The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions.

BACKGROUND: Accountable care organizations (ACOs) and the employment of nurse practitioners (NP) in place of physicians are strategies that aim to reduce the cost and improve the quality of routine care delivered in skilled nursing facilities (SNF). The recent expansion of ACOs and nurse practitioners into SNF settings in the United States may be associated with improved health outcomes for patients. OBJECTIVES: To determine the relationship between ACO attribution and NP care delivery during SNF visits and the relationship between NP care delivery during SNF visits and unplanned hospital readmissions. METHODS: We obtained a sample of 527,329 fee-for-service Medicare beneficiaries with 1 or more SNF stays between 2012 and 2017. We used logistic regression to measure the association between patient ACO attribution and evaluation and management care delivered by NPs in addition to the relationship between evaluation and management services delivered by NPs and hospital readmissions. RESULTS: ACO beneficiaries were 1.26% points more likely to receive 1 or more E&M services delivered by an NP during their SNF visits [Marginal Effect (ME): 0.0126; 95% CI: (0.009, 0.0160)]. ACO-attributed beneficiaries receiving most of their E&M services from NPs during their SNF visits were at a lower risk of readmission than ACO-attributed beneficiaries receiving no NP E&M care (5.9% vs. 7.1%; P <0.001). CONCLUSIONS: Greater participation by the NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. ACOs attributed beneficiaries were more likely to obtain the benefits of greater nurse practitioner involvement in their care.

Resource Use Among Diabetes Patients Who Mainly Visit Primary Care Physicians Versus Medical Specialists: a Retrospective Cohort Study.

BACKGROUND: It is not uncommon for medical specialists to predominantly care for patients with certain chronic conditions rather than primary care physicians (PCPs), yet the resource implications from such patterns of care are not well understood. OBJECTIVE: To assess resource use of diabetes patients who predominantly visit a PCP versus a medical specialist. DESIGN: Retrospective cohort study of diabetes patients aging into the traditional Medicare program. Patients were attributed to a PCP or medical specialist annually based on a preponderance of ambulatory care visits and categorized according to whether attribution changed year to year. Propensity score weighting was used to balance baseline demographic characteristics, diabetes complications, and underlying health conditions between patients attributed to PCPs and to medical specialists. Spending and utilization were measured up to 3 patient-years. SUBJECTS: A total of 141,558 patient-years. MAIN MEASURES: Total visits, unique physicians, hospital admissions, emergency department visits, procedures, imaging, and tests. KEY RESULTS: Each year, roughly 70% of patients maintained attribution to a PCP and 15% to a medical specialist relative to the previous year. After propensity weighting, patients continuously attributed to a PCP versus medical specialist from 1 year to the next had lower average total payer payments ($10,326 [SD $57,386] versus $14,971 [SD $74,112], P<0.0001) and lower total patient out-of-pocket payments ($1,707 [SD $6,020] versus $2,443 [SD $7,984], P<0.0001). Rates of hospitalization, emergency department visits, procedures, imaging, and tests were lower among patients attributed to PCPs as well. CONCLUSIONS: Older adults with diabetes who receive more of their ambulatory care from a PCP instead of a medical specialist show evidence of lower resource use.

Variation in Benzodiazepine and Antipsychotic Prescribing Among Hospice Agencies.

