Differences in rehabilitation evaluation access for rural and socially disadvantaged stroke survivors.

BACKGROUND: Most stroke survivors have ongoing deficits and report unmet needs. Despite evidence that rehabilitation improves stroke survivors' function, access to occupational and physical therapy is limited. Describing access to care for disadvantaged communities for different levels of stroke severity will provide proportions used to create Markov economic models to demonstrate the value of rehabilitation. OBJECTIVES: The objective of this study was to explore differences in the frequency of rehabilitation evaluations via outpatient therapy and home health for Medicare Part B ischemic stroke survivors in rural and socially disadvantaged locations. METHODS: We completed a retrospective, descriptive cohort analysis using the 2018 and 2019 5% Medicare Limited Data Sets (LDS) from the Centers for Medicare and Medicaid Services using STROBE guidelines for observational studies. We extracted rehabilitation Current Procedural Terminology (CPT) codes for those who received occupational or physical therapy to examine differences in therapy evaluations for rural and socially disadvantaged populations. RESULTS: Of the 9,076 stroke survivors in this cohort, 44.2% did not receive any home health or outpatient therapy. Of these, 64.7% had a moderate or severe stroke, indicating an unmet need for therapy. Only 2.0% of stroke survivors received outpatient occupational therapy within the first year Rural and socially disadvantaged communities accessed rehabilitation evaluations at lower rates than general stroke survivors. CONCLUSIONS: These findings describe the poor access to home health and outpatient rehabilitation for stroke survivors, particularly in traditionally underserved populations. These results will influence future economic evaluations of interventions aimed at improving access to care.

Health Care Utilization After Nonfatal Firearm Injuries.

OBJECTIVES: Despite the high incidence of firearm injuries, little is known about health care utilization after nonfatal childhood firearm injuries. This study aimed to describe health care utilization and costs after a nonfatal firearm injury among Medicaid and commercially insured youth using a propensity score matched analysis. METHODS: We conducted a propensity score matched cohort analysis using 2015 to 2018 Medicaid and Commercial Marketscan data comparing utilization in the 12-months post firearm injury for youth aged 0 to 17. We matched youth with a nonfatal firearm injury 1:1 to comparison noninjured youth on demographic and preindex variables. Outcomes included inpatient hospitalizations, emergency department (ED) visits, and outpatient visits as well as health care costs. Following propensity score matching, regression models estimated relative risks of the health care utilization outcomes, adjusting for demographic and clinical covariates. RESULTS: We identified 2110 youth with nonfatal firearm injury. Compared with matched noninjured youth, firearm injured youth had a 5.31-fold increased risk of inpatient hospitalization (95% confidence interval [CI] 3.93-7.20), 1.49-fold increased risk of ED visit (95% CI 1.37-1.62), and 1.06-fold increased risk of outpatient visit (95% CI 1.03-1.10) 12-months postinjury. Adjusted 12-month postindex costs were $7581 (95% CI $7581-$8092) for injured youth compared with $1990 (95% CI $1862-2127) for comparison noninjured youth. CONCLUSIONS: Youth who suffer nonfatal firearm injury have a significantly increased risk of hospitalizations, ED visits, outpatient visits, and costs in the 12 months after injury when compared with matched youth. Applied to the 11 258 US youth with nonfatal firearm injuries in 2020, estimates represent potential population health care savings of $62.9 million.

Determining the Marginal Cost Differences of a Telehealth Versus an In-person Occupational Therapy Evaluation Session for Stroke Survivors Using Time-driven Activity-based Costing.

OBJECTIVE: To estimate the marginal cost differences and care delivery process of a telerehabilitation vs outpatient session. DESIGN: This study used a time-driven activity-based costing approach including (1) observation of rehabilitation sessions and creation of manual time stamps, (2) structured and recorded interviews with 2 occupational therapists familiar with outpatient therapy and 2 therapists familiar with telerehabilitation, (3) collection of standard wages for providers, and (4) the creation of an iterative flowchart of both an outpatient and telerehabilitation session care delivery process. SETTING: Telerehabilitation and outpatient therapy evaluation. PARTICIPANTS: Three therapists familiar with care deliver for telerehabilitation or outpatient therapy (N=3). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Marginal cost difference between telerehabilitation and outpatient therapy evaluations. RESULTS: Overall, telerehabilitation ($225.41) was more costly than outpatient therapy ($168.29) per session for a cost difference of $57.12. Primary time drivers of this finding were initial phone calls (0 minutes for OP therapists vs 35 minutes for TR) and post documentation (5 minutes for OP vs 30 minutes for TR) demands for telerehabilitation. CONCLUSIONS: Telerehabilitation is an emerging platform with the potential to reduce costs, improve health care inequities, and facilitate better patient outcomes. Improvements in documentation practices, staffing, technology, and reimbursement structuring would allow for a more successful translation.

