Filling the Gaps in the Pandemic Response: Impact of COVID-19 on Telehealth in the Military Health System

Introduction: As a result of the COVID-19 pandemic, telehealth use became widespread, allowing for continued health care while minimizing COVID-19 transmission risk for patients and providers. This rapid scale-up highlighted shortcomings of the current telehealth infrastructure in many health systems. We aimed to identify and address gaps in the United States Military Health System (MHS) response to the COVID-19 pandemic related to the implementation and utilization of telehealth. Methods: We conducted semistructured key informant interviews of MHS stakeholders, including policymakers, program managers, and health care providers. We recruited respondents using purposive and snowball sampling until we reached thematic saturation. Interviews were conducted virtually from December 2022 to March 2023 and coded by deductive thematic analysis using NVivo. Results: We interviewed 28 key informants. Several themes emerged from the interviews and were categorized into four defined areas of obstacles to the effective utilization of telehealth: administrative, technical, organizational, and quality issues. While respondents had positive perceptions of telehealth, issues such as billing, licensure portability, network connectivity and technology, and ability to monitor health outcomes represent major barriers in the current system, preventing the potential for further expansion. Conclusions: While the shift to telehealth during the COVID-19 pandemic demonstrated robust potential within the MHS, it highlighted shortcomings that impair the utility and expansion of telehealth on a level comparable to that of other large health systems. Future focus should be directed toward generating and implementing actionable recommendations that target these identified challenges in the MHS.

Development and evaluation of a list of high-risk inpatient procedures in patients 65 years and older

BACKGROUND

Inpatient procedures are common and important health events for older Americans. To facilitate surgical outcomes research, we sought to create and evaluate lists of International Classification of Disease, Tenth Revision (ICD-10) codes for high-risk inpatient procedures, defined as having at least a 1% inpatient mortality.

METHODS

This retrospective national cohort study analyzes Medicare claims from 2018 for patients 65 years and older undergoing inpatient procedures. Surgical Diagnosis Related Group (DRG) codes in the inpatient claims were used to identify procedures. We identified the primary ICD-10 procedure code for each patient and then compiled all codes with at least a 1% inpatient mortality yielding three separate lists: one list that was blind to elective versus urgent/emergent status, and one each for urgent/emergent and elective procedures. Clinical review by three surgeons was used to remove procedures unlikely to be the proximate cause of mortality. For evaluation, we examined the mortality of each code among fee-for-service Medicare beneficiaries in 2017, 2019, and 2020 to determine how many of these satisfied the 1% mortality criterion.

RESULTS

This study included 2,241,419 patients from 2018 undergoing inpatient procedures. The final result included 231 (blind to elective vs urgent/emergent status), 167 (urgent/emergent status), and 119 (elective status) ICD-10 procedure codes for the three lists. Our evaluation from 2017, 2019, and 2020 demonstrated that in our master list, which was blind to elective versus urgent/emergent status, 97.8% of procedures had an inpatient mortality of at least 1%. In our high-risk procedures lists for urgent/emergent and elective procedures, 100% and 94.1% of codes met this requirement.

CONCLUSIONS

We developed and evaluated lists of ICD-10 codes representing high-risk procedures in patients 65 years and older. These lists will be powerful tools for researchers studying surgical outcomes.

Short-term outcomes of prehospital opioid pain management for older adults with fall-related injury

BACKGROUND

Opioids are recommended for pain management in patients being cared for and transported by emergency medical services, but no specific guidelines exist for older adults with fall-related injury. Prior research suggests prehospital opioid administration can effectively manage pain in older adults, but less is known about safety in this population. We compared short-term safety outcomes, including delirium, disposition, and length of stay, among older adults with fall-related injury according to whether they received prehospital opioid analgesia.

METHODS

We linked Medicare claims data with prehospital patient care reports for older adults (≥65) with fall-related injury in Illinois between January 1, 2014 and December 31, 2015. We used weighted regression models (logistic, multinomial logistic, and Poisson) to assess the association between prehospital opioid analgesia and incidence of inpatient delirium, hospital disposition, and length of stay.

RESULTS

Of 28,150 included older adults, 3% received prehospital opioids. Patients receiving prehospital opioids (vs. no prehospital opioids) were less likely to be discharged home from the emergency department (adjusted probability = 0.30 [95% CI: 0.25, 0.34] vs. 0.47 [95% CI: 0.46, 0.48]), more likely to be discharged to a non-home setting after an inpatient admission (adjusted probability = 0.43 [95% CI: 0.39, 0.48] vs. 0.30 [95% CI: 0.30, 0.31]), had inpatient length of stay 0.4 days shorter (p < 0.001) and ICU length of stay 0.7 days shorter (p = 0.045). Incidence of delirium did not vary between treatment and control groups.

CONCLUSIONS

Few older adults receive opioid analgesia in the prehospital setting. Prehospital opioid analgesia may be associated with hospital disposition and length of stay for older adults with fall-related injury. However, our findings do not provide evidence of an association with inpatient delirium. These findings should be considered when developing guidelines for prehospital pain management specific to the older adult population.

The Comparative Effectiveness and Provider-induced Demand Collaboration Project: A Pioneering Military-Civilian Academic Partnership to Build Health Services Research Capacity for the Military Health System

INTRODUCTION

Like civilian health systems, the United States Military Health System (MHS) confronts challenges in achieving the aims of reducing cost, and improving quality, access, and safety, but historically has lacked coordinated health services research (HSR) capabilities that enabled knowledge translation and iterative learning from its wealth of data. A military-civilian academic partnership called the Comparative Effectiveness and Provider-Induced Demand Collaboration (EPIC), formed in 2011, demonstrated early proof-of-concept in using the MHS claims database for research focused on drivers of variation in health care. This existing partnership was reorganized in 2015 and its topics expanded to meet the need for HSR in support of emerging priorities and to develop current and HSR capacity within the MHS.

MATERIALS AND METHODS

A Donabedian framework of structure, process, and outcomes was applied to support the project, through a core of principal investigators, researchers, analysts, and administrators. Within this framework, new researchers and student trainees learn foundations of HSR while performing secondary analysis of claims data from the MHS Data Repository (MDR) focusing on Health and Readiness, Pediatrics, Policy, Surgery, Trauma, and Women's Health.

RESULTS

Since 2015, the project has trained 25 faculty, staff, and providers; 51 students and residents; 21 research fellows across multiple disciplines; and as of 2022, produced 107 peer-reviewed publications and 130 conference presentations, across all five themes and six cores. Research results have been incorporated into Federal and professional policy guidelines. Major research areas include opioid usage and prescribing, value-based care, and racial disparities. EPIC researchers provide direct support to MHS leaders and enabling expertise to clinical providers.

CONCLUSIONS

EPIC, through its Donabedian framework and utilization of the MHS Data Repository as a research tool, generates actionable findings and builds capacity for continued HSR across the MHS. Eight years after its reorganization in 2015, EPIC continues to provide a platform for capacity building and knowledge translation.

Distinguishing Clinical from Statistical Significances in Contemporary Comparative Effectiveness Research

OBJECTIVE

To determine the prevalence of clinical significance reporting in contemporary comparative effectiveness research (CER).

BACKGROUND

In CER, a statistically significant difference between study groups may or may not be clinically significant. Misinterpreting statistically significant results could lead to inappropriate recommendations that increase healthcare costs and treatment toxicity.

METHODS

CER studies from 2022 issues of Annals of Surgery, Journal of the American Medical Association, Journal of Clinical Oncology, Journal of Surgical Research, and Journal of the American College of Surgeons were systematically reviewed by two different investigators. The primary outcome of interest was whether authors specified what they considered to be a clinically significant difference in the Methods.

RESULTS

Of 307 reviewed studies, 162 were clinical trials and 145 were observational studies. Authors specified what they considered to be a clinically significant difference in 26 studies (8.5%). Clinical significance was defined using clinically validated standards in 25 studies and subjectively in 1 study. Seven studies (2.3%) recommended a change in clinical decision-making, all with primary outcomes achieving statistical significance. Five (71.4%) of these studies did not have clinical significance defined in their methods. In randomized controlled trials with statistically significant results, sample size was inversely correlated with effect size (r=-0.30, P=0.038).

CONCLUSION

In contemporary CER, most authors do not specify what they consider to be a clinically significant difference in study outcome. Most studies recommending a change in clinical-decision making did so based on statistical significance alone, and clinical significance was usually defined with clinically validated standards.