BACKGROUND: Benzodiazepines and antipsychotics are routinely prescribed for symptom management in hospice. There is minimal evidence to guide prescribing in this population, and little is known about how prescribing varies across hospice agencies. OBJECTIVE: Examine patient- and hospice agency-level characteristics associated with incident prescribing of benzodiazepines and antipsychotics in hospice. DESIGN: Retrospective cohort study of a 20% sample of Medicare beneficiaries newly enrolled in hospice. PARTICIPANTS: Medicare hospice beneficiaries ≥ 65 years old between 2014 and 2016, restricted to those without benzodiazepine (N = 169,688) or antipsychotic (N = 190,441) prescription fills in the 6 months before hospice enrollment. MAIN MEASURES: The primary outcome was incident (i.e., new) prescribing of a benzodiazepine or antipsychotic. A series of multilevel Cox regression models with random intercepts for hospice agency were fit to examine the association of incident benzodiazepine and antipsychotic prescribing with patient and hospice agency characteristics. KEY RESULTS: A total of 91,728 (54.1%) and 58,175 (30.5%) hospice beneficiaries were newly prescribed an incident benzodiazepine or antipsychotic. The prescribing rate of the hospice agency was the strongest predictor of incident prescribing: Compared to patients in bottom-quartile benzodiazepine-prescribing agencies, those in top-quartile agencies were 10.7 times more likely to be prescribed an incident benzodiazepine (adjusted hazard ratio [AHR] 10.7, 95% CI 10.1-11.3). For incident antipsychotic prescribing, patients in top-quartile agencies were 51.7 times more likely to receive an antipsychotic (AHR 51.7, 95% CI 44.3-60.4) compared to those in the bottom quartile. Results remained consistent accounting for comfort kit prescribing. CONCLUSIONS: The pattern of benzodiazepine or antipsychotic prescribing of a hospice agency strongly predicts whether a hospice enrollee is prescribed these medications, exceeding every other patient-level factor. While the appropriate level of prescribing in hospice is unclear, this variation may reflect a strong local prescribing culture across individual hospice agencies.

The Effect of Healthcare Provider Availability on Spine Spending.

BACKGROUND: Spine conditions are costly and a major cause of disability. A growing body of evidence suggests that healthcare utilization and spending are driven by provider availability, which varies geographically and is a topic of healthcare policy debate. OBJECTIVE: To estimate the effect of provider availability on spine spending. DESIGN: Retrospective cohort study using relocation as a natural experiment. PARTICIPANTS: Fee-for-service Medicare beneficiaries over age 65 who relocated to a new hospital referral region between 2010 and 2014. MAIN MEASURES: We used generalized linear models to evaluate how changes in per-beneficiary availability of three types of healthcare providers (primary care physicians, spine surgeons, and chiropractors) affected annual per-beneficiary spine spending. We evaluated increases and decreases in provider availability separately. To account for the relative sizes of the provider workforces, we also calculated estimates of the effects of changes in national workforce size on changes in national spine spending. KEY RESULTS: The association between provider availability and spending was generally stronger among beneficiaries who experienced a decrease (versus an increase) in availability. Of the three provider groups, spine surgeon availability was most strongly associated with spending. Among beneficiaries who experienced a decrease in availability, a decrease in one spine surgeon per 10,000 beneficiaries was associated with a decrease of $36.97 (95% CI: $12.51, $61.42) in annual spending per beneficiary, versus a decrease of $1.41 (95% CI: $0.73, $2.09) for a decrease in primary care physician availability. However, changes in the national workforce size of primary care physicians were associated with the largest changes in national spine spending. CONCLUSIONS: Provider availability affects individual spine spending, with substantial changes observed at the national level. The effect depends on provider type and whether availability increases or decreases. Policymakers should consider how changes in the size of the physician workforce affect healthcare spending.

Access to primary care and cognitive impairment: results from a national community study of aging Americans.

BACKGROUND: Despite a growing burden of Alzheimer's Disease and related dementias (ADRD) in the US, the relationship between health care and cognitive impairment prevention is unclear. Primary care manages risk causing conditions and risk reducing behaviors for dementia, so we examine the association between individual and area-level access to primary care and cognitive impairment in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. METHODS: REGARDS participants with a cognitive assessment and vascular measurements at their baseline visit were included in this cross-sectional analysis. Cognitive impairment was defined as a Six-Item Screener (SIS) score < 5. Primary care supply, primary care utilization and emergency department (ED) utilization were measured at the primary care service area (PCSA) level based on participant's address. Individual access to care was self-reported. Models were adjusted for confounding by demographics, socioeconomic status and behavioral risk factors. RESULTS: Among 25,563 adults, living in a PCSA with low primary care supply was associated with 25% higher odds of cognitive impairment (OR 1.25 CI 1.07-1.45). Not having a regular source of medical care was associated with 14% higher odds of cognitive impairment (OR 1.14 CI 1.02-1.28), and living in a PCSA with high emergency department utilization was associated with 12% higher odds of cognitive impairment (OR 1.12 CI 1.02-1.23). CONCLUSIONS: Our results are an important first step in understanding how health care may prevent cognitive impairment. They highlight the importance of primary care and suggest future work clarifying its role in preventing cognitive decline is imperative.

Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US.

Importance: Community-dwelling older adults with dementia have a high prevalence of psychotropic and opioid use. In these patients, central nervous system (CNS)-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death. Objective: To determine the extent of CNS-active polypharmacy among community-dwelling older adults with dementia in the US. Design, Setting, and Participants: Cross-sectional analysis of all community-dwelling older adults with dementia (identified by International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes; N = 1 159 968) and traditional Medicare coverage from 2015 to 2017. Medication exposure was estimated using prescription fills between October 1, 2017, and December 31, 2018. Exposures: Part D coverage during the observation year (January 1-December 31, 2018). Main Outcomes and Measures: The primary outcome was the prevalence of CNS-active polypharmacy in 2018, defined as exposure to 3 or more medications for longer than 30 days consecutively from the following classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, and opioids. Among those who met the criterion for polypharmacy, duration of exposure, number of distinct medications and classes prescribed, common class combinations, and the most commonly used CNS-active medications also were determined. Results: The study included 1 159 968 older adults with dementia (median age, 83.0 years [interquartile range {IQR}, 77.0-88.6 years]; 65.2% were female), of whom 13.9% (n = 161 412) met the criterion for CNS-active polypharmacy (32 139 610 polypharmacy-days of exposure). Those with CNS-active polypharmacy had a median age of 79.4 years (IQR, 74.0-85.5 years) and 71.2% were female. Among those who met the criterion for CNS-active polypharmacy, the median number of polypharmacy-days was 193 (IQR, 88-315 polypharmacy-days). Of those with CNS-active polypharmacy, 57.8% were exposed for longer than 180 days and 6.8% for 365 days; 29.4% were exposed to 5 or more medications and 5.2% were exposed to 5 or more medication classes. Ninety-two percent of polypharmacy-days included an antidepressant, 47.1% included an antipsychotic, and 40.7% included a benzodiazepine. The most common medication class combination included an antidepressant, an antiepileptic, and an antipsychotic (12.9% of polypharmacy-days). Gabapentin was the most common medication and was associated with 33.0% of polypharmacy-days. Conclusions and Relevance: In this cross-sectional analysis of Medicare claims data, 13.9% of older adults with dementia in 2018 filled prescriptions consistent with CNS-active polypharmacy. The lack of information on prescribing indications limits judgments about clinical appropriateness of medication combinations for individual patients.

The Influence of Stereotactic Body Radiation Therapy Adoption on Prostate Cancer Treatment Patterns.

PURPOSE: To our knowledge it is unknown whether stereotactic body radiation therapy of prostate cancer is a substitute for other radiation treatments or surgery, or for expanding the pool of patients who undergo treatment instead of active surveillance. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology, and End Results)-Medicare we identified men diagnosed with prostate cancer between 2007 and 2011. We developed physician-hospital networks by identifying the treating physician of each patient based on the primary treatment received and subsequently assigning each physician to a hospital. We examined the relative distribution of prostate cancer treatments stratified by whether stereotactic body radiation therapy was performed in a network by fitting logistic regression models with robust SEs to account for patient clustering in networks. RESULTS: We identified 344 physician-hospital networks, including 30 (8.7%) and 314 (91.3%) in which stereotactic body radiation therapy was and was not performed, respectively. Networks in which that therapy was and was not done did not differ with time in the performance of robotic and radical prostatectomy, and active surveillance (all p >0.05). The relationship with intensity modulated radiation therapy did not show any consistent temporal pattern. In networks in which it was performed less intensity modulated radiation therapy was initially done but there were similar rates in later years. Brachytherapy trends differed among networks in which stereotactic body radiation therapy was vs was not performed with a lower brachytherapy rate in networks in which stereotactic body radiation therapy was done (p=0.03). CONCLUSIONS: Surgery and active surveillance rates did not differ in networks in which stereotactic body radiation therapy was vs was not performed but when that therapy was done there was a lower brachytherapy rate. Stereotactic body radiation therapy may represent more of an alternative to brachytherapy than to active surveillance.

