Comparison of Low-Value Care Among Commercial and Medicaid Enrollees.

BACKGROUND: Low-value healthcare is costly and inefficient and may adversely affect patient outcomes. Despite increases in low-value service use, little is known about how the receipt of low-value care differs across payers. OBJECTIVE: To evaluate differences in the use of low-value care between patients with commercial versus Medicaid coverage. DESIGN: Retrospective observational analysis of the 2017 Rhode Island All-payer Claims Database, estimating the probability of receiving each of 14 low-value services between commercial and Medicaid enrollees, adjusting for patient sociodemographic and clinical characteristics. Ensemble machine learning minimized the possibility of model misspecification. PARTICIPANTS: Medicaid and commercial enrollees aged 18-64 with continuous coverage and an encounter at which they were at risk of receiving a low-value service. INTERVENTION: Enrollment in Medicaid or Commercial insurance. MAIN MEASURES: Use of one of 14 validated measures of low-value care. KEY RESULTS: Among 110,609 patients, Medicaid enrollees were younger, had more comorbidities, and were more likely to be female than commercial enrollees. Medicaid enrollees had higher rates of use for 7 low-value care measures, and those with commercial coverage had higher rates for 5 measures. Across all measures of low-value care, commercial enrollees received more (risk difference [RD] 6.8 percentage points; CI: 6.6 to 7.0) low-value services than their counterparts with Medicaid. Commercial enrollees were also more likely to receive low-value services typically performed in the emergency room (RD 11.4 percentage points; CI: 10.7 to 12.2) and services that were less expensive (RD 15.3 percentage points; CI 14.6 to 16.0). CONCLUSION: Differences in the provision of low-value care varied across measures, though average use was slightly higher among commercial than Medicaid enrollees. This difference was more pronounced for less expensive services indicating that financial incentives may not be the sole driver of low-value care.

Association of Inclusion of Medicare Advantage Patients in Hospitals' Risk-Standardized Readmission Rates, Performance, and Penalty Status.

Importance: The Hospital Readmissions Reduction Program publicly reports and financially penalizes hospitals according to 30-day risk-standardized readmission rates (RSRRs) exclusively among traditional Medicare (TM) beneficiaries but not persons with Medicare Advantage (MA) coverage. Exclusively reporting readmission rates for the TM population may not accurately reflect hospitals' readmission rates for older adults. Objective: To examine how inclusion of MA patients in hospitals' performance is associated with readmission measures and eligibility for financial penalties. Design, Setting, and Participants: This is a retrospective cohort study linking the Medicare Provider Analysis and Review file with the Healthcare Effectiveness Data and Information Set at 4070 US acute care hospitals admitting both TM and MA patients. Participants included patients admitted and discharged alive with a diagnosis of acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia between 2011 and 2015. Data analyses were conducted between April 1, 2018, and November 20, 2020. Exposures: Admission to an acute care hospital. Main Outcomes and Measures: The outcome was readmission for any reason occurring within 30 days after discharge. Each hospital's 30-day RSRR was computed on the basis of TM, MA, and all patients and estimated changes in hospitals' performance and eligibility for financial penalties after including MA beneficiaries for calculating 30-day RSRRs. Results: There were 748 033 TM patients (mean [SD] age, 76.8 [83] years; 360 692 [48.2%] women) and 295 928 MA patients (mean [SD] age, 77.5 [7.9] years; 137 422 [46.4%] women) hospitalized and discharged alive for AMI; 1 327 551 TM patients (mean [SD] age, 81 [8.3] years; 735 855 [55.4%] women) and 457 341 MA patients (mean [SD] age, 79.8 [8.1] years; 243 503 [53.2%] women) for CHF; and 2 017 020 TM patients (mean [SD] age, 80.7 [8.5] years; 1 097 151 [54.4%] women) and 610 790 MA patients (mean [SD] age, 79.6 [8.2] years; 321 350 [52.6%] women) for pneumonia. The 30-day RSRRs for TM and MA patients were correlated (correlation coefficients, 0.31 for AMI, 0.40 for CHF, and 0.41 for pneumonia) and the TM-based RSRR systematically underestimated the RSRR for all Medicare patients for each condition. Of the 2820 hospitals with 25 or more admissions for at least 1 of the outcomes of AMI, CHF, and pneumonia, 635 (23%) had a change in their penalty status for at least 1 of these conditions after including MA data. Changes in hospital performance and penalty status with the inclusion of MA patients were greater for hospitals in the highest quartile of MA admissions. Conclusions and Relevance: In this cohort study, the inclusion of data from MA patients changed the penalty status of a substantial fraction of US hospitals for at least 1 of 3 reported conditions. This suggests that policy makers should consider including all hospital patients, regardless of insurance status, when assessing hospital quality measures.