The response of the Military Health System (MHS) to the COVID-19 pandemic: a summary of findings from MHS reviews

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic caused major disruptions to the US Military Health System (MHS). In this study, we evaluated the MHS response to the pandemic to understand the impact of the pandemic response in a large, national, integrated healthcare system providing care for ~ 9 million beneficiaries.

METHODS

We performed a narrative literature review of 16 internal Department of Defense (DoD) reports, including reviews mandated by the US Congress in response to the pandemic. We categorized the findings using the Doctrine, Organization, Training, Materiel, Leadership, Personnel, Facilities, and Policy (DOTMLPF-P) framework developed by the DoD to assess system efficiency and effectiveness.

RESULTS

The majority of the findings were in the policy, organization, and personnel categories. Key findings showed that the MHS structure to address surge situations was beneficial during the pandemic response, and the rapid growth of telehealth created the potential impact for improved access to routine and specialized care. However, organizational transition contributed to miscommunication and uneven implementation of policies; disruptions affected clinical training, upskilling, and the supply chain; and staffing shortages contributed to burnout among healthcare workers.

CONCLUSION

Given its highly integrated, vertical structure, the MHS was in a better position than many civilian healthcare networks to respond efficiently to the pandemic. However, similar to the US civilian sector, the MHS also experienced delays in care, staffing and materiel challenges, and a rapid switch to telehealth. Lessons regarding the importance of communication and preparation for future public health emergency responses are relevant to civilian healthcare systems responding to COVID-19 and other similar public health crises.

Development and Validation of a Novel Literature-Based Method to Identify Disparity-Sensitive Surgical Quality Metrics

BACKGROUND

Disparity in surgical care impedes the delivery of uniformly high-quality care. Metrics that quantify disparity in care can help identify areas for needed intervention. A literature-based Disparity-Sensitive Score (DSS) system for surgical care was adapted by the Metrics for Equitable Access and Care in Surgery (MEASUR) group. The alignment between the MEASUR DSS and Delphi ratings of an expert advisory panel (EAP) regarding the disparity sensitivity of surgical quality metrics was assessed.

STUDY DESIGN

Using DSS criteria MEASUR co-investigators scored 534 surgical metrics which were subsequently rated by the EAP. All scores were converted to a 9-point scale. Agreement between the new measurement technique (ie DSS) and an established subjective technique (ie importance and validity ratings) were assessed using the Bland-Altman method, adjusting for the linear relationship between the paired difference and the paired average. The limit of agreement (LOA) was set at 1.96 SD (95%).

RESULTS

The percentage of DSS scores inside the LOA was 96.8% (LOA, 0.02 points) for the importance rating and 94.6% (LOA, 1.5 points) for the validity rating. In comparison, 94.4% of the 2 subjective EAP ratings were inside the LOA (0.7 points).

CONCLUSIONS

Applying the MEASUR DSS criteria using available literature allowed for identification of disparity-sensitive surgical metrics. The results suggest that this literature-based method of selecting quality metrics may be comparable to more complex consensus-based Delphi methods. In fields with robust literature, literature-based composite scores may be used to select quality metrics rather than assembling consensus panels.

How Hospitals Are Addressing The Effects Of Racism: A Mixed-Methods Study Of Hospital Equity Officers

Hospital equity officers have become critical leaders in the effort to address the determinants of health care disparities, including structural racism. In this mixed-methods study, we surveyed a national sample of equity officers and interviewed a subset of respondents to provide additional perspective. About one-half of survey respondents reported at least some obstacles to achieving their health equity objectives, including racist beliefs among people working in their hospitals and health care systems, policies that perpetuate racism, and a lack of staff diversity. To address these challenges, some hospitals are collecting information about instances of racism, reviewing clinical algorithms for evidence of bias, or forming community partnerships. However, in interviews, equity officers pointed out that racism is a public health issue that cannot be adequately addressed solely within the health care system. Given the relative newness of most hospital equity officer positions, our research may be viewed as an early glimpse into the challenges and opportunities of this evolving work.

Effect of type of definitive treatment on race-based differences in prostate cancer-specific survival

BACKGROUND

Racial and ethnic disparities in prostate cancer (PCa) mortality are partially mediated by inequities in quality of care. Intermediate- and high-risk PCa can be treated with either surgery or radiation, therefore we designed a study to assess the magnitude of race-based differences in cancer-specific survival between these two treatment modalities.

METHODS

Non-Hispanic Black (NHB) and non-Hispanic White (NHW) men with localized intermediate- and high-risk PCa, treated with surgery or radiation between 2004 and 2015 in the Surveillance, Epidemiology and End Results database were included in the study and followed until December 2018. Unadjusted and adjusted survival analyses were employed to compare cancer-specific survival by race and treatment modality. A model with an interaction term between race and treatment was used to assess whether the type of treatment amplified or attenuated the effect of race/ethnicity on prostate cancer-specific mortality (PCSM).

RESULTS

15,178 (20.1%) NHB and 60,225 (79.9%) NHW men were included in the study. NHB men had a higher cumulative incidence of PCSM (p = 0.005) and were significantly more likely to be treated with radiation than NHW men (aOR: 1.89, 95% CI: 1.81-1.97, p < 0.001). In the adjusted models, NHB men were significantly more likely to die from PCa compared with NHW men (aHR: 1.18, 95% CI: 1.03-1.35, p = 0.014), and radiation was associated with a significantly higher odds of PCSM (aHR: 2.10, 95% CI: 1.85-2.38, p < 0.001) compared with surgery. Finally, the interaction between race and treatment on PCSM was not significant, meaning that no race-based differences in PCSM were found within each treatment modality.

CONCLUSIONS

NHB men with intermediate- and high-risk PCa had a higher rate of PCSM than NWH men in a large national cancer registry, though NHB and NHW men managed with the same treatment achieved similar PCa survival outcomes. The higher tendency for NHB men to receive radiation was similar in magnitude to the difference in cancer survival between racial and ethnic groups.

US clinicians' perspectives on advance care planning for persons with dementia: A qualitative study

BACKGROUND

Although advance care planning (ACP) for persons with dementia (PWD) can promote patient-centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians.

METHODS

Qualitative study using semi-structured interviews (August 2018-December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision-making was approached, and how decision-making capacity was assessed.

RESULTS

Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision-making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision-making assessments that allow PWD and carepartner involvement regardless of the patients' capacity.

CONCLUSIONS

Clinicians found early ACP for PWD valuable in promoting patient-centered care among an at-risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models.

Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study

BACKGROUND

Alzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery.

METHODS

Colorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes.

RESULTS

5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001).

CONCLUSIONS

The diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.

Does Being Poor and Sick Modify the Effect of Individuals on High-Deductible Health Plan (HDHP) Reporting Delayed/Foregone Care?

OBJECTIVE

To assess the influence of being both poor and sick on the association of high-deductible health plans (HDHPs) with delayed/forgone care.

FINDINGS

In this cross-sectional study that included 14,203 respondents, representing 120 million Americans, individuals insured by HDHPs had 2.23 times the odds of delayed/foregone care compared with non-HDHP insureds. When examined across strata of income and health status, the association yielded similar odds of delayed/foregone care. Additionally, the interaction of being poor and sick on the association of HDHPs to delayed/foregone care was not statistically significant. Meaning. Being insured on a HDHP affected delayed/foregone care largely consistently, regardless of health, income, or combined health/income category.

Disparity-Sensitive Measures in Surgical Care: A Delphi Panel Consensus

BACKGROUND

In the US, disparities in surgical care impede the delivery of uniformly high-quality care to all patients. There is a lack of disparity-sensitive measures related to surgical care. The American College of Surgeons Metrics for Equitable Access and Care in Surgery group, through research and expert consensus, aimed to identify disparity-sensitive measures in surgical care.

STUDY DESIGN

An environmental scan, systematic literature review, and subspecialty society surveys were conducted to identify potential disparity-sensitive surgical measures. A modified Delphi process was conducted where panelists rated measures on both importance and validity. In addition, a novel literature-based disparity-sensitive scoring process was used.

RESULTS

We identified 841 potential disparity-sensitive surgical measures. From these, our Delphi and literature-based approaches yielded a consensus list of 125 candidate disparity-sensitive measures. These measures were rated as both valid and important and were supported by the existing literature.

CONCLUSION

There are profound disparities in surgical care within the US healthcare system. A multidisciplinary Delphi panel identified 125 potential disparity-sensitive surgical measures that could be used to track health disparities, evaluate the impact of focused interventions, and reduce healthcare inequity.