The natural history of urinary incontinence subtypes in the Nurses' Health Studies.

BACKGROUND: Urinary incontinence subtypes often differ by symptom severity and treatment profiles; in particular, mixed urinary incontinence is generally associated with worse symptoms and less successful treatment. Yet, limited information exists on the natural history of different urinary incontinence subtypes, which could help to better identify and treat patients prior to development of more intractable disease. OBJECTIVE: To evaluate the onset of urinary incontinence subtypes, and transitions between subtypes over 8 years, using 2 large cohorts of middle-aged and older women with incident urinary incontinence. MATERIALS AND METHODS: We identified 10,349 women with incident urinary incontinence (stress, urgency, and mixed subtypes) from the Nurses' Health Study and the Nurses' Health Study II who were 41-83 years of age, using repeated mailed questionnaires. We defined stress urinary incontinence as leakage with coughing, sneezing, or activity; urgency urinary incontinence as urine loss with a sudden feeling of bladder fullness or when a toilet was inaccessible; and mixed urinary incontinence when women reported that stress and urgency symptoms occurred equally. In subsequent questionnaires 4 and 8 years later, we continued to track symptom severity and subtypes. In addition, to obtain predicted probabilities of urinary incontinence subtypes 4 years and 8 years after urinary incontinence onset, we used multivariable-adjusted generalized estimating equations with a multinomial outcome. RESULTS: At urinary incontinence onset in 2004-2005, 56% of women reported stress urinary incontinence symptoms, 23% reported urgency urinary incontinence symptoms, and 21% reported mixed urinary incontinence symptoms. Women with stress urinary incontinence or urgency urinary incontinence at onset were likely to report the same urinary incontinence type 4 and 8 years later (stress urinary incontinence at onset: 70% and 60% reported stress urinary incontinence at years 4 and 8, respectively; urgency urinary incontinence at onset: 68% and 64% reported urgency urinary incontinence at years 4 and 8, respectively). Nonetheless, for both stress and urgency urinary incontinence, women with more severe symptoms at onset were more likely to progress to mixed urinary incontinence. Women with mixed urinary incontinence at onset had more variation over time, although the largest subset continued to report mixed urinary incontinence (45% reported mixed urinary incontinence at year 4; 43% reported mixed urinary incontinence at year 8). Few women across all urinary incontinence subtypes reported resolution of symptoms over 4-8 years of follow-up (4-12%). When considering the likelihood of remaining with or progressing to mixed urinary incontinence over follow-up, according to age, body mass index, and urinary incontinence severity, we found that older and younger women had similar predicted probability of remaining with or progressing to mixed urinary incontinence (eg, women <60 years of age at onset with severe mixed urinary incontinence had a 54% (95% confidence interval, 53-55) probability of mixed urinary incontinence 8 years later, vs 57% (95% confidence interval, 56-58) of women ≥70 years of age with severe mixed urinary incontinence at onset). Obese women were somewhat more likely to progress to mixed urinary incontinence regardless of urinary incontinence type at onset (eg, women with body mass index <25 kg/m2 at onset with severe stress urinary incontinence had a 30% predicted probability of mixed urinary incontinence 8 years after onset, vs 36% of women with body mass index of 30+ kg/m2 at onset with severe stress urinary incontinence). CONCLUSION: Most women with incident stress and urgency urinary incontinence continued to experience similar subtype symptoms over 8 years. However, obese women and those with more severe symptoms were more likely to remain with or progress to mixed urinary incontinence.

Modeling peer effect modification by network strength: The diffusion of implantable cardioverter defibrillators in the US hospital network.

