RESUMO
OBJECTIVE: Compare comorbidity identification in Medicare and Veterans Health Administration (VA) data for the purposes of risk adjustment. DATA SOURCES: Analysis of Medicare and VA datasets for dually-enrolled Veterans receiving care in both settings, fiscal years 2010-2014. STUDY DESIGN: A retrospective analysis of administrative data for a national sample of cancer decedents. DATA EXTRACTION METHODS: Comorbidities were evaluated using Elixhauser and Charlson coding algorithms. PRINCIPAL FINDINGS: Clinical comorbidities were more likely to be recorded in Medicare than in VA datasets. Of 42 comorbidities, 36 (86%) were recorded at a different frequency. For example, congestive heart failure was recorded for 22.0% of patients in Medicare data and for 11.3% of patients in VA data (P<0.001). CONCLUSION: There are large differences in comorbidity assessment across VA and Medicare administrative data for the same patient, posing challenges for risk adjustment.
Assuntos
Comorbidade , Definição da Elegibilidade/normas , Medicare/estatística & dados numéricos , Risco Ajustado/métodos , United States Department of Veterans Affairs/estatística & dados numéricos , Idoso , Definição da Elegibilidade/métodos , Definição da Elegibilidade/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Privatização/estatística & dados numéricos , Estudos Retrospectivos , Risco Ajustado/estatística & dados numéricos , Estados UnidosRESUMO
BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) has released quality measures regarding potentially avoidable hospitalizations visits in the 30 days after receipt of outpatient chemotherapy. This study evaluated the proportions of patients treated by Medicare-reimbursed clinicians and Veterans Health Administration (VA) clinicians who experienced avoidable acute care in order to evaluate differences in health system performance. METHODS: This retrospective evaluation of Medicare and VA administrative data used a cohort of cancer decedents (fiscal years 2010-2014). Cohort members were veterans aged 66 years or older at death who were dually enrolled in Medicare and the VA. Chemotherapy was identified through International Classification of Diseases, Ninth Revision and Current Procedural Terminology (ICD-9) codes. CMS defines avoidable hospitalizations as those related to anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis in the 30 days after chemotherapy. Following CMS guidance, this study compared the proportions of patients with potentially avoidable hospitalizations, using hierarchical generalized estimating equations. RESULTS: There were 27,443 patients who received outpatient chemotherapy. Patients receiving Medicare chemotherapy were significantly more likely to have potentially avoidable hospitalizations than patients receiving VA chemotherapy (adjusted odds ratio, 1.58; 95% confidence interval, 1.41-1.78; P < .001). In predicted estimates, 7.1% of Medicare-treated veterans had potentially avoidable hospitalizations in the 30 days after chemotherapy, compared with 4.6% of VA-treated veterans. CONCLUSIONS: Results indicate veterans with cancer receiving chemotherapy in the VA have higher quality care with respect to avoidable hospitalizations than veterans receiving chemotherapy through Medicare. As more veterans seek care in the private sector under the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, concerted efforts may be warranted to ensure that veterans do not experience a decline in care quality.
Assuntos
Assistência Ambulatorial/métodos , Medicare , Neoplasias/tratamento farmacológico , Admissão do Paciente , Qualidade da Assistência à Saúde , Serviços de Saúde para Veteranos Militares , Veteranos , Idoso , Idoso de 80 Anos ou mais , Centers for Medicare and Medicaid Services, U.S. , Hospitais de Veteranos , Humanos , Masculino , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Saúde dos VeteranosRESUMO
Importance: Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services. Objective: To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life. Design, Setting, and Participants: This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48â¯937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019. Exposures: American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days. Main Outcomes and Measures: Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region. Results: Of 48â¯937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23â¯612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15â¯952 (95% CI, $15â¯676-$16â¯206; P < .001). The biggest contributor to these differences was $21â¯093 (95% CI, $20â¯364-$21â¯689) for intensive care unit stay, while the smallest contributor was $3460 (95% CI, $2927-$3880) for chemotherapy. Mean (SD) expected beneficiary costs for the last month of life were $133 ($50) for patients with no medically intensive service and $1257 ($408) for patients with at least 1 medically intensive service (P < .001). Conclusions and Relevance: Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families.
