Higher Surgeon Procedure Volume Is Associated with Improved Hemodialysis Vascular Access Outcomes.

The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AVG (P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure (P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure.

Admission diagnoses among patients with heart failure: Variation by ACO performance on a measure of risk-standardized acute admission rates.

BACKGROUND: A key quality metric for Accountable Care Organizations (ACOs) is the rate of hospitalization among patients with heart failure (HF). Among this patient population, non-HF-related hospitalizations account for a substantial proportion of admissions. Understanding the types of admissions and the distribution of admission types across ACOs of varying performance may provide important insights for lowering admission rates. METHODS: We examined admission diagnoses among 220 Medicare Shared Savings Program ACOs in 2013. ACOs were stratified into quartiles by their performance on a measure of unplanned risk-standardized acute admission rates (RSAARs) among patients with HF. Using a previously validated algorithm, we categorized admissions by principal discharge diagnosis into: HF, cardiovascular/non-HF, and noncardiovascular. We compared the mean admission rates by admission type as well as the proportion of admission types across RSAAR quartiles (Q1-Q4). RESULTS: Among 220 ACOs caring for 227,356 patients with HF, the median (IQR) RSAARs per 100 person-years ranged from 64.5 (61.7-67.7) in Q1 (best performers) to 94.0 (90.1-99.9) in Q4 (worst performers). The mean admission rates by admission types for ACOs in Q1 compared with Q4 were as follows: HF admissions: 9.8 (2.2) vs 14.6 (2.8) per 100 person years (P < .0001); cardiovascular/non-HF admissions: 11.1 (1.6) vs 15.9 (2.6) per 100 person-years (P < .0001); and noncardiovascular admissions: 42.7 (5.4) vs 69.6 (11.3) per 100 person-years (P < .0001). The proportion of admission due to HF, cardiovascular/non-HF, and noncardiovascular conditions was 15.4%, 17.5%, and 67.1% in Q1 compared with 14.6%, 15.9%, and 69.4% in Q4 (P < .007). CONCLUSIONS: Although ACOs with the best performance on a measure of all-cause admission rates among people with HF tended to have fewer admissions for HF, cardiovascular/non-HF, and noncardiovascular conditions compared with ACOs with the worst performance (highest admission rates), the largest difference in admission rates were for noncardiovascular admission types. Across all ACOs, two-thirds of admissions of patients with HF were for noncardiovascular causes. These findings suggest that comprehensive approaches are needed to reduce the diverse admission types for which HF patients are at risk.

Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans.

OBJECTIVE: Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. METHODS: The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. RESULTS: Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. CONCLUSIONS: VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.

Octogenarians' post-acute care use after cardiac valve surgery and recovery: clinical implications.

Octogenarians receiving cardiac valve surgery is increasing and recovery is challenging. Post-acute care (PAC) services assist with recovery, yet services provided in facilities do not provide adequate cardiac-focused care or long-term self-management support. The purpose of the paper was to report post-acute care discharge rates in octogenarians and propose clinical implications to improve PAC services. Using a 2003 Medicare Part A database, we studied post-acute care service use in octogenarians after cardiac valve surgery. We propose expansion of the Geriatric Cardiac Care model to include broader clinical therapy dynamics. The sample (n = 10,062) included patients over 80 years discharged from acute care following valve surgery. Post-acute care services were used by 68% of octagarians following cardiac valve surgery (1% intermediate rehabilitation, 35% skilled nursing facility, 32% home health). The large percentage of octagarians using PAC point to the importance of integrating geriatric cardiac care into post-acute services to optimize recovery outcomes.

Propensity scores with misclassified treatment assignment: a likelihood-based adjustment.

