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1.
Am J Surg ; 219(4): 571-577, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32147020

RESUMEN

INTRODUCTION: Bariatric surgery is an effective treatment for obesity resulting in both sustained weight loss and reduction in obesity-related comorbidities. It is uncertain how sociodemographic factors affect postoperative outcomes. METHODS: The National Inpatient Sample was queried for patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2005 to 2014. Factors associated with selection of SG over RYGB, increased postoperative length of stay (LOS) greater than 3 days, and inpatient mortality were compared by race, insurance status, and other clinical and hospital factors. RESULTS: The database captured 781,413 patients, of which 525,986 had a RYGB and 255,428 had SG. There was an increase in the incidence of SG over RYGB over time. Among the self-pay/uninsured, the increased incidence began several years earlier than other groups. Black patients had greater odds of increased postoperative LOS (OR 1.40) and in-hospital mortality (OR 2.11). CONCLUSION: Sociodemographic factors are associated with differences in temporal trends in the adoption of SG versus RYGB for surgical weight loss.


Asunto(s)
Gastrectomía/tendencias , Derivación Gástrica/tendencias , Mortalidad Hospitalaria , Tiempo de Internación/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Comorbilidad , Grupos de Población Continentales/estadística & datos numéricos , Conjuntos de Datos como Asunto , Femenino , Financiación Personal/estadística & datos numéricos , Humanos , Renta/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Masculino , Medicaid/estadística & datos numéricos , Pacientes no Asegurados/estadística & datos numéricos , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Sector Privado , Factores Raciales , Factores Sexuales , Estados Unidos/epidemiología , Adulto Joven
2.
PLoS One ; 15(2): e0228553, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32023311

RESUMEN

IMPORTANCE: Medicare beneficiaries with high medical needs can benefit from Advance Care Planning (ACP). Medicare reimburses clinical providers for ACP discussions, but it is unknown whether high-need beneficiaries are receiving this service. OBJECTIVE: To compare rates of billed ACP discussions among a cohort of high-need Medicare beneficiaries with the non-high-needs Medicare population. DESIGN: Retrospective analysis of Medicare Fee-for-Service (FFS) claims in 2017 comparing high-need beneficiaries (seriously ill, frail, ESRD, and disabled) with non-high need beneficiaries. SETTING: Nationally representative FFS Medicare 20% sample. PARTICIPANTS: Medicare beneficiaries were assigned to one of the following classifications: seriously ill (65+), frail (65+), seriously ill & frail (65+); non-high need (65+); end stage renal disease (ESRD) or disabled (<65). All participants had data available for years 2016-2017. EXPOSURE: Receipt of a billed ACP discussion, CPT codes 99497 or 99498. MAIN OUTCOME AND MEASURE: Rates of billed ACP visits were compared between high-need patients and non-high-need patients. Rates were adjusted for the 65+ population for sex, age, race/ethnicity, Charlson comorbidity index, Medicare/Medicaid dual eligibility status, and Hospital Referral Region. RESULTS: Among the 65+ groups, those most likely to have a billed ACP discussion included seriously ill & frail (5.2%), seriously ill (4.2%), and frail (3.3%). Rates remained consistent after adjusting (4.5%, 4.0%, 3.1%, respectively). Each subgroup differed significantly (p < .05) from non-high need beneficiaries (2.3%) in both unadjusted and adjusted analyses. Among the <65 high need groups, the rates were 2.7% for ESRD and 1.3% for the disabled (the latter p < .05 compared with non-high needs). CONCLUSIONS AND RELEVANCE: While rates of billed ACP discussions varied among patient groups with high medical needs, overall they were relatively low, even among a cohort of patients for whom ACP may be especially relevant.


Asunto(s)
Planificación Anticipada de Atención/estadística & datos numéricos , Planificación Anticipada de Atención/normas , Current Procedural Terminology , Planes de Aranceles por Servicios/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Medicare/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Estudios Retrospectivos , Estados Unidos
3.
Am J Surg ; 219(4): 557-562, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32007235

RESUMEN

BACKGROUND: The "white-flight" phenomenon of the mid-20th century contributed to the perpetuation of residential segregation in American society. In light of recent reports of racial segregation in our healthcare system, could a contemporary "white-flight" phenomenon also exist? METHODS: The New York Statewide Planning and Research Cooperative System was used to identify all Manhattan and Bronx residents of New York city who underwent elective cardiothoracic, colorectal, general, and vascular surgeries from 2010 to 2016. Primary outcome was borough of surgical care in relation to patient's home borough. Multivariable analyses were performed. RESULTS: White patients who reside in the Bronx are significantly more likely than racial minorities to travel into Manhattan for elective surgical care, and these differences persist across different insurance types, including Medicare. CONCLUSIONS: Marked race-based differences in choice of location for elective surgical care exist in New York city. If left unchecked, these differences can contribute to furthering racial segregation within our healthcare system.


