RESUMO
BACKGROUND: Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care. OBJECTIVE: To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations. DESIGN: Retrospective cohort study. SETTING: Medicare. PARTICIPANTS: Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019. MEASUREMENTS: Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes. RESULTS: The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF. LIMITATION: Generalizability to other payers. CONCLUSION: Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF. PRIMARY FUNDING SOURCE: National Institute on Aging.
RESUMO
Although emergency department (ED) and hospital overcrowding were reported during the later parts of the COVID-19 pandemic, the true extent and potential causes of this overcrowding remain unclear. Using data on the traditional fee-for-service Medicare population, we examined patterns in ED and hospital use during the period 2019-22. We evaluated trends in ED visits, rates of admission from the ED, and thirty-day mortality, as well as measures suggestive of hospital capacity, including hospital Medicare census, length-of-stay, and discharge destination. We found that ED visits remained below baseline throughout the study period, with the standardized number of visits at the end of the study period being approximately 25 percent lower than baseline. Longer length-of-stay persisted through 2022, whereas hospital census was considerably above baseline until stabilizing just above baseline in 2022. Rates of discharge to postacute facilities initially declined and then leveled off at 2 percent below baseline in 2022. These results suggest that widespread reports of overcrowding were not driven by a resurgence in ED visits. Nonetheless, length-of-stay remains higher, presumably related to increased acuity and reduced available bed capacity in the postacute care system.
Assuntos
COVID-19 , Serviço Hospitalar de Emergência , Tempo de Internação , Medicare , Estados Unidos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/tendências , Humanos , COVID-19/epidemiologia , Medicare/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Idoso , Feminino , Pandemias , Masculino , Alta do Paciente/estatística & dados numéricos , Alta do Paciente/tendências , SARS-CoV-2 , Hospitalização/estatística & dados numéricos , Hospitalização/tendências , Número de Leitos em Hospital/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/tendências , Aglomeração , Visitas ao Pronto SocorroRESUMO
Importance: Despite its importance to medical education and competency assessment for internal medicine trainees, evidence about the relationship between physicians' milestone residency ratings or the American Board of Internal Medicine's initial certification examination and their hospitalized patients' outcomes is sparse. Objective: To examine the association between physicians' milestone ratings and certification examination scores and hospital outcomes for their patients. Design, Setting, and Participants: Retrospective cohort analyses of 6898 hospitalists completing training in 2016 to 2018 and caring for Medicare fee-for-service beneficiaries during hospitalizations in 2017 to 2019 at US hospitals. Main Outcomes and Measures: Primary outcome measures included 7-day mortality and readmission rates. Thirty-day mortality and readmission rates, length of stay, and subspecialist consultation frequency were also assessed. Analyses accounted for hospital fixed effects and adjusted for patient characteristics, physician years of experience, and year. Exposures: Certification examination score quartile and milestone ratings, including an overall core competency rating measure equaling the mean of the end of residency milestone subcompetency ratings categorized as low, medium, or high, and a knowledge core competency measure categorized similarly. Results: Among 455â¯120 hospitalizations, median patient age was 79 years (IQR, 73-86 years), 56.5% of patients were female, 1.9% were Asian, 9.8% were Black, 4.6% were Hispanic, and 81.9% were White. The 7-day mortality and readmission rates were 3.5% (95% CI, 3.4%-3.6%) and 5.6% (95% CI, 5.5%-5.6%), respectively, and were 8.8% (95% CI, 8.7%-8.9%) and 16.6% (95% CI, 16.5%-16.7%) for mortality and readmission at 30 days. Mean length of stay and number of specialty consultations were 3.6 days (95% CI, 3.6-3.6 days) and 1.01 (95% CI, 1.00-1.03), respectively. A high vs low overall or knowledge milestone core competency rating was associated with none of the outcome measures assessed. For example, a high vs low overall core competency rating was associated with a nonsignificant 2.7% increase in 7-day mortality rates (95% CI, -5.2% to 10.6%; P = .51). In contrast, top vs bottom examination score quartile was associated with a significant 8.0% reduction in 7-day mortality rates (95% CI, -13.0% to -3.1%; P = .002) and a 9.3% reduction in 7-day readmission rates (95% CI, -13.0% to -5.7%; P < .001). For 30-day mortality, this association was -3.5% (95% CI, -6.7% to -0.4%; P = .03). Top vs bottom examination score quartile was associated with 2.4% more consultations (95% CI, 0.8%-3.9%; P < .003) but was not associated with length of stay or 30-day readmission rates. Conclusions and Relevance: Among newly trained hospitalists, certification examination score, but not residency milestone ratings, was associated with improved outcomes among hospitalized Medicare beneficiaries.
