEVANCE In this study, remote physician visits were noninferior to in-home physician visits during home hospital care for adverse events and patient experience, although in-home physician care was necessary to support many patients receiving remote care. Our findings may allow for a more efficient, scalable home hospital approach but require further research. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04080570.
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Affiliation(s)
- David M. Levine
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mary Paz
- MGH Institute of Health Professions, Boston, Massachusetts
| | | | - Ryan Beaumont
- Northeastern University Bouvé College of Health Sciences, Boston, Massachusetts
| | - Robert B. Boxer
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Charles A. Morris
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kathryn A. Britton
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Figueroa JF, Tosin-Oni M, Phelan J, Orav EJ, Epstein AM. Changes in Employment Status and Access to Care During COVID-19 Pandemic Among Low-Income Adults in 4 Southern States. J Gen Intern Med 2022; 37:2795-2802. [PMID: 35428901 PMCID: PMC9012249 DOI: 10.1007/s11606-022-07547-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/30/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND While the impact of the COVID-19 recession on the economy is clear, there is limited evidence on how the COVID-19 pandemic-related job losses among low-income people may have affected their access to health care. OBJECTIVE To determine the association of job loss during the pandemic with insurance coverage and access to and affordability of health care among low-income adults. DESIGN Using a random digit dialing telephone survey from October 2020 to December 2020 of low-income adults in 4 states-Arkansas, Kentucky, Louisiana, and Texas-we conducted a series of multivariable logistic regression analyses, adjusting for demographics, chronic conditions, and state of residence. PARTICIPANTS US citizens aged 19-64 with a family income less than 138% of the federal poverty line who became newly unemployed during pandemic, remained employed during pandemic, or were chronically unemployed before and during the pandemic. MAIN MEASURES Rates of insurance, type of insurance coverage, measures of access to/affordability of care, and food/housing security KEY RESULTS: Of 1,794 respondents, 14.5% were newly unemployed, 49.6% were chronically unemployed, and 35.7% were employed. The newly unemployed were slightly younger and more likely Black or Latino. The newly unemployed were more likely to report uninsurance compared to the employed (+16.4 percentage points, 95% CI 6.0-26.9), and the chronically unemployed (+26.4 percentage points, 95% CI 16.2-36.6), mostly driven by Texas' populations. The newly unemployed also reported lower rates of access to care and higher rates of financial barriers to care. They were also more likely to report food and housing insecurity compared to others. CONCLUSIONS In a survey of 4 Southern States during pandemic, the newly unemployed had higher rates of uninsurance and worse access to care-largely due to financial barriers-and reported more housing and food insecurity than other groups. Our study highlights the vulnerability of low-income populations who experienced a job loss, especially in Texas, which did not expand Medicaid.
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Affiliation(s)
- Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA. .,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Motunrayo Tosin-Oni
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jessica Phelan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - E John Orav
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arnold M Epstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Abstract
IMPORTANCE Little is known about changes in obstetric outcomes during the COVID-19 pandemic. OBJECTIVE To assess whether obstetric outcomes and pregnancy-related complications changed during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included pregnant patients receiving care at 463 US hospitals whose information appeared in the PINC AI Healthcare Database. The relative differences in birth outcomes, pregnancy-related complications, and length of stay (LOS) during the pandemic period (March 1, 2020, to April 31, 2021) were compared with the prepandemic period (January 1, 2019, to February 28, 2020) using logistic and Poisson models, adjusting for patients' characteristics, and comorbidities and with month and hospital fixed effects. EXPOSURES COVID-19 pandemic period. MAIN OUTCOMES AND MEASURES The 3 primary outcomes were the relative change in preterm vs term births, mortality outcomes, and mode of delivery. Secondary outcomes included the relative change in pregnancy-related complications and LOS. RESULTS There were 849 544 and 805 324 pregnant patients in the prepandemic and COVID-19 pandemic periods, respectively, and there were no significant differences in patient characteristics between periods, including age (≥35 years: 153 606 [18.1%] vs 148 274 [18.4%]), race and ethnicity (eg, Hispanic patients: 145 475 [47.1%] vs 143 905 [17.9%]; White patients: 456 014 [53.7%] vs 433 668 [53.9%]), insurance type (Medicaid: 366 233 [43.1%] vs 346 331 [43.0%]), and comorbidities (all standardized mean differences <0.10). There was a 5.2% decrease in live births during the pandemic. Maternal death during delivery hospitalization increased from 5.17 to 8.69 deaths per 100 000 pregnant patients (odds ratio [OR], 1.75; 95% CI, 1.19-2.58). There were minimal changes in mode of delivery (vaginal: OR, 1.01; 95% CI, 0.996-1.02; primary cesarean: OR, 1.02; 95% CI, 1.01-1.04; vaginal birth after cesarean: OR, 0.98; 95% CI, 0.95-1.00; repeated cesarean: OR, 0.96; 95% CI, 0.95-0.97). LOS during delivery hospitalization decreased by 7% (rate ratio, 0.931; 95% CI, 0.928-0.933). Lastly, the adjusted odds of gestational hypertension (OR, 1.08; 95% CI, 1.06-1.11), obstetric hemorrhage (OR, 1.07; 95% CI, 1.04-1.10), preeclampsia (OR, 1.04; 95% CI, 1.02-1.06), and preexisting chronic hypertension (OR, 1.06; 95% CI, 1.03-1.09) increased. No significant changes in preexisting racial and ethnic disparities were observed. CONCLUSIONS AND RELEVANCE During the COVID-19 pandemic, there were increased odds of maternal death during delivery hospitalization, cardiovascular disorders, and obstetric hemorrhage. Further efforts are needed to ensure risks potentially associated with the COVID-19 pandemic do not persist beyond the current state of the pandemic.