Asunto(s)
Conducta de Elección , Grupos de Población Continentales/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Ubicación de la Práctica Profesional/estadística & datos numéricos , Femenino , Disparidades en Atención de Salud , Humanos , Seguro de Salud/estadística & datos numéricos , Masculino , Medicaid/estadística & datos numéricos , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Ciudad de Nueva York/epidemiología , Participación del Paciente , Factores Raciales , Estados Unidos
4.
Am J Med Sci ; 359(4): 218-225, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32087942

RESUMEN

BACKGROUND: This study aimed to describe the prevalence of type 2 diabetes and combinations of multiple chronic conditions (MCCs) that are leading causes of death (LCD) and confirm that disparities exist between groups based on race and sex. MATERIALS AND METHODS: We conducted a retrospective cohort study using 2012 Medicare claims data from beneficiaries with type 2 diabetes over the age of 65 in the state of Michigan. RESULTS: Female beneficiaries have type 2 diabetes and 1 or more MCCs that are LCD more often than males. Most type 2 diabetes patients have diabetes alone without MCCs, while a large proportion have at least 1 additional chronic condition that is a LCD. One in 3 patients have 3 or more chronic conditions. The most prevalent type 2 diabetes coexisting MCCs are congestive heart failure (CHF), chronic obstructive pulmonary disease and chronic kidney disease. Asian/Pacific Islanders have the highest prevalence of type 2 diabetes without MCCs, and the highest prevalence of diabetes plus CHF. While fewer black beneficiaries have diabetes alone or 1 additional MCC, the prevalence of 3 or more MCCs in blacks generally exceeds the prevalence in other races. In beneficiaries with newly diagnosed type 2 diabetes, chronic obstructive pulmonary disease and CHF are the first new chronic conditions to be diagnosed after an initial type 2 diabetes diagnosis. CONCLUSIONS: Race and sex disparities occur in the prevalence of type 2 diabetes and MCCs that are LCD in Medicare beneficiaries in the state of Michigan.


Asunto(s)
Enfermedad Crónica/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Anciano , Anciano de 80 o más Años , Enfermedad Crónica/etnología , Estudios de Cohortes , Diabetes Mellitus Tipo 2/etnología , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Medicare/estadística & datos numéricos , Michigan/epidemiología , Prevalencia , Estudios Retrospectivos , Factores Sexuales , Factores Socioeconómicos , Estados Unidos
5.
Ann Emerg Med ; 75(5): 597-608, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-31973914

RESUMEN

STUDY OBJECTIVE: Accountable care organizations are provider networks aiming to improve quality while reducing costs for populations. It is unknown how value-based care within accountable care organizations affects emergency medicine care delivery and payment. Our objective was to describe how accountable care has impacted emergency care redesign and payment. METHODS: We performed a qualitative study of accountable care organizations, consisting of semistructured interviews with emergency department (ED) and accountable care organization leaders responsible for strategy, care redesign, and payment. We analyzed transcripts for key themes, using thematic analysis techniques. RESULTS: We performed 22 interviews across 7 accountable care organizations. All sites were enrolled in the Medicare Shared Savings Program; however, sites varied in region and maturity with respect to population health initiatives. Nearly all sites were focused on reducing low-value ED visits, expanding alternate venues for acute unscheduled care, and redesigning care to reduce ED admission rates through expanded care coordination, including programs targeting high-risk populations such as older adults and frequent ED users, telehealth, and expanded use of direct transfer to skilled nursing facilities from the ED. However, there has been no significant reform of payment for emergency medical care within these accountable care organizations. Nearly all informants expressed concern in regard to reduced ED reimbursement, given accountable care organization efforts to reduce ED utilization and increase clinician participation in alternative payment contracts. No participants expressed a clear vision for reforming payment for ED services. CONCLUSION: Care redesign within accountable care organizations has focused on outpatient access and alternatives to hospitalization. However, there has been little influence on emergency medicine payment, which remains fee for service. Evidence-based policy solutions are urgently needed to inform the adoption of value-based payment for acute unscheduled care.