Assuntos
Certificação , Competência Clínica , Mortalidade Hospitalar , Medicina Interna , Internato e Residência , Readmissão do Paciente , Humanos , Medicina Interna/educação , Medicina Interna/normas , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Internato e Residência/normas , Certificação/normas , Estados Unidos , Feminino , Masculino , Tempo de Internação/estatística & dados numéricos , Medicare , Idoso , Médicos Hospitalares/normas , Avaliação Educacional/normasRESUMO
Importance: In 2013, Medicare implemented payments for transitional care management (TCM) services, which provide increased reimbursement to clinicians providing ambulatory care to patients after discharge from medical facilities to the community. Objective: To determine whether the introduction of TCM payments was associated with an increase in timely postdischarge follow-up. Design, Setting, and Participants: This cross-sectional interrupted time-series study assessed quarterly postdischarge visit rates before (2010-2012) and after (2013-2019) TCM implementation 100% sample of Medicare fee-for-service beneficiaries discharged to the community after a hospital or skilled nursing facility stay. Data analyses were performed February 1 to December 15, 2023. Exposure: Implementation of payments for TCM. Main Outcomes and Measures: Timely postdischarge primary care follow-up, defined as receipt of a primary care ambulatory visit within 14 days of discharge. Secondary outcomes included receipt of a TCM visit and specialty care follow-up. Results: The study sample comprised 79â¯125â¯965 eligible discharges. Of these, 55.4% were female; 1.5% were Asian, 12.1% Black, 5.6% Hispanic, and 79.0% were White individuals; and 79.6% were beneficiaries aged 65 years and older. Timely primary care follow-up increased from 31.5% in 2010 to 38.8% in 2019 (absolute increase 7.3%), whereas specialist follow-up increased from 27.6% to 30.8% (absolute increase 3.2%). By 2019, 11.3% of eligible patients received TCM services. Interrupted time-series analyses demonstrated an increased slope of timely primary care follow-up after the introduction of TCM services (pre-TCM slope, 0.12% per quarter vs post-TCM slope, 0.29% per quarter; difference, 0.13%; 95% CI, 0.02% to 0.22%). Receipt of timely follow-up increased for all demographic groups; however, Black, Hispanic, and Medicaid dual-eligible patients and patients residing in urban areas and counties with high-level social deprivation were less likely to receive follow-up during the study period. These disparities widened for Black patients (difference-in-differences in pre-TCM vs post-TCM slope, -0.14%; 95% CI, -0.25% to -0.2%) and patients who were Medicaid dual-eligible (difference-in-differences pre-TCM vs post-TCM slope, -0.21%; 95% CI, -0.35% to -0.07%). Conclusions: These findings indicate that Medicare's introduction of payments for TCM services was associated with a persistent increase in the rate of timely postdischarge primary care but did not narrow demographic or socioeconomic disparities. Most beneficiaries did not receive timely primary care follow-up.