Changes in Elective and Urgent Surgery Among TRICARE Beneficiaries During the COVID-19 Pandemic

BACKGROUND

COVID-19 is known to have altered the capacity to perform surgical procedures in numerous health care settings. The impact of this change within the direct and private-sector settings of the Military Health System has not been effectively explored, particularly as it pertains to disparities in surgical access and shifting of services between sectors. We sought to characterize how the COVID-19 pandemic influenced access to care for surgical procedures within the direct and private-sector settings of the Military Health System.

METHODS

We retrospectively evaluated claims for patients receiving urgent and elective surgical procedures in March-September 2017, 2019, and 2020. The pre-COVID period consisted of 2017 and 2019 and was compared to 2020. We adjusted for sociodemographic characteristics, medical comorbidities, and region of care using multivariable Poisson regression. Subanalyses considered the impact of race and sponsor rank as a proxy for socioeconomic status.

RESULTS

During the period of the COVID-19 pandemic, there was no significant difference in the adjusted rate of urgent surgical procedures in direct (risk ratio, 1.00; 95% CI, 0.97-1.03) or private-sector (risk ratio, 0.99; 95% CI, 0.97-1.02) care. This was also true for elective surgeries in both settings. No significant disparities were identified in any of the racial subgroups or proxies for socioeconomic status we considered in direct or private-sector care.

CONCLUSIONS

We found a similar performance of elective and urgent surgeries in both the private sector and direct care during the first 6 months of the COVID-19 pandemic. Importantly, no racial disparities were identified in either care setting.

In-hospital Outcomes for COVID-19 Patients in the Military Health System: Comparison of Military and Civilian Facility Treatment

INTRODUCTION

Beneficiaries of TRICARE, an insurance program of the military health system, can choose to receive care within the private sector (fee-for-service) or direct (budget-based facilities with salaried providers) care setting. Previous studies in several specialties have shown that there are disparities in both resource utilization and outcomes between the two settings. In this study, we sought to determine differences in outcomes between coronavirus disease 2019 (COVID-19) patients treated in the private sector versus direct care.

MATERIALS AND METHODS

Using TRICARE claims data, we identified patients admitted to the hospital for COVID-19 between March and September 2020. Cases were classified, according to the facility where they were admitted for treatment, as private sector or direct care. We abstracted patient sociodemographic characteristics, comorbid conditions, and outcomes including in-hospital mortality, intensive care unit (ICU) admission, ventilator use, in-hospital complications, and 30-day readmission. We used multivariable regression models, adjusted for covariates, to determine the association between health care settings and outcomes.

RESULTS

A total of 3,177 patients were included. Of these, 2,147 (68%) and 1,030 (32%) received care in the private sector and direct care settings, respectively. The average age of the study cohort was 52 years (SD = 21), and 84% had at least one medical comorbidity. In adjusted analyses, we found significant differences in the rates of ICU admission, with patients treated in private sector care having lower odds of being admitted to the ICU (odds ratio, 0.64; 95% CI, 0.53-0.76). There were no significant differences in the rates of in-hospital mortality, ventilator use, in-hospital complications, and 30-day readmissions.

CONCLUSION

With the exception of ICU admission rates, which are higher in the direct care setting, we encountered comparable hospital-based outcomes for patients treated for COVID-19 within the military health system, whether care was received under private sector or direct care.

Practice Billing for Medicare Advance Care Planning Across the USA

BACKGROUND

Medicare introduced billing codes in 2016 to encourage clinicians to engage in advance care planning (ACP) and promote goal-concordantend-of-life care, but uptake has been modest. While prior research examined individual-level factors in ACP billing, organization-level factors associated with physician practices billing for ACP remain unknown.

OBJECTIVE

Examine the role of practices in ACP billing.

DESIGN

Retrospective cohort study analyzing 2016-2018 national Medicare data.

PARTICIPANTS

A total of 53,926 practices with at least 10 attributed Medicare beneficiaries.

MAIN MEASURES

Outcomes were practice-level ACP billing (any use by the practice) and ACP use rate by practice-attributed beneficiaries. Practice characteristics were number of beneficiaries attributed to the practice; percentage of beneficiaries by race, Medicare-Medicaid dual enrollment, sex, and age; practice size; and specialty mix.

KEY RESULTS

Fifteen percent of practices billed for ACP. In adjusted models, we found higher odds of ACP billing and higher ACP use rates among practices with more primary care physicians (billing AOR: 10.01, 95%CI: 8.81-11.38 for practices with 75-100% (vs 0) primary care physicians), and those serving more Medicare beneficiaries (billing AOR: 4.55, 95%CI 4.08-5.08 for practices with highest (vs lowest) quintile of beneficiaries), and larger shares of female beneficiaries (billing AOR: 3.06, 95% CI 2.01-4.67 for 75-100% (vs <25%) female ).

CONCLUSIONS

Several years after Medicare introduced ACP reimbursements for physicians, relatively few practices bill for ACP. ACP billing was more likely in large practices with a greater percentage of primary care physicians. To increase ACP billing uptake, policymakers and health system leaders might target interventions to larger practices where a small number of physicians already bill for ACP and to specialty practices that serve as the primary source of care for seriously ill patients.

Associations between dementia diagnosis and end-of-life care utilization

BACKGROUND

Dementia is a leading cause of death for older adults and is more common among persons from racial/ethnic minoritized groups, who also tend to experience more intensive end-of-life care. This retrospective cohort study compared end-of-life care in persons with and without dementia and identified dementia's moderating effects on the relationship between race/ethnicity and end-of-life care.

METHODS

Administrative claims data for 463,590 Medicare fee-for-service decedents from 2016 to 2018 were analyzed. Multivariable logistic and linear regression analyses examined the association of dementia with 5 intensive and 2 quality of life-focused measures. Intensity measures included hospital admission, ICU admission, receipt of any of 5 intensive procedures (CPR, mechanical ventilation, intubation, dialysis initiation, and feeding tube insertion), hospital death, and Medicare expenditures (last 30 days of life). Quality of life measures included timely hospice care (>3 days before death) and days at home (last 6 months of life). Models were adjusted for demographic and clinical factors.

RESULTS

54% of Medicare decedents were female, 85% non-Hispanic White, 8% non-Hispanic Black, and 4% Hispanic. Overall, 51% had a dementia diagnosis claim. In adjusted models, decedents with dementia had 16%-29% lower odds of receiving intensive services (AOR hospital death: 0.71, 95% CI: 0.70-0.72; AOR hospital admission: 0.84, 95% CI: 0.83-0.86). Patients with dementia had 45% higher odds of receiving timely hospice (AOR: 1.45, 95% CI: 1.42-1.47), but spent 0.74 fewer days at home (adjusted mean: -0.74, 95% CI: (-0.98)-(-0.49)). Compared to non-Hispanic White individuals, persons from racial/ethnic minoritized groups were more likely to receive intensive services. This effect was more pronounced among persons with dementia.

CONCLUSIONS

Although overall dementia was associated with fewer intensive services near death, beneficiaries from racial/ethnic groups minoritized with dementia experienced more intensive service use. Particular attention is needed to ensure care aligns with the needs and preferences of persons with dementia and from racial/ethnic minoritized groups.

Patients living with dementia have worse outcomes when undergoing high-risk procedures

BACKGROUND

Patients with Alzheimer's Disease and Related Dementias (ADRD) undergoing inpatient procedures represent a population at elevated risk for adverse outcomes including postoperative complications, mortality, and discharge to a higher level of care. Outcomes may be particularly poor in patients with ADRD undergoing high-risk procedures. We sought to determine traditional (e.g., 30-day mortality) and patient-centered (e.g., discharge disposition) outcomes in patients with ADRD undergoing high-risk inpatient procedures.

METHODS

This retrospective cohort study analyzed electronic health records linked to fee-for-service Medicare claims data at a tertiary care academic health system. All patients from a large multi-hospital health system undergoing high-risk inpatient procedures from October 1, 2015 to September 30, 2017 with continuous Medicare Parts A and B enrollment in the 12 months prior to and 90 days following the procedure were included.

RESULTS

This study included 6779 patients. 536 (7.9%) had ADRD. A multivariable analysis of outcomes demonstrated higher risks for postoperative complications (OR 1.49, 95% CI 1.23-1.81) and 90-day mortality (OR 1.44 [95% CI 1.09-1.91]) in patients with ADRD compared to those without. Patients with ADRD were more likely to be discharged to a higher level of care (OR 1.70, 95% CI 1.32-2.18) and only 37.3% of patients admitted from home were discharged to home.