We develop methodology that allows peer effects (also referred to as social influence and contagion) to be modified by the structural importance of the focal actor's position in the network. The methodology is first developed for a single peer effect and then extended to simultaneously model multiple peer-effects and their modifications by the structural importance of the focal actor. This work is motivated by the diffusion of implantable cardioverter defibrillators (ICDs) in patients with congestive heart failure across a cardiovascular disease patient-sharing network of United States hospitals. We apply the general methodology to estimate peer effects for the adoption of capability to implant ICDs, the number of ICD implants performed by hospitals that are capable, and the number of patients referred to other hospitals by noncapable hospitals. Applying our novel methodology to study ICD diffusion across hospitals, we find evidence that exposure to ICD-capable peer hospitals is strongly associated with the chance a hospital becomes ICD-capable and that the direction and magnitude of the association is extensively modified by the strength of that hospital's position in the network, even after controlling for effects of geography. Therefore, interhospital networks, rather than geography per se, may explain key patterns of regional variations in healthcare utilization.

A Framework for Aging-Friendly Services and Supports in the Age of COVID-19.

COVID-19 has revealed gaps in services and supports for older adults, even as needs for health and social services have dramatically increased and may produce a cascade of disability after the pandemic subsides. In this essay, we discuss the perfect storm of individual and environmental risk factors, including deconditioning, reductions in formal and informal care support, and social isolation. We then evaluate opportunities that have arisen for strengthening person-centered services and supports for older adults, through in-home acute and primary medical care, aggressive use of video telehealth and social interaction, and implementation of volunteer or paid intergenerational service.

Outpatient Evaluation and Management Visits for Urinary Incontinence in Older Women.

PURPOSE: The aims of this investigation were to examine how often outpatient visits addressing urinary incontinence in women with self-reported incontinence symptoms occur and to explore characteristics associated with an outpatient visit for incontinence. MATERIALS AND METHODS: We studied the records of 18,576 women from the Nurses' Health Study who were 65 years old or older, reported prevalent incontinence symptoms in 2012 on a mailed questionnaire and were linked with Medicare utilization data. We compared demographic, personal and clinical characteristics in women with and without claims for outpatient visits for urinary incontinence. In logistic regression models we controlled for potential confounding factors, including age, race, parity, body mass index, medical comorbidities, smoking status, health seeking behavior, disability, physical function and geographic region. RESULTS: In this linkage between symptom report and insurance claims data we found that only 16% of older women with current incontinence symptoms also had an outpatient visit addressing incontinence in the prior 2 years. In multivariable adjusted models severe vs slight incontinence (OR 3.75, 95% CI 3.10-4.53) and urgency vs stress incontinence (OR 1.80, 95% CI 1.56-2.08) were the strongest predictors of undergoing outpatient evaluation. CONCLUSIONS: Overall only a small percent of women who report urinary incontinence symptoms also have medical outpatient visits for incontinence, which is a marker of care seeking. Our study highlights the discordance between the high prevalence of incontinence in older women and the lack of clinical assessment despite symptoms even among nurses with high health care literacy.

Developing and Validating a Measure to Estimate Poverty in Medicare Administrative Data.

OBJECTIVE: To develop and validate a measure that estimates individual level poverty in Medicare administrative data that can be used in studies of Medicare claims. DATA SOURCES: A 2008 to 2013 Medicare Current Beneficiary Survey linked to 2008 to 2013 Medicare fee-for-service beneficiary summary file and census data. STUDY DESIGN AND METHODS: We used the Medicare Current Beneficiary Survey to define individual level poverty status and linked to Medicare administrative data (N=38,053). We partitioned data into a measure derivation dataset and a validation dataset. In the derivation data, we used a logistic model to regress poverty status on measures of dual eligible status, part D low-income subsidy, and demographic and administrative data, and modeled with and without linked census and nursing home data. Each beneficiary receives a predicted poverty score from the model. Performance was evaluated in derivation and validation data and compared with other measures used in the literature. We present a measure for income-only poverty as well as one for income and asset poverty. PRINCIPAL FINDINGS: A score (predicted probability of income poverty) >0.5 yielded 58% sensitivity, 94% specificity, and 84% positive predictive value in the derivation data; our score yielded very similar results in the validation data. The model's c-statistic was 0.84. Our poverty score performed better than Medicaid enrollment, high zip code poverty, and zip code median income. The income and asset version performed similarly well. CONCLUSIONS: A poverty score can be calculated using Medicare administrative data for use as a continuous or binary measure. This measure can improve researchers' ability to identify poverty in Medicare administrative data.

