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1.
N Engl J Med ; 388(15): 1396-1404, 2023 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-36961127

RESUMO

BACKGROUND: Black Americans are exposed to higher annual levels of air pollution containing fine particulate matter (particles with an aerodynamic diameter of ≤2.5 µm [PM2.5]) than White Americans and may be more susceptible to its health effects. Low-income Americans may also be more susceptible to PM2.5 pollution than high-income Americans. Because information is lacking on exposure-response curves for PM2.5 exposure and mortality among marginalized subpopulations categorized according to both race and socioeconomic position, the Environmental Protection Agency lacks important evidence to inform its regulatory rulemaking for PM2.5 standards. METHODS: We analyzed 623 million person-years of Medicare data from 73 million persons 65 years of age or older from 2000 through 2016 to estimate associations between annual PM2.5 exposure and mortality in subpopulations defined simultaneously by racial identity (Black vs. White) and income level (Medicaid eligible vs. ineligible). RESULTS: Lower PM2.5 exposure was associated with lower mortality in the full population, but marginalized subpopulations appeared to benefit more as PM2.5 levels decreased. For example, the hazard ratio associated with decreasing PM2.5 from 12 µg per cubic meter to 8 µg per cubic meter for the White higher-income subpopulation was 0.963 (95% confidence interval [CI], 0.955 to 0.970), whereas equivalent hazard ratios for marginalized subpopulations were lower: 0.931 (95% CI, 0.909 to 0.953) for the Black higher-income subpopulation, 0.940 (95% CI, 0.931 to 0.948) for the White low-income subpopulation, and 0.939 (95% CI, 0.921 to 0.957) for the Black low-income subpopulation. CONCLUSIONS: Higher-income Black persons, low-income White persons, and low-income Black persons may benefit more from lower PM2.5 levels than higher-income White persons. These findings underscore the importance of considering racial identity and income together when assessing health inequities. (Funded by the National Institutes of Health and the Alfred P. Sloan Foundation.).


Assuntos
Poluição do Ar , Suscetibilidade a Doenças , Desigualdades de Saúde , Material Particulado , Grupos Raciais , Fatores Socioeconômicos , Idoso , Humanos , Poluentes Atmosféricos/efeitos adversos , Poluentes Atmosféricos/análise , Poluição do Ar/efeitos adversos , Poluição do Ar/análise , Poluição do Ar/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Suscetibilidade a Doenças/economia , Suscetibilidade a Doenças/epidemiologia , Suscetibilidade a Doenças/etnologia , Suscetibilidade a Doenças/mortalidade , Exposição Ambiental/efeitos adversos , Exposição Ambiental/análise , Exposição Ambiental/estatística & dados numéricos , Medicare/estatística & dados numéricos , Material Particulado/efeitos adversos , Material Particulado/análise , Pobreza/estatística & dados numéricos , Fatores Raciais/estatística & dados numéricos , Grupos Raciais/estatística & dados numéricos , Classe Social , Estados Unidos/epidemiologia , Brancos/estatística & dados numéricos
2.
N Engl J Med ; 388(19): 1779-1789, 2023 May 11.
Artigo em Inglês | MEDLINE | ID: mdl-37163624

RESUMO

BACKGROUND: Since 2010, Black persons in the United States have had a greater increase in opioid overdose-related mortality than other groups, but national-level evidence characterizing racial and ethnic disparities in the use of medications for opioid use disorder (OUD) is limited. METHODS: We used Medicare claims data from the 2016-2019 period for a random 40% sample of fee-for-service beneficiaries who were Black, Hispanic, or White; were eligible for Medicare owing to disability; and had an index event related to OUD (nonfatal overdose treated in an emergency department or inpatient setting, hospitalization with injection drug use-related infection, or inpatient or residential rehabilitation or detoxification care). We measured the receipt of medications to treat OUD (buprenorphine, naltrexone, and naloxone), the receipt of high-risk medications (opioid analgesics and benzodiazepines), and health care utilization, all in the 180 days after the index event. We estimated differences in outcomes according to race and ethnic group with adjustment for beneficiary age, sex, index event, count of chronic coexisting conditions, and state of residence. RESULTS: We identified 25,904 OUD-related index events among 23,370 beneficiaries, with 3937 events (15.2%) occurring among Black patients, 2105 (8.1%) among Hispanic patients, and 19,862 (76.7%) among White patients. In the 180 days after the index event, patients received buprenorphine after 12.7% of events among Black patients, after 18.7% of those among Hispanic patients, and after 23.3% of those among White patients; patients received naloxone after 14.4%, 20.7%, and 22.9%, respectively; and patients received benzodiazepines after 23.4%, 29.6%, and 37.1%, respectively. Racial differences in the receipt of medications to treat OUD did not change appreciably from 2016 to 2019 (buprenorphine receipt: after 9.1% of index events among Black patients vs. 21.6% of those among White patients in 2016, and after 14.1% vs. 25.5% in 2019). In all study groups, patients had multiple ambulatory visits in the 180 days after the index event (mean number of visits, 6.6 after events among Black patients, 6.7 after events among Hispanic patients, and 7.6 after events among White patients). CONCLUSIONS: Racial and ethnic differences in the receipt of medications to treat OUD after an index event related to this disorder among patients with disability were substantial and did not change over time. The high incidence of ambulatory visits in all groups showed that disparities persisted despite frequent health care contact. (Funded by the National Institute on Drug Abuse and the National Institute on Aging.).