Propensity score methods are widely used in comparative effectiveness research using claims data. In this context, the inaccuracy of procedural or billing codes in claims data frequently misclassifies patients into treatment groups, that is, the treatment assignment ($T$) is often measured with error. In the context of a validation data where treatment assignment is accurate, we show that misclassification of treatment assignment can impact three distinct stages of a propensity score analysis: (i) propensity score estimation; (ii) propensity score implementation; and (iii) outcome analysis conducted conditional on the estimated propensity score and its implementation. We examine how the error in $T$ impacts each stage in the context of three common propensity score implementations: subclassification, matching, and inverse probability of treatment weighting (IPTW). Using validation data, we propose a two-step likelihood-based approach which fully adjusts for treatment misclassification bias under subclassification. This approach relies on two common measurement error-assumptions; non-differential measurement error and transportability of the measurement error model. We use simulation studies to assess the performance of the adjustment under subclassification, and also investigate the method's performance under matching or IPTW. We apply the methods to Medicare Part A hospital claims data to estimate the effect of resection versus biopsy on 1-year mortality among $10\,284$ Medicare beneficiaries diagnosed with brain tumors. The ICD9 billing codes from Medicare Part A inaccurately reflect surgical treatment, but SEER-Medicare validation data are available with more accurate information.

Cost Drivers After Surgical Management of Proximal Humerus Fractures in Medicare Patients.

OBJECTIVES: This comparative effectiveness study sought to determine the impact of complications, readmission, and procedure choice on in-hospital and total 90-day costs for surgical management of proximal humerus fractures. METHODS: Medicare claims data from the Upstate New York area (2008-2009) were evaluated. The study included all patients treated with open reduction and internal fixation (ORIF) or hemiarthroplasty for proximal humerus fracture identified by ICD-9 codes. The primary end points included in-hospital costs and total health care costs within 90 days after the index operation. Multivariable generalized linear models with negative binomial distributions and log link function were used for cost analysis. RESULTS: ORIF was performed in 52 cases and hemiarthroplasty in 57 cases, total n = 109. On univariate analysis, readmission increased in-hospital cost by $54,345 and total 90-day costs by $63,104, whereas complications increased in-hospital cost by $23,300 and total 90-day costs by $30,237. On multivariable analysis, ORIF was associated with 29% lower in-hospital cost compared with hemiarthroplasty [Odds Ratio 0.71; 95% Confidence Interval (CI), 0.54-0.92; P = 0.01], and readmission was associated with a 5.68-fold in-hospital cost increase (Odds Ratio 5.68; CI, 3.57-9.03; P < 0.0001). CONCLUSIONS: Complications and hospital readmission continue to drive cost upward underscoring the need for best practice. The acute inpatient period costs may be decreased with ORIF in appropriately selected patients with proximal humerus fractures in comparison with hemiarthroplasty. This study provides real world cost estimates with the cost implications of complications, readmissions, and procedure choice. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparative Risk of Anaphylactic Reactions Associated With Intravenous Iron Products.

IMPORTANCE: All intravenous (IV) iron products are associated with anaphylaxis, but the comparative safety of each product has not been well established. OBJECTIVE: To compare the risk of anaphylaxis among marketed IV iron products. DESIGN, SETTING, AND PARTICIPANTS: Retrospective new user cohort study of IV iron recipients (n = 688,183) enrolled in the US fee-for-service Medicare program from January 2003 to December 2013. Analyses involving ferumoxytol were limited to the period January 2010 to December 2013. EXPOSURES: Administrations of IV iron dextran, gluconate, sucrose, or ferumoxytol as reported in outpatient Medicare claims data. MAIN OUTCOMES AND MEASURES: Anaphylaxis was identified using a prespecified and validated algorithm defined with standard diagnosis and procedure codes and applied to both inpatient and outpatient Medicare claims. The absolute and relative risks of anaphylaxis were estimated, adjusting for imbalances among treatment groups. RESULTS: A total of 274 anaphylaxis cases were identified at first exposure, with an additional 170 incident anaphylaxis cases identified during subsequent IV iron administrations. The risk for anaphylaxis at first exposure was 68 per 100,000 persons for iron dextran (95% CI, 57.8-78.7 per 100,000) and 24 per 100,000 persons for all nondextran IV iron products combined (iron sucrose, gluconate, and ferumoxytol) (95% CI, 20.0-29.5 per 100,000) , with an adjusted odds ratio (OR) of 2.6 (95% CI, 2.0-3.3; P < .001). At first exposure, when compared with iron sucrose, the adjusted OR of anaphylaxis for iron dextran was 3.6 (95% CI, 2.4-5.4); for iron gluconate, 2.0 (95% CI 1.2, 3.5); and for ferumoxytol, 2.2 (95% CI, 1.1-4.3). The estimated cumulative anaphylaxis risk following total iron repletion of 1000 mg administered within a 12-week period was highest with iron dextran (82 per 100,000 persons, 95% CI, 70.5- 93.1) and lowest with iron sucrose (21 per 100,000 persons, 95% CI, 15.3- 26.4). CONCLUSIONS AND RELEVANCE: Among patients in the US Medicare nondialysis population with first exposure to IV iron, the risk of anaphylaxis was highest for iron dextran and lowest for iron sucrose.