Assuntos
Planos de Pagamento por Serviço Prestado/economia , Cuidados Paliativos na Terminalidade da Vida/economia , Unidades de Terapia Intensiva/economia , Tempo de Internação/economia , Medicare , Veteranos/estatística & dados numéricos , Idoso , Efeitos Psicossociais da Doença , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Feminino , Financiamento Pessoal , Gastos em Saúde , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Neoplasias/economia , Neoplasias/mortalidade , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The release of highly effective but costly medications for the treatment of hepatitis C virus combined with a doubling in the incidence of hepatitis C virus have posed substantial financial challenges for many healthcare systems. We provide estimates of the cost of treating patients with hepatitis C virus that can inform the triage of pharmaceutical care in systems with limited healthcare resources. METHODS: We conducted an observational study using a national US cohort of 206,090 veterans with laboratory-identified hepatitis C virus followed from Fiscal Year 2010 to 2014. We estimated the cost of: non-advanced Fibrosis-4; advanced Fibrosis-4; hepatocellular carcinoma; liver transplant; and post-liver transplant. The former two stages were ascertained using laboratory result data; the latter stages were ascertained using administrative data. Costs were obtained from the Veterans Health Administration's activity-based cost accounting system and more closely represent the actual costs of providing care, an improvement on the charge data that generally characterizes the hepatitis C virus cost literature. Generalized estimating equations were used to estimate and predict costs per liver disease stage. Missing data were multiply imputed. RESULTS: Annual costs of care increased as patients progressed from non-advanced Fibrosis-4 to advanced Fibrosis-4, hepatocellular carcinoma, and liver transplant (all p < 0.001). Post-liver transplant, costs decreased significantly (p < 0.001). In simulations, patients were estimated to incur the following annual costs: US $17,556 for non-advanced Fibrosis-4; US $20,791 for advanced Fibrosis-4; US $46,089 for liver cancer; US $261,959 in the year of the liver transplant; and US $18,643 per year after the liver transplant. CONCLUSIONS: Cost differences of treating non-advanced and advanced Fibrosis-4 are relatively small. The greatest cost savings would be realized from avoiding progression to liver cancer and transplant.
Assuntos
Hepatite C Crônica/economia , Cirrose Hepática/patologia , Saúde dos Veteranos , Idoso , Antivirais/economia , Análise Custo-Benefício , Feminino , Hepacivirus , Hepatite C Crônica/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Estados UnidosRESUMO
IMPORTANCE: Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans' end-of-life care is unknown. OBJECTIVE: To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life. DESIGN, SETTING, AND PARTICIPANTS: A modified difference-in-differences study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13â¯085 veterans newly diagnosed with stage IV non-small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018. EXPOSURES: Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability. MAIN OUTCOMES AND MEASURES: Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis. RESULTS: Of the 13â¯085 veterans included in the study, 12â¯858 (98%) were men; 10â¯531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67-3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53-0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62-0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, -$358 to -$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference. CONCLUSIONS AND RELEVANCE: Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.
Assuntos
Custos de Cuidados de Saúde , Cuidados Paliativos na Terminalidade da Vida , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/terapia , Veteranos , Idoso , Idoso de 80 Anos ou mais , Efeitos Psicossociais da Doença , Bases de Dados Factuais , Feminino , Hospitais de Veteranos/economia , Hospitais de Veteranos/estatística & dados numéricos , Humanos , Masculino , Sistema de RegistrosRESUMO
PURPOSE: Veterans with advanced cancer can receive hospice care concurrently with treatments such as radiation and chemotherapy. However, variations exist in concurrent care use across Veterans Affairs (VA) medical centers (VAMCs), and overall, concurrent care use is relatively rare. In this qualitative study, we aimed to identify, describe, and explain factors that influence the provision of concurrent cancer care (defined as chemotherapy or radiation treatments provided with hospice) for veterans with terminal cancer. METHODS: From August 2015 to April 2016, we conducted six site visits and interviewed 76 clinicians and staff at six VA sites and their contracted community hospices, including community hospices (n = 16); VA oncology (n = 25); VA palliative care (n = 17); and VA inpatient hospice and palliative care units (n = 18). RESULTS: Thematic qualitative content analysis found three themes that influenced the provision of concurrent care: (1) clinicians and staff at community hospices and at VAs viewed concurrent care as a viable care option, as it preserved hope and relationships while patient goals are clarified during transitions to hospice; and (2) the presence of dedicated liaisons facilitated care coordination and education about concurrent care; however, (3) clinicians and staff concerns about Medicare guideline compliance hindered use of concurrent care. CONCLUSIONS: While concurrent care is used by a small number of veterans with advanced cancer, VA staff valued having the option available and as a bridge to hospice. Hospice staff felt concurrent care improved care coordination with VAMCs, but use may be tempered due to concerns related to Medicare compliance.