CONCLUSIONS

Compared to those without ADRD, patients living with ADRD undergoing high-risk procedures have poor traditional and patient-centered outcomes including increased risks for 90-day mortality, postoperative complications, longer hospital lengths of stay, and discharge to a higher level of care. These data may be used by patients, their surrogates, and their physicians to help align surgical decision-making with health care goals.

Advance Care Planning Experiences Among Sexual and Gender Minority People

IMPORTANCE

Advance care planning (ACP) can promote patient-centered end-of-life (EOL) care and is intended to ensure that medical treatments are aligned with patient's values. Sexual and gender minority (SGM) people face greater discrimination in health care settings compared with heterosexual, cisgender people, but it is unknown whether such discrimination occurs in ACP and how it might affect the ACP experiences of SGM people.

OBJECTIVES

To increase understanding of barriers and facilitators of ACP facing SGM individuals.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-methods national study of ACP included a telephone survey of self-identified SGM and non-SGM participants in a nationally representative sample drawn from a larger omnibus national panel by SSRS. Qualitative interviews were conducted with a subset of survey participants who identified as SGM. Data were collected from October 2020 to March 2021.

EXPOSURES

Self-identified SGM.

MAIN OUTCOMES AND MEASURES

The survey included 4 items from the validated ACP Engagement Survey, adapted to capture experiences of discrimination. Interviews asked about participants' experiences with ACP, including the appointment of medical decision-makers, sharing preferences, and experiences within the health care system more broadly.

RESULTS

A total of 603 adults participated in the survey, with 201 SGM individuals (mean [SD] age, 45.7 [18.7] years; 101 [50.2%] female; 22 [10.9%] Black, 37 [18.4%] Hispanic, and 140 [69.7%] White individuals) and 402 non-SGM individuals (mean [SD] age, 53.7 [19.2] years; 199 [49.5%] female; 35 [8.7%] Black, 41 [10.2%] Hispanic, and 324 [80.6%] White individuals). Regarding reasons for not completing ACP, SGM respondents, compared with non-SGM respondents, were more likely to say "I don't see the need" (72 [73.5%] vs 131 [57.2%], P = .006) and "I feel discriminated against by others" (12 [12.2%] vs 6 [2.6%], P < .001). Of 25 completed interviews among SGM participants, 3 main themes were identified: how fear and experiences of discrimination affect selection of clinicians and whether to disclose SGM identity; concerns about whether EOL preferences and medical decision-makers would be supported; and a preference to discuss EOL decisions and values outside of clinical settings.

CONCLUSIONS AND RELEVANCE

This study found that fear of disclosing sexual orientation or gender identity information and discrimination are important barriers to ACP for SGM in clinical settings, but discussions of preferences and values still occur between many SGM people and medical decision-makers. More SGM-specific patient-centered care might better support these discussions within the health care system. Furthermore, health systems can facilitate improved engagement by supporting clinician sensitivity training, including guidance on documentation and requirements.

Use of Advance Care Planning Codes Among Transgender Medicare Beneficiaries

Purpose: We examined the use of advance care planning (ACP) among Medicare beneficiaries who were identified as transgender. Methods: This study is a cross-sectional analysis of Medicare claims from 2016 to 2018, comparing ACP visits between transgender and other beneficiaries. Results: Beneficiaries identified as transgender were slightly more likely than those who were dual eligible for Medicaid and Medicare, and the remaining fee-for-service Medicare population, to have received a claim for ACP. However, racial and ethnic differences exist and transgender beneficiaries were more likely to receive an ACP claim from hospice/palliative care clinicians compared with primary care clinicians relative to other beneficiaries. Conclusions: Differences in ACP provision may exacerbate disparities in access to ACP benefits faced by transgender patients.

Access to definitive treatment and survival for intermediate-risk and high-risk prostate cancer at hospital systems serving health disparity populations

6555

Background: Socioeconomic and racial disparities in prostate cancer (PCa) can be attributed to patient-level and physician-level factors. However, there is growing interest in investigating the role of the facility of care in driving cancer disparities. Therefore, we sought to examine receipt of guideline-concordant definitive treatment, time to treatment initiation (TTI), and survival for men with PCa receiving care at hospital systems serving health disparity populations (HSDPs). Methods: We conducted a retrospective analysis of the National Cancer Database (2004-2016) among men with intermediate-risk or high-risk PCa eligible for definitive treatment. The primary outcomes were receipt of definitive treatment and TTI within 90 days of diagnosis. The secondary outcome was survival. We defined HSDPs as minority-serving hospitals – facilities in the highest decile of proportion of Non-Hispanic Black (NHB) or Hispanic cancer patients – and/or high-burden safety-net hospitals – facilities in the highest quartile of proportion of underinsured patients. We used mixed-effect models with facility-level random intercept to compare outcomes between HSDPs and non-HSDPs among the entire cohort and among men who received definitive treatment. We evaluated interactions between HSDP status and race for each of the outcomes. Results: The cohort included 821,931 men with intermediate-risk or high-risk PCa. We included 968 non-HSDPs (72.2%) and 373 HSDPs (27.8%) facilities. Treatment at HSDPs was associated with lower odds of receipt of definitive treatment (aOR 0.64; 95% CI 0.57-0.71; p < 0.001), lower odds of TTI within 90 days of diagnosis (aOR 0.74; 95% CI 0.68-0.79; p < 0.001), and worse survival (aHR 1.05; 95% CI 1.02-1.09; p = 0.003). However, no difference was found in survival among patients who received definitive treatment. NHB men at HSDPs had also worse outcomes than NHB men treated at non-HSDPs as well as NHW men treated at HSDPs (Table). Conclusions: Patients treated at HSDPs were less likely to receive timely definitive treatment and had worse survival. NHB men have worse outcomes than NHW at HSDPs. NHB men with PCa remain largely disadvantaged since they are more likely to be treated at hospitals with worse outcomes and have worse outcomes than other patients at those same institutions. [Table: see text]

Association of Trauma Center Designation With Postdischarge Survival Among Older Adults With Injuries

Importance

Trauma centers improve outcomes for young patients with serious injuries. However, most injury-related hospital admissions and deaths occur in older adults, and it is not clear whether trauma center care provides the same benefit in this population.

Objective

To examine whether 30- and 365-day mortality of injured older adults is associated with the treating hospital's trauma center level.

Design, Setting, and Participants

This prospective, population-based cohort study used Medicare claims data from January 1, 2013, to December 31, 2016, for all fee-for-service Medicare beneficiaries 66 years or older with inpatient admission for traumatic injury in 2014 to 2015. Data analysis was performed from January 1 to June 31, 2021. Preinjury health was measured using 2013 claims, and outcomes were measured through 2016. The population was stratified by anatomical injury pattern. Propensity scores for level I trauma center treatment were estimated using the Abbreviated Injury Scale, age, and residential proximity to trauma center and then used to match beneficiaries from each trauma level (I, II, III, and IV/non-trauma centers) by injury type.

Exposure

Admitting hospital's trauma center level.

Main Outcomes and Measures

Case fatality rates (CFRs) at 30 and 365 days after injury, estimated in the matched sample using multivariable, hierarchical logistic regression models.

Results

A total of 433 169 Medicare beneficiaries (mean [SD] age, 82.9 [8.3] years; 68.4% female; 91.5% White) were included in the analysis. A total of 206 275 (47.6%) were admitted to non-trauma centers and 161 492 (37.3%) to level I or II trauma centers. Patients with isolated extremity fracture had the fewest deaths (365-day CFR ranged from 16.1% [95% CI, 11.2%-22.4%] to 17.4% [95% CI, 11.8%-24.6%] by trauma center status). Patients with both hip fracture and traumatic brain injury had the most deaths (365-day CFRs ranged from 33.4% [95% CI, 25.8%-42.1%] to 35.8% [95% CI, 28.9%-43.5%]).

Conclusions and Relevance

These findings suggest that older adults do not benefit from existing trauma center care, which is designed with younger patients in mind. There is a critical need to improve trauma care practices to address common injury mechanisms and types of injury in older adults.

Geospatial Analysis of Access to Emergency Cesarean Delivery for Military and Civilian Populations in the US

IMPORTANCE

Many women in the US, particularly those living in rural areas, have limited access to obstetric care. Military-civilian partnership could improve access to obstetric care and benefit military personnel, their civilian dependents, and the civilian population as a whole.

