Do Financial Incentives Affect Utilization for Chronically Ill Medicare Beneficiaries?

OBJECTIVE: The objective of this study was to examine the price sensitivity for provider visits among Medicare Advantage beneficiaries. DATA SOURCES: We used Medicare Advantage encounter data from 2014 to 2017 accessed as part of an evaluation for the Center for Medicare & Medicaid Innovation. STUDY DESIGN: We analyzed the effect of cost-sharing on the utilization of 2 outcome categories: number of visits (specialist and primary care) and the probability of any visit (specialist and primary care). Our main independent variable was the size of the copayment for the visit, which we regressed on the outcomes with several beneficiary-level and plan-level control variables. DATA COLLECTION/EXTRACTION METHODS: We included beneficiaries with at least 1 of 4 specific chronic conditions and matched comparison beneficiaries. We did not require beneficiaries to be continuously enrolled from 2014 to 2017, but we required a full year of data for each year they were observed. This resulted in 371,140 beneficiary-year observations. PRINCIPAL FINDINGS: Copay reductions were associated with increases in utilization, although the changes were small, with elasticities <-0.2. We also found evidence of substitution effects between primary care provider (PCP) and specialist visits, particularly cardiology and endocrinology. When PCP copays declined, visits to these specialists also declined. CONCLUSIONS: We find that individuals with chronic conditions respond to changes in copays, although these responses are small. Reductions in PCP copays lead to reduced use of some specialists, suggesting that lowering PCP copays could be an effective way to reduce the use of specialist care, a desirable outcome if specialists are overused.

Impact of the Affordable Care Act Medicaid Expansion on Utilization of Mental Health Care.

BACKGROUND: The Affordable Care Act's Medicaid expansions (ME) increased insurance coverage for low-income Americans, among whom unmet need for mental health care is high. Empirical evidence regarding the impact of expanding insurance coverage on use of mental health services among low income and minority populations is lacking. METHODS: Data on mental health service use collected between 2007 and 2015 by the Medical Expenditures Panel Survey from nationally representative cross-sectional samples of low income (income<138% of the federal poverty line) adults were analyzed. Use trends among people in states that expanded Medicaid (ME states; n=29,827) were compared with concurrent trends among people in states that did not (non-ME states; n=22,873), with statistical adjustment for demographic characteristics and psychological distress. RESULTS: Annual outpatient visits for mental health conditions increased by 0.513 (0.053-0.974) visits per person, from a baseline rate in ME states of 0.894 visits per person. However, no significant changes were observed in number of mental health related hospital stays, emergency department visits or prescription fills. The increase outpatient visits was limited to Hispanics and non-Hispanic Whites, with no increase in service use observed among non-Hispanic Blacks. There was no apparent increase in the number of users of outpatient mental health care (AOR=0.992, P=0.942) and a marginally significant (P=0.096) increase of 3.144 visits per user. DISCUSSION: ME had a limited but positive impact on use of mental health services by low income Americans, although it may also have increased racial/ethnic disparities.

Quality of care and patient-reported outcomes in carpal tunnel syndrome: A prospective observational study.

INTRODUCTION: Higher quality care for carpal tunnel syndrome (CTS) may be associated with better outcomes. METHODS: This prospective observational study recruited adults diagnosed with CTS from 30 occupational health centers, evaluated physicians' adherence to recommended care processes, and assessed results of the Boston Carpal Tunnel Questionnaire (BCTQ) and Short Form Health Survey version 2 (SF-12v2) at recruitment and at 18 months. RESULTS: Among 343 individuals, receiving better care (80th vs. 20th percentile for adherence) was associated with greater improvements in BCTQ Symptom Severity scores (-0.18, 95% confidence interval [CI] -0.32 to -0.05), BCTQ Functional Status scores (-0.21, 95% CI -0.34 to -0.08), and SF12-v2 Physical Component scores (1.75, 95% CI 0.33-3.16). Symptoms improved more when physicians assessed and managed activity, patients underwent necessary surgery, and employers adjusted job tasks. DISCUSSION: Efforts should be made to ensure that patients with CTS receive essential care processes including necessary surgery and activity assessment and management. Muscle Nerve 57: 896-904, 2018.

Measuring Care Continuity: A Comparison of Claims-based Methods.