Changes in Use of Postacute Care Associated With Accountable Care Organizations in Hip Fracture, Stroke, and Pneumonia Hospitalized Cohorts.

OBJECTIVE: To examine changes in more and less discretionary condition-specific postacute care use (skilled nursing, inpatient rehabilitation, home health) associated with Medicare accountable care organization (ACO) implementation. DATA SOURCES: 2009-2014 Medicare fee-for-service claims. STUDY DESIGN: Difference-in-difference methodology comparing postacute outcomes after hospitalization for hip fracture and stroke (where rehabilitation is fundamental to the episode of care) to pneumonia, (where it is more discretionary) for beneficiaries attributed to ACO and non-ACO providers. PRINCIPAL FINDINGS: Across all 3 cohorts, in the baseline period ACO patients were more likely to receive Medicare-paid postacute care and had higher episode spending. In hip fracture patients where rehabilitation is standard of care, ACO implementation was associated with 6%-8% increases in probability of admission to a skilled nursing facility or inpatient rehabilitation (compared with home without care), and a slight reduction in readmissions. In a clinical condition where rehabilitation is more discretionary, pneumonia, ACO implementation was not associated with changes in postacute location, but episodic spending decreased 2%-3%. Spending decreases were concentrated in the least complex patients. Across all cohorts, the length of stay in skilled nursing facilities decreased with ACO implementation. CONCLUSIONS: ACOs decreased spending on postacute care by decreasing use of discretionary services. ACO implementation was associated with reduced length of stay in skilled nursing facilities, while hip fracture patients used institutional postacute settings at higher rates. Among pneumonia patients, we observed decreases in spending, readmission days, and mortality associated with ACO implementation.

Evaluation of Physician Network-Based Measures of Care Coordination Using Medicare Patient-Reported Experience Measures.

BACKGROUND: There is significant promise in analyzing physician patient-sharing networks to indirectly measure care coordination, yet it is unknown whether these measures reflect patients' perceptions of care coordination. OBJECTIVE: To evaluate the associations between network-based measures of care coordination and patient-reported experience measures. DESIGN: We analyzed patient-sharing physician networks within group practices using data made available by the Centers for Medicare and Medicaid Services. SUBJECTS: Medicare beneficiaries who provided responses to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey in 2016 (data aggregated by physician group practice made available through the Physician Compare 2016 Group Public Reporting). MAIN MEASURES: The outcomes of interest were patient-reported experience measures reflecting aspects of care coordination (CAHPS). The predictor variables of interests were physician group practice density (the number of physician pairs who share patients adjusting for the total number of physician pairs) and clustering (the extent to which sets of three physicians share patients). KEY RESULTS: Four hundred seventy-six groups had patient-reported measures available. Patients' perception of "Clinicians working together for your care" was significantly positively associated with both physician group practice density (Est (95 % CI) = 5.07(0.83, 9.33), p = 0.02) and clustering (Est (95 % CI) = 3.73(1.01, 6.44), p = 0.007). Physician group practice clustering was also significantly positively associated with "Getting timely care, appointments, and information" (Est (95 % CI) = 4.63(0.21, 9.06), p = 0.04). CONCLUSIONS: This work suggests that network-based measures of care coordination are associated with some patient-reported experience measures. Evaluating and intervening on patient-sharing networks may provide novel strategies for initiatives aimed at improving quality of care and the patient experience.

Short-term survival after colorectal cancer in a screened versus unscreened population.