OBJECTIVE

To identify medical facilities within military and civilian geographic areas that present opportunities for military-civilian partnership in obstetric care and to assess whether civilian use of military medical treatment facilities (MTFs) could improve access to emergency cesarean delivery care in the US.

DESIGN, SETTING, AND PARTICIPANTS

This geospatial epidemiological population-based cross-sectional study was conducted from November 2020 to March 2021. ArcGIS Pro software, version 2.7 (Esri), was used to assess population coverage for TRICARE (military insurance) beneficiaries and civilian populations and to estimate 30-minute travel time to 2392 total military and civilian medical facilities that were capable of providing emergency cesarean delivery care in the continental US. Data on health insurance coverage for TRICARE beneficiaries and their civilian dependents per county were obtained from the American Community Survey tables available through ArcGIS Pro software. Demographic characteristics of the general population were obtained from the 2020 key demographic indicators published by Esri. Race and ethnicity were not examined because the data used for this study were aggregated and did not include further categorization by race or ethnicity.

MAIN OUTCOMES AND MEASURES

Population coverage rates (measured in percentages) within 30-minute catchment areas, defined as areas that were within a 30-minute travel time to a medical facility capable of providing emergency cesarean delivery care.

RESULTS

A total of 29 MTFs and 2363 civilian hospitals capable of providing emergency cesarean delivery were identified across the contiguous US. Overall, an estimated 167 759 762 women (3 640 000 TRICARE beneficiaries and 164 119 762 civilians) were included in these service areas. The analysis identified 17 of 29 MTFs (58.6%) capable of providing emergency cesarean delivery care that were located within 30-minute catchment areas. Of those, 3 MTFs were the only facilities capable of providing emergency cesarean delivery care within a 30-minute travel time in those regions, and 14 additional MTFs had catchment areas partially overlapping with civilian hospitals that also covered areas without alternative access to emergency cesarean delivery. Expanded use of these 14 MTFs could enhance access to emergency cesarean delivery care not otherwise covered by current civilian hospitals.

CONCLUSIONS AND RELEVANCE

In this study, 58.6% of MTFs capable of providing emergency cesarean delivery care were located in areas with the potential to improve access to obstetric care within a 30-minute travel time. Maintenance of MTFs in these important access regions could be prioritized in the context of restructuring MTFs. This prioritization has the potential to improve access to emergency cesarean delivery care for underserved civilian populations in the US, particularly among those living in rural areas.

Understanding The Use Of Medicare Procedure Codes For Advance Care Planning: A National Qualitative Study

In 2016 Medicare introduced advance care planning Current Procedural Terminology (CPT) codes to reimburse clinicians for time spent providing the service. Despite recent increases, use of these codes remains low for reasons incompletely captured by quantitative research. To further identify barriers and facilitators to code use for Medicare fee-for-service enrollees, we conducted case studies at eleven health systems, including 272 interviews with clinicians, administrators, and key leadership. Five themes related to use of the new codes emerged: code-based constraints to billing, burdening patients with unexpected charges, ethical concerns with billing for discussion of advance care plans, incentives to signal the importance of their use in billing, and increasing both workflow burden and the need for institutional supports and training. Respondents also observed that use was facilitated by health systems' investment in clinician training and in processes to audit the codes' use. Our findings suggest that increased reimbursement, strong institutional commitment and support, and streamlined workflow could improve the use of the new CPT codes to document receipt of and ensure access to Medicare advance care planning.

UDI2Claims: Planning a Pilot Project to Transmit Identifiers for Implanted Devices to the Insurance Claim

BACKGROUND

In response to problems with the current postmarket surveillance of medical devices, the U.S. Food and Drug Administration mandated device labelers to include a unique device identifier (UDI), composed of a device identifier (DI) and production identifier. Including the DI in insurance claims could be a potent method to monitor implanted devices, yet implementation has lagged because of questions of benefit and operational concerns.

METHODS

To illustrate the potential benefit of including DIs in claims, rates of 90-day adverse events after implantation using an electronic health record (EHR) were compared with the EHR plus claims, which capture utilization outside that EHR's health system. To explore operations, we planned a pilot project to transmit the DI of implanted devices from the point of care to the claim at two provider/payer pairs.

RESULTS

By querying claims plus EHR, estimated rates of patients with potential adverse events were as much as 3.75 times higher. For our pilot, our multistakeholder team identified and resolved the following five challenges: (1) capturing the DI at the point of care; (2) selecting a location for the DI on the claim form; (3) transmitting the DI to the claim form; (4) analyzing the claim forms received by the payer; and (5) verifying the quality of the transmitted information.

CONCLUSIONS

Including DIs on claims could allow more complete data capture of adverse events for implanted devices than the EHR data. We overcame challenges in transmitting the DI to the claim with attention to planning and multistakeholder involvement.

Analysis of Surgical Volume in Military Medical Treatment Facilities and Clinical Combat Readiness of US Military Surgeons

Importance

Low surgical volume in the US Military Health System (MHS) has been identified as a challenge to military surgeon readiness. The Uniformed Services University of Health Sciences, in partnership with the American College of Surgeons, developed the Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program that includes a tool for quantifying the clinical readiness value of surgeon workload, known as the KSA metric.

Objective

To describe changes in US military general surgeon procedural volume and readiness using the KSA metric.

Design, Setting, and Participants

This cohort study analyzed general surgery workload performed across the MHS, including military and civilian facilities, between fiscal year 2015 and 2019 and the calculated KSA metric value. The surgeon-level readiness among military general surgeons was calculated based on the KSA metric readiness threshold. Data were obtained from TRICARE, the US Department of Defense health insurance product.

Main Outcomes and Measures

The main outcomes were general surgery procedural volumes and the KSA metric point value of those procedures across the MHS as well as the number of military general surgeons meeting the KSA metric readiness threshold. Aggregate facility and regional market-level claims data were used to calculate the procedural volumes and KSA metric readiness value of those procedures. Annual adjusted KSA metric points earned were used to determine the number of individual US military general surgeons meeting the readiness threshold.

Results

The number of general surgery procedures generating KSAs in military hospitals decreased 25.6%, from 128 377 in 2015 to 95 461 in 2019, with a 19.1% decrease in the number of general surgeon KSA points (from 7 155 563 to 5 790 001). From 2015 to 2019, there was a 3.2% increase in both the number of procedures (from 419 980 to 433 495) and KSA points (from 21 071 033 to 21 748 984) in civilian care settings. The proportion of military general surgeons meeting the KSA metric readiness threshold decreased from 16.7% (n = 97) in 2015 to 10.1% (n = 68) in 2019.

Conclusions and Relevance

This study noted that the number of KSA metric points and procedural volume in military hospitals has been decreasing since 2015, whereas both measures have increased in civilian facilities. The findings suggest that loss of surgical workload has resulted in further decreases in military surgeon readiness and may require substantial changes in patient care flow in the MHS to reverse the change.

In defense of Direct Care: Limiting access to military hospitals could worsen quality and safety

OBJECTIVE

Ongoing health care reforms within the US Military Health System (MHS) are expected to shift >1.9 million MHS beneficiaries from military treatment facilities (MTFs) into local civilian hospitals over the next 1-2 years. The objective of this study was to examine how such health care reforms are likely to affect the quality of MHS care.

DATA SOURCES

Adult MHS beneficiaries, aged 18-64 years, treated in MTFs (under a program known as Direct Care) were compared against (1) MHS beneficiaries treated in locally available civilian hospitals (under a program known as Purchased Care) and (2) similarly-aged adult civilian patients across the United States. MHS beneficiaries in Direct and Purchased Care were identified from fiscal-year 2016-2018 MHS inpatient claims. National inpatients were identified in the 2017 Nationwide Readmissions Database.

STUDY DESIGN

Retrospective cohort.

DATA COLLECTION

Differences in quality were compared using two sets of quality metrics endorsed by the US Agency for Healthcare Research and Quality (AHRQ): Inpatient Quality Indicators, 19 quality metrics that look at differences in in-hospital mortality, and Patient Safety Indicators, 18 quality metrics that look at differences in in-hospital morbidity and adverse events. Among MHS beneficiaries (Direct and Purchased Care), we further simulated what changes in quality indicators might look like under various proposed scenarios of reduced access to Direct Care.

