Ten-year incidence of age-related macular degeneration according to diabetic retinopathy classification among medicare beneficiaries.

PURPOSE: To compare the longitudinal incidence over 10 years of dry and wet age-related macular degeneration (AMD) in a U.S. sample of Medicare beneficiaries with no diabetes mellitus, diabetes mellitus without retinopathy, nonproliferative diabetic retinopathy (NPDR), and proliferative diabetic retinopathy (PDR). METHODS: Using Medicare claims data, the 10-year incidence of dry and wet AMD from 1995 to 2005 in beneficiaries older than 69 years with newly diagnosed diabetes mellitus (n = 6,621), NPDR (n = 1,307), and PDR (n = 327) compared with each other and matched controls without diabetes for each group. RESULTS: After controlling for covariates, newly diagnosed NPDR was associated with significantly increased risk of incident diagnosis of dry AMD (hazard ratio, 1.24; 95% confidence interval: 1.08-1.43) and wet AMD (hazard ratio 1.68; 95% confidence interval: 1.23-2.31). Newly diagnosed PDR was associated with significantly increased risk of wet AMD only (hazard ratio 2.15; 95% confidence interval: 1.07-4.33). Diabetes without retinopathy did not affect risk of dry or wet AMD. There was no difference in risk of wet AMD in PDR compared with NPDR. CONCLUSION: Elderly individuals with NPDR or PDR may be at higher risk of AMD compared to those without diabetes mellitus or diabetic retinopathy.

Longitudinal evidence on punctal plug use in an elderly population.

PURPOSE: The purpose of this study was to determine whether changes in Medicare reimbursement for punctal plug insertion were associated with a decrease in the incidence of insertion and dry eye diagnosis. METHODS: Incident cases of dry eye syndrome (DES) diagnoses and punctal plug insertions among Medicare beneficiaries were identified from Medicare 5% Part B from 1994 to 2008, using a 3-year look-back. Dry eye syndrome diagnoses and punctal plug insertion codes were ascertained from the international classification of diseases and current procedural terminology codes. Medicare payment data were obtained from the Centers for Medicare and Medicaid Services from 1994 to 2008 for punctal plug insertion. Rates were calculated for both the incidence of DES and the use of punctal plugs. RESULTS: From 2001 to 2008, inflation-adjusted Medicare reimbursement for punctal plug insertion decreased 55.1%, whereas the Medicare population-adjusted incidence of dry eye diagnosis increased 23.3%. Nine percent of individuals diagnosed with DES between 1991 and 2008 underwent punctal plug placement with a mean of 2.0 plugs placed per patient. Total punctal plug placement increased 322.2% between 1994 and 2003, and then reached a plateau. First-time punctal plug insertion rates within 365 days of DES diagnosis increased 111.8% from 1994 to 2002, and then declined 47.0% from 2002 to 2008. CONCLUSIONS: Although the frequency of DES diagnosis in the Medicare population has increased over time, first-time punctal plug insertion rates, especially within the first year following DES diagnosis, have declined coincidently with the increasing presence of a medical alternative and declining Medicare payment. Choice of therapies may have cost and care implications.

Correction: The investment case as a mechanism for addressing the NCD burden: Evaluating the NCD institutional context in Jamaica, and the return on investment of select interventions.

[This corrects the article DOI: 10.1371/journal.pone.0223412.].

The investment case as a mechanism for addressing the NCD burden: Evaluating the NCD institutional context in Jamaica, and the return on investment of select interventions.