Incidence of Poststroke Depression in Patients With Poststroke Dysphagia.

PURPOSE: Poststroke dysphagia and poststroke depression (PSD) can have devastating effects on stroke survivors, including increased burden of care, higher health care costs, poor quality of life, and greater mortality; however, there is a dearth of research examining depression in patients diagnosed with dysphagia after stroke. Thus, we aimed to study the incidence of PSD in patients with poststroke dysphagia to provide foundational knowledge about this patient population. METHOD: We conducted a retrospective, cross-sectional study of individuals with a primary diagnosis of acute ischemic stroke (AIS) and secondary diagnoses of dysphagia and/or depression using administrative claims data from the 2017 Medicare 5% Limited Data Set. RESULTS: The proportion of depression diagnosis in patients with poststroke dysphagia was significantly higher than the proportion of depression diagnosis in those without poststroke dysphagia during acute hospitalization: 12.01% versus 9.52%, respectively (p = .003). CONCLUSIONS: Our results demonstrated that persons with poststroke dysphagia were as, or slightly more, likely to have PSD compared to the general stroke population, and to our knowledge, they establish the first reported incidence of PSD in Medicare patients with dysphagia after AIS. Future research is warranted to further explore the effects of PSD on poststroke dysphagia.

Disparities in Use of Patient Portals Among Adults in Family Medicine.

OBJECTIVE: This study examined patient portal utilization by analyzing the pattern of time and feature use of patients, and thus to identify functionalities of portal use and patient characteristics that may inform future strategies to enhance communication and care coordination through online portals. METHODS: We conducted a retrospective study of patients at 18 family medicine clinics over a 5-year period using access log records in the electronic health record database. Dimensionality reduction analysis was applied to group portal functionalities into 4 underlying feature domains: messaging, health information management, billing/insurance, and resource/education. Negative binomial regression analysis was used to evaluate how patient and practice characteristics affected the use of each feature domain. RESULTS: Patients with more chronic conditions, lab tests, or prescriptions generally showed greater patient portal usage. However, patients who were male, elderly, in minority groups, or living in rural areas persistently had lower portal usage. Individuals on public insurance were also less likely than those on commercial insurance to use patient portals, although Medicare patients showed greater portal usage on health information management features, and uninsured patients had greater usage on viewing resource/education features. Having Internet access only affected the use of messaging features. CONCLUSION: Efforts to enroll patients in online portals do not guarantee patients will use the portals to manage their health. When considering the use of patient portals for improving telehealth, clinicians need to be aware of technological, socioeconomic, and cultural challenges faced by their patients.

A Modification of Time-Driven Activity-Based Costing for Comparing Cost of Telehealth and In-Person Visits.

Introduction: Cost studies of telehealth (TH) and virtual visits are few and report mixed results of the economic impact of virtual care and TH. Largely missing from the literature are studies that identify the cost of delivering TH versus in-person care. The objective was to demonstrate a modified time-driven activity-based costing (TDABC) approach to compare weighted labor cost of an in-person pediatric clinic sick visit before COVID-19 to the same virtual and in-person sick-visit during COVID-19. Methods: We examined visits before and during COVID-19 using: (1) recorded structured interviews with providers; (2) iterative workflow mapping; (3) electronic health records time stamps for validation; (4) standard cost weights for wages; and (5) clinic CPT billing code mix for complexity weighs. We examined the variability in estimated time using a decision tree model and Monte Carlo simulations. Results: Workflow charts were created for the clinic before COVID-19 and during COVID-19. Using TDABC and simulations for varying time, the weighted cost of clinic labor for sick visit before COVID-19 was $54.47 versus $51.55 during COVID-19. Discussion: The estimated mean labor cost for care during the pandemic has not changed from the pre-COVID period; however, this lack of a difference is largely because of the increased use of TH. Conclusions: Our TDABC approach is feasible to use under virtual working conditions; requires minimal provider time for execution; and generates detailed cost estimates that have "face validity" with providers and are relevant for economic evaluation.