Asunto(s)
Organizaciones Responsables por la Atención , Medicina de Emergencia/economía , Medicare , Medicina de Emergencia/estadística & datos numéricos , Práctica Clínica Basada en la Evidencia , Planes de Aranceles por Servicios , Investigación sobre Servicios de Salud , Humanos , Masculino , Medicare/economía , Medicare/estadística & datos numéricos , Investigación Cualitativa , Mecanismo de Reembolso , Estados Unidos
6.
BMJ ; 368: l6831, 2020 01 15.
Artículo en Inglés | MEDLINE | ID: mdl-31941686

RESUMEN

OBJECTIVES: To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. DESIGN: Retrospective cohort study. SETTING: Medicare claims data for 2008-16 in the United States. PARTICIPANTS: Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia-conditions included in the US Hospital Readmissions Reduction Program. MAIN OUTCOME MEASURES: Post-discharge 30 day mortality according to patients' 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. RESULTS: 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (-0.09% to -0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. CONCLUSIONS: The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.


Asunto(s)
Unidades de Observación Clínica/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Insuficiencia Cardíaca , Infarto del Miocardio , Neumonía , Atención Subaguda , Anciano , Anciano de 80 o más Años , Femenino , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Humanos , Revisión de Utilización de Seguros , Masculino , Uso Excesivo de los Servicios de Salud/prevención & control , Medicare/estadística & datos numéricos , Mortalidad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Alta del Paciente/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Neumonía/mortalidad , Neumonía/terapia , Estudios Retrospectivos , Atención Subaguda/métodos , Atención Subaguda/organización & administración , Atención Subaguda/tendencias , Estados Unidos/epidemiología
7.
Med Care ; 58(2): 108-113, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31934957

RESUMEN

INTRODUCTION: New low back pain (LBP) is a common outpatient complaint. Little is known about how care is delivered over the course of a year to patients who develop new LBP and whether such care patterns are guideline-concordant. METHODS: This retrospective analysis included Medicare claims of 162,238 opioid-naïve beneficiaries with new LBP from January 1, 2011, through December 31, 2014. Simple rates of modality use [computed tomography and magnetic resonance imaging (advanced imaging), physical therapy (PT), opioid and nonopioid medications] and percentiles (5th percentile, 25th percentile, median, 75th percentile, and 95th percentile) were reported. RESULTS: Within the first year, 29.4% [95% confidence interval (CI), 29.1-29.8] of patients with ≥2 visits for new LBP received advanced imaging, and 48.4% (95% CI, 47.7-49.0) of these patients received advanced imaging within 6 weeks of the first visit; 17.3% (95% CI, 17.1-17.6) of patients with ≥2 visits received PT; 42.2% (95% CI, 41.8-42.5) of patients with ≥2 visits received non-steroidal anti-inflammatory drugs (NSAIDs), 16.9% (95% CI, 16.6-17.1) received a muscle relaxant, and 26.2% (95% CI, 25.9-26.6) received tramadol; 32.3% (95% CI, 31.9-32.6) of patients with ≥2 visits received opioids; 52.4% (95% CI, 51.7-53.0) of these patients had not received a prescription NSAID, and 82.2% (95% CI, 81.7-82.7) of these patients had not received PT. CONCLUSIONS: Many patients who develop new LBP receive guideline nonconcordant care such as early advanced imaging and opioids before other modalities like PT and prescription NSAIDs.


Asunto(s)
Analgésicos/uso terapéutico , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/terapia , Medicare/estadística & datos numéricos , Modalidades de Fisioterapia , Anciano , Anciano de 80 o más Años , Analgésicos Opioides/uso terapéutico , Femenino , Humanos , Revisión de Utilización de Seguros/estadística & datos numéricos , Dolor de la Región Lumbar/diagnóstico por imagen , Masculino , Fármacos Neuromusculares/uso terapéutico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estudios Retrospectivos , Estados Unidos
8.
PLoS One ; 15(1): e0227681, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31940401