Variation in Hospital-Based Rehabilitation Services Among Patients With Ischemic Stroke in the United States.

BACKGROUND: Little is known about variation in use of rehabilitation services provided in acute care hospitals for people who have had a stroke. OBJECTIVE: The objective was to examine patient and hospital sources of variation in acute care rehabilitation services provided for stroke. DESIGN: This was a retrospective, cohort design. METHODS: The sample consisted of Medicare fee-for-service beneficiaries with ischemic stroke admitted to acute care hospitals in 2010. Medicare claims data were linked to the Provider of Services file to gather information on hospital characteristics and the American Community Survey for sociodemographic data. Chi-square tests compared patient and hospital characteristics stratified by any rehabilitation use. We used multilevel, multivariable random effect models to identify patient and hospital characteristics associated with the likelihood of receiving any rehabilitation and with the amount of therapy received in minutes. RESULTS: Among 104,295 patients, 85.2% received rehabilitation (61.5% both physical therapy and occupational therapy; 22.0% physical therapy only; and 1.7% occupational therapy only). Patients received 123 therapy minutes on average (median [SD] = 90.0 [99.2] minutes) during an average length of stay of 4.8 [3.5] days. In multivariable analyses, male sex, dual enrollment in Medicare and Medicaid, prior hospitalization, ICU stay, and feeding tube were associated with lower odds of receiving any rehabilitation services. These same variables were generally associated with fewer minutes of therapy. Patients treated by tissue plasminogen activator, in limited-teaching and nonteaching hospitals, and in hospitals with inpatient rehabilitation units, were more likely to receive more therapy minutes. LIMITATION: The findings are limited to patients with ischemic stroke. CONCLUSION: Only 61% of patients with ischemic stroke received both physical therapy and occupational therapy services in the acute setting. We identified considerable variation in the use of rehabilitation services in the acute care setting following a stroke.

Adolescent Bariatric Surgery: Effects of Socioeconomic, Demographic, and Hospital Characteristics on Cost, Length of Stay, and Type of Procedure Performed.

BACKGROUND: Despite the efficacy of bariatric surgery in adolescents and the increasing rates of adolescent obesity, the use of bariatric surgery remains low. Treatment cost and length of stay (LOS) could be influencing the utilization of bariatric surgery. METHODS: We used the Kids' Inpatient Database (KID) from 2006, 2009, and 2012. Adolescents with a primary diagnosis of obesity who underwent bariatric surgery were included. Multinomial logistic and linear regression modeling was used to determine the association of the predictor variables with type of procedure and treatment cost and LOS, respectively. RESULTS: We identified 1799 adolescents who underwent bariatric surgery. The majority of the subjects were female (77%) and White (60%). The most commonly performed procedure was Roux-en-Y gastric bypass (56%). Race, region, hospital teaching status, and hospital ownership affected the type of procedure performed. Self-pay patients were less likely to undergo Roux-en-Y gastric bypass (RYGB) than sleeve gastrectomy (SG) when compared to patients with private insurance. Teaching hospitals were less likely to perform RYGB or AGB than SG when compared to non-teaching hospitals. Treatment cost was significantly affected by income, teaching hospital status, hospital size, and surgery type. LOS was affected by income quartile, region, and surgery type. CONCLUSION: Socioeconomic and demographic factors as well as hospital characteristics affect not only the LOS and treatment cost, but also the type of bariatric surgery performed in adolescents. Identifying and understanding the factors influencing procedure choice, treatment cost, and LOS can improve care and healthcare resource utilization.