PRINCIPAL FINDINGS

A total of 502,252 MHS admissions from 37 MTFs and surrounding civilian hospitals were included (326,076 Direct Care, 179,176 Purchased Care). Nationwide, 9.34 million adult admissions from 2453 hospitals were included. On average, MHS beneficiaries treated in MTFs experienced better inpatient quality and improved patient safety compared with MHS beneficiaries treated in locally available civilian hospitals (e.g., summary observed-to-expected ratio for medical mortality: 0.98 vs. 1.03, p < 0.001) and adult patients across the United States (0.98 vs. 1.02, p < 0.001). Simulations of proposed changes resulted in consistently worse outcomes for MHS patients, whether reducing MTF access by 10%, 20%, or 50% nationwide; limiting MTF access to active-duty beneficiaries; or closing MTFs with the worst performance on patient safety (p < 0.001 for overall quality indicators for each).

CONCLUSIONS

Reducing access to MTFs could result in significant harm to MHS patients. The results underscore the importance of health-policy planning based on evidence-based evaluation and the need to consider the consequential downstream effects caused by changes in access to care.

Association of Public Reporting of Medicare Dialysis Facility Quality Ratings With Access to Kidney Transplantation

IMPORTANCE

Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known.

OBJECTIVE

To determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged ≥18 years) patients in the US Renal Data System beginning long-term dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021.

EXPOSURES

Dialysis center quality, as defined by Medicare DFC star ratings.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics.

RESULTS

Of 507 581 patients beginning long-term dialysis in the US from 2013 to 2017, 291 802 (57.4%) were male, 266 517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively.

CONCLUSIONS AND RELEVANCE

In this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.

Long-term prescription opioid use among US military service members injured in combat

INTRODUCTION

During the Global War on Terrorism, many US Military service members sustained injuries with potentially long-lasting functional limitations and chronic pain. We sought to understand the patterns of prescription opioid use among service members injured in combat.

METHODS

We queried the Military Health System Data Repository to identify service members injured in combat between 2007 and 2011. Sociodemographics, injury characteristics, treatment information, and costs of care were abstracted for all eligible patients. We surveyed for prescription opioid utilization subsequent to hospital discharge and through 2018. Negative binomial regression was used to identify factors associated with cumulative prescription opioid use.

RESULTS

We identified 3,981 service members with combat-related injuries presenting during the study period. The median age was 24 years (interquartile range [IQR], 22-29 years), 98.5% were male, and the median follow-up was 3.3 years. During the study period, 98% (n = 3,910) of patients were prescribed opioids at least once and were prescribed opioids for a median of 29 days (IQR, 9-85 days) per patient-year of follow-up. While nearly all patients (96%; n = 3,157) discontinued use within 6 months, 91% (n = 2,882) were prescribed opioids again after initially discontinuing opioids. Following regression analysis, patients with preinjury opioid exposure, more severe injuries, blast injuries, and enlisted rank had higher cumulative opioid use. Patients who discontinued opioids within 6 months had an unadjusted median total health care cost of US $97,800 (IQR, US $42,364-237,135) compared with US $230,524 (IQR, US $134,387-370,102) among those who did not discontinue opioids within 6 months (p < 0.001).

CONCLUSION

Nearly all service members injured in combat were prescribed opioids during treatment, and the vast majority experienced multiple episodes of prescription opioid use. Only 4% of the population met the criteria for sustained prescription opioid use at 6 months following discharge. Early discontinuation may not translate to long-term opioid cessation in this population.

LEVEL OF EVIDENCE

Epidemiology study, level III.

Association of Advance Care Planning Visits With Intensity of Health Care for Medicare Beneficiaries With Serious Illness at the End of Life

Question

What is the association of a billed advance care planning (ACP) visit with intensive use of health care services at the end of life (EOL) for Medicare beneficiaries with serious illness?

Findings

In this cohort study of claims data of 955 777 Medicare beneficiaries with serious illness who died in 2017 and 2018, billed ACP visits that occurred during the decedents’ EOL course but before the last month of life were relatively uncommon. However, their occurrence was associated with less intensive use of EOL health care services.

Meaning

The findings of this cohort study suggest that ACP is associated with less intensive use of EOL health care services.

Importance

Advance care planning (ACP) is intended to maximize the concordance of preferences with end-of-life (EOL) care and is assumed to lead to less intensive use of health care services. The Centers for Medicare & Medicaid Services began reimbursing clinicians for ACP discussions with patients in 2016.

Objective

To determine whether billed ACP visits are associated with intensive use of health care services at EOL.

Design, Setting, and Participants

This prospective patient-level cohort analysis of seriously ill patients included Medicare fee-for-service beneficiaries who met criteria for serious illness from January 1 to December 31, 2016, and died from January 1, 2017, to December 31, 2018. Analyses were completed from November 1, 2020, to March 31, 2021.

Main Outcomes and Measures

Five measures of EOL health care services used (inpatient admission, emergency department visit, and/or intensive care unit stay within 30 days of death; in-hospital death; and timing of first hospice bill) and a measure of EOL expenditures. Analyses were adjusted for age, race and ethnicity, sex, Charlson Comorbidity Index, Medicare-Medicaid dual eligibility, and expenditure by hospital referral region (high, medium, or low). The primary exposure was receipt of a billed ACP service classified as none, timely (>1 month before death), or late (first ACP visit ≤1 month before death).

Results

Of the 955 777 Medicare beneficiaries who met criteria for serious illness in 2016 and died in 2017 or 2018, 522 737 (54.7%) were women, 764 666 (80.0%) were 75 years or older, and 822 684 (86.1%) were non-Hispanic White individuals. Among the study population, 81 131 (8.5%) had a timely ACP visit, and an additional 22 804 (2.4%) had a late ACP visit. After multivariable adjustment, compared with patients without any billed ACP visit, patients with a timely ACP visit experienced significantly less intensive EOL care on 4 of 5 measures, including in-hospital death (adjusted odds ratio [aOR], 0.85; 95% CI, 0.84-0.87), hospital admission (aOR, 0.84; 95% CI, 0.83-0.85), intensive care unit admission (aOR, 0.87; 95% CI, 0.85-0.88), and emergency department visit (OR, 0.83; 95% CI, 0.82-0.84). Only small or insignificant differences in late hospice use or mean total EOL expenditures were noted. Compared with patients without ACP, patients with late ACP experienced more intensive EOL care, including in-hospital death (aOR, 1.22; 95% CI, 1.19-1.26), hospital admission (aOR, 5.28; 95% CI, 5.07-5.50), intensive care unit admission (aOR, 1.57; 95% CI, 1.53-1.62), and emergency department visit (aOR, 3.87; 95% CI, 3.72-4.02).

Conclusions and Relevance

In this cohort study of US Medicare beneficiaries, billed ACP services during the EOL course of patients with serious illness were relatively uncommon, but if they occurred before the last month of life, they were associated with less intensive use of EOL services. Further research on the variables affecting hospice use and expenditures in the EOL period and the differential effect of late ACP is recommended to understand the relative role of ACP in achieving goal-concordant care.

Effect of Medicaid Expansion on Receipt of Definitive Treatment and Time to Treatment Initiation by Racial and Ethnic Minorities and at Minority-Serving Hospitals: A Patient-Level and Facility-Level Analysis of Breast, Colon, Lung, and Prostate Cancer

PURPOSE

We sought to investigate the association between Medicaid expansion under the Affordable Care Act and access to stage-appropriate definitive treatment for breast, colon, non-small-cell lung, and prostate cancer for underserved racial and ethnic minorities and at minority-serving hospitals (MSHs).

METHODS

We conducted a retrospective, difference-in-differences study including minority patients with nonmetastatic breast, colon, non-small-cell lung, and prostate cancer and patients treated at MSHs between the age of 40 and 64, with tumors at stages eligible for definitive treatment from the National Cancer Database. We not only defined non-Hispanic Black and Hispanic cancer patients as racial and ethnic minorities but also report findings for non-Hispanic Black cancer patients separately. We examined the effect of Medicaid expansion on receipt of stage-appropriate definitive therapy, time to treatment initiation (TTI) within 30 days of diagnosis, and TTI within 90 days of diagnosis.

RESULTS

Receipt of definitive treatment for minorities in expansion states did not change compared with minority patients in nonexpansion states. The proportion of racial and ethnic minorities in expansion states receiving treatment within 30 days increased (difference-in-differences: +3.62%; 95% CI, 1.63 to 5.61; P < .001) compared with minority patients in nonexpansion states; there was no change for TTI within 90 days. Analysis focused on Black cancer patients yielded similar results. In analyses stratified by MSH status, there was no change in receipt of definitive therapy, TTI within 30 days, and TTI within 90 days when comparing MSHs in expansion states with MSHs in nonexpansion states.