Assuntos
Analgésicos Opioides , Benzodiazepinas , Disparidades em Assistência à Saúde , Antagonistas de Entorpecentes , Transtornos Relacionados ao Uso de Opioides , Idoso , Humanos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Benzodiazepinas/administração & dosagem , Benzodiazepinas/uso terapêutico , Buprenorfina/uso terapêutico , Medicare/estatística & dados numéricos , Naloxona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/complicações , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etnologia , Estados Unidos/epidemiologia , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Overdose de Opiáceos/epidemiologia , Overdose de Opiáceos/etnologia , Overdose de Opiáceos/etiologia , Overdose de Opiáceos/prevenção & controle , Negro ou Afro-Americano/estatística & dados numéricos , Brancos/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricos , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/administração & dosagem , Antagonistas de Entorpecentes/uso terapêutico
3.
Natl Vital Stat Rep ; 72(12): 1-64, 2023 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-38048433

RESUMO

Objectives-This report presents complete period life tables for the United States by Hispanic origin and race and sex, based on age-specific death rates in 2021. Methods-Data used to prepare the 2021 life tables are 2021 final mortality statistics; July 1, 2021, population estimates based on the Blended Base population estimates produced by the U.S. Census Bureau; and 2021 Medicare data for people ages 66-99. The methodology used to estimate life tables for the Hispanic population remains unchanged from that developed for the publication of life tables by Hispanic origin for data year 2006. The same methodology is used to estimate life tables for the American Indian and Alaska Native non-Hispanic and Asian non-Hispanic populations. The methodology used to estimate the 2021 life tables for all other groups was first implemented with data year 2008. Results-In 2021, the overall expectation of life at birth was 76.4 years, decreasing 0.6 year from 77.0 in 2020. From 2020 to 2021, life expectancy at birth decreased by 0.7 year for males (from 74.2 to 73.5) and by 0.6 year for females (79.9 to 79.3). Between 2020 and 2021, life expectancy decreased by 1.5 years for the American Indian and Alaska Native non-Hispanic population (67.1 to 65.6), 0.7 year for the White non-Hispanic population (77.4 to 76.7), 0.3 year for the Black non-Hispanic population (71.5 to 71.2), 0.1 year for the Hispanic population (77.9 to 77.8), and 0.1 year for the Asian non-Hispanic population (83.6 to 83.5).


Assuntos
Tábuas de Vida , Idoso , Feminino , Humanos , Recém-Nascido , Masculino , Etnicidade/estatística & dados numéricos , Hispânico ou Latino , Expectativa de Vida/etnologia , Medicare/estatística & dados numéricos , Estados Unidos/epidemiologia , Idoso de 80 Anos ou mais
4.
Circulation ; 148(3): 210-219, 2023 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-37459409

RESUMO

BACKGROUND: The association of historical redlining policies, a marker of structural racism, with contemporary heart failure (HF) risk among White and Black individuals is not well established. METHODS: We aimed to evaluate the association of redlining with the risk of HF among White and Black Medicare beneficiaries. Zip code-level redlining was determined by the proportion of historically redlined areas using the Mapping Inequality Project within each zip code. The association between higher zip code redlining proportion (quartile 4 versus quartiles 1-3) and HF risk were assessed separately among White and Black Medicare beneficiaries using generalized linear mixed models adjusted for potential confounders, including measures of the zip code-level Social Deprivation Index. RESULTS: A total of 2 388 955 Medicare beneficiaries (Black n=801 452; White n=1 587 503; mean age, 71 years; men, 44.6%) were included. Among Black beneficiaries, living in zip codes with higher redlining proportion (quartile 4 versus quartiles 1-3) was associated with increased risk of HF after adjusting for age, sex, and comorbidities (risk ratio, 1.08 [95% CI, 1.04-1.12]; P<0.001). This association remained significant after further adjustment for area-level Social Deprivation Index (risk ratio, 1.04 [95% CI, 1.002-1.08]; P=0.04). A significant interaction was observed between redlining proportion and Social Deprivation Index (Pinteraction<0.01) such that higher redlining proportion was significantly associated with HF risk only among socioeconomically distressed regions (above the median Social Deprivation Index). Among White beneficiaries, redlining was associated with a lower risk of HF after adjustment for age, sex, and comorbidities (risk ratio, 0.94 [95% CI, 0.89-0.99]; P=0.02). CONCLUSIONS: Historical redlining is associated with an increased risk of HF among Black patients. Contemporary zip code-level social determinants of health modify the relationship between redlining and HF risk, with the strongest relationship between redlining and HF observed in the most socioeconomically disadvantaged communities.