Use of Hospital-Based Rehabilitation Services and Hospital Readmission Following Ischemic Stroke in the United States.

OBJECTIVE: To examine the association between hospital-based rehabilitation service use and all-cause 30-day hospital readmission among patients with ischemic stroke. DESIGN: Secondary analysis of inpatient Medicare claims data using Standard Analytical Files. SETTING: Acute hospitals across the United States. PARTICIPANTS: From nationwide data, Medicare fee-for-service beneficiaries (N=88,826) aged 66 years or older hospitalized for ischemic stroke between January to November 2010. INTERVENTIONS: Hospital-based rehabilitation services were quantified using Medicare inpatient claims revenue center codes for evaluation (occupational therapy [OT] and physical therapy [PT]), as well as the number of therapy units delivered. Therapy minutes for both OT and PT services were categorized into none, low, medium, and high. MAIN OUTCOME MEASURES: All-cause 30-day hospital readmission. A generalized linear mixed model was used to examine the effect of hospital-based rehabilitation services on 30-day hospital readmission, after adjusting for patient and hospital characteristics. RESULTS: In fully adjusted models, compared to patients who received no PT, we observed a monotonic inverse relationship between the amount of PT and hospital readmission. For low PT (30 minutes), the odds ratio (OR) was 0.90 (95% confidence interval [CI], 0.83-0.96). For medium PT (>30 to ≤75 minutes), the OR was 0.89 (95% CI, 0.82-0.95). For high PT (>75 minutes), the OR was 0.86 (95% CI, 0.80-0.93). CONCLUSION: Hospital-based PT services were associated with lower risk of 30-day hospital readmission in patients with ischemic stroke.

Sociodemographic determinants of non-accidental traumatic injuries in children.

BACKGROUND: Traumatic injuries account for 18% of child abuse cases and 1680 children die from abuse annually. We set out to determine the impact of sociodemographic characteristics on resource utilization and outcomes in nonaccidental trauma (NAT). METHODS: We used the Kid's Inpatient Database to identify children with two main subgroups of child abuse diagnoses: NAT and other forms of child abuse. Income was represented by quartiles. Statistical analysis included descriptive statistics and regression analyses. RESULTS: We identified 5617 children requiring hospital admission due to NAT. Medicaid insurance payer status was associated with higher rates of traumatic injuries than private insurance. Black race, male sex, and high-income-quartile were independent factors associated with increased cost. We identified an increased risk of mortality in younger children and those with self-pay/uninsured status. CONCLUSION: NAT represents a prevalent cause of childhood mortality. This study identifies sociodemographic factors associated with increased occurrence, higher resource utilization, and increased mortality in NAT.

Adapting the Elixhauser comorbidity index for cancer patients.

BACKGROUND: This study was designed to adapt the Elixhauser comorbidity index for 4 cancer-specific populations (breast, prostate, lung, and colorectal) and compare 3 versions of the Elixhauser comorbidity score (individual comorbidities, summary comorbidity score, and cancer-specific summary comorbidity score) with 3 versions of the Charlson comorbidity score for predicting 2-year survival with 4 types of cancer. METHODS: This cohort study used Texas Cancer Registry-linked Medicare data from 2005 to 2011 for older patients diagnosed with breast (n = 19,082), prostate (n = 23,044), lung (n = 26,047), or colorectal cancer (n = 16,693). For each cancer cohort, the data were split into training and validation cohorts. In the training cohort, competing risk regression was used to model the association of Elixhauser comorbidities with 2-year noncancer mortality, and cancer-specific weights were derived for each comorbidity. In the validation cohort, competing risk regression was used to compare 3 versions of the Elixhauser comorbidity score with 3 versions of the Charlson comorbidity score. Model performance was evaluated with c statistics. RESULTS: The 2-year noncancer mortality rates were 14.5% (lung cancer), 11.5% (colorectal cancer), 5.7% (breast cancer), and 4.1% (prostate cancer). Cancer-specific Elixhauser comorbidity scores (c = 0.773 for breast cancer, c = 0.772 for prostate cancer, c = 0.579 for lung cancer, and c = 0.680 for colorectal cancer) performed slightly better than cancer-specific Charlson comorbidity scores (ie, the National Cancer Institute combined index; c = 0.762 for breast cancer, c = 0.767 for prostate cancer, c = 0.578 for lung cancer, and c = 0.674 for colorectal cancer). Individual Elixhauser comorbidities performed best (c = 0.779 for breast cancer, c = 0.783 for prostate cancer, c = 0.587 for lung cancer, and c = 0.687 for colorectal cancer). CONCLUSIONS: The cancer-specific Elixhauser comorbidity score performed as well as or slightly better than the cancer-specific Charlson comorbidity score in predicting 2-year survival. If the sample size permits, using individual Elixhauser comorbidities may be the best way to control for confounding in cancer outcomes research. Cancer 2018;124:2018-25. © 2018 American Cancer Society.