BACKGROUND: Assessing care continuity is important in evaluating the impact of health care reform and changes to health care delivery. Multiple measures of care continuity have been developed for use with claims data. OBJECTIVE: This study examined whether alternative continuity measures provide distinct assessments of coordination within predefined episodes of care. RESEARCH DESIGN AND SUBJECTS: This was a retrospective cohort study using 2008-2009 claims files for a national 5% sample of beneficiaries with congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. MEASURES: Correlations among 4 measures of care continuity-the Bice-Boxerman Continuity of Care Index, Herfindahl Index, usual provider of care, and Sequential Continuity of Care Index-were derived at the provider- and practice-levels. RESULTS: Across the 3 conditions, results on 4 claims-based care coordination measures were highly correlated at the provider-level (Pearson correlation coefficient r=0.87-0.98) and practice-level (r=0.75-0.98). Correlation of the results was also high for the same measures between the provider- and practice-levels (r=0.65-0.92). CONCLUSIONS: Claims-based care continuity measures are all highly correlated with one another within episodes of care.

Variation in treatment associated with life expectancy in a population-based cohort of men with early-stage prostate cancer.

BACKGROUND: Men with major comorbidities are at risk for overtreatment of prostate cancer due to uncertainty regarding their life expectancy. We sought to characterize life expectancy and treatment in a population-based cohort of men with differing ages and comorbidity burdens at diagnosis. METHODS: We sampled 96,032 men aged ≥66 years with early-stage prostate cancer who had Gleason scores ≤7 and were diagnosed during 1991 to 2007 from the Surveillance, Epidemiology, and End Results-Medicare database. We calculated cumulative incidence of other-cause mortality and determined treatment patterns among subgroups defined by age and Charlson comorbidity index scores. RESULTS: Overall, life expectancy was <10 years (10-year other-cause mortality rate, >50%) for 50,049 of 96,032 men (52%). Life expectancy differed by age and comorbidity score and was <10 years for men ages 66 to 69 years with Charlson scores ≥2, for men ages 70 to 74 years with Charlson scores ≥1, and for all men ages 75 to 79 years and ≥80 years. Among those who had a life expectancy <10 years, treatment was aggressive (surgery, radiation, or brachytherapy) for 68% of men aged 66 to 69 years, 69% of men aged 70 to 74 years, 57% of men aged 75 to 79 years, and 24% of men aged ≥80 years. Among these men, aggressive treatment was predominantly radiation therapy (50%, 53%, 63%, and 69%, respectively) and less frequently was surgery (30%, 25%, 13%, and 9%, respectively). Multivariate models revealed little variation in the probability of aggressive treatment by comorbidity status within age subgroups despite substantial differences in mortality. CONCLUSIONS: Men aged <80 years at diagnosis who have life expectancies <10 years often receive aggressive treatment for low-risk and intermediate-risk prostate cancer, mostly with radiation therapy.

Comparative effectiveness of aggressive versus nonaggressive treatment among men with early-stage prostate cancer and differing comorbid disease burdens at diagnosis.

BACKGROUND: This study sought to compare the effectiveness of aggressive versus nonaggressive treatment in reducing cancer-specific mortality for older men with early-stage prostate cancer across differing comorbid disease burdens at diagnosis. METHODS: In total, the authors sampled 140,553 men aged ≥ 66 years with early-stage prostate cancer who were diagnosed between 1991 and 2007 from the Surveillance, Epidemiology, and End Results-Medicare database. Propensity-adjusted competing-risks regression analysis was used to compare the risk of cancer-specific mortality between men who received aggressive versus nonaggressive treatment among comorbidity subgroups. RESULTS: In propensity-adjusted competing-risks regression analysis, aggressive treatment was associated with a significantly lower risk of cancer-specific mortality among men who had Charlson scores of 0, 1, and 2 but not among men who had Charlson scores ≥ 3 (subhazard ratio, 0.85; 95% confidence interval, 0.62-1.18). The absolute reduction in 15-year cancer-specific mortality between men who received aggressive versus nonaggressive treatment was 6.1%, 4.3%, 3.9%, and 0.9% for men with Charlson scores of 0, 1, 2, and ≥ 3, respectively. Among men who had well-differentiated and moderately-differentiated tumors, aggressive treatment again was associated with a lower risk of cancer-specific mortality for those who had Charlson scores of 0, 1, and 2 but not for those who had Charlson scores ≥ 3 (subhazard ratio, 1.14; 95% confidence interval, 0.70-1.89). The absolute reduction in 15-year cancer-specific mortality between men who received aggressive versus nonaggressive treatment was 3.8%, 3%, 1.9%, and -0.5% for men with Charlson scores of 0, 1, 2, and ≥ 3, respectively. CONCLUSIONS: The cancer-specific survival benefit from aggressive treatment for early-stage prostate cancer diminishes with increasing comorbidity at diagnosis. Men with Charlson scores ≥ 3 garner no survival benefit from aggressive treatment.