Noncommunicable diseases (NCDs) are a broad challenge for decision-makers. NCDs account for seven out of every 10 deaths globally, with 42 percent occurring prematurely in individuals under age 70. Despite their heavy toll, NCDs are underfunded, with only around two percent of global funding dedicated to the disease set. Country governments are responsible for funding targeted actions to reduce the NCD burden, but among other priorities, many have yet to invest in the health-system interventions and policy measures that can reduce the burden. This article examines "investment cases" as a potential mechanism for catalyzing attention to-and funding for-NCDs. In Jamaica, using the UN inter-agency OneHealth Tool, we conducted an economic analysis to estimate the return-on-investment from scaling up strategic clinical interventions, and from implementing or intensifying policy measures that target NCD risk factors. In addition, we conducted an institutional and context (ICA) analysis, interviewing stakeholders across sectors to take stock of promising policy pathways (e.g., areas of general consensus, political appetite and opportunity) as well as challenges to implementation. The economic analysis found that scaling up clinical interventions that target CVD, diabetes, and mental health disorders, and policy measures that target tobacco and alcohol use, would save over 6,600 lives between 2017-2032, and avert JMD 81.3 billion (USD 640 million) in direct and indirect economic costs that result from mortality and morbidity linked to NCDs. The ICA uncovered government economic growth targets and social priorities that would be aided by increased attention to NCDs, and it linked these targets and priorities to the economic analysis.

Effects of admission and treatment strategies of DWI courts on offender outcomes.

PURPOSE: The purpose of this study is to classify DWI courts on the basis of the mix of difficult cases participating in the court (casemix severity) and the amount of involvement between the court and participant (service intensity). Using our classification typology, we assessed how casemix severity and service intensity are associated with program outcomes. We expected that holding other factors constant, greater service intensity would improve program outcomes while a relatively severe casemix would result in worse program outcomes. METHODS: The study used data from 8 DWI courts, 7 from Michigan and 1 from North Carolina. Using a 2-way classification system based on court casemix severity and program intensity, we selected participants in 1 of the courts, and alternatively 2 courts as reference groups. Reference group courts had relatively severe casemixes and high service intensity. We used propensity score matching to match participants in the other courts to participants in the reference group court programs. Program outcome measures were the probabilities of participants': failing to complete the court's program; increasing educational attainment; participants improving employment from time of program enrollment; and re-arrest. RESULTS: For most outcomes, our main finding was that higher service intensity is associated with better outcomes for court participants, as anticipated, but a court's casemix severity was unrelated to study outcomes. CONCLUSIONS: Our results imply that devoting more resources to increasing duration of treatment is productive in terms of better outcomes, irrespective of the mix of participants in the court's program.

Do specialty courts achieve better outcomes for children in foster care than general courts?

OBJECTIVE: This study assessed the effects of unified family and drug treatment courts (DTCs) on the resolution of cases involving foster care children and the resulting effects on school performance. METHOD: The first analytic step was to assess the impacts of presence of unified and DTCs in North Carolina counties on time children spent in foster care and the type of placement at exit from foster care. In the second step, the same data on foster care placements were merged with school records for youth in Grades 3-8 in public schools. The effect of children's time in foster care and placement outcomes on school performance as measured by math and reading tests, grade retention, and attendance was assessed using child fixed-effects regression. RESULTS: Children in counties with unified family courts experienced shorter foster care spells and higher rates of reunification with parents or primary caregivers. Shorter foster care spells translated into improved school performance measured by end-of-grade reading and math test scores. Adult DTCs were associated with lower probability of reunification with parents/primary caregivers. CONCLUSION: The shortened time in foster care implies an efficiency gain attributable to unified family courts, which translate into savings for the court system through the use of fewer resources. Children also benefit through shortened stays in temporary placements, which are related to some improved educational outcomes.

Despite 'welcome to Medicare' benefit, one in eight enrollees delay first use of part B services for at least two years.

Much research has focused on the possible overuse of health care services within Medicare, but there is also substantial evidence of underuse. In recent years, Congress has added a "welcome to Medicare" physician visit and a number of preventive services with no cost sharing to the Medicare benefit package to encourage early and appropriate use of services. We examined national longitudinal data on first claims for Part B services-the portion of Medicare that covers physician visits-to learn how people used these benefits. We found that 12 percent of people, or about one in eight, who enrolled in Medicare at age sixty-five waited more than two years before making their first use of care covered by Part B. In part, this delay reflected patterns of use before enrollment, in that people who sought preventive care before turning sixty-five continued to do so after enrolling in Medicare. Enrollees with Medigap coverage, higher household wealth, and a higher level of education typically received care under Part B sooner than others, whereas having greater tolerance for risk was more likely to lead enrollees to delay use of Part B services. Men had a lower probability of using Part B services early than women; blacks and members of other minority groups were less likely to use services early than whites. Although the "welcome to Medicare" checkup does not appear to have had a positive effect on use of services soon after enrollment, the percentage of beneficiaries receiving Part B services in the first two years after enrollment has steadily increased over time. Whether or not delays in receipt of care should be a considerable public policy concern may depend on what factors are leading specific categories of enrollees to delay care and how such delays affect health.