Assuntos
Insuficiência Cardíaca , Medicare , Características da Vizinhança , Determinantes Sociais da Saúde , Idoso , Humanos , Masculino , População Negra , Comorbidade , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/etnologia , Insuficiência Cardíaca/psicologia , Medicare/economia , Medicare/estatística & dados numéricos , Fatores Socioeconômicos , Estados Unidos/epidemiologia , População Branca , Estresse Financeiro/economia , Estresse Financeiro/epidemiologia , Estresse Financeiro/etnologia , Características da Vizinhança/estatística & dados numéricos , Determinantes Sociais da Saúde/etnologia , Determinantes Sociais da Saúde/estatística & dados numéricos
5.
Am J Epidemiol ; 193(7): 987-995, 2024 07 08.
Artigo em Inglês | MEDLINE | ID: mdl-38497546

RESUMO

In this study we examined the association between payor type, a proxy for health-care affordability, and presenting COVID-19 disease severity among 2108 polymerase chain reaction-positive nonelderly patients admitted to an acute-care hospital between March 1 and June 30, 2020. The adjacent-category logit model was used to fit pairwise odds of individuals' having (1) an asymptomatic-to-mild modified sequential organ failure assessment (mSOFA) score (0-3) versus a moderate-to-severe mSOFA score (4-7) and (2) a moderate-to-severe mSOFA score (4-7) versus a critical mSOFA score (>7). Despite representing the smallest population, Medicare recipients experienced the highest in-hospital death rate (19%), a rate twice that of the privately insured. The uninsured had the highest rate of critical mSOFA score on admission and had twice the odds of presenting with a critical illness when compared with the privately insured (odds ratio = 2.08, P =.03). Because payor type was statistically related to the most severe presentations of COVID-19, we question whether policy changes affecting health-care affordability might have prevented deaths and rationing of scarce resources, such as intensive care unit beds and ventilators.


Assuntos
COVID-19 , Índice de Gravidade de Doença , Humanos , COVID-19/epidemiologia , Masculino , Feminino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Adulto , Seguro Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , SARS-CoV-2 , Escores de Disfunção Orgânica , Mortalidade Hospitalar , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitalização/economia
6.
Crit Care Med ; 52(9): 1333-1343, 2024 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-38780374

RESUMO

OBJECTIVES: Despite its importance, detailed national estimates of ICU utilization and outcomes remain lacking. We aimed to characterize trends in ICU utilization and outcomes over a recent 12-year period in the United States. DESIGN/SETTING: In this longitudinal study, we examined hospitalizations involving ICU care ("ICU hospitalizations") alongside hospitalizations not involving ICU care ("non-ICU hospitalizations") among traditional Medicare beneficiaries using 100% Medicare part A claims data and commercial claims data for the under 65 adult population from 2008 to 2019. PATIENTS/INTERVENTIONS: There were 18,313,637 ICU hospitalizations and 78,501,532 non-ICU hospitalizations in Medicare, and 1,989,222 ICU hospitalizations and 16,732,960 non-ICU hospitalizations in the commercially insured population. MEASUREMENTS AND MAIN RESULTS: From 2008 to 2019, about 20% of Medicare hospitalizations and 10% of commercial hospitalizations involved ICU care. Among these ICU hospitalizations, length of stay and ICU length of stay decreased on average. Mortality and hospital readmissions on average also decreased, and they decreased more among ICU hospitalizations than among non-ICU hospitalizations, for both Medicare and commercially insured patients. Both Medicare and commercial populations experienced a growth in shorter ICU hospitalizations (between 2 and 7 d in length), which were characterized by shorter ICU stays and lower mortality. Among these short hospitalizations in the Medicare population, for common clinical diagnoses cared for in both ICU and non-ICU settings, patients were increasingly triaged into an ICU during the study period, despite being younger and having shorter hospital stays. CONCLUSIONS: ICUs are used in a sizeable share of hospitalizations. From 2008 to 2019, ICU length of stay and mortality have declined, while short ICU hospitalizations have increased. In particular, for clinical conditions often managed both within and outside of an ICU, shorter ICU hospitalizations involving younger patients have increased. Our findings motivate opportunities to better understand ICU utilization and to improve the value of ICU care for patients and payers.


Assuntos
Hospitalização , Unidades de Terapia Intensiva , Tempo de Internação , Medicare , Humanos , Estados Unidos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Feminino , Pessoa de Meia-Idade , Medicare/estatística & dados numéricos , Estudos Longitudinais , Tempo de Internação/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Adulto , Mortalidade Hospitalar/tendências , Readmissão do Paciente/estatística & dados numéricos , Idoso
7.
Cancer Causes Control ; 35(7): 1017-1031, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38546924

RESUMO

PURPOSE: To examine racial-ethnic variation in adherence to established quality metrics (NCCN guidelines and ASCO quality metrics) for breast cancer, accounting for individual-, facility-, and area-level factors. METHODS: Data from women diagnosed with invasive breast cancer at 66+ years of age from 2000 to 2017 were examined using SEER-Medicare. Associations between race and ethnicity and guideline-concordant diagnostics, locoregional treatment, systemic therapy, documented stage, and oncologist encounters were estimated using multilevel logistic regression models to account for clustering within facilities or counties. RESULTS: Black and American Indian/Alaska Native (AIAN) women had consistently lower odds of guideline-recommended care than non-Hispanic White (NHW) women (Diagnostic workup: ORBlack 0.83 (0.79-0.88), ORAIAN 0.66 (0.54-0.81); known stage: ORBlack 0.87 (0.80-0.94), ORAIAN 0.63 (0.47-0.85); seeing an oncologist: ORBlack 0.75 (0.71-0.79), ORAIAN 0.60 (0.47-0.72); locoregional treatment: ORBlack 0.80 (0.76-0.84), ORAIAN 0.84 (0.68-1.02); systemic therapies: ORBlack 0.90 (0.83-0.98), ORAIAN 0.66 (0.48-0.91)). Commission on Cancer accreditation and facility volume were significantly associated with higher odds of guideline-concordant diagnostics, stage, oncologist visits, and systemic therapy. Black residential segregation was associated with significantly lower odds of guideline-concordant locoregional treatment and systemic therapy. Rurality and area SES were associated with significantly lower odds of guideline-concordant diagnostics and oncologist visits. CONCLUSIONS: This is the first study to examine guideline-concordance across the continuum of breast cancer care from diagnosis to treatment initiation. Disparities were present from the diagnostic phase and persisted throughout the clinical course. Facility and area characteristics may facilitate or pose barriers to guideline-adherent treatment and warrant future investigation as mediators of racial-ethnic disparities in breast cancer care.


