Assessing the accuracy of race-and-ethnicity data in the Outcome and Assessment Information Set.

BACKGROUND: Limitations in the quality of race-and-ethnicity information in Medicare's data systems constrain efforts to assess disparities in care among older Americans. Using demographic information from standardized patient assessments may be an efficient way to enhance the accuracy and completeness of race-and-ethnicity information in Medicare's data systems, but it is critical to first establish the accuracy of these data as they may be prone to inaccurate observer-reported or third-party-based information. This study evaluates the accuracy of patient-level race-and-ethnicity information included in the Outcome and Assessment Information Set (OASIS) submitted by home health agencies. METHODS: We compared 2017-2022 OASIS-D race-and-ethnicity data to gold-standard self-reported information from the Medicare Consumer Assessment of Healthcare Providers and Systems® survey in a matched sample of 304,804 people with Medicare coverage. We also compared OASIS data to indirect estimates of race-and-ethnicity generated using the Medicare Bayesian Improved Surname and Geocoding (MBISG) 2.1.1 method and to existing Centers for Medicare & Medicaid Services (CMS) administrative records. RESULTS: Compared with existing CMS administrative data, OASIS data are far more accurate for Hispanic, Asian American and Native Hawaiian or other Pacific Islander, and White race-and-ethnicity; slightly less accurate for American Indian or Alaska Native race-and-ethnicity; and similarly accurate for Black race-and-ethnicity. However, MBISG 2.1.1 accuracy exceeds that of both OASIS and CMS administrative data for every racial-and-ethnic category. Patterns of inconsistent reporting of racial-and-ethnic information among people for whom there were multiple observations in the OASIS and Consumer Assessment of Healthcare Providers and Systems (CAHPS) datasets suggest that some of the inaccuracies in OASIS data may result from observation-based reporting that lessens correspondence with self-reported data. CONCLUSIONS: When health record data on race-and-ethnicity includes observer-reported information, it can be less accurate than both true self-report and a high-performing imputation approach. Efforts are needed to encourage collection of true self-reported data and explicit record-level data on the source of race-and-ethnicity information.

Association of Medicare Advantage Premiums With Measures of Quality and Patient Experience.

Importance: Quality of care varies substantially across Medicare Advantage plans. The price information that Medicare Advantage enrollees are most likely to consider when selecting a Medicare Advantage plan is the monthly premium. Enrollees may select plans to minimize premium or, alternatively, use premium as a proxy for quality and select plans with higher premiums; however, quality implications of these choices are unknown. Objective: To determine the extent to which the quality of care offered by Medicare Advantage plans varies within vs across premium levels. Design, Setting, and Participants: This was a retrospective cross-sectional study of the population enrolled in Medicare Advantage plans in 2016 to 2017 using clinical quality measures from the Healthcare Effectiveness Data and Information Set (HEDIS), patient experience measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and administrative data. Data were analyzed from March 2021 to March 2022. Exposures: Medicare Advantage monthly premium. Main Outcomes and Measures: Ten publicly reported 2017 HEDIS measures and 5 publicly reported 2017 CAHPS measures linearly transformed to a 0 to 100 scale. Results: The 168 968 Medicare Advantage CAHPS respondents were representative of the enrollee population (14% were <65 years old and eligible through disability; 24% ≥80 years old; sex and race/ethnicity data were not considered); 40% were in 591 plans with no monthly premiums and less than 6% were in 144 plans with monthly premiums of $120 or more. There were from 77 054 to 2 139 422 enrollees by HEDIS measure. Among all Medicare Advantage enrollees, 79% were in plans with either a $0 premium or a low monthly premium (≤$60); patient experience and clinical quality were generally similar in these 2 categories of plans. To a small extent, enrollees in moderately high ($60-$120) and high (≥$120) premium plans reported better patient experience (+1.4 [95% CI, 0.7-2.1] and 2.2 [95% CI, 1.5-2.9] points) and received better clinical care (1.4 [95% CI, 0.3-2.5] to 3.3 [5% CI, 2.1-4.5] percentage points on most measures than those with $0 and low-premium plans. Quality differences within each premium level category were substantial; the within-premium category plan-level SDs were 6.5 points and 7.2 percentage points for patient experience and clinical quality, respectively. A plan at the 50th percentile of clinical quality and patient experience in the high premium category would fall in the 65th and 62nd percentile within the $0-premium category, respectively. Conclusions and Relevance: This population-based cross-sectional study found that although quality of care and patient experience were slightly higher with higher-premium plans, quality varied widely within each premium category. High-quality care and patient experience were found in each price category. Thus, paying higher premiums is not necessary for higher quality care in Medicare Advantage plans. Greater engagement of enrollees and advocates with quality of care and patient experience information for Medicare Advantage plan selection is recommended.