Adverse health outcomes associated with surgical management of the small renal mass.

PURPOSE: Partial and radical nephrectomy are treatments for the small renal mass. Partial nephrectomy is considered the gold standard as it may protect against renal dysfunction compared to radical nephrectomy. However, both treatments may cause adverse health outcomes. MATERIALS AND METHODS: A matched cohort study was performed using the SEER (Surveillance, Epidemiology and End Results)-Medicare data set. Individuals treated with partial or radical nephrectomy for 4 cm or smaller nonmetastatic renal cell carcinoma were compared to 2 control groups (nonmuscle invasive bladder cancer and noncancer). A greedy algorithm matched surgical groups to controls. Medicare claims were examined for renal, cardiovascular and secondary cancer events. RESULTS: Patients who underwent partial nephrectomy (1,471) and radical nephrectomy (4,299) were matched to controls. The time to event model demonstrated an increased risk of renal events for both treatments. Compared to the bladder cancer control and noncancer control groups, radical nephrectomy hazard ratios for renal events were 2.415 (p <0.0001) and 6.211 (p <0.0001), respectively, while partial nephrectomy hazard ratios were 1.513 (p <0.0001) and 4.926 (p <0.0001), respectively. Secondary cancers were increased for partial nephrectomy and radical nephrectomy compared to both control groups (p <0.0001). Cardiovascular events were increased for both treatments compared to noncancer controls (p <0.0001), but not compared to bladder cancer controls. CONCLUSIONS: Partial nephrectomy and radical nephrectomy may lead to adverse health outcomes. Compared to controls, partial nephrectomy and radical nephrectomy are associated with worsened renal outcomes. The increase in secondary cancers and cardiovascular events with both treatments is notable, and requires further investigation. Further research should investigate if active surveillance of the appropriately selected small renal mass limits adverse health outcomes.

Are disparities in mental health care for Medicaid beneficiaries lower in managed care?

BACKGROUND: There are large and persistent racial and ethnic disparities in the use of mental health care in the United States. Medicaid managed care plans have the potential to reduce racial and ethnic disparities in use of mental health care through monitoring of need and active management of use of services across the populations they cover. This study compares racial and ethnic disparities among Medicaid beneficiaries in managed care with those not in managed care. METHODS: We compared Medicaid beneficiaries enrolled health maintenance organizations (HMOs) with those in fee-for-service (FFS) using data from the 2007-2015 Medical Expenditure Panel Survey (N = 26,113). We specified two-part propensity score adjusted models to estimate differences in mental health related emergency department visits, hospital stays, prescription fills, and outpatient visits overall and by race/ethnicity. RESULTS: HMO enrollment was associated with lower odds of having a mental health prescription (OR = 0.86, 95 % CI 0.78-0.96) or outpatient visit (OR = 0.82 95 % CI 0.73-0.92). These differences were similar across racial and ethnic groups or larger among Non-Hispanic Black and Hispanic beneficiaries than among Non-Hispanic White beneficiaries. CONCLUSIONS: Medicaid managed care has not improved the inequitable allocation of mental health care across racial and ethnic groups. Explicit attention to monitoring of racial and ethnic differences in use of mental health care in Medicaid managed care is warranted. IMPLICATIONS: Improvement in racial and ethnic disparities in mental health care in Medicaid manage care is unlikely to occur without targeted accountability mechanisms, such as required reporting or other contracting requirements.

Overall survival advantage with partial nephrectomy: a bias of observational data?