Assuntos
Medicare , Cuidado Transicional , Estados Unidos , Humanos , Idoso , Feminino , Masculino , Assistência ao Convalescente , Estudos Transversais , Seguimentos , Alta do PacienteRESUMO
BACKGROUND: Understanding how cardiovascular disease treatment and outcomes differ for socioeconomically disadvantaged patients across countries may reveal insights into the impact of countries' policy initiatives on health equity. However, methods of undertaking these studies are poorly characterized. METHODS: We performed a scoping review to identify studies describing between-country comparisons of socioeconomic inequalities in the care of acute myocardial infarction (AMI). We sought to determine the extent to which such comparisons have been conducted, the methodologies used, and outcomes assessed. We searched Medline from January 1, 2013 to September 30, 2023 for peer-reviewed English-language publications. Studies were included if they stratified patients by a measure of socioeconomic disadvantage (eg, race, ethnicity, income, education, occupation, immigrant status) and made comparisons between 2 or more countries. RESULTS: Our search yielded 4861 articles focused on patients with AMI, of which 7 met our inclusion criteria. Common individual-level proxies for disadvantage were self-reported income or education. In contrast, we found no cross-country comparisons focused on other measures of disadvantage such as race and ethnicity. There was marked heterogeneity in methods and thresholds used to define socioeconomic disadvantage at the individual level. All included studies found that patients with higher income and higher educational attainment had improved AMI outcomes. CONCLUSIONS: Between-country comparisons of socioeconomic disparities in AMI outcomes are scarce and heterogeneous, but all identified studies relied on metrics of disadvantage including income and education that could be uniformly measured across countries. We found no articles addressing other types of inequities, likely because of significant methodologic challenges.
Assuntos
Infarto do Miocárdio , Fatores Socioeconômicos , Humanos , Infarto do Miocárdio/terapia , Infarto do Miocárdio/epidemiologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Disparidades Socioeconômicas em SaúdeRESUMO
The use of many services is lower in Medicare Advantage (MA) compared with traditional Medicare, generating cost savings for insurers, whereas the quality of ambulatory services is higher. This study examined the role of selective contracting with providers in achieving these outcomes, focusing on primary care physicians. Assessing primary care physician costliness based on the gap between observed and predicted costs for their traditional Medicare patients, we found that the average primary care physician in MA networks was $433 less costly per patient (2.9 percent of baseline) compared with the regional mean, with less costly primary care physicians included in more networks than more costly ones. Favorable selection of patients by MA primary care physicians contributed partially to this result. The quality measures of MA primary care physicians were similar to the regional mean. In contrast, primary care physicians excluded from all MA networks were $1,617 (13.8 percent) costlier than the regional mean, with lower quality. Primary care physicians in narrow networks were $212 (1.4 percent) less costly than those in wide networks, but their quality was slightly lower. These findings highlight the potential role of selective contracting in reducing costs in the MA program.
Assuntos
Medicare Part C , Médicos de Atenção Primária , Idoso , Estados Unidos , Humanos , Redução de Custos , SeguradorasRESUMO
Fragmented care delivery is a barrier to improving health system performance worldwide. Investment in meso-level organisations is a potential strategy to improve health system integration, however, its effectiveness remains unclear. In this paper, we provide an overview of key international and Australian integrated care policies. We then describe Collaborative Commissioning - a novel health reform policy to integrate primary and hospital care sectors in New South Wales (NSW), Australia and provide a case study of a model focussed on older person's care. The policy is theorised to achieve greater integration through improved governance (local stakeholders identifying as part of one health system), service delivery (communities perceive new services as preferable to status quo) and incentives (efficiency gains are reinvested locally with progressively higher value care achieved). If effectively implemented at scale, Collaborative Commissioning has potential to improve health system performance in Australia and will be of relevance to similar reform initiatives in other countries.