Race, Income and Insurance Status Affect Neonatal Sepsis Mortality and Healthcare Resource Utilization.

BACKGROUND: Socioeconomic disparities negatively impact neonatal health. The influence of sociodemographic disparities on neonatal sepsis is understudied. We examined the association of insurance payer status, income, race and gender on neonatal sepsis mortality and healthcare resource utilization. METHODS: We used the Kid's Inpatient Database, a nationwide population-based survey from 2006, 2009 and 2012. Neonates diagnosed with sepsis were included in the study. Multivariable logistic regression (mortality) and multivariable linear regression (length of stay and total hospital costs) were constructed to determine the association of patient and hospital characteristics. RESULTS: Our study cohort included a weighted sample of 160,677 septic neonates. Several sociodemographic disparities significantly increased mortality. Self-pay patients had increased mortality (odds ratio 3.26 [95% confidence interval: 2.60-4.08]), decreased length of stay (-2.49 ± 0.31 days, P < 0.0001) and total cost (-$5015.50 ± 783.15, P < 0.0001) compared with privately insured neonates. Additionally, low household income increased odds of death compared with the most affluent households (odds ratio 1.19 [95% confidence interval: 1.05-1.35]). Moreover, Black neonates had significantly decreased length of stay (-0.86 ± 0.25, P = 0.0005) compared with White neonates. CONCLUSIONS: This study identified specific socioeconomic disparities that increased odds of death and increased healthcare resource utilization. Moreover, this study provides specific societal targets to address to reduce neonatal sepsis mortality in the United States.

Decline in opioid prescribing after federal rescheduling of hydrocodone products.

PURPOSE: To examine differences in opioid prescribing by patient characteristics and variation in hydrocodone combination product (HCP) prescribing attributed to states, before and after the 2014 Drug Enforcement Administration's reclassification of HCP from schedule III to the more restrictive schedule II. METHODS: We used 2013 to 2015 data for 9 202 958 patients aged 18 to 64 from a large nationally representative commercial health insurance program to assess the temporal trends in the monthly rate of opioid prescribing. RESULTS: HCP prescribing decreased by 26% from June 2013 to June 2015; the rate of prescriptions for any opioid decreased by 11%. Prescribing of non-hydrocodone schedule III opioids increased slightly while prescribing of non-hydrocodone schedule II opioids and tramadol was stable. Absolute decreases in HCP prescribing rates were larger in patients being treated for cancer (-2.26% vs -0.7% for non-cancer patients, P < 0.0001) and in those with high comorbidities (-2.13% vs -0.55% for those with no comorbidity, P < 0.0001). Differences in the absolute and relative changes in HCP prescribing rates among states were large; for example, a relative decrease of 46.7% in Texas and a 12.7% increase in South Dakota. The variation in HCP prescribing attributable to the state of residence increased from 6.6% in 2013 to 8.7% in 2015. CONCLUSIONS: The 2014 federal policy was associated with a decrease in rates of HCP and total opioid prescribing. The large decrease in the rates of HCP prescribing for patients with actively treated cancer may represent an unintended consequence.

Outcomes of Laparoscopic Colectomy in Younger and Older Patients: An Analysis of Nationwide Readmission Database.