BACKGROUND: Partial nephrectomy (PN) and radical nephrectomy (RN) are standard treatments for a small renal mass. Retrospective studies suggest an overall survival (OS) advantage, however a randomized phase 3 trial suggests otherwise. The effects of both surgical modalities on OS were evaluated compared with controls. METHODS: A matched cohort study was performed using the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset. Individuals treated with PN or RN for localized renal cell carcinoma (RCC) measuring ≤4 cm were compared with 2 control groups (non-muscle-invasive bladder cancer (BCC) and noncancer controls (NCC). Using a greedy algorithm, RCC groups were matched with controls by demographics and comorbidities. OS for surgical groups and controls were compared. The cause of death was evaluated for cancer groups when differences in OS were noted. RESULTS: Patients undergoing PN and RN were matched with controls. All cancer groups had >95% 10-year cancer-specific survival (CSS). Median OS was similar between RN (9.05 years) and BCC (8.67 years; P = .067) and NCC (8.77 years; P = .49). Median OS was improved for PN (10.45 years) compared with BCC (8.75 years; P<.001) and NCC controls (8.76 years; P<.001). A multivariate Cox hazards model demonstrated that PN improved OS compared with NCC (hazard ratio, 1.257; P<.001) and BCC (hazard ratio, 1.364; P<.001). CONCLUSIONS: RN patients had similar OS compared with controls, suggesting that this treatment modality does not compromise survival. Patients undergoing PN had improved OS compared with controls, suggesting possible selection bias. The apparent survival advantage conferred by PN in SEER-Medicare case series is likely the result of selection bias involving unmeasured confounders.

Recurrence of high-risk bladder cancer: a population-based analysis.

BACKGROUND: Patients with bladder cancer are apt to develop multiple recurrences that require intervention. The recurrence, progression, and bladder cancer-related mortality rates were examined in a cohort of individuals with high-grade non-muscle-invasive bladder cancer. METHODS: Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, subjects were identified who had a diagnosis of high-grade, non-muscle-invasive disease in 1992 to 2002 and who were followed until 2007. Multivariate competing-risks regression analyses were then used to examine recurrence, progression, and bladder cancer-related mortality rates. RESULTS: Of 7410 subjects, 2897 (39.1%) experienced a recurrence without progression, 2449 (33.0%) experienced disease progression, of whom 981 succumbed to bladder cancer. Using competing-risks regression analysis, the 10-year recurrence, progression, and bladder cancer-related mortality rates were found to be 74.3%, 33.3%, and 12.3%, respectively. Stage T1 was the only variable associated with a higher rate of recurrence. Women, black race, undifferentiated grade, and stage Tis and T1 were associated with a higher risk of progression and mortality. Advanced age (≥ 70) was associated with a higher risk of bladder cancer-related mortality. CONCLUSIONS: Nearly three-fourths of patients diagnosed with high-risk bladder cancer will recur, progress, or die within 10 years of their diagnosis. Even though most patients do not die of bladder cancer, the vast majority endures the morbidity of recurrence and progression of their cancer. Increasing efforts should be made to offer patients intravesical therapy with the goal of minimizing the incidence of recurrences. Furthermore, the high recurrence rate seen during the first 2 years of diagnosis warrants an intense surveillance schedule.

Downstream complications following urinary diversion.

PURPOSE: Surveillance following urinary diversion should be tailored to capture complications downstream from the initial reconstruction. Most analyses of the morbidity associated with urinary diversion are restricted to the index admission or the immediate postoperative period. We characterize the long-term medical and surgical complications and burden of health care use after urinary diversion. MATERIALS AND METHODS: Using the 5% Medicare sample from 1998 to 2005 we identified individuals who underwent cutaneous and orthotopic continent urinary diversion, ileal conduit or other types of diversion including enterocystoplasty from physician claims for the index admission. We restricted our sample to subjects with claims 1 year before surgery and at least 2 years after the diversion. We included benign and malignant primary diagnoses, and evaluated the incidence of medical and surgical complications 2 and 5 years after surgery. We stratified complications by diversion type and compared long-term complications after urinary diversion surgery. RESULTS: Of the 1,565 subjects identified 80% underwent ileal conduit urinary diversion, 7% underwent cutaneous or orthotopic continent diversion and 13% underwent other types of reconstruction. Urinary stone formation, wound complications and fistula complications were more common following continent diversion 5 years after surgery, while ureteral obstruction and renal failure/impairment were more common after ileal conduit diversion. Overall we estimated that more than 16% of patients experienced renal failure or impairment after urinary diversion. CONCLUSIONS: Complications are common after urinary diversion and continue to occur through 5 years postoperatively. Urolithiasis and delayed wound complications appear to occur more commonly after continent diversion than after other urinary diversions. A large proportion of patients experience renal deterioration after diversion. These results highlight the need to survey patients for the diversion related complications of cystectomy as rigorously as we monitor for cancer recurrence.