The Impact of Timing on Clinical and Economic Outcomes During Inter-ICU Transfer of Acute Respiratory Failure Patients: Time and Tide Wait for No One.

Approximately one in 30 patients with acute respiratory failure (ARF) undergoes an inter-ICU transfer. Our objectives are to describe inter-ICU transfer patterns and evaluate the impact of timing of transfer on patient-centered outcomes. DESIGN: Retrospective, quasi-experimental study. SETTING: We used the Healthcare Cost and Utilization Project State Inpatient Databases in five states (Florida, Maryland, Mississippi, New York, and Washington) during 2015-2017. PARTICIPANTS: We selected patients with International Classification of Diseases, 9th and 10th Revision codes of respiratory failure and mechanical ventilation who underwent an inter-ICU transfer (n = 6,718), grouping as early (≤ 2 d) and later transfers (3+ d). To control for potential selection bias, we propensity score matched patients (1:1) to model propensity for early transfer using a priori defined patient demographic, clinical, and hospital variables. MAIN OUTCOMES: Inhospital mortality, hospital length of stay (HLOS), and cumulative charges related to inter-ICU transfer. RESULTS: Six-thousand seven-hundred eighteen patients with ARF underwent inter-ICU transfer, 68% of whom (n = 4,552) were transferred early (≤ 2 d). Propensity score matching yielded 3,774 well-matched patients for this study. Unadjusted outcomes were all superior in the early versus later transfer cohort: inhospital mortality (24.4% vs 36.1%; p < 0.0001), length of stay (8 vs 22 d; p < 0.0001), and cumulative charges ($118,686 vs $308,977; p < 0.0001). Through doubly robust multivariable modeling with random effects at the state level, we found patients who were transferred early had a 55.8% reduction in risk of inhospital mortality than those whose transfer was later (relative risk, 0.442; 95% CI, 0.403-0.497). Additionally, the early transfer cohort had lower HLOS (20.7 fewer days [13.0 vs 33.7; p < 0.0001]), and lower cumulative charges ($66,201 less [$192,182 vs $258,383; p < 0.0001]). CONCLUSIONS AND RELEVANCE: Our study is the first to use a large, multistate sample to evaluate the practice of inter-ICU transfers in ARF and also define early and later transfers. Our findings of favorable outcomes with early transfer are vital in designing future prospective studies evaluating evidence-based transfer procedures and policies.

Impact of Community Health Workers on Access to Care for Rural Populations in the United States: A Systematic Review.

Community Health Worker (CHW) interventions have shown potential to reduce inequities for underserved populations. However, there is a lack of support for CHW integration in the delivery of health care. This may be of particular importance in rural areas in the Unites States where access to care remains problematic. This review aims to describe CHW interventions and their outcomes in rural populations in the US. Peer reviewed literature was searched in PubMed and PsycINFO for articles published in English from 2015 to February 2021. Title and abstract screening was performed followed by full text screening. Quality of the included studies was assessed using the Downs and Black score. A total of 26 studies met inclusion criteria. The largest proportion were pre-post program evaluation or cohort studies (46.2%). Many described CHW training (69%). Almost a third (30%) indicated the CHW was integrated within the health care team. Interventions aimed to provide health education (46%), links to community resources (27%), or both (27%). Chronic conditions were the concern for most interventions (38.5%) followed by women's health (34.6%). Nearly all studies reported positive improvement in measured outcomes. In addition, studies examining cost reported positive return on investment. This review offers a broad overview of CHW interventions in rural settings in the United States. It provides evidence that CHW can improve access to care in rural settings and may represent a cost-effective investment for the healthcare system.

Missing data methods for intensive care unit SOFA scores in electronic health records studies: results from a Monte Carlo simulation.