Assuntos
Neoplasias da Mama , Fidelidade a Diretrizes , Medicare , Programa de SEER , Humanos , Feminino , Neoplasias da Mama/terapia , Neoplasias da Mama/etnologia , Neoplasias da Mama/diagnóstico , Estados Unidos , Idoso , Medicare/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Idoso de 80 Anos ou mais , Etnicidade/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Guias de Prática Clínica como Assunto
8.
J Urol ; 212(3): 451-460, 2024 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-38920141

RESUMO

PURPOSE: Bladder outlet obstruction (BOO) is common in older adults. Many older adults who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty. A clinical tool that builds on frailty to predict surgical outcomes for the spectrum of BOO procedures would be helpful to aid in surgical decision-making but does not currently exist. MATERIALS AND METHODS: Medicare beneficiaries undergoing BOO surgery from 2014 to 2016 were identified and analyzed using the Medicare MedPAR, Outpatient, and Carrier files. Eight different BOO surgery categories were created. Baseline frailty was calculated for each beneficiary using the Claims-Based Frailty Index (CFI). All 93 variables in the CFI and the 17 variables in the Charlson Comorbidity Index were individually entered into stepwise logistic regression models to determine variables most highly predictive of complications. Similar and duplicative variables were combined into categories. Calibration curves and tests of model fit, including C statistics, Brier scores, and Spiegelhalter P values, were calculated to ensure the prognostic accuracy for postoperative complications. RESULTS: In total, 212,543 beneficiaries were identified. Approximately 42.5% were prefrail (0.15 ≤ CFI < 0.25), 8.7% were mildly frail (0.25 ≤ CFI < 0.35), and 1.2% were moderately-to-severely frail (CFI ≥0.35). Using stepwise logistic regression, 13 distinct prognostic variable categories were identified as the most reliable predictors of postoperative outcomes. Most models demonstrated excellent model discrimination and calibration with high C statistic and Spiegelhalter P values, respectively, and high accuracy with low Brier scores. Calibration curves for each outcome demonstrated excellent model fit. CONCLUSIONS: This novel risk assessment tool may help guide surgical prognostication among this vulnerable population.


Assuntos
Fragilidade , Complicações Pós-Operatórias , Obstrução do Colo da Bexiga Urinária , Humanos , Obstrução do Colo da Bexiga Urinária/cirurgia , Obstrução do Colo da Bexiga Urinária/etiologia , Obstrução do Colo da Bexiga Urinária/diagnóstico , Idoso , Masculino , Medição de Risco/métodos , Feminino , Fragilidade/complicações , Fragilidade/diagnóstico , Estados Unidos/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Idoso de 80 Anos ou mais , Medicare/estatística & dados numéricos , Procedimentos Cirúrgicos Urológicos/métodos , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Estudos Retrospectivos
9.
Ann Surg Oncol ; 31(9): 5896-5910, 2024 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-38872045

RESUMO

PURPOSE: This study was designed to characterize features of rapid relapse TNBC (rrTNBC), an aggressive, poor prognosis breast cancer subset using the National Cancer Database (NCDB). METHODS: Patients diagnosed with TNBC between 2010 and 2019 within NCDB were included in analyses. rrTNBC was defined as all-cause mortality ≤24 months from diagnosis. Patient demographic, tumor, and treatment association with rrTNBC were evaluated in univariate, bivariate analyses, and multiple logistic regression models. Two-part models are used to compare receipt of treatment (i.e., receipt of both chemotherapy and breast surgery) versus not in its relationship with rrTNBC. RESULTS: Overall, 14.5% of patients were categorized as rrTNBC. Age older than 75 years (-41.3%), Black race (-1.4%), Medicare (-2.6%), and Charlson-Deyo score ≥2 (-4.9%) were associated with a lower probability of receiving both chemotherapy and breast surgery. Not receiving both treatments (vs. receiving both chemotherapy and breast surgery) was associated with a two-to-three-fold higher probability of rrTNBC among patients aged older than 75 years (16.6% vs. 6%), having Medicare (3.6% vs. 1.6%), and Charlson-Deyo score ≥2 (16.6% vs. 5.9%). CONCLUSIONS: Age, insurance, and comorbidity were related to a lower likelihood of treatment; yet receiving treatment reduced the risk of rrTNBC threefold for each. These findings might be valuable to inform clinical care delivery, as well as future research that examines treatment protocols among diverse patients.