Patterns and predictors of urodynamics use in the United States.

PURPOSE: Due to the paucity of data on urodynamics on the national level, we assessed the use of urodynamics in a large sample of individuals in the United States and identified predictors of increased complexity of urodynamic procedures. MATERIALS AND METHODS: Using administrative health care claims for adults enrolled in private insurance plans in the United States from 2002 to 2007, we identified those who underwent cystometrogram and abstracted relevant demographic and clinical data. We used logistic regression to identify predictors of higher urodynamic complexity over basic cystometrogram, specifically cystometrogram plus pressure flow study and videourodynamics. RESULTS: We identified 16,574 urodynamic studies, of which 23% were cystometrograms, 71% were cystometrograms plus pressure flow studies and 6% were videourodynamics. Stress incontinence was the most common clinical condition for all studies (33.7%), cystometrogram (30.8%), cystometrogram plus pressure flow study (35.4%) and videourodynamics (24.4%). Urologists performed 59.8% of all urodynamics and gynecologists performed 35.5%. Providers with 14 or more urodynamic studies during the study period performed 75% of all urodynamics and were more likely to perform cystometrogram plus pressure flow study and videourodynamics. On regression analysis the most consistent predictors of cystometrogram plus pressure flow study and/or videourodynamics over cystometrogram were specialty (urologist) and the number of urodynamic tests performed by the provider. CONCLUSIONS: Most urodynamics in this series consisted of cystometrogram plus pressure flow study with stress incontinence the most common diagnosis. However, regardless of diagnosis, urologists and providers who performed more urodynamics were more likely to perform pressure flow study and/or videourodynamics in addition to cystometrogram. Further research is needed to determine whether these differences reflect gaps in the consistency or appropriateness of using urodynamics.

Association of the Kidney Failure Risk Equation With High Health Care Costs.

Introduction: The Kidney Failure Risk Equations (KFRE) are accurate and validated to predict the risk of kidney failure in individuals with chronic kidney disease (CKD), but their potential to predict health care costs in the US health care system is unknown. We assessed the association of kidney failure risk from the 4-variable and 8-variable 2-year KFRE models with monthly health care costs in US patients with CKD stages G3 and G4. Methods: This was an ancillary study to a larger observational, retrospective cohort study examining the association between serum bicarbonate and adverse kidney outcomes. Monthly medical costs were calculated from individual health care insurance claims. Generalized linear regression models were used to examine the association of KFRE score with health care costs. Results: A total of 1721 patients qualified for the study (1475 and 246 with CKD stages G3 and G4, respectively). For 8-variable KFRE, each 1% (absolute) increase in risk was associated with 13.5% (P < 0.001) and 4.1% (P < 0.001) higher monthly costs for patients with CKD stage G3 and G4, respectively. For 4-variable KFRE, a 1% increase in risk was associated with 6.7% (P = 0.016) and 2.9% (P= 0.014) increase in monthly costs for patients with CKD stage G3 and G4, respectively. Conclusion: Higher risks of kidney failure as predicted by the 4-variable or 8-variable KFRE were associated with higher 2-year medical costs for patients with CKD stages G3 and G4. The KFRE may be a useful tool to anticipate medical costs and target cost-reducing interventions for patients at risk of kidney failure.

Increasing Serum Bicarbonate is Associated With Reduced Risk of Adverse Kidney Outcomes in Patients with CKD and Metabolic Acidosis.