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Affiliation(s)
- Rose L. Molina
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Thomas C. Tsai
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Dannie Dai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mark Soto
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ning Rosenthal
- PINC AI Applied Sciences, Premier Inc, Charlotte, North Carolina
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
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Erfani P, Ojo A, John Orav E, Chino F, Lam MB. Utilization of National Cancer Institute-Designated Cancer Centers by Medicare Beneficiaries with Cancer. Ann Surg Oncol 2022; 29:7250-7258. [PMID: 35780214 DOI: 10.1245/s10434-022-12047-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 06/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Little is known about which patients use National Cancer Institute-designated cancer centers (NCICCs) nationally. This study aimed to identify sociodemographic characteristics associated with decreased NCICC use among Medicare beneficiaries. METHODS This study examined a national cohort of 534,008 Medicare beneficiaries with cancer in 2017 using multivariable logistic regressions for NCICC use. The covariates in the study were sex, age, cancer type, race/ethnicity, dual-eligibility status for Medicaid and Medicare, and NCICC presence in the home state. RESULTS In 2017, 19.5 % of Medicare beneficiaries with cancer used an NCICC at least once. Dual-eligible beneficiaries had 29 % lower adjusted odds of NCICC use than non-dual-eligible beneficiaries (adjusted odds ratio [aOR], 0.71; 95 % confidence interval [CI], 0.70-0.73; p < 0.001). American Indian/Alaska Native beneficiaries had 40 % lower odds of NCICC use than non-Hispanic white (NHW) beneficiaries (aOR, 0.60; 95 % CI, 0.53-0.68; p < 0.001). Compared with NHW beneficiaries, the odds of NCICC use were higher for black beneficiaries by 15 % (aOR, 1.15; 95 % CI, 1.12-1.18; p < 0.001), for Hispanic beneficiaries by 31 % (aOR, 1.31; 95 % CI, 1.26-1.35; p < 0.001), and for Asian/Pacific Islander beneficiaries by 126 % (aOR, 2.26; 95 % CI, 2.16-2.36; p < 0.001). Utilization declined steadily in older groups, with beneficiaries older than 95 years showing 73 % lower odds of NCICC use than beneficiaries younger than 65 years (aOR, 0.27; 95 % CI, 0.24-0.29; p < 0.001). CONCLUSIONS Medicaid-eligible, American Indian/Alaska Native, and older patients are substantially less likely to use NCICCs. Future research should focus on defining and addressing the barriers to NCICC access for these populations.
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Affiliation(s)
| | | | - E John Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Miranda B Lam
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA, 02115, USA.