Assuntos
Bases de Dados Factuais , Recidiva Local de Neoplasia , Neoplasias de Mama Triplo Negativas , Humanos , Feminino , Idoso , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/terapia , Recidiva Local de Neoplasia/epidemiologia , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Neoplasias de Mama Triplo Negativas/terapia , Neoplasias de Mama Triplo Negativas/patologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Taxa de Sobrevida , Seguimentos , Prognóstico , Mastectomia/estatística & dados numéricos , Fatores de Risco , Medicare/estatística & dados numéricos , Fatores Etários , Idoso de 80 Anos ou mais , Adulto
10.
Ann Surg Oncol ; 31(7): 4349-4360, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38538822

RESUMO

BACKGROUND: Oncology outreach is a common strategy for increasing rural access to cancer care, where traveling oncologists commute across healthcare settings to extend specialized care. Examining the extent to which physician outreach is associated with timely treatment for rural patients is critical for informing outreach strategies. METHODS: We identified a 100% fee-for-service sample of incident breast cancer patients from 2015 to 2020 Medicare claims and apportioned them into surgery and adjuvant therapy cohorts based on treatment history. We defined an outreach visit as the provision of care by a traveling oncologist at a clinic outside of their primary hospital service area. We used hierarchical logistic regression to examine the associations between patient receipt of preoperative care at an outreach visit (preoperative outreach) and > 60-day surgical delay, and patient receipt of postoperative care at an outreach visit (postoperative outreach) and > 60-day adjuvant delay. RESULTS: We identified 30,337 rural-residing patients who received breast cancer surgery, of whom 4071 (13.4%) experienced surgical delay. Among surgical patients, 14,501 received adjuvant therapy, of whom 2943 (20.3%) experienced adjuvant delay. In adjusted analysis, we found that patient receipt of preoperative outreach was associated with reduced odds of surgical delay (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.61-0.91); however, we found no association between patient receipt of postoperative outreach and adjuvant delay (OR 1.04, 95% CI 0.85-1.25). CONCLUSIONS: Our findings indicate that preoperative outreach is protective against surgical delay. The traveling oncologists who enable such outreach may play an integral role in catalyzing the coordination and timeliness of patient-centered care.


Assuntos
Neoplasias da Mama , Acessibilidade aos Serviços de Saúde , Medicare , População Rural , Humanos , Feminino , Neoplasias da Mama/cirurgia , Neoplasias da Mama/terapia , Idoso , População Rural/estatística & dados numéricos , Estados Unidos , Medicare/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Oncologia/estatística & dados numéricos , Seguimentos , Idoso de 80 Anos ou mais , Prognóstico , Planos de Pagamento por Serviço Prestado , Mastectomia
11.
Ann Surg Oncol ; 31(6): 3649-3660, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38319511

RESUMO

PURPOSE: This study was designed to provide a comprehensive and up-to-date understanding of population-level reoperation rates and incremental healthcare costs associated with reoperation for patients who underwent breast-conserving surgery (BCS). METHODS: This is a retrospective cohort study using Merative™ MarketScan® commercial insurance data and Medicare 5% fee-for-service claims data. The study included females aged 18-64 years in the commercial cohort and females aged 18 years and older in the Medicare cohort, who underwent initial BCS for breast cancer in 2017-2019. Reoperation rates within a year of the initial BCS and overall 1-year healthcare costs stratified by reoperation status were measured. RESULTS: The commercial cohort included 17,129 women with a median age of 55 (interquartile range [IQR] 49-59) years, and the Medicare cohort included 6977 women with a median age of 73 (IQR 69-78) years. Overall reoperation rates were 21.1% (95% confidence interval [CI] 20.5-21.8%) for the commercial cohort and 14.9% (95% CI 14.1-15.7%) for the Medicare cohort. In both cohorts, reoperation rates decreased as age increased, and conversion to mastectomy was more prevalent among younger women in the commercial cohort. The mean healthcare costs during 1 year of follow-up from the initial BCS were $95,165 for the commercial cohort and $36,313 for the Medicare cohort. Reoperations were associated with 24% higher costs in both the commercial and Medicare cohorts, which translated into $21,607 and $8559 incremental costs, respectively. CONCLUSIONS: The rates of reoperation after BCS have remained high and have contributed to increased healthcare costs. Continuing efforts to reduce reoperation need more attention.


Assuntos
Neoplasias da Mama , Custos de Cuidados de Saúde , Mastectomia Segmentar , Reoperação , Humanos , Feminino , Reoperação/estatística & dados numéricos , Reoperação/economia , Pessoa de Meia-Idade , Neoplasias da Mama/cirurgia , Neoplasias da Mama/economia , Estudos Retrospectivos , Mastectomia Segmentar/economia , Mastectomia Segmentar/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Adulto , Idoso , Seguimentos , Estados Unidos , Adolescente , Adulto Jovem , Mastectomia/economia , Medicare/economia , Medicare/estatística & dados numéricos , Prognóstico
12.
J Card Fail ; 30(6): 788-799, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38142043

RESUMO

BACKGROUND: Although many Medicare beneficiaries with heart failure (HF) are discharged with home health services, little is known about mortality rates and hospice use in this group. OBJECTIVES: To identify risk factors for 6-month mortality and hospice use among patients hospitalized due to HF who receive home health care, which could inform efforts to improve palliative and hospice use for these patients. METHODS: A retrospective cohort analysis was conducted in a 100% national sample of Medicare fee-for-service beneficiaries with HF who were discharged to home health care between 2017 and 2018. Multivariable Cox regression models examined factors associated with 6-month mortality, and multivariable logistic regression models examined factors associated with hospice use at the time of death. RESULTS: A total of 285,359 Medicare beneficiaries were hospitalized with HF and discharged with home health care; 15.5% (44,174) died within 6 months. Variables most strongly associated with mortality included: age > 85 years (hazard ratio [HR] 1.66, 95% CI 1.61-1.71), urgent/emergency hospital admission (HR 1.68, 1.61-1.76), and "serious" condition compared to "stable" condition (HR 1.64, CI 1.52-1.78). Among 44,174 decedents, 48.2% (21,284) received hospice care at the time of death. Those with lower odds of hospice use at death included patients who were: < 65 years (odds ratio [OR] 0.65, CI 0.59-0.72); of Black (OR 0.64, CI 0.59-0.68) or Hispanic race/ethnicity (OR 0.79, CI 0.72-0.88); and Medicaid-eligible (OR 0.80, CI 0.76-0.85). CONCLUSIONS: Although many patients hospitalized for HF are at risk of 6-month mortality and may benefit from palliative and/or hospice services, our findings indicate under-use of hospice care and important disparities in hospice use by race/ethnicity and socioeconomic status.