RESUMO
Importance: Much remains unknown about the extent of and factors that influence clinician-level variation in rates of admission from the emergency department (ED). In particular, emergency clinician risk tolerance is a potentially important attribute, but it is not well defined in terms of its association with the decision to admit. Objective: To further characterize this variation in rates of admission from the ED and to determine whether clinician risk attitudes are associated with the propensity to admit. Design, Setting, and Participants: In this observational cohort study, data were analyzed from the Massachusetts All Payer Claims Database to identify all ED visits from October 2015 through December 2017 with any form of commercial insurance or Medicaid. ED visits were then linked to treating clinicians and their risk tolerance scores obtained in a separate statewide survey to examine the association between risk tolerance and the decision to admit. Statistical analysis was performed from 2022 to 2023. Main Outcomes and Measures: The ratio between observed and projected admission rates was computed, controlling for hospital, and then plotted against the projected admission rates to find the extent of variation. Pearson correlation coefficients were then used to examine the association between the mean projected rate of admission and the difference between actual and projected rates of admission. The consistency of clinician admission practices across a range of the most common conditions resulting in admission were then assessed to understand whether admission decisions were consistent across different conditions. Finally, an assessment was made as to whether the extent of deviation from the expected admission rates at an individual level was associated with clinician risk tolerance. Results: The study sample included 392â¯676 ED visits seen by 691 emergency clinicians. Among patients seen for ED visits, 221â¯077 (56.3%) were female, and 236â¯783 (60.3%) were 45 years of age or older; 178â¯890 visits (46.5%) were for patients insured by Medicaid, 96â¯947 (25.2%) were for those with commercial insurance, 71â¯171 (18.5%) were Medicare Part B or Medicare Advantage, and the remaining 37â¯702 (9.8%) were other insurance category. Of the 691 clinicians, 429 (62.6%) were male; mean (SD) age was 46.5 (9.8) years; and 72 (10.4%) were Asian, 13 (1.9%) were Black, 577 (83.5%) were White, and 29 (4.2%) were other race. Admission rates across the clinicians included ranged from 36.3% at the 25th percentile to 48.0% at the 75th percentile (median, 42.1%). Overall, there was substantial variation in admission rates across clinicians; physicians were just as likely to overadmit or underadmit across the range of projected rates of admission (Pearson correlation coefficient, 0.046 [P = .23]). There also was weak consistency in admission rates across the most common clinical conditions, with intraclass correlations ranging from 0.09 (95% CI, 0.02-0.17) for genitourinary/syncope to 0.48 (95% CI, 0.42-0.53) for cardiac/syncope. Greater clinician risk tolerance (as measured by the Risk Tolerance Scale) was associated with a statistically significant tendency to admit less than the projected admission rate (coefficient, -0.09 [P = .04]). The other scales studied revealed no significant associations. Conclusions and Relevance: In this cohort study of ED visits from Massachusetts, there was statistically significant variation between ED clinicians in admission rates and little consistency in admission tendencies across different conditions. Admission tendencies were minimally associated with clinician innate risk tolerance as assessed by this study's measures; further research relying on a broad range of measures of risk tolerance is needed to better understand the role of clinician attitudes toward risk in explaining practice patterns and to identify additional factors that may be associated with variation at the clinician level.
Assuntos
Hospitalização , Medicare , Humanos , Masculino , Feminino , Idoso , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Estudos de Coortes , Serviço Hospitalar de Emergência , SíncopeRESUMO
BACKGROUND: Sex differences in acute myocardial infarction treatment and outcomes are well documented, but it is unclear whether differences are consistent across countries. The objective of this study was to investigate the epidemiology, use of interventional procedures, and outcomes for older females and males hospitalized with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) in 6 diverse countries. METHODS: We conducted a serial cross-sectional cohort study of 1â 508â 205 adults aged ≥66 years hospitalized with STEMI and NSTEMI between 2011 and 2018 in the United States, Canada, England, the Netherlands, Taiwan, and Israel using administrative data. We compared females and males within each country with respect to age-standardized hospitalization rates, rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery within 90 days of hospitalization, and 30-day age- and comorbidity-adjusted mortality. RESULTS: Hospitalization rates for STEMI and NSTEMI decreased between 2011 and 2018 in all countries, although the hospitalization rate ratio (rate in males/rate in females) increased in virtually all countries (eg, US STEMI ratio, 1.58:1 in 2011 and 1.73:1 in 2018; Israel NSTEMI ratio, 1.71:1 in 2011 and 2.11:1 in 2018). Rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery were lower for females than males for STEMI in all countries and years (eg, US cardiac catheterization in 2018, 88.6% for females versus 91.5% for males; Israel percutaneous coronary intervention in 2018, 76.7% for females versus 84.8% for males) with similar findings for NSTEMI. Adjusted mortality for STEMI in 2018 was higher for females than males in 5 countries (the United States, Canada, the Netherlands, Israel, and Taiwan) but lower for females than males in 5 countries for NSTEMI. CONCLUSIONS: We observed a larger decline in acute myocardial infarction hospitalizations for females than males between 2011 and 2018. Females were less likely to receive cardiac interventions and had higher mortality after STEMI. Sex disparities seem to transcend borders, raising questions about the underlying causes and remedies.