CONCLUSION

In our cohort of cancer patients with treatment-eligible disease, we found no significant association between Medicaid expansion and changes in receipt of definitive treatment for breast, prostate, lung, and colon cancer for racial and ethnic minorities and at MSHs. Medicaid expansion was associated with improved TTI at the patient level for racial and ethnic minorities, but not at the facility level for MSHs. Targeted interventions addressing the needs of MSHs are still needed to continue mitigating national facility-level disparities in cancer outcomes.

Preoperative Frailty Status and Intensity of End-of-Life Care Among Older Adults After Emergency Surgery

CONTEXT

Emergency general surgery (EGS) is common and highly morbid for older adults, particularly for those who are frail. However, there are little data on the quality of end-of-life care (EOLC) for this population.

OBJECTIVES

We sought to examine the association of frailty with intensity of EOLC for older adults with and without frailty who undergo EGS but die within one year.

METHODS

This retrospective cohort study included 100% Medicare fee-for-service beneficiaries, ≥66 years, who underwent one of five EGS procedures with the highest mortality (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy) between 2008 and 2014 and died within one year. A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < 0.15), prefrail (0.15 ≤ CFI < 0.25), mildly frail (0.25 ≤ CFI < 0.35), and moderately to severe frail (CFI ≥ 0.35). Multivariable adjusted logistic or Poisson regression compared post-discharge and EOL healthcare utilization.

RESULTS

Among 138,916 older EGS adults who died within one year, 32.2% were not frail, 31.7% were prefrail, 29.8% had mild frailty and 6.3% had moderate-to-severe frailty. Decedents with any degree of frailty experienced high-intensity EOLC (P < 0.01), low rates of hospice use (P < 0.01), and fewer days at home. Of those who survived the index hospitalization but died within one year, moderate-to-severely frail decedents had the highest odds of visiting an emergency department (odds ratio [OR] = 1.19, CI = 1.13-1.27), rehospitalization (OR = 1.23, CI = 1.16-1.31), or an intensive care unit admission (OR = 1.22, CI = 1.13-1.30) in the last 30 days of life compared to nonfrail decedents.

CONCLUSION

While all older patients undergoing EGS have poor end-of-life outcomes, frail EGS patients receive the highest intensity EOLC and represent a vulnerable population for whom targeted interventions could limit burdensome treatment.

Long-Term Healthcare Expenditures Following Combat-Related Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is one of the most common injuries resulting from U.S. Military engagements since 2001. Long-term consequences in terms of healthcare utilization are unknown. We sought to evaluate healthcare expenditures among U.S. military service members with TBI, as compared to a matched cohort of uninjured individuals.

METHODS

We identified service members who were treated for an isolated combat-related TBI between 2007 and 2011. Controls consisted of hospitalized active duty service members, without any history of combat-related injury, matched by age, biologic sex, year of hospitalization, and duration of follow-up. Median total healthcare expenditures over the entire surveillance period represented our primary outcome. Expenditures in the first year (365 days) following injury (hospitalization for controls) and for subsequent years (366th day to last healthcare encounter) were considered secondarily. Negative binomial regression was used to identify the adjusted influence of TBI.

RESULTS

The TBI cohort consisted of 634 individuals, and there were 1,268 controls. Healthcare expenditures among those with moderate/severe TBI (median $154,335; interquartile range [IQR] $88,088-$360,977) were significantly higher as compared to individuals with mild TBI (median $113,951; IQR $66,663-$210,014) and controls (median $43,077; IQR $24,403-$83,590; P < .001). Most expenditures were incurred during the first year following injury.

CONCLUSION

This investigation represents the first continuous observation of healthcare utilization among individuals with combat-related TBI. Our findings speak to continued consumption of health care well beyond the immediate postinjury period, resulting in total expenditures approximately six to seven times higher than those of service members hospitalized for noncombat-related reasons.

Lung Cancer Strategist Program: A novel care delivery model to improve timeliness of diagnosis and treatment in high-risk patients

INTRODUCTION

The diagnosis and treatment of lung cancer is challenged by complex diagnostic pathways and fragmented care that can lead to care disparities for vulnerable patients.

METHODS

A multi-institutional, multidisciplinary conference was convened to address the complexity of lung cancer care particularly in patients at high-risk for treatment delay. The resulting care delivery model, called the Lung Cancer Strategist Program (LCSP), was led by a thoracic-trained advanced practice provider (APP) with emphasis on expedited surgery and early oncologic consultation in the assessment of a newly diagnosed suspicious lung nodule. We performed a retrospective review to evaluate care efficiency and oncologic outcomes in the first 100 LCSP patients compared to 100 concurrent patients managed via routine surgical referral.

RESULTS

In the 78 LCSP and 41 routine referral patients managed via nodule surveillance, LCSP patients had a shorter time from suspicious finding to work-up (3 vs. 26 days, p < 0.001) and to surveillance decision (12.5 vs. 39 days, p < 0.001). In the 22 LCSP and 59 routine referral patients treated for intrathoracic malignancy, LCSP patients had fewer hospital visits (4 vs 6, p < 0.001), clinicians seen (1.5 vs. 2, p = 0.08), and diagnostic studies (4 vs 5, p = 0.01) with a shorter time to diagnosis (30.5 vs. 48 days, p = 0.02) and treatment (40.5 vs. 68.5 days, p = 0.02).

CONCLUSIONS

Patient triage through a thoracic-trained APP in consultation with surgical, medical, and radiation oncology facilitates rapid assessment of benign versus malignant lesions with reduced time to diagnosis and treatment, even among patients at high-risk for treatment delay.

Advance care planning among Medicare beneficiaries with dementia undergoing surgery

IMPORTANCE

Advance care planning (ACP), in which patients or their surrogates discuss goals and preferences for care with physicians, attorneys, friends, and family, is an important approach to help align goals with actual treatment. ACP may be particularly valuable in patients with advanced serious illnesses such as Alzheimer's disease and related dementias (ADRDs) for whom surgery carries significant risks.

OBJECTIVE

To determine the frequency, timing, and factors associated with ACP billing in Medicare beneficiaries with ADRD undergoing nontrauma inpatient surgery.

DESIGN

This national cohort study analyzes Medicare fee-for-service claims data from 2016 to 2017. All patients had a 6-month lookback and follow-up period.

SETTING

National Medicare fee-for-service data.

PARTICIPANTS

All patients with ADRD, defined according to the Chronic Conditions Warehouse, undergoing inpatient surgery from July 1, 2016 to June 30, 2017.

EXPOSURES

Patient demographics, medical history, and procedural outcomes.

MAIN OUTCOME

ACP billing codes from 6 months before to 6 months after admission for inpatient surgery.

RESULTS

This study included 289,428 patients with ADRD undergoing surgery, of whom 21,754 (7.5%) had billed ACP within the 6 months before and after surgical admission. In a multivariable analysis, patients of white race, male sex, and residence in the Southern and Midwestern United States were at the highest risk of not receiving ACP. Of all patients who received ACP, 5960 (27.4%) did so before surgery while 12,658 (52.8%) received ACP after surgery. Timing of ACP after surgery was associated with an Elixhauser comorbidity index of 3 or higher (1.23, p = 0.045) and major postoperative complication or death (odds ratio 1.52, p < 0.0001).

CONCLUSIONS AND RELEVANCE

Overall ACP billing code use is low among Medicare patients with ADRD undergoing surgery. Billed ACP appears to have a reactive pattern, occurring most commonly after surgery and in association with postoperative mortality and complications. Additional study is warranted to understand barriers to use.

Patient perspectives on the need for implanted device information: Implications for a post-procedural communication framework

BACKGROUND

Shared decision making and patient-centred communication have become part of pre-procedural decisions and perioperative care across medical specialties. However, gaps exist in patient communication about the implanted device received and the benefits in sharing information about their procedure and device.

OBJECTIVE

To understand the patients' knowledge of identifying information for their implanted devices and perspectives on sharing their implanted device information.

METHODS

Four focus groups were conducted with patients who had received a cardiac or vascular implanted device from one of the study sites within the previous 6 months. Data were transcribed and thematically analysed.

RESULTS

Five themes emerged: lack of awareness of identifying information on implanted devices; value of information on implanted devices; varying trust with sharing device information; perceived risk with sharing device information; and lack of consensus on a systematic process for tracking implanted devices.

DISCUSSION

Patients desire post-procedural information on their implanted device and a designated plan for longitudinal follow-up, but lack trust and perceive risk with broadly sharing their implanted device information.