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Fabregas JC, Riley KE, Brant JM, George TJ, Orav EJ, Lam MB. Association of social determinants of health with late diagnosis and survival of patients with pancreatic cancer. J Gastrointest Oncol 2022; 13:1204-1214. [PMID: 35837201 DOI: 10.21037/jgo-21-788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/30/2022] [Indexed: 12/22/2022] Open
Abstract
Background Pancreatic cancer disparities have been described. However, it is unknown if they contribute to a late diagnosis and survival of patients with metastatic disease. Identifying their role is important as it will open the door for interventions. We hypothesize that social determinants of health (SDH) such as income, education, race, and insurance status impact (I) stage of diagnosis of PC (Stage IV vs. other stages), and (II) overall survival (OS) in Stage IV patients. Methods Using the National Cancer Database, we evaluated a primary outcome of diagnosis of Stage IV PC and a secondary outcome of OS. Primary predictors included race, income, education, and insurance. Covariates included age, sex and Charlson-Deyo comorbidity score. Univariate, multivariable logistic regression models evaluated risk of a late diagnosis. Univariate, multivariable Cox proportional hazards model examined OS. 95% confidence intervals were used. Results 230,877 patients were included, median age of 68 years (SD 12.1). In univariate analysis, a better education, higher income, and insurance decreased the odds of Stage IV PC, while Black race increased it. In multivariable analysis, education [>93% high-school completion (HSC) vs. <82.4%, OR 0.96 (0.93-0.99)] and insurance [private vs. no, OR 0.72 (0.67-0.74)] significantly decreased the risk of a late diagnosis, whereas Black race increased the odds [vs. White, OR 1.09 (1.07-1.12)]. In univariate Cox analysis, having a higher income, insurance and better education improved OS, while Black race worsened it. In multivariable Cox, higher income [>$63,333 (vs. <$40,277), HR 0.87 (0.85-0.89)] and insurance [private vs. no, HR 0.77 (0.74-0.79)] improved OS. Conclusions SDH impacted the continuum of care for patients with advanced pancreatic cancer, including stage at diagnosis and overall survival.
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Affiliation(s)
- Jesus C Fabregas
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA.,University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Kristen E Riley
- Harvard Medical School, Department of Medicine, Boston, MA, USA
| | | | - Thomas J George
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA.,University of Florida Health Cancer Center, Gainesville, FL, USA
| | - E John Orav
- Harvard Medical School, Department of Medicine, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Miranda B Lam
- Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Department of Radiation Oncology, Boston, MA, USA.,Harvard T. H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA, USA
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Milligan M, Orav EJ, Mitchell AP, Lam M. Market determinants of commercial prices for intravenous chemotherapy infusions. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.1585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1585 Background: Recent price transparency legislation mandated that hospitals across the country report their individually negotiated prices with insurers. Using this data, we sought to characterize the prices paid for standard intravenous (IV) chemotherapy infusions, and determine the hospital, regional, and market factors associated with higher prices. Methods: We utilized a database of U.S. hospital-reported price transparency data to characterize prices for the most commonly billed chemotherapy drug administration Common Procedural Terminology (CPT) codes— 96413 (initial IV chemotherapy infusion) and 96415 (additional hour of IV chemotherapy). We obtained standard charges and commercial prices negotiated with private payers from hospitals that directly administer chemotherapy. To assess variation in prices, we calculated the ratio of the 90th percentile price to the 10th percentile price among private payers in each hospital and among hospitals in each Hospital Referral Region (HRR). We performed multivariable linear regressions to assess hospital, regional, and market factors associated with higher prices. Results: A total of 1,458 hospitals reported at least one price for CPT code 96413 or 96415. Hospitals reported 1 chargemaster and a median of 18 (IQR: 8–35) commercial prices negotiated with different private payers. National median commercial prices for CPT codes 96413 and 96415 were $536.00 (IQR: $326.43-$784.63) and $175.06 (IQR: $98.28-$327.25), respectively. Within each hospital, the 90th percentile commercial price was 2.2 times higher, on average, than the 10th percentile price for CPT code 96413, and 2.8 times higher for 96415. Among different hospitals within each HRR, the median commercial price at the 90th percentile hospital was 1.5 times higher than at the 10th percentile for CPT code 96413, and 2.3 times higher for 96415. On multivariable analysis, higher prices for CPT code 96413 were observed at for-profit hospitals ($215.12 higher than government not-for-profit hospitals, 95% CI: $55.22-$429.61). Higher prices for CPT code 96415 were observed at hospitals with higher predicted practice costs ($35.79 for every 1% increase in the geographical practice cost index, 95% CI: $16.69-$54.87), and a lower disproportionate share percentage ($0.96 for every 1% decrease in DSH patient percentage, 95% CI: $0.08-$19.41). Conclusions: Commercial prices for commonly billed IV chemotherapy infusions demonstrate significant variability. Prices for identical infusions vary by a factor of 2 depending on which hospital or private payer a patient selects. While prices for CPT code 96415 are largely explained by the relative cost of care, prices for the more expensive 96413 appear to be driven by the profit-status of the hospital. Further study is required to characterize the implications of such high levels of price variability on access to care and overall healthcare costs.