Aim: Missing data cause problems through decreasing sample size and the potential for introducing bias. We tested four missing data methods on the Sequential Organ Failure Assessment (SOFA) score, an intensive care research severity adjuster. Methods: Simulation study using 2015-2017 electronic health record data, where the complete dataset was sampled, missing SOFA score elements imposed and performance examined of four missing data methods - complete case analysis, median imputation, zero imputation (recommended by SOFA score creators) and multiple imputation (MI) - on the outcome of in-hospital mortality. Results: MI performed well, whereas other methods introduced varying amounts of bias or decreased sample size. Conclusion: We recommend using MI in analyses where SOFA score component values are missing in administrative data research.

A comparison of administrative claims-based risk predictors for pediatric asthma.

OBJECTIVES: Head-to-head comparisons are needed to determine the most accurate and appropriate administrative claims-based exacerbation risk predictor for emergency department (ED) visits and hospitalizations among children with asthma. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed 2013-2014 MarketScan Medicaid data. Children aged 2 to 17 years were included. Seven risk predictors were compared for accuracy in predicting 3-month subsequent ED visits/hospitalizations for asthma: 3-month rolling asthma medication ratio (AMR), Healthcare Effectiveness Data and Information Set (HEDIS) criteria, revised HEDIS criteria, quarterly short-acting ß-agonist (SABA) claims, prior ED visit, prior hospitalization, and prior ED visit or hospitalization. Sensitivity, specificity, positive and negative predictive value (NPV), and percentage of population identified as high risk were compared for each risk predictor utilizing the McNemar test to identify statistically significant differences in risk prediction accuracy. RESULTS: A total of 214,452 children were included; the mean age was 7.8 years. HEDIS and revised HEDIS identified prohibitively large cohorts as high risk (67% and 48%, respectively). For the remaining measures, the NPV range is narrow (97%-99%), indicating high performance at identifying patients who would not benefit from intervention. The ED visit and ED/hospitalization measures have superior sensitivities (44% and 49%, respectively) compared with pharmacy claims-based measures (AMR [5%] and SABA count [10%]). Pharmacy claims-based measures identify a smaller proportion of patients as high risk and maintain high NPV. CONCLUSIONS: Pharmacy-based asthma exacerbation risk predictors such as the AMR and SABA count can rule out low-risk patients with a high degree of specificity and NPV, which is a primary goal of real-time risk monitoring in pediatric asthma.

Assessing Health Care Utilization and Compliance in Kawasaki Disease.

OBJECTIVE: To characterize health care utilization and costs associated with care after diagnosis of Kawasaki disease including adherence to guidelines for echocardiograms. STUDY DESIGN: We analyzed children hospitalized for Kawasaki disease using 2015-2017 national Truven MarketScan commercial claims data. The mean 90-day prehospitalization utilization and costs were quantified and compared with the 90 days posthospitalization via Wilcoxon 2-sample test. Adherence to echocardiogram guidelines was examined using multivariable logistic regression to identify factors associated with adherence. RESULTS: The mean total payments 90 days prior to hospitalization ($2090; n = 360) were significantly lower than those after discharge ($3778), though out of pocket costs were higher ($400 vs $270) (P < .0001). There was an increase in office visits, medical procedures, and echocardiograms after discharge. A majority of health care utilization before hospitalization occurred in the 7 days immediately prior to the date of admission; 51% obtained an echocardiogram within the first 2 weeks, and 14% were completely adherent with recommendations. Children with greater utilization prior to admission were more likely to adhere to American Heart Association guidelines for follow-up echocardiograms (OR 1.03, 95% CI 1.01-1.06). CONCLUSIONS: Outpatient health care expenditure nearly doubles after Kawasaki disease hospital discharge when compared with prehospitalization, suggesting the financial ramifications of this diagnosis persist beyond costs incurred during hospitalization. A significant portion of patients do not receive guideline recommended follow-up echocardiograms. This issue should be explored in more detail given the morbidity and mortality associated with this diagnosis.

Minimally important difference in cost savings: Is it possible to identify an MID for cost savings?