Colorectal Cancer Identification Methods Among Kansas Medicare Beneficiaries, 2008-2010.

INTRODUCTION: Population-based data are limited on how often colorectal cancer (CRC) is identified through screening or surveillance in asymptomatic patients versus diagnostic workup for symptoms. We developed a process for assessing CRC identification methods among Medicare-linked CRC cases from a population-based cancer registry to assess identification methods (screening/surveillance or diagnostic) among Kansas Medicare beneficiaries. METHODS: New CRC cases diagnosed from 2008 through 2010 were identified from the Kansas Cancer Registry and matched to Medicare enrollment and claims files. CRC cases were classified as diagnostic-identified versus screening/surveillance-identified using a claims-based algorithm for determining CRC test indication. Factors associated with screening/surveillance-identified CRC were analyzed using logistic regression. RESULTS: Nineteen percent of CRC cases among Kansas Medicare beneficiaries were screening/surveillance-identified while 81% were diagnostic-identified. Younger age at diagnosis (65 to 74 years) was the only factor associated with having screening/surveillance-identified CRC in multivariable analysis. No association between rural/urban residence and identification method was noted. CONCLUSION: Combining administrative claims data with population-based registry records can offer novel insights into patterns of CRC test use and identification methods among people diagnosed with CRC. These techniques could also be extended to other screen-detectable cancers.

Review of MRI wrist examination since introduction of Medicare item number.

INTRODUCTION: The Australian Health Department provided extended rebatable requesting rights to general practitioners in 2012 for magnetic resonance imaging (MRI) examinations in patients less than 16 years of age for a small set of clinically appropriate indications. Included item numbers 63522 and 63523 'referral by a medical practitioner (excluding a specialist and consultant physician) for a scan of wrist following radiographic examination where scaphoid fracture is suspected'. The aim of this study is to evaluate MRI examinations of suspected scaphoid fractures in the paediatric population following the Medicare item number introduction. METHODS: Review of 60 consecutive MR wrist examinations requested by general practitioners and performed between 30 November 2012 and 16 July 2014 for a rebatable magnet in a private clinical setting. The indication for all studies was to exclude a clinically suspected fractured scaphoid following a normal radiograph. All patients were less than 16 years of age at time of examination. RESULTS: Sixty examinations were performed; 51 revealed pathology (85% of cases) with nine normal examinations (15%). Twenty-nine studies revealed one of more fractures involving the carpals, metacarpals or distal radius. In total, 41 fractures were identified on MRI examination with 29 carpal bone fractures, six distal radius fractures and six metacarpal fractures. CONCLUSIONS: The results highlight the sensitivity of MR wrist examination and its diagnostic benefit in clinically suspected paediatric scaphoid fractures. In addition, it reflects the prudent referral nature of general practitioners.

Total joint arthroplasty: trends in medicare reimbursement and implant prices.

Total joint arthroplasty (TJA) continues to be a popular target of cost control efforts. In order to provide a unique overview of financial trends facing TJA, we analyzed Medicare databases including 100% of beneficiaries, as well as industry surveys of implant list prices. Although there was a substantial increase in TJA utilization over the period 2000-2011 (+26.9%), growth has been stagnant since 2005. New coding schemes have made complicated cases more lucrative for hospitals (+2.5% to 6.5% per year), while reimbursements for uncomplicated cases have fallen (-0.7% to -0.6%). Physician reimbursements have declined on all case types (-2.5% to -2.1% per year), while list prices of orthopedic implants have risen (+4.8% to 5.5%). These trends should be kept in mind while contemplating future changes to TJA payment.

The increasing role of nonradiologists in performing ultrasound-guided invasive procedures.