BACKGROUND: Prior studies report safety and effectiveness of laparoscopic colectomy in older patients. The study aimed to examine the impact of laparoscopic colectomy on 30-day readmissions, discharge destination, hospital length of stay, and cost in younger (19-65 years) and older adults (>65 years). MATERIALS AND METHODS: We used the nationwide readmission database from 2013 to study adults undergoing elective colectomy. The outcomes were 30-day readmissions, discharge destination for the index hospitalization (routine, skilled nursing facility [SNF]/intermediate care facility [ICF], home healthcare), length of stay, and cost. Multivariable analyses were conducted to determine the association of laparoscopic colectomy on outcome; logistic regression for 30-day readmission, multinomial logistic regression for discharge destination, and linear regression for length of stay and cost. An interaction between age and colectomy approach was included, and all models controlled gender, income, insurance status, All Patients Refined Diagnosis Related Groups (APR-DRG), Elixhauser comorbidities, hospital bed size, ownership, and teaching status. RESULTS: Of 79,581 colectomies, 40.2% were laparoscopic. Laparoscopic colectomy was more frequent in younger patients (41.9% versus 38.5%, p < .0001). Regardless of age, patients undergoing laparoscopic colectomy were 20% less likely to be readmitted within 30 days (odds ratio [OR] 0.80, confidence interval [95% CI] 0.75-0.85). For postdischarge destination, laparoscopic colectomy offered higher benefits to younger patients (SNF/ICF: OR 0.42, 95% CI 0.36-0.49; home health: OR 0.32, 95% CI 0.30-0.35) than older patients (SNF/ICF: OR 0.50, 95% CI 0.47-0.54; home health: OR 0.59, 95% CI 0.55-0.62). Regardless of age, laparoscopic colectomy resulted in 1.46 days (p < .0001) shorter hospital stays compared to open colectomy. Laparoscopic colectomy had significantly lower cost compared to open approach, particularly in younger ($1,466) versus older ($632) patients. CONCLUSIONS: Laparoscopic colectomy is superior to an open approach, with fewer 30-day readmissions, fewer discharges to SNF/ICF or home health, shorter hospital stays, and less overall cost; younger patients benefit more than older patients.

Trends in Primary Care Provision to Medicare Beneficiaries by Physicians, Nurse Practitioners, or Physician Assistants: 2008-2014.

OBJECTIVES: To document the temporal trends in alternative primary care models in which physicians, nurse practitioners (NPs), or physician assistants (PAs) engaged in care provision to the elderly, and examine the role of these models in serving elders with multiple chronic conditions and those residing in rural and health professional shortage areas (HPSAs). DESIGN: Serial cross-sectional analysis of Medicare claims data for years 2008, 2011, and 2014. SETTING: Primary care outpatient setting. PARTICIPANTS: Medicare fee-for-service beneficiaries who had at least 1 primary care office visit in each study year. The sample size is 2 471 498. MEASUREMENTS: Physician model-Medicare beneficiary's primary care office visits in a year were conducted exclusively by physicians; shared care model-conducted by a group of professionals that included physicians and either NPs or PAs or both; NP/PA model: conducted either by NPs or PAs or both. RESULTS: There was a decrease in the physician model (85.5% to 70.9%) and an increase in the shared care model (11.9% to 23.3%) and NP/PA model (2.7% to 5.9%) from 2008 to 2014. Compared with the physician model, the adjusted odds ratio (AOR) of receiving NP/PA care was 3.97 (95% CI 3.80-4.14) in rural and 1.26 (95% CI 1.23-1.29) in HPSAs; and the AOR of receiving shared care was 1.66 (95% CI 1.61-1.72) and 1.14 (95% CI 1.13-1.15), respectively. Beneficiaries with 3 or more chronic conditions were most likely to received shared care (AOR = 1.67, 95% CI 1.65-1.70). CONCLUSION: The increase in shared care practice signifies a shift toward bolstering capacity of the primary care delivery system to serve elderly populations with growing chronic disease burden and to improve access to care in rural and HPSAs.

Current Risk Adjustment and Comorbidity Index Underperformance in Predicting Post-Acute Utilization and Hospital Readmissions After Joint Replacements: Implications for Comprehensive Care for Joint Replacement Model.