Assuntos
Insuficiência Cardíaca , Serviços de Assistência Domiciliar , Cuidados Paliativos na Terminalidade da Vida , Medicare , Humanos , Estados Unidos/epidemiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Masculino , Feminino , Serviços de Assistência Domiciliar/estatística & dados numéricos , Serviços de Assistência Domiciliar/tendências , Medicare/estatística & dados numéricos , Idoso de 80 Anos ou mais , Estudos Retrospectivos , Idoso , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Fatores de Risco
13.
Med Care ; 62(6): 396-403, 2024 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-38598671

RESUMO

BACKGROUND: The provision of high-quality hospital care requires adequate space, buildings, and equipment, although redundant infrastructure could also drive service overprovision. OBJECTIVE: To explore the distribution of physical hospital resources-that is, capital assets-in the United States; its correlation with indicators of community health and nonhealth factors; and the association between hospital capital density and regional hospital utilization and costs. RESEARCH DESIGN: We created a dataset of n=1733 US counties by analyzing the 2019 Medicare Cost Reports; 2019 State Inpatient Database Community Inpatient Statistics; 2020-2021 Area Health Resource File; 2016-2020 American Community Survey; 2022 PLACES; and 2019 CDC WONDER. We first calculated aggregate hospital capital assets and investment at the county level. Next, we examined the correlation between community's medical need (eg, chronic disease prevalence), ability to pay (eg, insurance), and supply factors with 4 metrics of capital availability. Finally, we examined the association between capital assets and hospital utilization/costs, adjusted for confounders. RESULTS: Counties with older and sicker populations generally had less aggregate hospital capital per capita, per hospital day, and per hospital discharge, while counties with higher income or insurance coverage had more hospital capital. In linear regressions controlling for medical need and ability to pay, capital assets were associated with greater hospital utilization and costs, for example, an additional $1000 in capital assets per capita was associated with 73 additional discharges per 100,000 population (95% CI: 45-102) and $19 in spending per bed day (95% CI: 12-26). CONCLUSIONS: The level of investment in hospitals is linked to community wealth but not population health needs, and may drive use and costs.


Assuntos
Hospitalização , Humanos , Estados Unidos , Hospitalização/estatística & dados numéricos , Hospitalização/economia , Custos Hospitalares/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Saúde Pública/economia
14.
Med Care ; 62(9): 583-589, 2024 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-38889199

RESUMO

BACKGROUND: Advanced primary care models are key in moving primary care practices toward greater accountability for the quality and cost of a beneficiary's care. One critical but often overlooked detail in model design is the beneficiary attribution methodology. Attribution results are key inputs in calculating practice payments. Stable attribution yields predictable practice payments, fostering longer-term investments in advanced primary care. OBJECTIVE: We examine attribution stability for Medicare fee-for-service beneficiaries in Medicare's Comprehensive Primary Care Plus (CPC+) Model. DESIGN: To measure attribution stability, we calculate churn rates, which we define as the percentage of beneficiaries eligible for CPC+ who were not attributed to the same practice in a later period. Using 2017-2021 CPC+ program data and Medicare administrative data, we calculate churn rates for CPC+ overall and for beneficiary subgroups. To assess whether CPC+ attribution was responsive enough to changes in a beneficiary's practice, we calculate how long before attribution changes following a beneficiary's long-distance move. RESULTS: We find that for every 100 beneficiaries attributed to a CPC+ practice, 88 were still attributed to the same practice a year later (ie, churn rate of 12%), 79 were attributed 2 years later, 74 three years later, and 70 four years later. However, some vulnerable subgroups, such as disabled beneficiaries, had higher churn rates. Our analysis of long-distance movers reveals that only after 5 quarters did attribution change for more than half of these movers. CONCLUSIONS: Overall, high attribution stability may have encouraged CPC+ practices to make longer-term investments in advanced primary care.