Assuntos
Infarto do Miocárdio , Infarto do Miocárdio sem Supradesnível do Segmento ST , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Masculino , Feminino , Estados Unidos/epidemiologia , Idoso , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Estudos Transversais , Países Desenvolvidos , Saúde Global , Resultado do Tratamento , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/efeitos adversos , Fatores de RiscoRESUMO
BACKGROUND: Timely primary care follow-up after acute care discharge may improve outcomes. OBJECTIVE: To evaluate whether post-discharge follow-up rates differ among patients discharged from hospitals directly affiliated with their primary care clinic (same-site), other hospitals within their health system (same-system), and hospitals outside their health system (outside-system). DESIGN: Retrospective cohort study. PATIENTS: Adult patients of five primary care clinics within a 14-hospital health system who were discharged home after a hospitalization or emergency department (ED) stay. MAIN MEASURES: Primary care visit within 14 days of discharge. A multivariable Poisson regression model was used to estimate adjusted rate ratios (aRRs) and risk differences (aRDs), controlling for sociodemographics, acute visit characteristics, and clinic characteristics. KEY RESULTS: The study included 14,310 discharges (mean age 58.4 [SD 19.0], 59.5% female, 59.5% White, 30.3% Black), of which 57.7% were from the same-site, 14.3% same-system, and 27.9% outside-system. By 14 days, 34.5% of patients discharged from the same-site hospital received primary care follow-up compared to 27.7% of same-system discharges (aRR 0.88, 95% CI 0.79 to 0.98; aRD - 6.5 percentage points (pp), 95% CI - 11.6 to - 1.5) and 20.9% of outside-system discharges (aRR 0.77, 95% CI [0.70 to 0.85]; aRD - 11.9 pp, 95% CI - 16.2 to - 7.7). Differences were greater for hospital discharges than ED discharges (e.g., aRD between same-site and outside-system - 13.5 pp [95% CI, - 20.8 to - 8.3] for hospital discharges and - 10.1 pp [95% CI, - 15.2 to - 5.0] for ED discharges). CONCLUSIONS: Patients discharged from a hospital closely affiliated with their primary care clinic were more likely to receive timely follow-up than those discharged from other hospitals within and outside their health system. Improving care transitions requires coordination across both care settings and health systems.