Medicare costs for neovascular age-related macular degeneration, 1994-2007.

PURPOSE: To assess changes in Medicare payments for neovascular age-related macular degeneration (AMD) since introduction of anti-vascular endothelial growth factor (VEGF) therapies. DESIGN: Retrospective, longitudinal cohort study. METHODS: Using the Medicare 5% sample, beneficiaries with new diagnoses of neovascular AMD in 1994 (N = 2497), 2000 (N = 3927), and 2006 (N = 6041) were identified using International Classification of Diseases (ICD-9-CM). The total first-year health care and eye care costs were calculated for each beneficiary. Propensity score matching was used to match individuals in the 2000 and 2006 cohorts with the 1994 cohort on age, sex, race, Charlson Comorbidity Index, and low vision/blindness. RESULTS: The number of beneficiaries newly diagnosed with neovascular AMD more than doubled between the 1994 and 2006 cohorts. Overall yearly Part B payments per beneficiary increased significantly from $3567 for the 1994 to $5991 for the 2006 cohort (P < .01) in constant 2008 dollars. Payments for eye care alone doubled from $1504 for the 1994 cohort to $3263 for the 2006 cohort (P < .01). Most of the increase in payments for eye care in 2006 reflected payments for anti-VEGF injections, which were $1609 over 1 year. Mean annual numbers of visits and imaging studies also increased significantly between the 1994 and 2006 cohort. Results were similar in the matched sample. CONCLUSIONS: The introduction of anti-VEGF intravitreal injections has offered remarkable clinical benefits for patients with neovascular AMD, but these benefits have come at the cost of an increased financial burden of providing care for these patients.

Ocular complications after anti-vascular endothelial growth factor therapy in Medicare patients with age-related macular degeneration.

PURPOSE: To determine longitudinal rates of ocular complications after anti-vascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (AMD) in a nationally representative longitudinal sample. DESIGN: Retrospective, longitudinal case-control study. METHODS: Using the Medicare 5% claims database, diagnoses of neovascular AMD and anti-VEGF injections of ranibizumab, bevacizumab, or pegaptanib were identified from International Classification of Diseases and Current Procedural Terminology procedure codes. Six thousand one hundred fifty-four individuals undergoing anti-VEGF treatment for neovascular AMD (total of 40 903 injections) were compared with 6154 matched controls with neovascular AMD who did not undergo anti-VEGF treatment. Propensity score matching was used to match individuals receiving anti-VEGF injections with controls. Rates of postinjection adverse outcomes (endophthalmitis, rhegmatogenous retinal detachment, retinal tear, uveitis, and vitreous hemorrhage) were analyzed by cumulative incidence and Cox proportional hazards model to control for demographic factors and ocular comorbidities. RESULTS: At the 2-year follow-up, the rates of endophthalmitis per injection (0.09%; P<.01), uveitis (0.11%; P<.01), and vitreous hemorrhage per injection (0.23%; P < .01) were significantly higher in the anti-VEGF treatment group. With Cox proportional hazards modeling, the anti-VEGF treatment group had a 102% higher risk of severe ocular complications overall and a 4% increased risk per injection, both of which were statistically significant (P<.01). CONCLUSIONS: Rates of endophthalmitis, uveitis, and vitreous hemorrhage were higher in the group treated with anti-VEGF injection than in the control group, although these nevertheless were rare in both groups. The overall risk of severe ocular complications was significantly higher in the anti-VEGF treatment group.