Introduction: Low serum bicarbonate at a single point in time is associated with accelerated kidney decline in patients with chronic kidney disease (CKD). We modeled how changes in serum bicarbonate over time affect incidence of adverse kidney outcomes. Methods: We analyzed data from Optum's deidentified Integrated Claims-Clinical data set of US patients (2007-2019) with ≥1 year of prior medical record data, CKD stages G3 to G5, and metabolic acidosis (i.e., index serum bicarbonate 12 to <22 mmol/l). The primary predictor of interest was the change in serum bicarbonate, evaluated at each postindex outpatient serum bicarbonate test as a time-dependent continuous variable. The primary outcome was a composite of either a ≥40% decline in estimated glomerular filtration rate (eGFR) from index or evidence of dialysis or transplantation, evaluated using Cox proportional hazards models. Results: A total of 24,384 patients were included in the cohort with median follow-up of 3.7 years. A within-patient increase in serum bicarbonate over time was associated with a lower risk of the composite kidney outcome. The unadjusted hazard ratio (HR) per 1-mmol/l increase in serum bicarbonate was 0.911 (95% confidence interval [CI]: 0.905-0.917; P < 0.001). After adjustment for baseline eGFR and serum bicarbonate, the time-adjusted effect of baseline eGFR and other covariates, the HR per 1-mmol/l increase in serum bicarbonate was largely unchanged (0.916 [95% CI: 0.910-0.922; P < 0.001]). Conclusion: In a real-world population of US patients with CKD and metabolic acidosis, a within-patient increase in serum bicarbonate over time independent of changes in eGFR, was associated with a lower risk of CKD progression.

Quality of care in patients with bladder cancer: a case report?

BACKGROUND: Although there is level I evidence demonstrating the superiority of intravesical therapy in patients with bladder cancer, surveillance strategies are primarily founded on expert opinion. The authors examined compliance with surveillance and treatment strategies and the pursuant impact on survival in patients with high-grade disease. METHODS: Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the authors identified subjects with a diagnosis of high-grade, non-muscle-invasive disease between 1992 and 2002 who survived 2 years and did not undergo definitive treatment during that time. Nonlinear mixed-effects regression analyses was used to examine compliance with surveillance and treatment strategies. After adjusting for confounders using a propensity score-weighted approach, the authors determined whether individual and comprehensive strategies during the initial 2 years after diagnosis were associated with survival after 2 years. RESULTS: Of 4790 subjects, only 1 received all the recommended measures. Although mean utilization for most measures significantly increased after 1997, only compliance with an induction course of bacillus Calmette-Guerin (BCG) increased (13% to 20%; P < .001). On multivariate analysis, compliance with ≥ 4 cystoscopies, ≥ 4 cytologies, and BCG instillation was found to be lower among octogenarians and higher among those with undifferentiated, Tis, and T1 tumors, and among those individuals diagnosed after 1997. Subjects compliant with these measures had a lower hazard of mortality (hazard ratio, 0.41; 95% confidence interval, 0.18-0.93) than those who received < 4 cystoscopies, < 4 cytologies, and no BCG. CONCLUSION: There was a statistically significant survival advantage found among those who received at least half of the recommended care. Improving compliance with these process-of-care measures via systematic quality improvement initiatives serves as the primary target to meliorate bladder cancer care.

Medicare payments for outpatient urological surgery by location of care.

PURPOSE: The cost implications associated with offloading outpatient surgery from hospitals to ambulatory surgery centers and the physician office remain poorly defined. Therefore, we determined whether payments for outpatient surgery vary by location of care. MATERIALS AND METHODS: Using national Medicare claims from 1998 to 2006, we identified elderly patients who underwent 1 of 22 common outpatient urological procedures. For each procedure we measured all relevant payments (in United States dollars) made during the 30-day claims window that encompassed the procedure date. We then categorized payment types (hospital, physician and outpatient facility). Finally, we used multivariable regression to compare price standardized payments across hospitals, ambulatory surgery centers and the physician office. RESULTS: Average total payments for outpatient surgery episodes varied widely from $200 for urethral dilation in the physician office to $5,688 for hospital based shock wave lithotripsy. For all but 2 procedure groups, ambulatory surgery centers and physician offices were associated with lower overall episode payments than hospitals. For instance, average total payments for urodynamic procedures performed at ambulatory surgery centers were less than a third of those done at hospitals (p <0.001). Compared to hospitals, office based prostate biopsies were nearly 75% less costly (p <0.001). Outpatient facility payments were the biggest driver of these differences. CONCLUSIONS: These data support policies that encourage the provision of outpatient surgery in less resource intensive settings.

Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery.