CONCLUSION

After receiving an implanted device, post-procedural patient communication needs to be expanded to include identifying information on the device including the unique device identifier, how long-term tracking will be supported and the process for notification in case of a problem with the device. This communication should also include education on how sharing device information supports patients' long-term health care, post-market safety surveillance and research.

PATIENT OR PUBLIC CONTRIBUTION

The research team included members who were also patients with implanted devices.

Where Is the Value in Ambulatory Versus Inpatient Surgery?

OBJECTIVE

The aim of this study was to estimate the effect of index surgical care setting on perioperative costs and readmission rates across 4 common elective general surgery procedures.

SUMMARY BACKGROUND DATA

Facility fees seem to be a driving force behind rising US healthcare costs, and inpatient-based fees are significantly higher than those associated with ambulatory services. Little is known about factors influencing where patients undergo elective surgery.

METHODS

All-payer claims data from the 2014 New York and Florida Healthcare Cost and Utilization Project were used to identify 73,724 individuals undergoing an index hernia repair, primary total or partial thyroidectomy, laparoscopic cholecystectomy, or laparoscopic appendectomy in either the inpatient or ambulatory care setting. Inverse probability of treatment weighting-adjusted gamma generalized linear and logistic regression was employed to compare costs and 30-day readmission between inpatient and ambulatory-based surgery, respectively.

RESULTS

Approximately 87% of index surgical cases were performed in the ambulatory setting. Adjusted mean index surgical costs were significantly lower among ambulatory versus inpatient cases for all 4 procedures (P < 0.001 for all). Adjusted odds of experiencing a 30-day readmission after thyroidectomy [odds ratio (OR) 0.70, 95% confidence interval (CI), 0.53-0.93; P = 0.03], hernia repair (OR 0.28, 95% CI, 0.20-0.40; P < 0.001), and laparoscopic cholecystectomy (OR 0.37, 95% CI, 0.32-0.43; P < 0.001) were lower in the ambulatory versus inpatient setting. Readmission rates among ambulatory versus inpatient-based laparoscopic appendectomy were comparable (OR 0.63, 95% CI, 0.31-1.26; P = 0.19).

CONCLUSIONS

Ambulatory surgery offers significant costs savings and generally superior 30-day outcomes relative to inpatient-based care for appropriately selected patients across 4 common elective general surgery procedures.

Designing a Strategy Trial for the Management of Gout: The Use of a Modified Delphi Panel

OBJECTIVE

Disagreement exists between rheumatology and primary care societies regarding gout management. This paper describes a formal process for gathering input from stakeholders in the planning of a trial to compare gout management strategies.

METHODS

We recruited patients, nurses, physician assistants, primary care clinicians, and rheumatologists to participate in a modified Delphi panel (mDP) to provide input on design of a trial focused on optimal management for primary care patients with gout. The 16 panelists received a plain-language briefing document that discussed the rationale for the trial, key clinical issues in gout, and aspects of trial design. The panelists also received information and considerations on nine voting questions (VQs), judged to be the key design questions. Cognitive interviews with panelists ensured that the VQs were understood by the range of panelists involved in the mDP. Panelists were asked to score all VQs from 1 (definitely no) to 9 (definitely yes). Two voting rounds were conducted-round 1 by email and round 2 by video conference.

RESULTS

The VQs were modified through the cognitive interviews. The round 1 voting resulted in consensus on eight items, with consensus defined as median voting score in the same tercile (1-3, 4-6 or 7-9). Re-voting at the meeting (round 2) reached consensus on the remaining item.

CONCLUSION

An mDP with various stakeholders facilitated consensus on the design of a trial of different management strategies for chronic gout. This method may be useful for designing trials of clinical questions with substantial disagreement across stakeholders.

Transmitting Device Identifiers of Implants From the Point of Care to Insurers: A Demonstration Project

BACKGROUND

For implanted devices, an effective postmarket surveillance system does not exist. For medications, the Food and Drug Administration's Sentinel Initiative plays that role, relying mainly on drug codes in insurance claims. Unique device identifiers (UDIs) could play an analogous role for implants, but there is no mandate for providers to include UDIs in claims or for payers to record them. Objections have been raised to incorporating UDIs into claims based on a potential burden on providers.

METHODS

To assess this purported barrier, we modified information systems at 2 provider-payer dyads to allow for the transmission of UDI data from provider to payer. In addition, to illustrate the potential benefit of including device data in claims, we used our data to compare rates of 90-day adverse events after implantation using the electronic health record (EHR) alone with the EHR plus claims.

RESULTS

The software system modifications were modest and performed as designed. Moreover, the level of difficulty of their development and implementation was comparable to that associated with a typical new release of an existing system. In addition, our data demonstrated the ability of claims-based data plus EHR data to reveal a larger percentage of postprocedure adverse events than data from EHRs alone.

CONCLUSIONS

Modifying information systems to allow for the transmission of UDI data from providers to payers should not impose a substantial burden on either. Implementation of a postmarket surveillance system based on such data in claims will require, however, the development of a system analogous to Sentinel.

"Don't Talk to Them About Goals of Care": Understanding Disparities in Advance Care Planning

BACKGROUND

Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions.

METHOD

In this national study, we conducted semi-structured interviews with purposively selected clinicians from 6 diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians' perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them.

RESULTS

Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians' difficulty approaching ACP (preconceived views of patients' preferences, narrow definitions of successful ACP, and lack of institutional resources), while the final theme illustrated facilitators to ACP (acknowledging bias and rejecting stereotypes, mission-driven focus on ACP, and acceptance of all preferences).

CONCLUSIONS

Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP.

Association of balanced abdominal organ transplant center volumes with patient outcomes

BACKGROUND

The volume-outcome relationship for organ-specific transplantation is well-described; it is unknown if the relative balance of kidney compared with liver volumes within an institution relates to organ-specific outcomes. We assessed the association between relative balance within a transplant center and outcomes.

METHODS

National retrospective analysis of isolated kidney and liver transplants in United States 2005-2014 followed through 2019. Latent class analysis defined transplant center phenotypes. Multivariate Cox models estimated death-censored graft loss and mortality.

RESULTS

Latent class analysis identified four phenotypes: kidney only (n = 117), kidney dominant (n = 36), mixed/balanced (n = 90), and liver dominant (n = 13). Compared to mixed centers, the risk of kidney graft loss was higher at kidney-dominant (HR 1.07, p < .001) and liver-dominant (HR 1.10, p < .001) centers, while kidney-only (HR 1.06, p = .01) centers had higher mortality. Liver graft loss was not associated with phenotype, but risk of patient death was lower (HR 0.93, p = .02) at liver dominant and higher (HR 1.06, p = .02) at kidney-dominant centers.

CONCLUSIONS

A mixed phenotype was associated with improved kidney transplant outcomes, whereas liver transplant outcomes were best at liver-dominant centers. While these findings need to be verified with center-level resources, optimization of shared resources could improve patient and organ outcomes.

Strategies for spinal surgery reimbursement: bundling in the working-age population

Introduction

Bundled payments for spine surgery, which is known for having high overall cost with wide variation, have been previously studied in older adults. However, there has been limited work examining bundled payments in working-age patients. We sought to identify the variation in the cost of spine surgery among working age adults in a large, national insurance claims database.

Methods

We queried the TRICARE claims database for all patients, aged 18–64, undergoing cervical and non-cervical spinal fusion surgery between 2012 and 2014. We calculated the case mix adjusted, price standardized payments for all aspects of care during the 60-, 90-, and 180-day periods post operation. Variation was assessed by stratifying Hospital Referral Regions into quintiles.

Results

After adjusting for case mix, there was significant variation in the cost of both cervical ($10,538.23, 60% of first quintile) and non-cervical ($20,155.59, 74%). Relative variation in total cost decreased from 60- to 180-days (63 to 55% and 76 to 69%). Index hospitalization was the primary driver of costs and variation for both cervical (1st-to-5th quintile range: $11,033–$19,960) and non-cervical ($18,565–$36,844) followed by readmissions for cervical ($0–$11,521) and non-cervical ($0–$13,932). Even at the highest quintile, post-acute care remained the lowest contribution to overall cost ($2070 & $2984).

Conclusions

There is wide variation in the cost of spine surgery across the United States for working age adults, driven largely by index procedure and readmissions costs. Our findings suggest that implementing episodes longer than the current 90-day standard would do little to better control cost variation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06112-0.