Aims: United States' (US) colorectal cancer (CRC) screening and treatment practices seek to reduce mortality. We examined the survival of US patients compared with patients in the virtually unscreened Norwegian population. Methods: We compared short-term survival after CRC between the US and Norway using relative survival (RS) and excess mortality (EMR) analyses. The CRC patients were aged 50 and older diagnosed in the US (Surveillance, Epidemiology and End Results registry, 2004, N=9511) and in Norway (Cancer Registry of Norway, 2003-2005, N=8256). Results: Death occurred within three years for 39% of the CRC patients. Stage distributions were more favorable for US patients. Stage-specific survival was similar for localized and regional cancers, but more favorable for US distant cancers. In multivariate models of patient, tumor and treatment characteristics, patients (especially below age 80) in the US experienced longer survival (EMR 0.9, CI 0.8-0.9). Stage-specific analyses showed, however, that survival for localized cancers was relatively shorter in the US than in Norway (EMR 1.4, CI 1.1-1.8), but longer for distant cancers (EMR 0.8, CI 0.7-0.8). Conclusions: The enhanced survival for US CRC patients likely reflects a screening-related earlier diagnostic stage distribution, as well as prioritized life extension for patients with metastatic cancers, reflecting vastly different health care systems in the two countries. CRC screening is currently under consideration in Norway. For survival outcomes, the current findings do not discourage such an implementation. Other screening-related aspects such as feasibility and cost-benefit are, however, also relevant and warrant further research within a socialized health system.

Assessing Variation in Implantable Cardioverter Defibrillator Therapy Guideline Adherence With Physician and Hospital Patient-sharing Networks.

BACKGROUND: Implantable cardioverter defibrillator (ICD) therapy is used for primary prevention of death among people with heart failure, and new evidence in 2005 on its effectiveness changed practice guidelines in the United States. OBJECTIVES: The objective of this study is to examine how the connectedness of physicians and hospitals, measured using network analysis, relates to guideline-consistent ICD implantation. RESEARCH DESIGN: We constructed physician and hospital networks for cardiovascular disease. Physicians were linked if they shared cardiovascular disease patients; these links were aggregated by hospital affiliation to construct a hospital network. SUBJECTS: Medicare beneficiaries who underwent ICD therapy for primary prevention from 2007 to 2011. MEASURES: The clinical outcome of interest was guideline-consistent ICD implantation, calculated using the National Cardiovascular Data Registry. The exposure variables of interest were the network measures of the ICD surgeon, the referring hospital, and the hospital where the ICD surgery occurred. RESULTS: We focused on patients who were referred between hospitals for ICD implantation because they were more likely influenced by the hospital network (n=28,179). Patients were less likely to meet guidelines if their referring hospital had more connections to other hospitals (OR, 0.49; 95% confidence interval, 0.25-0.96) and more likely to meet guidelines if their ICD surgery hospital had more connections (OR, 1.61; 95% confidence interval, 0.98-2.64). The ICD surgeon's network measures were not associated with guideline-consistent implantation. CONCLUSIONS: Associations between the hospital network measures and guideline adherence suggests new approaches to better disseminate clinical guidelines across health systems.

Leveraging Linkage of Cohort Studies With Administrative Claims Data to Identify Individuals With Cancer.

BACKGROUND: In an effort to overcome quality and cost constraints inherent in population-based research, diverse data sources are increasingly being combined. In this paper, we describe the performance of a Medicare claims-based incident cancer identification algorithm in comparison with observational cohort data from the Nurses' Health Study (NHS). METHODS: NHS-Medicare linked participants' claims data were analyzed using 4 versions of a cancer identification algorithm across 3 cancer sites (breast, colorectal, and lung). The algorithms evaluated included an update of the original Setoguchi algorithm, and 3 other versions that differed in the data used for prevalent cancer exclusions. RESULTS: The algorithm that yielded the highest positive predictive value (PPV) (0.52-0.82) and κ statistic (0.62-0.87) in identifying incident cancer cases utilized both Medicare claims and observational cohort data (NHS) to remove prevalent cases. The algorithm that only used NHS data to inform the removal of prevalent cancer cases performed nearly equivalently in statistical performance (PPV, 0.50-0.79; κ, 0.61-0.85), whereas the version that used only claims to inform the removal of prevalent cancer cases performed substantially worse (PPV, 0.42-0.60; κ, 0.54-0.70), in comparison with the dual data source-informed algorithm. CONCLUSIONS: Our findings suggest claims-based algorithms identify incident cancer with variable reliability when measured against an observational cohort study reference standard. Self-reported baseline information available in cohort studies is more effective in removing prevalent cancer cases than are claims data algorithms. Use of claims-based algorithms should be tailored to the research question at hand and the nature of available observational cohort data.