Assuntos
Planos de Pagamento por Serviço Prestado , Medicare , Atenção Primária à Saúde , Estados Unidos , Humanos , Atenção Primária à Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Masculino , Idoso , Feminino , Idoso de 80 Anos ou mais
15.
Med Care ; 62(8): 511-520, 2024 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-38833712

RESUMO

BACKGROUND: Several antidementia medications have been approved for symptomatic treatment of cognitive and functional impairment due to Alzheimer disease. Antipsychotics are often prescribed off-label for behavioral symptoms. OBJECTIVE: The aim of this study was to describe the basis for regional variation in antidementia and antipsychotic medication use. SETTING: US nursing homes (n=9735), hospital referral regions (HRR; n=289). SUBJECTS: Long-stay residents with dementia (n=273,004). METHODS: Using 2018 Minimum Data Set 3.0 linked to Medicare data, facility information, and Dartmouth Atlas files, we calculated prevalence of use and separate multilevel logistic models [outcomes: memantine, cholinesterase inhibitor (ChEI), antipsychotic use] estimated adjusted odds ratios (aOR) and 95% CIs for resident, facility, and HRR characteristics. We then fit a series of cross-classified multilevel logistic models to estimate the proportional change in cluster variance (PCV). RESULTS: Overall, 20.9% used antipsychotics, 16.1% used memantine, and 23.3% used ChEIs. For antipsychotics, facility factors [eg, use of physical restraints (aOR: 1.08; 95% CI: 1.05-1.11) or poor staffing ratings (aOR: 1.10; 95% CI: 1.06-1.14)] were associated with more antipsychotic use. Nursing homes in HRRs with the highest health care utilization had greater antidementia drug use (aOR memantine: 1.68; 95% CI: 1.44-1.96). Resident/facility factors accounted for much regional variation in antipsychotics (PCV STATE : 27.80%; PCV HRR : 39.54%). For antidementia medications, HRR-level factors accounted for most regional variation (memantine PCV STATE : 37.44%; ChEI PCV STATE : 39.02%). CONCLUSION: Regional variations exist in antipsychotic and antidementia medication use among nursing home residents with dementia suggesting the need for evidence-based protocols to guide the use of these medications.


Assuntos
Antipsicóticos , Inibidores da Colinesterase , Demência , Memantina , Casas de Saúde , Humanos , Casas de Saúde/estatística & dados numéricos , Antipsicóticos/uso terapêutico , Demência/tratamento farmacológico , Estados Unidos , Masculino , Feminino , Idoso de 80 Anos ou mais , Idoso , Inibidores da Colinesterase/uso terapêutico , Memantina/uso terapêutico , Medicare/estatística & dados numéricos
16.
Med Care ; 62(8): 530-537, 2024 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-38889206

RESUMO

OBJECTIVE: The Medicare Annual Wellness Visit (AWV)-a prevention-focused annual check-up-has been available to beneficiaries with Part B coverage since 2011. The objective of this study was to estimate the effect of Medicare AWVs on breast cancer screening and diagnosis. DATA SOURCES AND STUDY SETTING: The National Cancer Institute's Surveillance, Epidemiology, and End Results cancer registry data linked to Medicare claims (SEER-Medicare), HRSA's Area Health Resources Files, the FDA's Mammography Facilities database, and CMS "Mapping Medicare Disparities" utilization data from 2013 to 2015. STUDY DESIGN: Using an instrumental variables approach, we estimated the effect of AWV utilization on breast cancer screening and diagnosis, using county Welcome to Medicare Visit (WMV) rates as the instrument. DATA COLLECTION/EXTRACTION METHODS: 66,088 person-year observations from 49,769 unique female beneficiaries. PRINCIPAL FINDINGS: For every 1-percentage point increase in county WMV rate, the probability of AWV increased by 1.7 percentage points. Having an AWV was associated with a 22.4-percentage point increase in the probability of receiving a screening mammogram within 6 months ( P <0.001). There was no statistically significant increase in the probability of breast cancer diagnosis (overall or early stage) within 6 months of an AWV. Findings were robust to multiple model specifications. CONCLUSIONS: Performing routine cancer screening is an evidence-based practice for diagnosing earlier-stage, more treatable cancers. The AWV effectively increases breast cancer screening and may lead to more timely screening. Continued investment in Annual Wellness Visits supports breast cancer screening completion by women who are most likely to benefit, thus reducing the risk of overscreening and overdiagnosis.


Assuntos
Neoplasias da Mama , Detecção Precoce de Câncer , Medicare , Programa de SEER , Humanos , Feminino , Neoplasias da Mama/diagnóstico , Estados Unidos , Detecção Precoce de Câncer/estatística & dados numéricos , Idoso , Medicare/estatística & dados numéricos , Idoso de 80 Anos ou mais , Mamografia/estatística & dados numéricos
17.
Med Care ; 62(6): 423-430, 2024 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-38728681

RESUMO

OBJECTIVE: Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions. DATA SOURCE: Medicare Fee-for-Service Data, 2018. STUDY DESIGN: We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics. DATA EXTRACTION METHODS: We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason. PRINCIPAL FINDINGS: In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other. CONCLUSIONS: There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.


Assuntos
Troca de Informação em Saúde , Medicare , Readmissão do Paciente , Readmissão do Paciente/estatística & dados numéricos , Humanos , Estados Unidos , Medicare/estatística & dados numéricos , Medicare/economia , Masculino , Feminino , Idoso , Troca de Informação em Saúde/estatística & dados numéricos , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos
18.
Med Care ; 62(6): 388-395, 2024 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-38620117

