Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001.

BACKGROUND: Rates of invasive testing and treatment for coronary artery disease have increased over time. Less is known about trends in the utilization of noninvasive cardiac testing for coronary artery disease. The objective of this study was 2-fold: to explore temporal trends in the utilization of noninvasive and invasive cardiac services in relation to changes in the prevalence of cardiac disease, and to examine whether temporal increases have been targeted to potentially underserved populations. METHODS AND RESULTS: We performed an annual cross-sectional population-based study of Medicare patients from 1993 to 2001. We identified stress testing, cardiac catheterization, and revascularization procedures, as well as hospitalizations for acute myocardial infarction, during each year and calculated population-based rates for each using the total fee-for-service Medicare population as the denominator and adjusting for age, gender, and race. We observed marked growth in the utilization rates of cardiac services over time, with relative rates nearly doubling for most services. Acute myocardial infarction hospitalization rates have remained stable over the study period. Although rates of all procedures except coronary artery bypass increased in all subgroups, differences in rates of cardiac testing and treatment between nonblack men and other subgroups persisted over time. CONCLUSIONS: Temporal increases in the use of noninvasive and invasive cardiac services are not explained by changes in disease prevalence and have not succeeded in narrowing preexisting treatment differences by gender and race. Such increases, although conferring benefit for some, may expose others to risk and cost without benefit.

Differences in cardiac stress testing by sex and race among Medicare beneficiaries.

BACKGROUND: Although there is a wide literature demonstrating sex and race differences in the receipt of invasive cardiac tests and treatments, much less is known about the influence of such characteristics on receipt of a stress test, the first event in the diagnostic/treatment cascade for many patients. We explored the influence of patient characteristics on receipt of a stress test, with special attention to sex and race. METHODS: We performed a nested case-control study of Medicare beneficiaries who were aged 66 years and older during 1999-2001 and were free of cardiac diagnoses and procedures for at least 1 year. Cases were recipients of a stress test. RESULTS: Cases were younger, less likely to be female or black, but more likely to live in high-income, highly educated, and urban areas than controls. Nonblack men were more likely to receive a stress test than women and black men, controlling for age, area characteristics, and clinical characteristics (odds ratio for nonblack men compared with black women 1.71). These results were not explained by physician visit frequency. CONCLUSIONS: Efforts at minimizing disparities in cardiac care must attend to what is, for many patients, the entry into the cardiac care system: the stress test. Our findings suggest that simple "access," as measured by physician visit frequency, is not a rate-limiting factor.

Epidemiology and short-term outcomes of injured medicare patients.

OBJECTIVES: To describe characteristics and short-term outcomes of Medicare patients hospitalized after injuries in 1999. DESIGN: Analysis of national population-based case series. SETTING: Hospitalized Medicare patients. PARTICIPANTS: All fee-for-service Medicare patients aged 65 and older admitted for the first time in 1999 with principal injury diagnoses (International Classification of Diseases, Ninth Revision, codes 800-904, 910-929, 940-957, 959). MEASUREMENTS: Incidence rates, stratified by anatomic location (hip, other extremity, spine, head, chest, other), sex, and age group (65-74, 75-84, >or=85). For each category, Charlson comorbidity scores, Abbreviated Injury Scores, hospital length of stay, discharge disposition, hospital mortality, 30-day mortality, and readmissions within 30 days of discharge. RESULTS: A total of 439,605 persons were admitted at least once (crude rate 1,654/100,000). Rates of hospitalization increased with age and were generally higher in women (except head injuries). Comorbidities were more common in men. Hip fractures constituted 46.6% of cases and other extremity injuries another 30.7%. Hospital mortality (3.7% overall) increased with age, was greater in men, and was highest in patients with head injuries. The proportion discharged to skilled nursing facilities (43.8% overall, range 10.0-61.9% by age/sex/anatomic category) also increased with age, was higher in women, and was highest in patients with hip fractures. Slightly more than one-tenth (12.3%) of patients were readmitted within 30 days. Thirty-day mortality was 2.0 times hospital mortality (range 1.2-3.4 by category). CONCLUSION: Most injuries resulting in hospitalization for the Medicare population involve the extremities, but other injuries have higher mortality. Many injured patients are not discharged home but receive additional institutional care. Thirty-day survival is much lower than observed hospital survival. Further studies of injuries using Medicare data are warranted.

Regional variation in hospital mortality and 30-day mortality for injured Medicare patients.

BACKGROUND: We sought to evaluate how survival of older patients with injuries differs by geographic region within the United States. METHODS: We analyzed Medicare fee-for-service records for patients aged 65 years and older with principal injury diagnoses (ICD-9 800-959, excluding 905, 930-939, 958). Cases were classified by Maximum Abbreviated Injury Score (AISmax) and Charlson Comorbidity score (0, 1, 2, >or=3). Hospital mortality and 30-day mortality were modeled as functions of age, sex, AISmax, comorbidity, and geographic region (northeast, midwest, south, west). RESULTS: Hospital and 30-day mortality were both higher with male sex and increased age, AISmax, or Charlson score. Adjusted hospital mortality was highest in the northeast and south, but 30-day adjusted mortality was lowest in the same two regions. CONCLUSIONS: Regional differences in risk-adjusted hospital survival for older patients with injuries are different from regional differences in 30-day survival. Hospital mortality as an outcome for older injured patients should be interpreted cautiously.