As healthcare costs continue to increase, studies assessing costs are becoming increasingly common, but researchers planning for studies that measure costs differences (savings) encounter a lack of literature or consensus among researchers on what constitutes "small" or "large" cost savings for common measures of resource use.  Other fields of research have developed approaches to solve this type of problem. Researchers measuring improvement in quality of life or clinical assessments have defined minimally important differences (MID) which are then used to define magnitudes when planning studies. Also, studies that measure cost effectiveness use benchmarks, such as cost/QALY, but do not provide benchmarks for cost differences. In a review of the literature, we found no publications identifying indicators of magnitude for costs. However, the literature describes three approaches used to identify minimally important outcome differences: (1) anchor-based, (2) distribution-based, and (3) a consensus-based Delphi methods. In this exploratory study, we used these three approaches to derive MID for two types of resource measures common in costing studies for: (1) hospital admissions (high cost); and (2) clinic visits (low cost). We used data from two (unpublished) studies to implement the MID estimation. Because the distributional characteristics of cost measures may require substantial samples, we performed power analyses on all our estimates to illustrate the effect that the definitions of "small" and "large" costs may be expected to have on power and sample size requirements for studies. The anchor-based method, while logical and simple to implement, may be of limited value in cases where it is difficult to identify appropriate anchors. We observed some commonalities and differences for the distribution and consensus-based approaches, which require further examination. We recommend that in cases where acceptable anchors are not available, both the Delphi and the distribution-method of MID for costs be explored for convergence.

A Cost Comparison of Infliximab Versus Intravenous Immunoglobulin for Refractory Kawasaki Disease Treatment.

BACKGROUND AND OBJECTIVES: In 10% to 20% of cases, Kawasaki disease is refractory to intravenous immunoglobulin (IVIg), an expensive medication under a national shortage. Data suggest that infliximab is a viable alternative to a second dose of IVIg, with similar efficacy and safety. We compared the cost of a second IVIg dose to that of infliximab in the treatment of refractory Kawasaki disease (rKD). METHODS: A decision analysis model was used to compare rKD treatments: a second dose of IVIg at 2 g/kg versus infliximab at 10 mg/kg. Infliximab monitoring times were 24, 36, and 48 hours. Direct hospital costs beginning at rKD diagnosis were estimated by using 2016-2017 Truven MarketScan data. Redbook was used for drug costs. Calculations were applied to 3 hypothetical cohorts of 100 patients aged 2 (12.5 kg), 4 (16 kg), and 8 years (25.5 kg). Indirect costs included parental missed workdays. RESULTS: The total direct cost for children receiving IVIg was $1 677 801, $1 791 652, and $2 100 675 for the 2-, 4-, and 8-year-old cohorts. The direct cost of infliximab with 24 hours of monitoring was $853 042, $899 096, and $1 024 101, respectively. A 20% bidirectional sensitivity analysis revealed stability of our model, with overall cost savings with use of infliximab. With monitoring 48 hours after infliximab treatment, 20% changes in length of stay (LOS) tipped the balance for the 2- and 4-year-old cohorts. Overall, IVIg and infliximab LOS had the most influence on our model. CONCLUSIONS: Infliximab has potential to yield shorter LOS and significant cost savings in the treatment of rKD. Infliximab treatment, followed by 24 hours of monitoring, nearly halved hospital costs, regardless of age.

Do Hospitals Providing Telehealth in Emergency Departments Have Lower Emergency Department Costs?

Background: Since 2003, the University of Mississippi Medical Center has operated a robust telehealth emergency department (ED) network, TelEmergency, which enhances access to emergency medicine-trained physicians at participating rural hospitals. TelEmergency was developed as a cost-control measure for financially constrained rural hospitals to improve access to quality, emergency care. However, the literature remains unclear as to whether ED telehealth services can be provided at lower costs compared with traditional in-person ED services. Introduction: Our objective was to empirically determine whether TelEmergency was associated with lower ED costs at rural hospitals when compared with similar hospitals without TelEmergency between 2010 and 2017. Materials and Methods: A panel of data for 2010-2017 was constructed at the hospital level. Hospitals with TelEmergency (n = 14 hospitals; 112 hospital-years) were compared with similar hospitals that did not use TelEmergency from Arkansas, Georgia, Mississippi, and South Carolina (n = 102; 766 hospital-years), matched using Coarsened Exact Matching. The relationship between total ED costs and treatment (e.g., participation in TelEmergency) was predicted using generalized estimating equations with a Poisson distribution, a log link, an exchangeable error term, and robust standard errors. Results: After controlling for ownership type, critical access hospital status, year, and size, TelEmergency was associated with an estimated 31.4% lower total annual ED costs compared with similar matched hospitals that did not provide TelEmergency. Conclusions: TelEmergency utilization was associated with significantly lower total annual ED costs compared with similarly matched hospitals that did not utilize TelEmergency. These findings suggest that access to quality ED care in rural communities can occur at lower costs.