OBJECTIVE: To compare the performances of 3 comorbidity indices, the Charlson Comorbidity Index, the Elixhauser Comorbidity Index, and the Centers for Medicare & Medicaid Services (CMS) risk adjustment model, Hierarchical Condition Category (HCC), in predicting post-acute discharge settings and hospital readmission for patients after joint replacement. METHODS: A retrospective study of Medicare beneficiaries with total knee replacement (TKR) or total hip replacement (THR) discharged from hospitals in 2009-2011 (n = 607,349) was performed. Study outcomes were post-acute discharge setting and unplanned 30-, 60-, and 90-day hospital readmissions. Logistic regression models were built to compare the performance of the 3 comorbidity indices using C statistics. The base model included patient demographics and hospital use. Subsequent models included 1 of the 3 comorbidity indices. Additional multivariable logistic regression models were built to identify individual comorbid conditions associated with high risk of hospital readmissions. RESULTS: The 30-, 60-, and 90-day unplanned hospital readmission rates were 5.3%, 7.2%, and 8.5%, respectively. Patients were most frequently discharged to home health (46.3%), followed by skilled nursing facility (40.9%) and inpatient rehabilitation facility (12.7%). The C statistics for the base model in predicting post-acute discharge setting and 30-, 60-, and 90-day readmission in TKR and THR were between 0.63 and 0.67. Adding the Charlson Comorbidity Index, the Elixhauser Comorbidity Index, or HCC increased the C statistic minimally from the base model for predicting both discharge settings and hospital readmission. The health conditions most frequently associated with hospital readmission were diabetes mellitus, pulmonary disease, arrhythmias, and heart disease. CONCLUSION: The comorbidity indices and CMS-HCC demonstrated weak discriminatory ability to predict post-acute discharge settings and hospital readmission following joint replacement.

Relative impact of surgeon and hospital volume on operative mortality and complications following pancreatic resection in Medicare patients.

BACKGROUND: Surgeon and hospital volume are both known to affect outcomes for patients undergoing pancreatic resection. The objective was to evaluate the relative effects of surgeon and hospital volume on 30-d mortality and 30-d complications after pancreatic resection among older patients. MATERIALS AND METHODS: The study used Texas Medicare data (2000-2012), identifying high-volume surgeons as those performing ≥4 pancreatic resections/year, and high-volume hospitals as those performing ≥11 pancreatic resections/year, on Medicare patients. Three-level hierarchical logistic regression models were used to evaluate the relative effects of surgeon and hospital volumes on mortality and complications, after adjusting for case mix differences. RESULTS: There were 2453 pancreatic resections performed by 490 surgeons operating in 138 hospitals. Of the total, 4.5% of surgeons and 6.5% of hospitals were high volume. The overall 30-d mortality was 9.0%, and the 30-d complication rate was 40.6%. Overall, 8.9% of the variance in 30-d mortality was attributed to surgeon factors and 9.8% to hospital factors. For 30-d complications, 4.7% of the variance was attributed to surgeon factors and 1.2% to hospital factors. After adjusting for patient, surgeon, and hospital characteristics, high surgeon volume (odds ratio [OR] = 0.54, 95% confidence interval [CI], 0.33-0.87) and high hospital volume (OR = 0.52; 95% CI, 0.30-0.92) were associated with lower risk of mortality; high surgeon volume (OR = 0.71, 95% CI, 0.55-0.93) was also associated lower risk of 30-d complications. CONCLUSIONS: Both hospital and surgeon factors contributed significantly to the observed variance in mortality, but only surgeon factors impacted complications.

Trends in Follow-Up of Patients Presenting to the Emergency Department with Symptomatic Cholelithiasis.