Assuntos
Alta do Paciente , Atenção Primária à Saúde , Humanos , Feminino , Masculino , Estudos Retrospectivos , Atenção Primária à Saúde/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Pessoa de Meia-Idade , Idoso , Adulto , Seguimentos , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Assistência ao Convalescente/estatística & dados numéricos , Assistência ao Convalescente/métodos , Estudos de Coortes , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricosRESUMO
PURPOSE: Prior studies have shown that treatment intensification for patients presenting with uncontrolled hypertension (HTN) rarely occurs, even during visits to the patient's own primary care physicians (PCPs). In this article, we identified predictors of treatment intensification for uncontrolled HTN. METHODS: We conducted a cross-sectional study using nationally representative survey data on visits by patients aged 18 or above with uncontrolled HTN, defined as a recorded SBP at least 140 and/or a DBP at least 90 using data from the National Ambulatory Medical Care Survey (NAMCS) 2008-2018. Our outcome is treatment intensification defined as the addition of a new blood pressure medication. RESULTS: We analyzed 22â559 visits to PCPs where uncontrolled HTN was noted, representing 801â023â786 visits nationally. Among these encounters, 2138 (10.3%) of the visits resulted in treatment intensification. Visits with the patient's own PCP had higher rates of treatment intensification than visits to another PCP (10.8 vs. 5.9%, P â<â0.0001). Visits for patients previously on antihypertensive medications had lower rates of treatment intensification (11% for no medications, 10.4% for one medication, 6.6% for ≥2 medications, P â<â0.0001), but there were no statistically significant differences in rates of intensification for those with relevant comorbidities (9.4% for no chronic conditions, 10.8% for one to two chronic conditions, 8.9% for at least three chronic conditions, P â=â0.12). Multivariable adjusted results were similar to the unadjusted findings. CONCLUSION: Visits for patients with uncontrolled HTN rarely result in treatment intensification. Substantial opportunity exists to improve management of HTN, particularly for patients on fewer medications or seen by a covering provider.
Assuntos
Hipertensão , Humanos , Estudos Transversais , Hipertensão/tratamento farmacológico , Anti-Hipertensivos/uso terapêutico , Anti-Hipertensivos/farmacologia , Pressão Sanguínea , Doença CrônicaRESUMO
There is debate about the value of preventive visits in primary care, and multiple policy trends during the past fifteen years may have influenced the likelihood of US adults undergoing preventive primary care visits. Using nationally representative, serial cross-sectional data on adult visits to primary care physicians from the 2001-19 National Ambulatory Medical Care Survey, we characterized temporal trends in the proportion of primary care visits with a preventive focus and the differential characteristics of these visits. Based on a sample of 139,783 unweighted (5,902,144,258 weighted) US primary care visits, we found that the proportion of primary care visits with a preventive focus increased between 2001 and 2019 (12.8 percent of visits in 2001-02 versus 24.6 percent in 2018-19; [Formula: see text]), with the greatest rate of increase seen for people with Medicare. Primary care visits with a preventive focus involved more time spent with the physician and addressed fewer reasons for the visit compared with problem-based visits. At least one of the following was significantly more likely to occur during a preventive visit than a problem-based visit: counseling provision, ordering of preventive labs, or ordering of a preventive image or procedure. Our findings demonstrate a relative increase in preventive versus problem-based visits in primary care and suggest the importance of enhanced insurance coverage in influencing preventive care delivery trends.
Assuntos
Medicare , Médicos , Idoso , Adulto , Humanos , Estados Unidos , Assistência Ambulatorial , Estudos Transversais , Visita a Consultório Médico , Atenção Primária à SaúdeRESUMO
Importance: As the US accelerates adoption of alternative payment through global payment models such as Accountable Care Organizations (ACOs) or Medicare Advantage (MA), high spending for cancer care is a potential target for savings. Objective: To quantify the extent to which ACOs and other risk-bearing organizations operating in a specific geographic area (hospital referral region [HRR]) could achieve savings by steering patients to efficient medical oncology practices. Design, Setting, and Participants: This observational study included serial cross-sections of Medicare beneficiaries with cancer from 2010 to 2018. Data were analyzed from August 2021 to March 2023. Main Outcomes and Measures: Total spending and spending by category in the 1-year period following an index visit for a patient with newly diagnosed (incident) or poor-prognosis cancer. Results: The incident cohort included 1â¯309â¯825 patients with a mean age of 74.0 years; the most common cancer types were breast (21.4%), lung (16.7%), and colorectal cancer (10.0%). The poor prognosis cohort included 1â¯429â¯973 (mean age, 72.7 years); the most common cancer types were lung (26.6%), lymphoma (11.7%), and leukemia (7.3%). Options for steering varied across markets; the top quartile market had 10 or more oncology practices, but the bottom quartile had 3 or fewer oncology practices. Total spending (including Medicare Part D) in the incident cohort increased from a mean of $57â¯314 in 2009 to 2010 to $66â¯028 in 2016 to 2017. Within markets, total spending for practices in the highest spending quartile was 19% higher than in the lowest quartile. Hospital spending was the single largest component of spending in both time periods ($20â¯390 and $19â¯718, respectively) followed by Part B (infused) chemotherapy ($8022 and $11â¯699). Correlations in practice-level spending between the first-year (2009) and second-year (2010) spending were high (>0.90 in all categories with most >0.98), but these attenuated over time. Conclusions and Relevance: These results suggest there may be opportunities for ACOs and other risk-bearing organizations to select or drive referrals to lower-spending oncology practices in many local markets.