A Longitudinal Examination of the Asthma Medication Ratio in Children with Medicaid.

Background/Objective: An efficient and accurate strategy for identifying children with asthma at high-risk for exacerbation is needed. The objective of this study is to conduct a longitudinal examination of the asthma medication ratio (AMR) (#of controller medication claims/(# of controller medication claims + # of rescue medication claims)) in Medicaid-funded children with asthma. This measure has the potential to be a near real-time risk assessment tool.Methods: We conducted a retrospective analysis of 2013-2014 Truven Health Medicaid data. We analyzed pharmacy and medical claims for a cohort of children with asthma. We identified patients age 2-17 years with at least one claim for an inhaled corticosteroid. We calculated an AMR for rolling 3-month periods and examined the proportion who were classified as low risk (AMR ≥ .5), high-risk (AMR < .5) and no medication claims (no asthma medication claims). Using logistic regression, we tested how the AMR predicted severe exacerbations.Results: 214,452 eligible children were identified. The mean age is 7.8 years. 8-9% had a high-risk AMR in any given period. High-risk AMR is associated with increased odds of a severe exacerbation in the subsequent 3 months (compared to all other children) (OR 1.7-1.9 depending on time period evaluated).Conclusions: In this analysis of Medicaid-insured children with asthma, we found that the AMR is a reliable predictor of exacerbations. This will inform the development of an AMR-based risk assessment and communication intervention.

A longitudinal examination of the asthma medication ratio in children.

OBJECTIVES: The asthma medication ratio (AMR) (number of controller medications / [number of controller medications + number of rescue medications]) can be calculated using claims data. This measure has not previously been studied longitudinally. Our objective is to conduct a longitudinal examination of the AMR in a large national cohort of children with asthma. STUDY DESIGN: Retrospective analysis of pharmacy and medical claims data. METHODS: Using 2013-2014 TruvenHealth MarketScan data, we identified children with asthma. Beginning with the month of first controller claim, we calculated an AMR for each rolling 3-month period and each rolling 6-month period and examined the proportion who had AMRs classified as low-risk (≥0.5), high-risk (<0.5), and missing for each period. Using logistic regression, we tested how a rolling AMR predicted a child's hospitalization or emergency department (ED) visit for asthma. RESULTS: We identified 197,316 patients aged 2 to 17 years with a claim for a controller. AMRs were relatively stable over time, with the majority of patients remaining in the same AMR category through a 12-month period. Using both the rolling 3-month and 6-month AMRs, a higher proportion of patients with high-risk AMRs (9.6% and 9.5%, respectively) had an ED visit or hospitalization compared with patients with low-risk (5.0% and 5.7%) and missing (3.5% and 3.2%) AMRs (P <.0001). Using logistic regression, the 3-month AMR is more strongly associated with subsequent ED visit or hospitalization than the 6-month AMR. CONCLUSIONS: AMR-based risk assignment is relatively stable over time. Three-month AMR calculation periods appear to provide the most accurate assessment of risk. Children with missing AMRs likely have inactive asthma and are at the lowest risk for emergent asthma visits.

Effect of frailty on resource use and cost for Medicare patients.

Aim: The effects of frailty and multiple chronic conditions (MCCs) on cost of care are rarely disentangled in archival data studies. We identify the marginal contribution of frailty to medical care cost estimates using Medicare data. Materials & methods: Use of the Faurot frailty score to identify differences in acute medical events and cost of care for patients, controlling for MCCs and medication use. Results: Estimated marginal cost of frailty was US$10,690 after controlling for demographics, comorbid conditions, polypharmacy and use of potentially inappropriate medications. Conclusion: Frailty contributes greatly to cost of care, but while often correlated, is not synonymous with MCCs. Thus, it is important to control separately for frailty in studies that compare medical care use and cost.