PURPOSE: Recent proliferation of mobile diagnostic ultrasound (US) units and improved resolution have allowed for widespread use of US by more providers, both for diagnosis and US-guided procedures (USGP). This study aims to document recent trends in utilization for USGP in the Medicare population. METHODS: Source data were obtained from the CMS Physician Supplier Procedure Summary Master Files from 2004 to 2010. Allowed billing claims submitted for USGP were extracted and volume was analyzed by provider type and setting. Compound annual growth rates were calculated. RESULTS: The total utilization rate for all USGP was 2,425 per 100,000 in 2004 and 4,870 in 2010, an increase of 100.8% (+2,445 per 100,000) with a compound annual growth rate of 12.3%. The year 2010 represents the first year that nonradiologists as a group performed more USGP than radiologists, at 922,672 versus 794,497 examinations, respectively. Nonradiologists accounted for 72.2% (599,751 of 830,925) of the USGP volume growth from 2004 to 2010. Most 2010 claims were submitted by radiologists (n = 794,497; 46.3%) and surgeons (n = 332,294; 19.4%). The largest overall volume increases from 2004 to 2010 were observed among radiologists, surgeons, anesthesiologists, rheumatologists, midlevel providers, primary care physicians, nonrheumatologist internal medicine subspecialists, and the aggregate of all other provider types. CONCLUSION: The year 2010 represents the first year that nonradiologists performed more USGP than radiologists. From 2004 to 2010, radiologists and surgeons experienced only modest growth in USGP volume, whereas several other provider types experienced more rapid growth. It is likely that many procedures that were previously performed without US guidance are now being performed with US guidance.

Linkage of a clinical surgical registry with Medicare inpatient claims data using indirect identifiers.

BACKGROUND: A variety of data sources are available for measuring the quality of health care. Linking records from different sources can create unique and powerful databases that can be used to evaluate clinically relevant questions and direct health care policy. The objective of this study was to develop and validate a deterministic linkage algorithm that uses indirect patient identifiers to reliably match records from a surgical clinical registry with Medicare inpatient claims data. METHODS: Patient records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), years 2005-2008, were linked to claims data in the Medicare Provider Analysis and Review file (MedPAR) by the use of a deterministic linkage algorithm and the following indirect patient identifiers: hospital, age, sex, diagnosis, procedure and dates of admission, discharge, and procedure. We validated the linkage procedure by systematically reviewing subsets of matched and unmatched records and by determining agreement on patient-level coding of inpatient mortality. RESULTS: Of the 150,454 records in ACS-NSQIP eligible for matching, 80.5% were linked to a MedPAR record. This percentage is within the expected match range given the estimated percentage of ACS-NSQIP patients likely to be Medicare beneficiaries. Systematic checks revealed no evidence of bias in the linkage procedure and there was excellent agreement on patient-level coding of mortality (kappa 0.969). The final linked database contained 121,070 patient records from 217 hospitals. CONCLUSION: This study demonstrates the feasibility and validity of a method for linking 2 data sources without direct personal identifiers. As clinical registries and other data sources continue to proliferate, linkage algorithms such as described here will be critical for quality measurement purposes.

Medicare payments: how much do chronic conditions matter?

OBJECTIVE: Analyze differences in Medicare Fee-for-Service utilization (i.e., program payments) by beneficiary characteristics, such as gender, age, and prevalence of chronic conditions. METHODS: Using the 2008 and 2010 Chronic Conditions Public Use Files, we conduct a descriptive analysis of enrollment and program payments by gender, age categories, and eleven chronic conditions. RESULTS: We find that the effect of chronic conditions on Medicare payments is dramatic. Average Medicare payments increase significantly with the number of chronic conditions. Finally, we quantify the effect of individual conditions and find that "Stroke / Transient Ischemic Attack" and "Chronic Kidney Disease" are the costliest chronic conditions for Part A, and "Cancer" and "Chronic Kidney Disease" are the costliest for Part B.

Clinical characteristics and outcomes of Medicare patients undergoing total hip arthroplasty, 1991-2008.