Assuntos
Organizações de Assistência Responsáveis , Leucemia , Medicare Part D , Estados Unidos , Humanos , Idoso , Oncologia , MamaRESUMO
Importance: Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management. Objective: To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults. Design, Setting, and Participants: In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023. Exposure: Incident dementia diagnosis. Main Outcomes and Measures: The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date. Results: The study included 266â¯675 adults with incident dementia and 266â¯675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase). Conclusions and Relevance: In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.
Assuntos
Doenças Cardiovasculares , Demência , Medicare Part D , Idoso , Humanos , Feminino , Estados Unidos/epidemiologia , Idoso de 80 Anos ou mais , Masculino , Demência/diagnóstico , Demência/tratamento farmacológico , Demência/epidemiologia , Estudos de Coortes , Antagonistas Colinérgicos/efeitos adversosRESUMO
BACKGROUND: Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. METHODS: We performed a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30-day readmission rates, and time-to-surgery. RESULTS: The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30-day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%-45%) and THA (0.2%-10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%-60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30-day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). CONCLUSIONS: We observed substantial between-country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence-based surgical approaches.
Assuntos
Artroplastia de Quadril , Hemiartroplastia , Fraturas do Quadril , Humanos , Idoso , Estudos Retrospectivos , Países Desenvolvidos , Estudos Transversais , Fraturas do Quadril/cirurgiaRESUMO
Importance: The role of patient-level factors that are unrelated to the specific clinical condition leading to an emergency department (ED) visit, such as functional status, cognitive status, social supports, and geriatric syndromes, in admission decisions is not well understood, partly because these data are not available in administrative databases. Objective: To determine the extent to which patient-level factors are associated with rates of hospital admission from the ED. Design, Setting, and Participants: This cohort study analyzed survey data collected from participants (or their proxies, such as family members) enrolled in the Health and Retirement Study (HRS) from January 1, 2000, to December 31, 2018. These HRS data were linked to Medicare fee-for-service claims data from January 1, 1999, to December 31, 2018. Information on functional status, cognitive status, social supports, and geriatric syndromes was obtained from the HRS data, whereas ED visits, subsequent hospital admission or ED discharge, and other claims-derived comorbidities and sociodemographic characteristics were obtained from Medicare data. Data were analyzed from September 2021 to April 2023. Main Outcomes and Measures: The primary outcome measure was hospital admission after an ED visit. A baseline logistic regression model was estimated, with a binary indicator of admission as the dependent variable of interest. For each primary variable of interest derived from the HRS data, the model was reestimated, including the HRS variable of interest as an independent variable. For each of these models, the odds ratio (OR) and average marginal effect (AME) of changing the value of the variable of interest were calculated. Results: A total of 42â¯392 ED visits by 11â¯783 unique patients were included. At the time of the ED visit, patients had a mean (SD) age of 77.4 (9.6) years, and visits were predominantly for female (25 719 visits [60.7%]) and White (32 148 visits [75.8%]) individuals. The overall percentage of patients admitted was 42.5%. After controlling for ED diagnosis and demographic characteristics, functional status, cognition status, and social supports all were associated with the likelihood of admission. For instance, difficulty performing 5 activities of daily living was associated with an 