Assuntos
Procedimentos Clínicos/organização & administração , Cuidados Paliativos na Terminalidade da Vida/organização & administração , Neoplasias/terapia , Cuidados Paliativos/organização & administração , United States Department of Veterans Affairs/organização & administração , Veteranos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Cuidados Paliativos na Terminalidade da Vida/métodos , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Enfermagem de Cuidados Paliativos na Terminalidade da Vida/métodos , Enfermagem de Cuidados Paliativos na Terminalidade da Vida/organização & administração , Hospitais para Doentes Terminais , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Neoplasias/patologia , Avaliação de Resultados em Cuidados de Saúde , Cuidados Paliativos/métodos , Pesquisa Qualitativa , Estudos Retrospectivos , Estados Unidos/epidemiologia , Veteranos/estatística & dados numéricosRESUMO
OBJECTIVES: To compare the quality of end-of-life care in Medicare Advantage (MA) and traditional Medicare (TM), specifically, receipt and length of hospice care. DESIGN: Retrospective analysis of administrative data. SETTING: Hospice care. PARTICIPANTS: Veterans dually enrolled in the Veterans Health Administration (VHA) and MA or TM who died between 2008 and 2013 (N = 1,515,441). MEASUREMENTS: Outcomes studied included use and duration of hospice care. Use of a VHA-enrolled population allowed for risk adjustment that is otherwise challenging when studying MA. RESULTS: Adjusted analyses revealed that MA beneficiaries were more likely to receive hospice than TM beneficiaries; results corroborate published non-risk-adjusted analyses. MA beneficiaries had shorter hospice duration; this is an opposite direction of effect than non-risk-adjusted analyses. Results were robust to multiple sensitivity analyses limiting the cohort to individuals in MA and TM who had equal opportunity for their comorbidities to be captured. Removing risk adjustment resulted in results that mirrored those in the existing published literature. CONCLUSION: Our work provides two important insights regarding MA that are important to consider as enrollment in this insurance mechanism grows. First, MA beneficiaries received poorer-quality end-of-life care than TM beneficiaries, as ascertained by exposure to hospice. Second, any comparisons made between MA and TM require proper risk adjustment to obtain correct directions of effect. We encourage the Centers for Medicare & Medicaid Services to make comorbidity data specific to MA enrollees available to researchers for these purposes.
Assuntos
Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Medicare Part C/estatística & dados numéricos , Medicare/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Idoso , Feminino , Cuidados Paliativos na Terminalidade da Vida/normas , Hospitais para Doentes Terminais/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Qualidade de Vida , Estudos Retrospectivos , Risco Ajustado , Estados Unidos , United States Department of Veterans AffairsRESUMO
OBJECTIVES: To determine whether implementation of interferon-free treatment for hepatitis C virus (HCV) reached groups less likely to benefit from earlier therapies, including patients with genotype 1 virus or contraindications to interferon treatment, and groups that faced treatment disparities: African Americans, patients with HIV co-infection, and those with drug use disorder. METHODS: Electronic medical records of the US Veterans Health Administration (VHA) were used to characterize patients with chronic HCV infection and the treatments they received. Initiation of treatment in 206,544 patients with chronic HCV characterized by viral genotype, demographic characteristics, and comorbid medical and mental illness was studied using a competing events Cox regression over 6 years. RESULTS: With the advent of interferon-free regimens, the proportion treated increased from 2.4% in 2010 to 18.1% in 2015, an absolute increase of 15.7%. Patients with genotype 1 virus, poor response to previous treatment, and liver disease had the greatest increase. Large absolute increases in the proportion treated were observed in patients with HIV co-infection (18.6%), alcohol use disorder (11.9%), and drug use disorder (12.6%) and in African American (13.7%) and Hispanic (13.5%) patients, groups that were less likely to receive interferon-containing treatment. The VHA spent $962 million on interferon-free treatments in 2015, 1.5% of its operating budget. CONCLUSIONS: The proportion of patients with HCV treated in VHA increased sevenfold. The VHA was successful in implementing interferon treatment in previously undertreated populations, and this may become the community standard of care.
Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Hepatite C/tratamento farmacológico , Veteranos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Hepacivirus/patogenicidade , Humanos , Interferons/uso terapêutico , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estados Unidos , United States Department of Veterans Affairs/organização & administraçãoRESUMO
OBJECTIVES: Cancer costs have increased substantially in the past decades, prompting specialty societies to urge oncologists to consider value in clinical decision making. Despite oncologists' crucial role in guiding cancer care, current literature is sparse with respect to the oncologists' views on value. Here, we evaluated oncologists perceptions of the use and measurement of value in cancer care. METHODS: We conducted in-depth, open-ended interviews with 31 US oncologists practicing nationwide in various environments. Oncologists discussed the definition, measurement, and implementation of value. Transcripts were analyzed using matrix and thematic analysis. RESULTS: Oncologists' definitions of value varied greatly. Some described versions of the standard health economic definition of value, that is, cost relative to health outcomes. Many others did not include cost in their definition of value. Oncologists considered patient goals and quality of life as important components of value that they perceived were missing from current value measurement. Oncologists prioritized a patient-centric view of value over societal or other perspectives. Oncologists were inclined to consider the value of a treatment only if they perceived treatment would pose a financial burden to patients. Oncologists had differing opinions regarding who should be responsible for determining whether care is low value but generally felt this should remain within the purview of the oncology community. CONCLUSIONS: Oncologists agreed that cost was an important issue, but disagreed about whether cost was involved in value as well as the role of value in guiding treatment. Better clarity and alignment on the definition of and appropriate way to measure value is critical to the success of efforts to improve value in cancer care.
Assuntos
Neoplasias/economia , Neoplasias/terapia , Oncologistas/psicologia , Adulto , Idoso , Atitude do Pessoal de Saúde , Tomada de Decisão Clínica/métodos , Tomada de Decisões , Feminino , Humanos , Entrevistas como Assunto/métodos , Masculino , Pessoa de Meia-Idade , Relações Médico-Paciente , Pesquisa Qualitativa , Estados UnidosRESUMO
Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA's directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010-14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA's integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purchasing programs should develop coordination and quality monitoring programs to guard against overly intensive end-of-life care.