A prospective study of the natural history of urinary incontinence in women.

BACKGROUND: Symptoms of urinary incontinence are commonly perceived to vary over time; yet, there is limited quantitative evidence regarding the natural history of urinary incontinence, especially over the long term. OBJECTIVE: We sought to delineate the course of urinary incontinence symptoms over time, using 2 large cohorts of middle-aged and older women, with data collected over 10 years. STUDY DESIGN: We studied 9376 women from the Nurses' Health Study, age 56-81 years at baseline, and 7491 women from the Nurses' Health Study II, age 39-56 years, with incident urinary incontinence in 2002 through 2003. Urinary incontinence severity was measured by the Sandvik severity index. We tracked persistence, progression, remission, and improvement of symptoms over 10 years. We also examined risk factors for urinary incontinence progression using logistic regression models. RESULTS: Among women age 39-56 years, 39% had slight, 45% had moderate, and 17% had severe urinary incontinence at onset. Among women age 56-81 years, 34% had slight, 45% had moderate, and 21% had severe urinary incontinence at onset. Across ages, most women reported persistence or progression of symptoms over follow-up; few (3-11%) reported remission. However, younger women and women with less severe urinary incontinence at onset were more likely to report remission or improvement of symptoms. We found that increasing age was associated with higher odds of progression only among older women (age 75-81 vs 56-60 years; odds ratio, 1.84; 95% confidence interval, 1.51-2.25). Among all women, higher body mass index was strongly associated with progression (younger women: odds ratio, 2.37; 95% confidence interval, 2.00-2.81; body mass index ≥30 vs <25 kg/m2; older women: odds ratio, 1.93; 95% confidence interval, 1.62-2.22). Additionally, greater physical activity was associated with lower odds of progression to severe urinary incontinence (younger women: odds ratio, 0.86; 95% confidence interval, 0.71-1.03; highest vs lowest quartile of activity; older women: odds ratio, 0.68; 95% confidence interval, 0.59-0.80). CONCLUSION: Most women with incident urinary incontinence continued to experience symptoms over 10 years; few had complete remission. Identification of risk factors for urinary incontinence progression, such as body mass index and physical activity, could be important for reducing symptoms over time.

E-Prescribing and Adverse Drug Events: An Observational Study of the Medicare Part D Population With Diabetes.

BACKGROUND: Although the adoption of e-prescriptions among physicians has increased substantially under the Medicare Improvements for Patients and Providers Act and Meaningful Use programs, little is known of its impact on patient outcomes. OBJECTIVE: To examine the impact of e-prescribing on emergency visits or hospitalizations for diabetes-related adverse drug events (ADEs) including hypoglycemia. DESIGN: This is a prospective, observational cohort study with patient fixed effects. SETTING: 2011-2013 fee for service Medicare. PATIENTS: In total, 3.1 million Medicare fee for service, Part D enrolled beneficiaries over age 66 with diabetes mellitus and at least 90 days of antidiabetic medications. MEASUREMENTS: E-prescribing was measured as the percentage of all prescriptions a person received transmitted to the pharmacy electronically. The outcome measure was the occurrence of an emergency department (ED) visit or hospitalization for hypoglycemia or diabetes-related ADE. RESULTS: Unadjusted results show that there were 21 ADEs per 1000 beneficiaries that had ≥75% of their medications e-prescribed. Beneficiaries with lower e-prescribing levels had significantly higher numbers of ADEs. We found a robust association between the greater use of electronic prescriptions in the outpatient setting and the lower risk of an inpatient or ED visit for an ADE event among Medicare beneficiaries with diabetes in our adjusted analysis. At the e-prescribing threshold of 75% and above, significant reductions in ADE risk can be seen. LIMITATIONS: As an observational study, the results show an association but do not prove causation. CONCLUSIONS: Use of e-prescribing is associated with lower risk of an ED visit or hospitalization for diabetes-related ADE.