RESUMEN

BACKGROUND: Older adults with Alzheimer's disease and related dementias (ADRD) are high-risk to experience hospitalizations and emergency room (ER) admissions. Mexican-Americans have a high prevalence of ADRD, but there is limited information on the healthcare use of older Mexican-Americans with ADRD. We used data from a cohort of older Mexican-Americans that has been linked with Medicare files to investigate differences in hospitalizations, ER admissions, and physician visits according to ADRD diagnosis. We also identify sociodemographic, health, and functional characteristics that may contribute to differences in healthcare utilization between Mexican-American Medicare beneficiaries with and without an ADRD diagnosis. METHODS AND FINDINGS: Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare Master Beneficiary Summary Files, Medicare Provider Analysis and Review files, Outpatient Standard Analytic files, and Carrier files. The final analytic sample included 1048 participants. Participants were followed for two years (eight quarters) after their survey interview. Generalized estimating equations were used to estimate the probability for one or more hospitalizations, ER admissions, and physician visits at each quarter. ADRD was associated with higher odds for hospitalizations (OR = 1.65, 95%CI = 1.29-2.11) and ER admissions (OR = 1.57, 95%CI = 1.23-1.94) but not physician visits (OR = 1.23, 95%CI = 0.91-1.67). The odds for hospitalizations (OR = 1.24, 95%CI = 0.97-1.60) and ER admissions (OR = 1.27, 95%CI = 1.01-1.59) were reduced after controlling for limitations in activities of daily living and comorbidities. CONCLUSIONS: Mexican-American Medicare beneficiaries with ADRD had significantly higher odds for one or more hospitalizations and ER admissions but similar physician visits compared to beneficiaries without ADRD. Functional limitations and comorbidities contributed to the higher hospitalizations and ER admissions for older Mexican-Americans with ADRD.


Asunto(s)
Americanos Mexicanos/psicología , Aceptación de la Atención de Salud/psicología , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Enfermedad de Alzheimer/diagnóstico , Enfermedad de Alzheimer/psicología , Estudios de Cohortes , Comorbilidad , Demencia/diagnóstico , Demencia/psicología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Pacientes Ambulatorios , Estados Unidos
9.
Mayo Clin Proc ; 95(1): 57-68, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31902429

RESUMEN

OBJECTIVE: To investigate the relationship of body mass index (BMI) with short- and long-term outcomes after transcatheter aortic valve replacement (TAVR). PATIENTS AND METHODS: The relationship between BMI and baseline characteristics and procedural characteristics was assessed for 31,929 patients who underwent TAVR between November 1, 2011, and March 31, 2015, from the STS/ACC TVT Registry. Registry data on 20,429 patients were linked to the Centers for Medicare and Medicaid Services to assess the association of BMI with 30-day and 1-year mortality using multivariable Cox proportional hazards models. The effect of BMI on mortality was also assessed with BMI as a continuous variable. Restricted cubic regression splines were used to model the effect of BMI and to determine appropriate cut points of BMI. RESULTS: Among 31,929 patients, 806 (2.5%) were underweight (BMI, <18.5 kg/m2), 10,755 (33.7%) had normal weight (BMI, 18.5- 24.9 kg/m2), 10,691 (33.5%) were overweight (BMI, 25.0-29.9 kg/m2), 5582 (17.5%) had class I obesity (BMI, 30.0-34.9 kg/m2), 2363 (7.4%) had class II obesity (BMI, 35.0-39.9 kg/m2), and 1732 (5.4%) had class III obesity (BMI, ≥40 kg/m2). Patients in various BMI categories were different in most baseline and procedural characteristics. On multivariable analysis, compared with normal-weight patients, underweight patients had higher mortality at 30 days and at 1 year after TAVR (hazard ratio [HR], 1.35; 95% CI, 1.02-1.78 and HR, 1.41; 95% CI, 1.17-1.69, respectively), whereas overweight patients and those with class I and II obesity had a decreased risk of mortality at 1 year (HR, 0.88; 95% CI, 0.81-0.95, HR, 0.80; 95% CI, 0.72-0.89, and HR, 0.84; 95% CI, 0.72-0.98, respectively). For BMI of 30 kg/m2 or less, each 1-kg/m2 increase was associated with a 2% and 4% decrease in the risk of 30-day and 1-year mortality, respectively; for BMI greater than 30 kg/m2, a 1-kg/m2 increase was associated with a 3% increased risk of 30-day mortality but not with 1-year mortality. CONCLUSION: Results of this large registry study evaluating the relationship of BMI and outcomes after TAVR support the existence of an obesity paradox among patients with severe aortic stenosis undergoing TAVR.


Asunto(s)
Estenosis de la Válvula Aórtica , Índice de Masa Corporal , Obesidad , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Estenosis de la Válvula Aórtica/epidemiología , Estenosis de la Válvula Aórtica/cirugía , Correlación de Datos , Femenino , Humanos , Efectos Adversos a Largo Plazo/mortalidad , Masculino , Medicare/estadística & datos numéricos , Mortalidad , Obesidad/diagnóstico , Obesidad/epidemiología , Modelos de Riesgos Proporcionales , Sistema de Registros/estadística & datos numéricos , Factores de Riesgo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del Tratamiento , Estados Unidos/epidemiología
10.
J Surg Res ; 246: 123-130, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31569034

RESUMEN

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.