Medicare Prescription Drug Plan Enrollees Report Less Positive Experiences Than Their Medicare Advantage Counterparts.

Since 2006, Medicare beneficiaries have been able to obtain prescription drug coverage through standalone prescription drug plans or their Medicare Advantage (MA) health plan, options exercised in 2015 by 72 percent of beneficiaries. Using data from community-dwelling Medicare beneficiaries older than age sixty-four in 700 plans surveyed from 2007 to 2014, we compared beneficiaries' assessments of Medicare prescription drug coverage when provided by standalone plans or integrated into an MA plan. Beneficiaries in standalone plans consistently reported less positive experiences with prescription drug plans (ease of getting medications, getting coverage information, and getting cost information) than their MA counterparts. Because MA plans are responsible for overall health care costs, they might have more integrated systems and greater incentives than standalone prescription drug plans to provide enrollees medications and information effectively, including, since 2010, quality bonus payments to these MA plans under provisions of the Affordable Care Act.

Cost analysis of vascular readmissions after common vascular procedures.

OBJECTIVE: This study analyzed readmissions and their associated hospital costs after common vascular surgeries at a single institution. METHODS: Patients undergoing open or endovascular abdominal aortic aneurysm repair, aortoiliac revascularization, or infrainguinal revascularization, from 2010 through 2012, were retrospectively evaluated. We compared 30- and 90-day readmission rates and costs by procedure group, and we tabulated reasons for readmission and procedures performed during readmission. We used both American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data and patient records; as NSQIP only captures 30-day data, we retrospectively reviewed patient charts to extend the evaluation to 90 days. Analyses were performed using parametric or nonparametric methods as appropriate. RESULTS: Two hundred nineteen cases were analyzed; the overall rate of index admission survivors experiencing at least one readmission within 30 days was 17% and within 90 days, 27%. Median readmission costs were $10,700, which added 39% to the median index costs of $27,700. Over half of readmissions (55%) included an operation. The most common cause for readmission was related to wound complications, comprising approximately 30% of the entire readmission cohort. Independent drivers of readmission costs were the need for additional surgical procedures, the use of intensive care unit services, and the number of days spent in the hospital above the median. Total 90-day costs were statistically equivalent between open and endovascular procedures when including readmissions. CONCLUSIONS: We found that vascular surgery readmissions occur at a rate of 17% at 30 days and 27% at 90 days. When including the costs of readmission for a wide variety of common vascular cases, there is no significant difference in total costs between endovascular and open procedures at 90 days.

Sample designs for measuring the health of small racial/ethnic subgroups.

Most national health surveys do not permit precise measurement of the health of racial/ethnic subgroups that comprise <1 per cent of the U.S. population. We identify three potentially promising sample design strategies for increasing the accuracy of national health estimates for a small target subgroup when used to supplement a small probability sample of that group and apply these strategies to American Indians/Alaska Natives (AI/AN) and Chinese using National Health Interview Survey data. These sample design strategies include (1) complete sampling of targets within households, (2) oversampling selected macrogeographic units, and (3) oversampling from an incomplete list frame. Stage (1) is promising for Chinese and AI/AN; (2) works for both groups, but it would be more cost-effective for AI/AN because of their greater residential concentration; (3) is somewhat effective for groups like Chinese with viable surname lists, but not for AI/AN. Both (2) and (3) efficiently improve measurement precision when the supplement is the same size as the existing core sample, with diminishing additional returns as the supplement grows relative to the core sample, especially for (3). To avoid large design effects, the oversampled geographic areas or lists must have good coverage of the target population. To reduce costs, oversampled geographic tracts and lists must consist primarily of targets. These techniques can be used simultaneously to substantially increase effective sample sizes (ESSs). For example, (1) and (2) in combination can be used to multiply the nominal sample size of AI/AN or Chinese by 8 and the ESS by 4.