Long-term survival of Medicare patients with head injury.

BACKGROUND: An increasing number of older patients are being hospitalized with traumatic brain injury (TBI). Knowledge of their expected long-term survival may be useful in making clinical decisions. METHODS: Patients age 65 or older admitted for the first time with head injury (ICD-9 800-804 or 850-854) during 1999 were identified in a complete national sample of fee-for-service Medicare hospitalization and denominator data. Cases were categorized by age, sex, maximum Abbreviated Injury Score (AISmax), and Charlson comorbidity score. Survival was determined at hospital discharge, and (using the denominator file) at 1, 6, 12, and 24 months after the initial hospital admission. RESULTS: For all cases (n = 30,684), the hospital mortality was 14.3%, but was cumulatively 19.75%, 30.5%, 36.1%, and 44.9% at successive times up to 24 months. Long-term mortality was higher with increased age, comorbidity, or AISmax, and higher in men. These effects persisted with multivariate logistic regression analysis and were used to construct a simplified prediction score for clinical use. CONCLUSIONS: The mortality for older patients with TBI is much higher than for an uninjured control population. The relative risk for death remains elevated after hospital discharge and for at least 2 years. Awareness of the expected prognosis may help family members and health care providers make appropriate clinical decisions during acute hospitalization.

Initial presentation of older injured patients to high-volume hospitals is not associated with lower 30-day mortality in Medicare data.

OBJECTIVE: To evaluate whether survival of older patients with severe injuries is positively associated with initial presentation to high-volume trauma hospitals. DESIGN: Historical cohort study. SETTING: We analyzed Medicare fee-for-service records. Cases were classified by maximum Abbreviated Injury Score (AISmax); those with isolated hip fractures or AISmax <3 were excluded. The initial hospital (emergency department or inpatient) for each case was classified by its number of included inpatient cases. PATIENTS: Patients aged >or=65 with principal injury diagnoses (ICD-9 800-959, excluding 905, 930-939, 958) admitted to hospitals or who died in emergency departments during 1999. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-day mortality was determined using Medicare denominator data and modeled as a function of hospital volume, AISmax, age, gender, and comorbidity. We found that 95,867 patients (74,894 AISmax = 3; 17,932 AISmax = 4; 3,041 AISmax = 5) were managed in 4,391 hospitals. More than 90% of the interhospital transfers were from emergency departments, mostly from low-volume to high-volume hospitals, and were more frequent with greater severity. Regression models showed no difference in 30-day survival between patients taken first to low-volume hospitals (and possibly transferred) vs. patients taken directly to high-volume hospitals. Prior studies showing a positive or negative effect of hospital volume on survival of older patients could be replicated but their findings could not be generalized. CONCLUSIONS: Existing systems of trauma care result in similar survival for older patients with serious injuries seen first at low-volume or high-volume hospitals.

The rising prevalence of androgen deprivation among older American men since the advent of prostate-specific antigen testing: a population-based cohort study.

OBJECTIVE: To investigate the effect of efforts in the early detection of prostate cancer using prostate-specific antigen (PSA) testing in the USA, by estimating the regional prevalence of androgen deprivation therapy (ADT) among older men in 1993-2000, and correlating the prevalence with early detection and aggressive treatment rates in 1987-91, as some authors predicted that ADT, a treatment traditionally reserved for advanced prostate cancer, would become less common over time as a result of such efforts. PATIENTS AND METHODS: A sample of 5% of men who were Medicare beneficiaries was used in this prospective population-based cohort study. The main outcome measures were the overall prevalence of ADT (medical and surgical) in the cohort from 1993 to 2000, and correlations between rates of prostate procedures in the 306 USA hospital referral regions in 1987-91 and prevalence of ADT in those regions from 1993 to 2000. RESULTS: The prevalence of ADT among these men in the USA increased steadily from 1.8% in 1993 to 2.9% in 2000 (P < 0.001). Regions with higher rates of prostate biopsy in 1987-91 had a higher prevalence of ADT in 1993, 1995 and 1997 (P < 0.05). Regions with higher rates of transurethral prostatectomy in 1987-91 had a higher prevalence of ADT in 1993-2000 (P < 0.01). Regions with higher rates of radical prostatectomy in 1987-91 had higher rates of ADT in 1993-99 (P < 0.05). CONCLUSIONS: Widespread early detection and aggressive treatment for prostate cancer in the USA has been associated with more, not less, ADT among older men over time.

Injuries among older Americans with and without Medicare.

OBJECTIVES: We evaluated the generalizability of Medicare fee-for-service data for patients hospitalized with injuries. METHODS: We used 1998-2000 Medicare hospitalization data and National Hospital Discharge Survey (NHDS) data to analyze patients aged 65 years and older with principal injury diagnoses. RESULTS: Demographics and injury patterns were similar in Medicare data and NHDS Medicare data. Injured patients without Medicare or health maintenance organization coverage were younger, less likely to have hip fractures, and more likely to have head or chest injuries. Mortality and discharge to long-term care were not significantly affected by insurance coverage, after we controlled for injury type and severity, age, gender, and comorbidity. Medicare patients had slightly longer hospital lengths of stay. CONCLUSIONS: Hospital outcomes are generally similar among older patients with a given anatomic injury, regardless of insurance coverage.