Asunto(s)
Organizaciones Responsables por la Atención/estadística & datos numéricos , Fijación de Fractura/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Fracturas de la Columna Vertebral/cirugía , Organizaciones Responsables por la Atención/economía , Anciano , Anciano de 80 o más Años , Grupos de Población Continentales/estadística & datos numéricos , Ahorro de Costo/economía , Ahorro de Costo/estadística & datos numéricos , Grupos Étnicos , Femenino , Fijación de Fractura/efectos adversos , Fijación de Fractura/economía , Gastos en Salud/estadística & datos numéricos , Disparidades en Atención de Salud/organización & administración , Mortalidad Hospitalaria , Humanos , Masculino , Medicare/economía , Medicare/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad/estadística & datos numéricos , Factores Socioeconómicos , Fracturas de la Columna Vertebral/economía , Estados Unidos/epidemiología
11.
Med Care ; 58(1): e1-e8, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31688554

RESUMEN

BACKGROUND: Misclassification of Medicare beneficiaries' race/ethnicity in administrative data sources is frequently overlooked and a limitation in health disparities research. OBJECTIVE: To compare the validity of 2 race/ethnicity variables found in Medicare administrative data [enrollment database (EDB) and Research Triangle Institute (RTI) race] against a gold-standard source also available in the Medicare data warehouse: the self-reported race/ethnicity variable on the home health Outcome and Assessment Information Set (OASIS). SUBJECTS: Medicare beneficiaries over the age of 18 who received home health care in 2015 (N=4,243,090). MEASURES: Percent agreement, sensitivity, specificity, positive predictive value, and Cohen κ coefficient. RESULTS: The EDB and RTI race variable have high validity for black race and low validity for American Indian/Alaskan Native race. Although the RTI race variable has better validity than the EDB race variable for other races, κ values suggest room for future improvements in classification of whites (0.90), Hispanics (0.87), Asian/Pacific Islanders (0.77), and American Indian/Alaskan Natives (0.44). DISCUSSION: The status quo of using "good-enough for government" race/ethnicity variables contained in Medicare administrative data for minority health disparities research can be improved through the use of self-reported race/ethnicity data, available in the Medicare data warehouse. Health services and policy researchers should critically examine the source of race/ethnicity variables used in minority health and health disparities research. Future work to improve the accuracy of Medicare beneficiaries' race/ethnicity data should incorporate and augment the self-reported race/ethnicity data contained in assessment and survey data, available within the Medicare data warehouse.


Asunto(s)
Grupos de Población Continentales/estadística & datos numéricos , Grupos Étnicos/estadística & datos numéricos , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Medicare/estadística & datos numéricos , Autoinforme/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Disparidades en el Estado de Salud , Disparidades en Atención de Salud , Humanos , Masculino , Evaluación de Resultado en la Atención de Salud , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Estados Unidos
12.
Am J Surg ; 219(1): 1-7, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31405521

RESUMEN

BACKGROUND: Considered the top 5% of healthcare utilizers, "super-utilizers" are estimated to consume as much as 40-55% of all healthcare costs. The aim of this study was to identify factors associated with switching between low- and super-utilization. METHODS: Low and super-utilizers who underwent abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft (CABG), colectomy, total hip arthroplasty (THA), total knee arthroplasty (TKA), or lung resection between 2013 and 2015 were identified from 100% Medicare Inpatient Standard Analytic Files. RESULTS: Among 1,049,160 patients, 788,488 (75.1%) and 21,700 (2.1%) patients were low- or super-utilizers prior to surgery, respectively. Among patients who were super-utilizers before surgery, 23% remained super-utilizers post-operatively, yet 26.8% patients became low-utilizers after surgery. Factors associated with moving from low-to super-utilization in the pre-versus post-operative setting included AAA repair, higher Charlson, and pulmonary failure. In contrast, pre-operative super-utilizers who became low-utilizers in the post-operative setting were less likely to be African American or have undergone CABG. CONCLUSION: While 3% of pre-operative low-utilizers became super-utilizers likely due to complications, nearly one quarter of all pre-operative super-utilizers became low-utilizers following surgery suggesting success of the surgery to resolve underlying conditions associated with preoperative super-utilization.


Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Artroplastia de Reemplazo de Cadera/economía , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/economía , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Colectomía/economía , Colectomía/estadística & datos numéricos , Puente de Arteria Coronaria/economía , Puente de Arteria Coronaria/estadística & datos numéricos , Costos de la Atención en Salud , Gastos en Salud , Medicare/economía , Medicare/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Neumonectomía/economía , Neumonectomía/estadística & datos numéricos , Procedimientos Quirúrgicos Vasculares/economía , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Periodo Posoperatorio , Periodo Preoperatorio , Estados Unidos
13.
Public Health Rep ; 135(1): 114-123, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31835012

RESUMEN

OBJECTIVES: Deaths from prescription opioid overdoses have reached an epidemic level in the United States, particularly among persons with disabilities. The 2014 federal rescheduling regulation is associated with reduced opioid prescribing in the general US population; however, to date, no data have been published on this regulation's effect on persons with disabilities. We examined whether the 2014 hydrocodone rescheduling change was associated with reduced opioid prescribing among adult Medicare beneficiaries with disabilities. METHODS: We identified 680 876 Medicare beneficiaries with disabilities aged 21-64 in 2013 and 657 687 in 2015 from a 20% national sample. We examined changes in the monthly opioid-prescribing rates from January 1, 2013, through December 31, 2015. We also compared opioid-prescribing rates in 2013 with rates in 2015. RESULTS: In 2014, the percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased by 0.154% per month (95% confidence interval [CI], -0.186 to -0.121, P < .001). The percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased from 32.2% in 2013 to 27.7% in 2015, whereas rates of any opioid prescribing, prolonged prescribing (≥90-day supply), and high-dose prescribing (≥100 morphine milligram equivalents per day for >30 days) decreased only modestly, from 50.2% to 49.0%, from 27.4% to 26.5%, and from 7.5% to 7.0%, respectively. CONCLUSIONS: The 2014 federal rescheduling of hydrocodone was associated with only minor changes in overall and potentially high-risk opioid-prescribing rates. Neither state variation in long-term prescribing nor beneficiary characteristics explained the changes in persistently high opioid-prescribing rates among adults with disabilities after the 2014 regulation. Future studies should examine patient and provider characteristics underlying the persistent high-risk prescribing patterns in this population.


Asunto(s)
Analgésicos Opioides/administración & dosificación , Personas con Discapacidad/estadística & datos numéricos , Control de Medicamentos y Narcóticos/legislación & jurisprudencia , Hidrocodona/administración & dosificación , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Comorbilidad , Grupos de Población Continentales , Utilización de Medicamentos , Femenino , Humanos , Masculino , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Prescripciones/estadística & datos numéricos , Características de la Residencia , Estudios Retrospectivos , Factores Socioeconómicos , Estados Unidos , Adulto Joven
14.
Surgery ; 167(1): 211-215, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31564486

RESUMEN

BACKGROUND: Primary aldosteronism is a common cause of secondary hypertension. Treatment with adrenalectomy or mineralocorticoid receptor-blockers can prevent long-term adverse outcomes. This study aimed to determine primary aldosteronism screening rats in patients with hypertension in an underserved urban healthcare system. METHODS: We reviewed records of outpatient adults in an urban healthcare system from 2013 to 2017. Chart review along with International Statistical Classification of Diseases, 9th and 10th editions, diagnosis codes were used to identify patients meeting inclusion criteria for screening according to the 2016 Endocrine Society guidelines. The corresponding aldosterone, plasma renin activity, and 24-hour urine aldosterone values were identified. Multivariate logistic regression was performed to determine positive predictors of screening. RESULTS: Of 15,511 hypertensive patients seen, 6,809 (43.8%) met criteria for screening. Blacks were the most common racial group, and Medicare and Medicaid were the most frequent insurers. The aldosterone-to-renin ratio level was checked in 86 (1.3%) patients; 22 (25.6%) had an aldosterone-to-renin ratio >20. Of the 77 patients with hypertension and incidentaloma, 14 (18.2%) had an aldosterone-to-renin ratio checked. Additional positive predictors for being screened were hypertension and hypokalemia and sustained hypertension. CONCLUSION: Screening rates for primary aldosteronism in an underserved population are low. Proper identification of primary aldosteronism in those at risk could help ameliorate long-term effects of disease.