CONTEXT: Total hip arthroplasty is a common surgical procedure but little is known about longitudinal trends. OBJECTIVE: To examine demographics and outcomes of patients undergoing primary and revision total hip arthroplasty. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort of 1,453,493 Medicare Part A beneficiaries who underwent primary total hip arthroplasty and 348,596 who underwent revision total hip arthroplasty. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes for primary and revision total hip arthroplasty between 1991 and 2008. MAIN OUTCOME MEASURES: Changes in patient demographics and comorbidity, hospital length of stay (LOS), mortality, discharge disposition, and all-cause readmission rates. RESULTS: Between 1991 and 2008, the mean age for patients undergoing primary total hip arthroplasty increased from 74.1 to 75.1 years and for revision total hip arthroplasty from 75.8 to 77.3 years (P < .001). The mean number of comorbid illnesses per patient increased from 1.0 to 2.0 for primary total hip arthroplasty and 1.1 to 2.3 for revision (P < .001). For primary total hip arthroplasty, mean hospital LOS decreased from 9.1 days in 1991-1992 to 3.7 days in 2007-2008 (P = .002); unadjusted in-hospital and 30-day mortality decreased from 0.5% to 0.2% and from 0.7% to 0.4%, respectively (P < .001). The proportion of primary total hip arthroplasty patients discharged home declined from 68.0% to 48.2%; the proportion discharged to skilled care increased from 17.8% to 34.3%; and 30-day all-cause readmission increased from 5.9% to 8.5% (P < .001). For revision total hip arthroplasty, similar trends were observed in hospital LOS, in-hospital mortality, discharge disposition, and hospital readmission rates. CONCLUSION: Among Medicare beneficiaries who underwent primary and revision hip arthroplasty between 1991 and 2008, there was a decrease in hospital LOS but an increase in the rates of discharge to postacute care and readmission.

The impact of paradoxical comorbidities on risk-adjusted mortality of Medicare beneficiaries with cardiovascular disease.

BACKGROUND: Persistent uncertainty remains regarding assessments of patient comorbidity based on administrative data for mortality risk adjustment. Some models include comorbid conditions that are associated with improved mortality while other models exclude these so-called paradoxical conditions. The impact of these conditions on patient risk assessments is unknown. OBJECTIVE: To examine trends in the prevalence of conditions with a paradoxical (protective) relationship with mortality, and the impact of including these conditions on assessments of risk adjusted mortality. METHODS: Patients age 65 and older admitted for acute myocardial infarction (AMI) or coronary artery bypass graft (CABG) surgery during 1994 through 2005 were identified in Medicare Part A files. Comorbid conditions defined using a common algorithm were categorized as having a paradoxical or non-paradoxical relationship with 30-day mortality, based upon regression coefficients in multivariable logistic regression models. RESULTS: For AMI, the proportion of patients with one or more paradoxical condition and one or more non-paradoxical condition increased by 24% and 3% respectively between 1994 and 2005. The odds of death for patients with one-or-more paradoxical comorbidities, relative to patients with no paradoxical comorbidity, declined from 0.69 to 0.54 over the study period. In contrast, the risk associated with having one or more non-paradoxical comorbidities increased from 2.66 to 4.62 for AMI. This pattern was even stronger for CABG. Risk adjustment models that included paradoxical comorbidities found larger improvements, in risk-adjusted mortality for AMI and CABG, over time than models that did not include paradoxical comorbidities. CONCLUSION: The relationship between individual comorbid conditions and mortality is changing over time, with potential impact on estimates of hospital performance and trends in mortality. Development of a standard approach for handling conditions with a paradoxical relationship to mortality is needed.

Trends in survival after surgery for breast cancer metastatic to the brain and spinal column in medicare patients: a population-based analysis.

BACKGROUND: Central nervous system (CNS) metastases are a common occurrence in patients with breast cancer and are identified in up to 30% of patients at autopsy. OBJECTIVE: To determine population-based estimates of survival times after surgical intervention for Medicare patients with metastatic breast cancer to the brain and spinal column. METHODS: Female breast cancer patients with metastases to the brain and spinal column and undergoing neurosurgical treatment were identified through the Surveillance, Epidemiology, and End Results-Medicare database. Estimates of survival were calculated with Kaplan-Meier estimation and a Cox proportional hazards model. RESULTS: There were 643 patients who underwent neurosurgical treatment of metastatic disease from 1986 to 2005. Of these patients, 264 underwent cranial surgery and 379 underwent spinal surgery. There were 40 deaths during the postoperative hospital admission for an inpatient postoperative death rate of 6.2%. Inpatient death has declined by approximately 50% for surgeries performed in the most recent decade; however, the 30-day mortality rate of 9.0% has remained constant. The median postoperative survival after cranial surgery was 7.8 months (95% confidence interval, 6.2-9.2), after laminectomy was 9.4 months (95% confidence interval, 6.3-15.7), and after spinal fusion was 15.7 months (95% confidence interval, 11.9-18.5). Survival after spinal fusion has increased by approximately 50% in the recent decade. Patients with increased survival after cranial surgery were younger, had fewer comorbidities, and had longer periods from breast cancer diagnosis to surgery. Patients with increased survival after spinal neurosurgery had lower-grade lesions and longer time periods from breast cancer diagnosis to surgical treatment. CONCLUSION: After surgically treated metastases, one-third of cranial patients and one-half of spinal patients are alive at 1 year. The overall postoperative survival has increased over time only for spinal fusion procedures.