RESUMO

STUDY DESIGN: Interrupted time series analysis of a retrospective, electronic health record cohort. OBJECTIVE: To determine the association between the implementation of Medicare's sepsis reporting measure (SEP-1) and sepsis diagnosis rates as assessed in clinical documentation. BACKGROUND: The role of health policy in the effort to improve sepsis diagnosis remains unclear. PATIENTS AND METHODS: Adult patients hospitalized with suspected infection and organ dysfunction within 6 hours of presentation to the emergency department, admitted to one of 11 hospitals in a multi-hospital health system from January 2013 to December 2017. Clinician-diagnosed sepsis, as reflected by the inclusion of the terms "sepsis" or "septic" in the text of clinical notes in the first two calendar days following presentation. RESULTS: Among 44,074 adult patients with sepsis admitted to 11 hospitals over 5 years, the proportion with sepsis documentation was 32.2% just before the implementation of SEP-1 in the third quarter of 2015 and increased to 37.3% by the fourth quarter of 2017. Of the 9 post-SEP-1 quarters, 8 had odds ratios for a sepsis diagnosis >1 (overall range: 0.98-1.26; P value for a joint test of statistical significance = 0.005). The effects were clinically modest, with a maximum effect of an absolute increase of 4.2% (95% CI: 0.9-7.8) at the end of the study period. The effect was greater in patients who did not require vasopressors compared with patients who required vasopressors ( P value for test of interaction = 0.02). CONCLUSIONS: SEP-1 implementation was associated with modest increases in sepsis diagnosis rates, primarily among patients who did not require vasoactive medications.


Assuntos
Documentação , Registros Eletrônicos de Saúde , Análise de Séries Temporais Interrompida , Medicare , Sepse , Humanos , Sepse/diagnóstico , Estados Unidos , Medicare/estatística & dados numéricos , Estudos Retrospectivos , Masculino , Feminino , Idoso , Documentação/estatística & dados numéricos , Documentação/normas , Pessoa de Meia-Idade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Idoso de 80 Anos ou mais
19.
Med Care ; 62(7): 434-440, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38848137

RESUMO

BACKGROUND: Hospitals are resurrecting the outdated "team nursing" model of staffing that substitutes lower-wage staff for registered nurses (RNs). OBJECTIVES: To evaluate whether reducing the proportion of RNs to total nursing staff in hospitals is in the best interest of patients, hospitals, and payers. RESEARCH DESIGN: Cross-sectional, retrospective. SUBJECTS: In all, 6,559,704 Medicare patients in 2676 general acute-care US hospitals in 2019. MEASURES: Patient outcomes: in-hospital and 30-day mortality, 30-day readmission, length of stay, and patient satisfaction. Avoidable Medicare costs associated with readmissions and cost savings to hospitals associated with shorter stays are projected. RESULTS: A 10 percentage-point reduction in RNs was associated with 7% higher odds of in-hospital death, 1% higher odds of readmission, 2% increase in expected days, and lower patient satisfaction. We estimate a 10 percentage-point reduction in RNs would result in 10,947 avoidable deaths annually and 5207 avoidable readmissions, which translates into roughly $68.5 million in additional Medicare costs. Hospitals would forgo nearly $3 billion in cost savings annually because of patients requiring longer stays. CONCLUSIONS: Reducing the proportion of RNs in hospitals, even when total nursing personnel hours are kept the same, is likely to result in significant avoidable patient deaths, readmissions, longer lengths of stay, and decreased patient satisfaction, in addition to excess Medicare costs and forgone cost savings to hospitals. Estimates represent only a 10 percentage-point dilution in skill mix; however, the team nursing model includes much larger reductions of 40-50 percentage-points-the human and economic consequences of which could be substantial.


Assuntos
Tempo de Internação , Medicare , Recursos Humanos de Enfermagem Hospitalar , Readmissão do Paciente , Admissão e Escalonamento de Pessoal , Humanos , Recursos Humanos de Enfermagem Hospitalar/economia , Recursos Humanos de Enfermagem Hospitalar/provisão & distribuição , Estudos Transversais , Estudos Retrospectivos , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Estados Unidos , Medicare/economia , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Feminino , Satisfação do Paciente , Mortalidade Hospitalar , Idoso
20.
Med Care ; 62(7): 441-448, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38625015

RESUMO

OBJECTIVE: To evaluate inter-hospital variation in 90-day total episode spending for sepsis, estimate the relative contributions of each component of spending, and identify drivers of spending across the distribution of episode spending on sepsis care. DATA SOURCES/STUDY SETTING: Medicare fee-for-service claims for beneficiaries (n=324,694) discharged from acute care hospitals for sepsis, defined by MS-DRG, between October 2014 and September 2018. RESEARCH DESIGN: Multiple linear regression with hospital-level fixed effects was used to identify average hospital differences in 90-day episode spending. Separate multiple linear regression and quantile regression models were used to evaluate drivers of spending across the episode spending distribution. RESULTS: The mean total episode spending among hospitals in the most expensive quartile was $30,500 compared with $23,150 for the least expensive hospitals ( P <0.001). Postacute care spending among the most expensive hospitals was almost double that of least expensive hospitals ($7,045 vs. $3,742), accounting for 51% of the total difference in episode spending between the most expensive and least expensive hospitals. Female patients, patients with more comorbidities, urban hospitals, and BPCI-A-participating hospitals were associated with significantly increased episode spending, with the effect increasing at the right tail of the spending distribution. CONCLUSION: Inter-hospital variation in 90-day episode spending on sepsis care is driven primarily by differences in post-acute care spending.


Assuntos
Planos de Pagamento por Serviço Prestado , Gastos em Saúde , Medicare , Sepse , Humanos , Sepse/economia , Sepse/terapia , Estados Unidos , Feminino , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Idoso , Planos de Pagamento por Serviço Prestado/economia , Gastos em Saúde/estatística & dados numéricos , Idoso de 80 Anos ou mais , Hospitais/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Cuidado Periódico
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