Asunto(s)
Adhesión a Directriz/estadística & datos numéricos , Hiperaldosteronismo/diagnóstico , Hipertensión/etiología , Tamizaje Masivo/estadística & datos numéricos , Servicios Urbanos de Salud/estadística & datos numéricos , Anciano , Aldosterona/sangre , Aldosterona/orina , Animales , Consenso , Femenino , Humanos , Hiperaldosteronismo/sangre , Hiperaldosteronismo/complicaciones , Hiperaldosteronismo/orina , Hipertensión/sangre , Hipertensión/orina , Masculino , Tamizaje Masivo/normas , Medicaid/estadística & datos numéricos , Medicare/estadística & datos numéricos , Persona de Mediana Edad , New York , Guías de Práctica Clínica como Asunto , Ratas , Renina/sangre , Estudios Retrospectivos , Estados Unidos , Servicios Urbanos de Salud/normas , Poblaciones Vulnerables/estadística & datos numéricos
15.
J Surg Res ; 245: 81-88, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31404894

RESUMEN

BACKGROUND: Delayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. METHODS: The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. RESULTS: 412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). CONCLUSIONS: ED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Heridas no Penetrantes/terapia , Escala Resumida de Traumatismos , Adolescente , Adulto , Anciano , Femenino , Hospitales Comunitarios/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Humanos , Masculino , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Medición de Riesgo/métodos , Análisis de Supervivencia , Estados Unidos , Heridas no Penetrantes/diagnóstico , Heridas no Penetrantes/mortalidad , Adulto Joven
16.
Medicine (Baltimore) ; 98(49): e18082, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31804317

RESUMEN

OBJECTIVES: Our study provides phase-specific cost estimates for pancreatic cancer based on stage and treatment. We compare treatment costs between the different phases and within the stage and treatment modality subgroups. METHODS: Our cohort included 20,917 pancreatic cancer patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed between 2000 and 2011. We allocated costs into four phases of care-staging (or surgery), initial, continuing, and terminal- and calculated the total, cancer-attributable, and patient-liability costs in 2018 US dollars. We fit linear regression models using log transformation to determine whether costs were predicted by age and calendar year. RESULTS: Monthly cost estimates were high during the staging and surgery phases, decreased over the initial and continuing phases, and increased during the three-month terminal phase. Overall, the linear regression models showed that cancer-attributable costs either remained stable or increased by year, and either were unaffected by age or decreased with older age; continuing phase costs for stage II patients increased with age. CONCLUSIONS: Our estimates demonstrate that pancreatic cancer costs can vary widely by stage and treatment received. These cost estimates can serve as an important baseline foundation to guide resource allocation for cancer care and research in the future.


Asunto(s)
Gastos en Salud/estadística & datos numéricos , Neoplasias Pancreáticas/economía , Neoplasias Pancreáticas/terapia , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Modelos Lineales , Masculino , Medicare/estadística & datos numéricos , Modelos Econométricos , Estadificación de Neoplasias , Programa de VERF , Cuidado Terminal/economía , Estados Unidos
18.
MMWR Morb Mortal Wkly Rep ; 68(43): 961-966, 2019 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-31671084

RESUMEN

Diabetes affects approximately 12% of the U.S. adult population and approximately 25% of adults aged ≥65 years. From 2009 to 2017, there was no significant change in diabetes prevalence overall or among persons aged 65-79 years (1). However, these estimates were based on survey data with <5,000 older adults. Medicare administrative data sets, which contain claims for millions of older adults, afford an opportunity to explore both trends over time and heterogeneity within an older population. Previous studies have shown that claims data can be used to identify persons with diagnosed diabetes (2). This study estimated annual prevalence and incidence of diabetes during 2001-2015 using Medicare claims data for beneficiaries aged ≥68 years and found that prevalence plateaued after 2012 and incidence decreased after 2006. In 2015 (the most recent year estimated) prevalence was 31.6%, and incidence was 3.0%. Medicare claims can serve as an important source of data for diabetes surveillance for the older population, which can inform prevention and treatment strategies.