PURPOSE: The cost efficiency gains achieved from moving procedures to ambulatory surgery centers and offices may be mitigated if the quality of surgical care at these facilities is not comparable to that at the hospital. Motivated by this, we assessed short-term morbidity and mortality for patients by location of care. MATERIALS AND METHODS: Using a national sample of Medicare claims (1998 to 2006), we identified elderly beneficiaries who underwent one of 22 common outpatient urological procedures. After determining the facility type where each procedure was performed, we measured 30-day mortality, unexpected admissions and postoperative complications. Finally, we fit multivariable logistic regression models to evaluate the association between occurrence of an adverse event and the ambulatory setting where surgical care was delivered. RESULTS: During the study period, there was a substantial increase in the frequency of nonhospital based outpatient surgery. Compared to ambulatory surgery centers and offices, hospitals treated more women (p <0.001). Those patients also tended to be less healthy (p <0.001). While patients experienced fewer postoperative complications following surgery at an ambulatory surgery center, procedures performed outside the hospital were associated with a higher likelihood of a same day admission (ambulatory surgery centers OR 6.96, 95% CI 4.44-10.90 and offices OR 3.64, 95% CI 2.48-5.36). However, notably with case mix adjustment the probability of any adverse event was exceedingly low across all ambulatory settings. CONCLUSIONS: These data indicate that small but measurable variation in surgical quality exists by location of care delivery.

Compliance with guidelines for patients with bladder cancer: variation in the delivery of care.

BACKGROUND: Clinical practice guidelines for the management of patients with bladder cancer encompass strategies that minimize morbidity and improve survival. In the current study, the authors sought to characterize practice patterns in patients with high-grade non-muscle-invasive bladder cancer in relation to established guidelines. METHODS: Surveillance, Epidemiology and End Results (SEER)-Medicare-linked data were used to identify subjects diagnosed with high-grade non-muscle-invasive bladder cancer between 1992 and 2002 who survived at least 2 years without undergoing definitive treatment (n = 4545). The authors used mixed-effects modeling to estimate the association and partitioned variation of patient sociodemographic, tumor, and provider characteristics with compliance measures. RESULTS: Of the 4545 subjects analyzed, only 1 received all the recommended measures. Approximately 42% of physicians have not performed at least 1 cystoscopy, 1 cytology, and 1 instillation of immunotherapy for a single patient nested within their practice during the initial 2-year period after diagnosis. After 1997, only use of radiographic imaging (odds ratio [OR], 1.19; 95% confidence interval [95% CI], 1.03-1.37) and instillation of immunotherapy (OR, 1.67; 95% CI, 1.39-2.01) were found to be significantly increased. Surgeon-attributable variation for individual guideline measures (cystoscopy, 25%; cytology, 59%; radiographic imaging, 10%; intravesical chemotherapy, 45%; and intravesical immunotherapy, 26%) contributes to this low compliance rate. CONCLUSIONS: There is marked underuse of guideline-recommended care in this potentially curable cohort. Unexplained provider-level factors significantly contribute to this low compliance rate. Future studies that identify barriers and modulators of provider-level adoption of guidelines are critical to improving care for patients with bladder cancer.

Readmissions in the postoperative period following urinary diversion.

PURPOSE: Most analyses of complications after urinary diversion are restricted to the index admission. Given the complexity of these reconstructions, readmissions occur commonly. We sought to characterize the burden and impact of readmissions in the postoperative period following urinary diversion. METHODS: Using 5% Medicare data for the years 1998-2005, we identified patients undergoing ileal conduit, continent, and other urinary diversions for benign and malignant indications. We examined the 90-day rates of readmission and evaluated factors associated with readmission after urinary diversion, either to the primary hospital or to a secondary facility. We assessed 90-day and 2-year mortality after urinary diversion and incorporated readmission status as a covariate in these multivariable models. RESULTS: Our study sample included 1,565 patients, of whom 491 patients (31%) were readmitted within 90 days of their urinary diversion. Patients readmitted after urinary diversion had higher comorbidity count than those not readmitted (59% of those readmitted with comorbidity count at least 1 versus 50% of those not readmitted, P=0.002). Other clinical and demographic characteristics did not differ by readmission status (P>0.12 for age, race, type of urinary diversion, and primary diagnosis). Complication rates were higher in readmitted patients than those not readmitted; 2-year mortality was associated with 90-day readmission status-18.8% of readmitted versus 12.8% of not readmitted patients died within 2 years of surgery (P=0.003). CONCLUSIONS: Readmissions occur commonly after urinary diversion. Many readmitted patients have complications of complex surgery managed at secondary hospitals, which may portend a quality concern that merits further study.