BACKGROUND: Fewer than 25% of Medicare beneficiaries presenting with symptomatic cholelithiasis undergo elective cholecystectomy. To better understand underuse of cholecystectomy, we examined physician follow-up patterns after emergency department (ED) visits for symptomatic gallstones. STUDY DESIGN: We used 100% Texas Medicare claims (2001 to 2010) to identify patients 66 years of age and older who presented to the ED with symptomatic cholelithiasis and were discharged home without cholecystectomy. Timing of outpatient physician visits after ED discharge and rates of emergent cholecystectomy based on physician follow-up patterns were compared. RESULTS: In total, 11,126 patients presented to the ED with symptomatic cholelithiasis and were discharged without cholecystectomy. After discharge, 5,327 patients (47.9%) had an outpatient surgeon visit, 29.0% saw another physician and never saw a surgeon, and 23.1% never saw a physician; 68.2% of patients who saw a surgeon underwent elective cholecystectomy; and 8.3% of patients who saw a surgeon, 14.6% of patients who saw other physicians and no surgeon, and 77.6% of patients who never saw any physician, required emergent hospitalization (p < 0.0001). For people who did not see a physician, mean time to emergent hospitalization was 7.5 days (median 2 days); 95.9% presented within 2 weeks after their initial presentation. CONCLUSIONS: Fewer than half of patients were evaluated by a surgeon after an initial ED visit for symptomatic gallstones. Patients who did not have physician follow-up were most likely to require emergent cholecystectomy, suggesting inappropriate ED discharge and highlighting the need for timely follow-up. Early outpatient surgical consultation is critical in determining appropriateness for cholecystectomy and avoiding emergent cholecystectomy in older patients with symptomatic gallstones.

Comparison of Comorbidity Scores in Predicting Surgical Outcomes.

INTRODUCTION: The optimal methodology for assessing comorbidity to predict various surgical outcomes such as mortality, readmissions, complications, and failure to rescue (FTR) using claims data has not been established. OBJECTIVE: Compare diagnosis-based and prescription-based comorbidity scores for predicting surgical outcomes. METHODS: We used 100% Texas Medicare data (2006-2011) and included patients undergoing coronary artery bypass grafting, pulmonary lobectomy, endovascular repair of abdominal aortic aneurysm, open repair of abdominal aortic aneurysm, colectomy, and hip replacement (N=39,616). The ability of diagnosis-based [Charlson comorbidity score, Elixhauser comorbidity score, Combined Comorbidity Score, Centers for Medicare and Medicaid Services-Hierarchical Condition Categories (CMS-HCC)] versus prescription-based Chronic disease score in predicting 30-day mortality, 1-year mortality, 30-day readmission, complications, and FTR were compared using c-statistics (c) and integrated discrimination improvement (IDI). RESULTS: The overall 30-day mortality was 5.8%, 1-year mortality was 17.7%, 30-day readmission was 14.1%, complication rate was 39.7%, and FTR was 14.5%. CMS-HCC performed the best in predicting surgical outcomes (30-d mortality, c=0.797, IDI=4.59%; 1-y mortality, c=0.798, IDI=9.60%; 30-d readmission, c=0.630, IDI=1.27%; complications, c=0.766, IDI=9.37%; FTR, c=0.811, IDI=5.24%) followed by Elixhauser comorbidity index/disease categories (30-d mortality, c=0.750, IDI=2.37%; 1-y mortality, c=0.755, IDI=5.82%; 30-d readmission, c=0.629, IDI=1.43%; complications, c=0.730, IDI=3.99%; FTR, c=0.749, IDI=2.17%). Addition of prescription-based scores to diagnosis-based scores did not improve performance. CONCLUSIONS: The CMS-HCC had superior performance in predicting surgical outcomes. Prescription-based scores, alone or in addition to diagnosis-based scores, were not better than any diagnosis-based scoring system.

The risk paradox: use of elective cholecystectomy in older patients is independent of their risk of developing complications.

BACKGROUND: We recently developed and validated a prognostic model that accurately predicts the 2-year risk of emergent gallstone-related hospitalization in older patients presenting with symptomatic gallstones. STUDY DESIGN: We used 100% Texas Medicare data (2000 to 2011) to identify patients aged 66 years and older with an initial episode of symptomatic gallstones not requiring emergency hospitalization. At presentation, we calculated each patient's risk of 2-year gallstone-related emergent hospitalization using the previously validated model. Patients were placed into the following risk groups based on model estimates: <30%, 30% to <60%, and ≥ 60%. Within each risk group, we calculated the percent of elective cholecystectomies (≤ 2.5 months from initial episode) performed. RESULTS: In all, 161,568 patients had an episode of symptomatic gallstones. Mean age was 76.5 ± 7.3 years and 59.9% were female. The 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across risk groups. For the overall cohort, 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group underwent elective cholecystectomy in the 2.5 months after the initial symptomatic episode. In patients with no comorbidities, elective cholecystectomy rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. Of patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months after the initial episode. CONCLUSIONS: The risk of recurrent acute biliary symptoms requiring hospitalization has no influence, or even a paradoxical negative influence, on the decision to perform elective cholecystectomy after an initial symptomatic episode. Translation of the risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.