Asunto(s)
Diabetes Mellitus/epidemiología , Medicare/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Masculino , Prevalencia , Estados Unidos/epidemiología
19.
Medicine (Baltimore) ; 98(46): e17960, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31725657

RESUMEN

Despite near universal health coverage under Medicare, racial disparities persist in the treatment of diffuse large B-cell lymphoma (DLBCL) among older patients in the United States. Studies evaluating DLBCL outcomes often treat socioeconomic status (SES) measures as confounders, potentially introducing biases when SES factors are mediators of disparities in cancer treatment.To examine differences in DLBCL treatment, we performed causal mediation analyses of SES measures, including: metropolitan statistical area (MSA) of residence; census-tract poverty level; and private Medicare supplementation using the Surveillance, Epidemiology and End Results-Medicare linked database between 2001 and 2011. In this retrospective cohort study of DLBCL patients ages 66+ years, we conducted a series of multivariable logistic regression analyses estimating odds ratios (OR) and 95% confidence intervals (CI) relating chemo- and/or immuno-therapy treatment and each SES measure, comparing non-Hispanic (NH)-black, Hispanic/Latino, and Asian/Pacific Islander (API) to NH-white patients.Compared to NH-white patients, racial/ethnic minority patients had lower odds of receiving chemo- and/or immuno-therapy treatment (NH-black: OR 0.84, 95% CI 0.65, 1.08; API: OR 0.80, 95% CI 0.64, 1.01; Hispanic/Latino: OR 0.78, 95% CI 0.64, 0.96) and higher odds of lacking private Medicare supplementation and residence within an urban MSA and poor census tracts. Adjustment for SES measures as confounders nullified observed racial differences. In causal mediation analyses, between 31% and 38% of race/ethnicity differences were mediated by having private Medicare supplementation.Providing equitable access to Medicare supplementation may reduce disparities in receipt of chemo- and/or immuno-therapy treatment in older DLBCL patients.


Asunto(s)
Grupos de Población Continentales/estadística & datos numéricos , Disparidades en Atención de Salud/etnología , Linfoma de Células B Grandes Difuso/terapia , Afroamericanos , Factores de Edad , Anciano , Anciano de 80 o más Años , Antineoplásicos/uso terapéutico , Americanos Asiáticos , Grupo de Ascendencia Continental Europea , Femenino , Hispanoamericanos , Humanos , Inmunoterapia/métodos , Modelos Logísticos , Linfoma de Células B Grandes Difuso/etnología , Linfoma de Células B Grandes Difuso/patología , Masculino , Medicare/estadística & datos numéricos , Estadificación de Neoplasias , Características de la Residencia , Estudios Retrospectivos , Programa de VERF , Factores Sexuales , Factores Socioeconómicos , Estados Unidos
20.
BMC Health Serv Res ; 19(1): 837, 2019 Nov 14.
Artículo en Inglés | MEDLINE | ID: mdl-31727168

RESUMEN

BACKGROUND: The Hospital Readmissions Reduction Program (HRRP) was established by the 2010 Patient Protection and Affordable Care Act (ACA) in an effort to reduce excess hospital readmissions, lower health care costs, and improve patient safety and outcomes. Although studies have examined the policy's overall impacts and differences by hospital types, research is limited on its effects for different types of vulnerable populations. The aim of this study was to analyze the impact of the HRRP on readmissions for three targeted conditions (acute myocardial infarction, heart failure, and pneumonia) among four types of vulnerable populations, including low-income patients, patients served by hospitals that serve a high percentage of low-income or Medicaid patients, and high-risk patients at the highest quartile of the Elixhauser comorbidity index score. METHODS: Data on patient and hospital information came from the Nationwide Readmission Database (NRD), which contained all discharges from community hospitals in 27 states during 2010-2014. Using difference-in-difference (DD) models, linear probability regressions were conducted for the entire sample and sub-samples of patients and hospitals in order to isolate the effect of the HRRP on vulnerable populations. Multiple combinations of treatment and control groups and triple difference (DDD) methods were used for testing the robustness of the results. All models controlled for the patient and hospital characteristics. RESULTS: There have been statistically significant reductions in readmission rates overall as well as for vulnerable populations, especially for acute myocardial infarction patients in hospitals serving the largest percentage of low-income patients and high-risk patients. There is also evidence of spillover effects for non-targeted conditions among Medicare patients compared to privately insured patients. CONCLUSIONS: The HRRP appears to have created the right incentives for reducing readmissions not only overall but also for vulnerable populations, accruing societal benefits in addition to previously found reductions in costs. As the reduction in the rate of readmissions is not consistent across patient and hospital groups, there could be benefits to adjusting the policy according to the socioeconomic status of a hospital's patients and neighborhood.


Asunto(s)
Cobertura del Seguro/estadística & datos numéricos , Medicare/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Poblaciones Vulnerables/estadística & datos numéricos , Humanos , Medicare/economía , Patient Protection and Affordable Care Act , Readmisión del Paciente/economía , Evaluación de Programas y Proyectos de Salud , Estados Unidos
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