8.5-percentage point (OR, 1.47; 95% CI, 1.29-1.66) AME increase in the likelihood of admission. Having dementia was associated with an AME increase in the likelihood of admission of 4.6 percentage points (OR, 1.23; 95% CI, 1.14-1.33). Living with a spouse was associated with an AME decrease in the likelihood of admission of 3.9 percentage points (OR, 0.84; 95% CI, 0.79-0.89), and having children living within 10 miles was associated with an AME decrease in the likelihood of admission of 5.0 percentage points (OR, 0.80; 95% CI, 0.71-0.89). Other common geriatric syndromes, including trouble falling asleep, waking early, trouble with vision, glaucoma or cataract, use of hearing aids or trouble with hearing, falls in past 2 years, incontinence, depression, and polypharmacy, were not meaningfully associated with the likelihood of admission. Conclusion and Relevance: Results of this cohort study suggest that the key patient-level characteristics, including social supports, cognitive status, and functional status, were associated with the decision to admit older patients to the hospital from the ED. These factors are critical to consider when devising strategies to reduce low-value admissions among older adult patients from the ED.
Assuntos
Atividades Cotidianas , Estado Funcional , Criança , Humanos , Feminino , Idoso , Estados Unidos/epidemiologia , Estudos de Coortes , Síndrome , Cognição Social , Estudos Retrospectivos , Medicare , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitais , CogniçãoRESUMO
Importance: Despite the increasing involvement of advanced practice practitioners (APPs; ie, nurse practitioners and physician assistants) in care delivery across specialties, the work patterns of APPs compared with physicians and how they are integrated into care teams have not been well characterized. Objective: To characterize differences between physicians and APPs across specialty types related to days with appointments, visit types seen, and time spent using the electronic health record (EHR). Design, Setting, and Participants: This nationwide, cross-sectional study used EHR data from physicians and APPs (ie, nurse practitioners and physician assistants) at all US institutions that used Epic Systems' EHR between January and May 2021. Data analysis was performed from March 2022 to April 2023. Main Outcomes and Measures: Appointment scheduling patterns, percentage of new and established and level of evaluation and management (E/M) visits, and EHR use metrics per day and week. Results: The sample consisted of 217â¯924 clinicians across 389 organizations, including 174â¯939 physicians and 42â¯985 APPs. Although primary care physicians were more likely than APPs to have more than 3 days per week with appointments (50 921 physicians [79.5%] vs 17â¯095 APPs [77.9%]), this trend was reversed for medical (38â¯645 physicians [64.8%] vs 8124 APPs [74.0%]) and surgical (24â¯155 physicians [47.1%] vs 5198 APPs [51.7%]) specialties. Medical and surgical specialty physicians saw 6.7 and 7.4 percentage points, respectively, more new patient visits than did their APP counterparts, whereas primary care physicians saw 2.8 percentage points fewer new patient visits than did APPs. Physicians saw a greater percentage of level 4 or 5 visits across all specialties. Medical and surgical physicians spent 34.3 and 45.8 fewer minutes per day, respectively, using the EHR than did APPs in their specialties, whereas primary care physicians spent 17.7 minutes per day more. These differences translated to primary care physicians spending 96.3 minutes more per week using the EHR than APPs, whereas medical and surgical physicians spent 149.9 and 140.7 fewer minutes, respectively, than did their APP counterparts. Conclusions and Relevance: This cross-sectional, national study of clinicians found significant differences in visit and EHR patterns for physicians compared with APPs across specialty types. By underscoring the different current usage of physicians vs APPs across specialty types, this study helps place into context the work and visit patterns of physicians compared with APPs and serves as a foundation for evaluations of clinical outcomes and quality.