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Affiliation(s)
| | | | | | - Miranda Lam
- Brigham and Women's Hospital/Dana Farber Cancer Institute, Boston, MA
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Milligan M, Erfani P, Orav EJ, Brooks GA, Lam M. Practice consolidation among U.S. medical oncologists over time. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e13627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e13627 Background: Physician practices across the U.S. are increasingly merging with hospitals and other practices. The extent of such “practice consolidation” varies by specialty and across geography but has not been well characterized within medical oncology. Methods: Utilizing Medicare data, we identified all medical oncologists (MO) who billed for Medicare services each year between 2015 and January 2022. We associated each physician to one or more unique practices via organizational Taxpayer Identification Numbers (TIN), and classified practices by the number of medical oncologists—including solo (1 MO), small (2-10 MOs), medium (11-24 MOs), and large (25+ MOs) practices. We defined the extent of regional healthcare markets according to Hospital Referral Regions (HRRs), and calculated levels of practice consolidation using the Herfindahl-Hirschman Index (HHI). The HHI is a commonly used measure of consolidation, calculated by summing the square of each practice’s market share. HHI values range from 0 to 1 with higher numbers indicating greater consolidation and less competition among practices. Finally, we generated a multivariable linear regression model to determine which regional market factors were associated with changes in levels of medical oncology practice consolidation over time. Results: Between 2015 and 2022, the number of practices with MOs in the U.S. declined 18.0% from 2,774 to 2,276, while the number of practicing MOs increased 14.5% from 11,727 to 13,433. The median medical oncology practice HHI increased from 0.3204 to 0.3480. Over time the proportion of solo practices fell (48.4% in 2015, 43.9% in 2022) while the proportion of medium and large practices increased (medium: 5.7% to 8.4%; large: 2.7% to 4.5%). By 2022, large practices had grown to employ a significantly larger proportion of all medical oncologists (33.6% to 43.7%, p < 0.001). Between 2015 and 2022, the proportion of practices solely comprised of MOs (as opposed to multispecialty practices) decreased from 40.0% to 28.2%. On multivariable analysis, HRRs with higher levels of hospital consolidation (p < 0.001), greater numbers of hospital beds per 1,000 persons (p = 0.02), and a lesser degree of baseline medical oncology practice consolidation in 2015 (p < 0.001) experienced more consolidation during the study period. Conclusions: Medical oncologists across the U.S. are increasingly working in larger practices. By 2022, more than 40% of all practicing MOs were employed at the largest 5% of practices. Consolidation of medical oncology practices occurred more readily in regions with higher levels of hospital consolidation and a greater supply of hospital beds, suggesting that integration into hospital systems may be a leading source of consolidation. Further study is required to determine the impact of practice consolidation on the cost, quality, and accessibility of cancer care.
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Affiliation(s)
| | | | | | | | - Miranda Lam
- Brigham and Women's Hospital/Dana Farber Cancer Institute, Boston, MA
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Mattle M, Meyer U, Lang W, Mantegazza N, Gagesch M, Mansky R, Kressig RW, Egli A, Orav EJ, Bischoff-Ferrari HA. Prevalence of Physical Activity and Sedentary Behavior Patterns in Generally Healthy European Adults Aged 70 Years and Older—Baseline Results From the DO-HEALTH Clinical Trial. Front Public Health 2022; 10:810725. [PMID: 35493350 PMCID: PMC9046658 DOI: 10.3389/fpubh.2022.810725] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 03/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background Physical activity (PA) is important for healthy aging and disease prevention whereas sedentary behavior (SB) accelerates health deterioration. Aim To investigate activity profiles regarding PA and SB among generally healthy European older adults. Methods Meeting PA recommendations was defined as ≥150 min/week of moderate and/or ≥75 min/week of vigorous PA. A cut-off of ≥5.5 h/day was used to define time spent with SB. We present prevalence of PA and SB overall and by sex, age, BMI, and country. We examined correlates with multivariate logistic regression models. Results Two thousand one hundred and fifty-five DO-HEALTH participants completed baseline information on activity profiles [mean age 74.9 years (SD 4.5), 61.8% women]. Overall, 62.2% met PA recommendations and overall, 37.1% spent ≥5.5 h/day with SB. Younger participants (70–74 years), men, and those with BMI <25 kg/m2 met PA recommendations more often. Per country, prevalence of meeting PA recommendations were: Austria 74.4%, France 51.0%, Germany 65.6%, Portugal 46.5%, and Switzerland 66.7%. Regarding SB, prevalence did not differ in all subgroups. In multivariate logistic regression analyses, being male, younger age, lower MoCA scores, and higher SPPB score were associated with greater odds, whereas higher BMI, more years of education, higher GDS score, and residing in Portugal were associated with lower odds of meeting PA recommendations. High BMI and higher MoCA scores were associated with greater odds of high SB. Conclusion Individualized public health efforts may be warranted even in active older adults, as profiles were less favorable in subgroups of older age, female sex and higher BMI.