Healthcare Costs for Insured Older U.S. Adults with Hearing Loss.

OBJECTIVES: To measure 18-month healthcare cost difference attributable to hearing loss (HL) in older adults. DESIGN: Matched cohort. SETTING: Retrospective analysis of administrative healthcare bills of insured older Americans. PARTICIPANTS: Older U.S. adults with health insurance in 3 cohorts matched based on HL diagnosis using propensity score methods (N=904,750). MEASUREMENTS: Comparison groups were defined as those with and without HL diagnosis using International Classification of Diseases, Ninth Revision, diagnosis codes from billing records. Outcomes measured include 18-month total healthcare payments and healthcare payments broken down according to payment type (inpatient, outpatient, prescription, hearing services). Three comparison cohorts were examined for these outcomes: individuals covered by Medicare plus supplemental private insurance (Cohort 1, n=782,216), those covered only under Medicare (Cohort 2, n=105,296), and those within the Medicare sample that were dually eligible for Medicare and Medicaid coverage (Subcohort 3, n=17,238). The quality of the propensity score match was examined using standardized differences in means or proportions between all matched covariates, and cost outcomes were analyzed using multiple generalized linear regression models. RESULTS: Fully adjusted models showed significantly higher 18-month healthcare payments for individuals with a diagnosis of HL without indication of use of hearing services than in those without a HL diagnosis in the 3 samples (payment differences: $3,587 Cohort 1, $3,779 Cohort 2, $4,657 Subcohort 3; all p<.001). Payment differences were also found between individuals with HL and indications of hearing services and those without HL. CONCLUSION: We observed more than 20% higher total healthcare payments over 18 months for a group of insured individuals with HL regardless of insurance type or hearing services use, indicating that negative health-related effects of HL may increase healthcare use unrelated to HL. Thus, clinical care to ameliorate HL may improve overall health.

Linking Existing Instruments to Develop an Activity of Daily Living Item Bank.

This study examined dimensionality and item-level psychometric properties of an item bank measuring activities of daily living (ADL) across inpatient rehabilitation facilities and community living centers. Common person equating method was used in the retrospective veterans data set. This study examined dimensionality, model fit, local independence, and monotonicity using factor analyses and fit statistics, principal component analysis (PCA), and differential item functioning (DIF) using Rasch analysis. Following the elimination of invalid data, 371 veterans who completed both the Functional Independence Measure (FIM) and minimum data set (MDS) within 6 days were retained. The FIM-MDS item bank demonstrated good internal consistency (Cronbach's α = .98) and met three rating scale diagnostic criteria and three of the four model fit statistics (comparative fit index/Tucker-Lewis index = 0.98, root mean square error of approximation = 0.14, and standardized root mean residual = 0.07). PCA of Rasch residuals showed the item bank explained 94.2% variance. The item bank covered the range of θ from -1.50 to 1.26 (item), -3.57 to 4.21 (person) with person strata of 6.3. The findings indicated the ADL physical function item bank constructed from FIM and MDS measured a single latent trait with overall acceptable item-level psychometric properties, suggesting that it is an appropriate source for developing efficient test forms such as short forms and computerized adaptive tests.

Stroke Administrative Severity Index: using administrative data for 30-day poststroke outcomes prediction.

AIM: Current stroke severity scales cannot be used for archival data. We develop and validate a measure of stroke severity at hospital discharge (Stroke Administrative Severity Index [SASI]) for use in billing data. METHODS: We used the NIH Stroke Scale (NIHSS) as the theoretical framework and identified 285 relevant International Classification of Diseases, 9th Revision diagnosis and procedure codes, grouping them into 23 indicator variables using cluster analysis. A 60% sample of stroke patients in Medicare data were used for modeling risk of 30-day postdischarge mortality or discharge to hospice, with validation performed on the remaining 40% and on data with NIHSS scores. RESULTS: Model fit was good (p > 0.05) and concordance was strong (C-statistic = 0.76-0.83). The SASI predicted NIHSS at discharge (C = 0.83). CONCLUSION: The SASI model and score provide important tools to control for stroke severity at time of hospital discharge. It can be used as a risk-adjustment variable in administrative data analyses to measure postdischarge outcomes.