Post-acute care services received by older adults following a cardiac event: a population-based analysis.

BACKGROUND: Post-acute care (PAC) is available for older adults who need additional services after hospitalization for acute cardiac events. With the aging population and an increase in the prevalence of cardiac disease, it is important to determine current PAC use for cardiac patients to assist health care workers to meet the needs of older cardiac patients. The purpose of this study was to determine the current PAC use and factors associated with PAC use for older adults following hospitalization for a cardiac event that includes coronary artery bypass graft and valve surgeries, myocardial infarction (MI), percutaneous coronary intervention (PCI), and heart failure (HF). METHODS AND RESULTS: A cross-sectional design and the 2003 Medicare part A database were used for this study. The sample (n = 1493521) consisted of patients 65 years and older discharged after their first cardiac event. Multinomial logistic regression was used to examine factors associated with PAC use. Overall, PAC use was 55% for cardiac valve surgery, 50% for MI, 45% for HF, 44% for coronary artery bypass graft, and 5% for PCI. Medical patients use more skilled nursing facility care, and surgical patients use more home health care. Only 0.1% to 3.4% of the cardiac patients use intermediate rehabilitation facilities. Compared with those who do not use PAC, those who use home health care and skilled nursing facility care are older and female, have a longer hospital length of stay, and have more comorbidity. Asians, Hispanics, and Native Americans were less likely to use PAC after hospitalization for an MI or HF. CONCLUSIONS: The current rate of PAC use indicates that almost half of nondisabled Medicare patients discharged from the hospital following a cardiac event use one of these services. Health care professionals can increase PAC use for Asians, Hispanics, and Native Americans by including culturally targeted communication. Optimizing recovery for cardiac patients who use PAC may require focused cardiac rehabilitation strategies.

The effect of hospice on Medicare and informal care costs: the U.S. Experience.

The effect of hospice on third-party payer costs has long been of great interest in the United States and other nations. The choice of hospice could also influence the costs experienced by patients and family members as compared with when Medicare beneficiaries choose to use normal care. This article considers both types of cost in the context of the United States. Hospice provides a rare example of a medical or multiprofessional intervention that improves quality of life for patients while reducing the costs of third-party insurers. Out-of-pocket costs do not differ by hospice use, but families experience higher informal costs when a loved one who is dying uses hospice. There are likely benefits of such interactions that would offset any costs, but these are hard to quantify. The Medicare program is supposed to provide necessary and reasonable care to beneficiaries, and hospice would easily pass any such assessment.

The impact of physician-owned specialty orthopaedic hospitals on surgical volume and case complexity in competing hospitals.

Published studies of physician-owned specialty hospitals have typically examined the impact of these hospitals on disparities, quality, and utilization at a national level. Our objective was to examine the impact of newly opened physician-owned specialty orthopaedic hospitals on individual competing general hospitals. We used Medicare Part A administrative data to identify all physician-owned specialty orthopaedic hospitals performing total hip arthroplasty (THA) and total knee arthroplasty (TKA) between 1991 and 2005. We identified newly opened specialty hospitals in three representative markets (Durham, NC, Kansas City, and Oklahoma City) and assessed their impact on surgical volume and patient case complexity for the five competing general hospitals located closest to each specialty hospital. The average general hospital maintained THA and TKA volume following the opening of the specialty hospitals. The average general hospital also did not experience an increase in patient case complexity. Thus, based on these three markets, we found no clear evidence that entry of physician-owned specialty orthopaedic hospitals resulted in declines in THA or TKA volume or increases in patient case complexity for the average competing general hospital.