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Affiliation(s)
- Michèle Mattle
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich - Waid, and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- *Correspondence: Michèle Mattle
| | - Ursina Meyer
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich - Waid, and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Wei Lang
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich - Waid, and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Noemi Mantegazza
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich - Waid, and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael Gagesch
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich - Waid, and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Richard Mansky
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich - Waid, and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Reto W. Kressig
- University Department of Geriatric Medicine FELIX PLATTER, Basel University, Basel, Switzerland
| | - Andreas Egli
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich - Waid, and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - E. John Orav
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | - Heike A. Bischoff-Ferrari
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich - Waid, and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- University Clinic for Aging Medicine, City Hospital Zurich - Waid, Zurich, Switzerland
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Figueroa JF, Katz IT, Hyle EP, Horneffer KE, Nambiar K, Phelan J, Orav EJ, Jha AK. The Association Of HIV With Health Care Spending And Use Among Medicare Beneficiaries. Health Aff (Millwood) 2022; 41:581-588. [PMID: 35377765 PMCID: PMC9153068 DOI: 10.1377/hlthaff.2021.01793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An increasingly older population of people with HIV raises concerns about how HIV may influence care for Medicare patients. We therefore sought to determine the extent to which HIV influences additional spending on and use of mental health and medical care among Medicare beneficiaries and, importantly, whether treatment with antiretroviral therapy may reduce this additional spending. Using 2016 Medicare claims, we compared risk-adjusted spending and utilization for Medicare beneficiaries with and without HIV, as well as subgroups of people receiving antiretroviral therapy (ART). Compared to beneficiaries without HIV, those with HIV receiving ART incurred 220.6 percent more spending, mostly driven by ART spending, whereas those with HIV not receiving ART incurred 95.4 percent more spending. Among beneficiaries with HIV, those receiving more months of ART had lower spending on treatment for other chronic conditions relative to those receiving fewer months of ART in a dose-response manner. Beneficiaries with HIV not receiving ART incurred the highest spending related to infections, mental health disorders, and other medical conditions compared to beneficiaries in other HIV subgroups receiving ART for various numbers of months. Our findings suggest that ART may be associated with Medicare Parts A and B savings, but ART adherence and the high prices of HIV drugs in Part D need to be addressed.
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Affiliation(s)
- José F Figueroa
- José F. Figueroa , Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
| | - Ingrid T Katz
- Ingrid T. Katz, Harvard University and Brigham and Women's Hospital
| | - Emily P Hyle
- Emily P. Hyle, Harvard University and Brigham and Women's Hospital
| | | | - Kavya Nambiar
- Kavya Nambiar, Brown University, Providence, Rhode Island
| | | | - E John Orav
- E. John Orav, Harvard University and Brigham and Women's Hospital
| | - Ashish K Jha
- Ashish K. Jha, Brown University and Providence Veterans Affairs Medical Center, Providence, Rhode Island
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Schnipper JL, Reyes Nieva H, Mallouk M, Mixon A, Rennke S, Chu E, Mueller S, Smith GRR, Williams MV, Wetterneck TB, Stein J, Dalal A, Labonville S, Sridharan A, Stolldorf DP, Orav EJ, Levin B, Gresham M, Yoon C, Goldstein J, Platt S, Nyenpan CT, Howell E, Kripalani S. Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study. BMJ Qual Saf 2022; 31:278-286. [PMID: 33927025 PMCID: PMC10964422 DOI: 10.1136/bmjqs-2020-012709] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 11/11/2020] [Revised: 03/26/2021] [Accepted: 04/10/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals. METHODS We conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression. RESULTS A total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions. CONCLUSION A multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.
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Affiliation(s)
- Jeffrey L Schnipper
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Harry Reyes Nieva
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Meghan Mallouk
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Amanda Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Stephanie Rennke
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Eugene Chu
- Division of Hospital Medicine, Parkland Health and Hospital System and Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Stephanie Mueller
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Gregory Randy R Smith
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark V Williams
- Division of Hospital Medicine, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Tosha B Wetterneck
- Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | | | - Anuj Dalal
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Brian Levin
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marcus Gresham
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Cathy Yoon
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jenna Goldstein
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Sara Platt
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | | | - Eric Howell
- Society of Hospital Medicine, Philadelphia, PA, USA
- Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Clinical Quality and Implementation Research, Nashville, TN, USA
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