PREOP-Gallstones: A Prognostic Nomogram for the Management of Symptomatic Cholelithiasis in Older Patients.

OBJECTIVE AND BACKGROUND: The decision regarding elective cholecystectomy in older patients with symptomatic cholelithiasis is complicated. We developed and validated a prognostic nomogram to guide shared decision making for these patients. METHODS: We used Medicare claims (1996-2005) to identify the first episode of symptomatic cholelithiasis in patients older than 65 years who did not undergo hospitalization or elective cholecystectomy within 2.5 months of the episode. We described current patterns of care and modeled their risk of emergent gallstone-related hospitalization or cholecystectomy at 2 years. Model discrimination and calibration were assessed using a random split sample of patients. RESULTS: We identified 92,436 patients who presented to the emergency department (8.3%) or physician's office (91.7%) and who were not immediately admitted. The diagnosis for the initial episode was biliary colic/dyskinesia (65.3%), acute cholecystitis (26.6%), choledocholithiasis (5.7%), or gallstone pancreatitis (2.4%). The 2-year emergent gallstone-related hospitalization rate was 11.1%, with associated in-hospital morbidity and mortality rates of 56.5% and 6.5%. Factors associated with gallstone-related acute hospitalization included male sex, increased age, fewer comorbid conditions, complicated biliary disease on initial presentation, and initial presentation to the emergency department. Our model was well calibrated and identified 51% of patients with a risk less than 10% for 2-year complications and 5.4% with a risk more than 40% (C statistic, 0.69; 95% confidence interval, 0.63-0.75). CONCLUSIONS: Surgeons can use this prognostic nomogram to accurately provide patients with their 2-year risk of developing gallstone-related complications, allowing patients and physicians to make informed decisions in the context of their symptom severity and its impact on their quality of life.

Surgeon and Facility Variation in the Use of Minimally Invasive Breast Biopsy in Texas.

OBJECTIVE AND BACKGROUND: Minimally invasive breast biopsy (MIBB) rates remain well below guideline recommendations of more than 90% and vary across geographic areas. Our aim was to determine the variation in use attributable to the surgeon and facility and determine the patient, surgeon, and facility characteristics associated with the use of MIBB. METHODS: We used 100% Texas Medicare claims data (2000-2008) to identify women older than 66 years with a breast biopsy (open or minimally invasive) and subsequent breast cancer diagnosis/operation within 1 year. The percentage of patients undergoing MIBB as the first diagnostic modality was estimated for each surgeon and facility. Three-level hierarchical generalized linear models (patients clustered within surgeons within facilities) were used to evaluate variation in MIBB use. RESULTS: A total of 22,711 patients underwent a breast cancer operation by 1226 surgeons at 525 facilities. MIBB was the initial diagnostic modality in 62.4% of cases. Only 7.0% of facilities and 12.9% of surgeons used MIBB for more than 90% of patients. In 3-level models adjusted for patient characteristics, the percentage of patients who received MIBB ranged from 7.5% to 96.0% across facilities (mean = 50.1%, median = 49.2%) and from 8.0% to 87.0% across surgeons (mean = 50.3%, median = 50.9%). The variance in MIBB use was attributable to facility (8.8%) and surgeon (15.4%) characteristics. Lower surgeon and facility volume, longer surgeon years in practice, and smaller facility bed size were associated with lower rates of MIBB use. CONCLUSIONS: Identification of surgeon and facility characteristics associated with low use of MIBB provides potential targets for interventions to improve MIBB rates and decrease variation in use. TYPE OF STUDY: Retrospective cohort.