Outcomes after endoscopic local excision of early-stage gastric adenocarcinoma in the United States.

BACKGROUND AND OBJECTIVES: Local excision (LE) for early-stage gastric cancer has expanded in the United States over recent years, however, national outcomes are unknown. The objective of the study was to evaluate national survival outcomes following LE for early-stage gastric cancer. METHODS: Patients with resectable gastric adenocarcinoma between 2010 and 2016 were identified from the National Cancer Database then classified by LE curability into eCuraA (high) and eCuraC (low) according to Japanese Gastric Cancer Association guidelines. Demographics, clinical/provider descriptors, and perioperative/survival outcomes were extracted. Propensity-weighted cox proportional hazards regression assessed factors associated with overall survival. RESULTS: Patients were stratified into eCuraA (N = 1167) and eCuraC (N = 13,905) subgroups. Postoperative 30-day mortality (0% vs 2.8%, p < 0.001) and readmission (2.3% vs 7.8%, p = 0.005) favored LE. Local excision was not associated with survival on propensity-weighted analyses. However, among eCuraC patients, LE was associated with higher likelihood of positive margins (27.1% vs 7.0%, p < 0.001), which was the strongest predictor of poor survival (HR 2.0, p < 0.001). CONCLUSIONS: Although early morbidity is low, oncologic outcomes following LE are compromised for eCuraC patients. These findings support careful patient selection and treatment centralization in the early adoption phase of LE for gastric cancer.

Increasing utilization of endoscopic local excision for early-stage gastric cancers in the United States.

BACKGROUND: The Japanese Gastric Cancer Association provided updated criteria for endoscopic local excision of early-stage gastric cancer in 2018. The purpose of this study was to evaluate utilization patterns for endoscopic local excision in the United States for resectable gastric adenocarcinoma. METHODS: Patients with resectable gastric adenocarcinoma were identified from the National Cancer Database between 2010 and 2017. Patients were classified into strict appropriate criteria, expanded criteria, and inappropriate based on the Japanese Gastric Cancer Association guidelines. Factors associated with endoscopic local excision were identified using univariate and logistic multivariate regression. RESULTS: Within the National Cancer Database, 46,334 patients were stratified into strict appropriate criteria (n = 1,405), expanded criteria (n = 727), and inappropriate (n = 43,675). Annual cases of local excision increased by 76.9% over the study period, from 273 in 2010 to 483 in 2017. Among patients who underwent local excision, 10.1% were classified as strict appropriate criteria, 1.6% were classified as expanded criteria, and 84.5% were classified as inappropriate. Among inappropriate patients, factors associated with endoscopic local excision were: more recent year of diagnosis, increasing age, female sex, tumor located in the cardia, smaller size, low-grade, absence of lymphovascular invasion, and treatment at an academic facility. CONCLUSION: The use of endoscopic local excision for gastric cancer has nearly doubled since 2010. However, most patients do not satisfy consensus criteria for endoscopic therapy.

CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease.

STUDY OBJECTIVES: To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on health care utilization among a nationally representative and sample of older adults with multiple morbidities and pre-existing cardiovascular disease and subsequently diagnosed with obstructive sleep apnea in the United States. METHODS: Our data source was a random 5% sample of Medicare administrative claims data. All participants (n = 1,921) were of age ≥ 65 years, diagnosed with cardiovascular disease and obstructive sleep apnea, and subsequently began treatment with CPAP between 2009-2013. Based on the number of CPAP machine charges, individuals were categorized as low, partial, or high adherers (ie, < 4, 4-12, and > 12 CPAP charges, respectively). The impact of CPAP adherence status on health care utilization was assessed across multiple points of service, including outpatient encounters, inpatient stays, emergency department visits, and prescription fills over 24 months following CPAP initiation. RESULTS: Significant differences in demographic and comorbid disease characteristics were observed between low adherers (n = 377), partial adherers (n = 236), and high adherers (n = 1,308). After adjusting for covariates and relative to low adherers, high adherers demonstrated reduced inpatient visits (hazard ratio 0.75; 95% confidence interval 0.57, 0.97). CONCLUSIONS: In this nationally representative sample of older Medicare beneficiaries with multiple morbidities and relative to low adherers, high adherers demonstrated reduced inpatient utilization. CITATION: Wickwire EM, Bailey MD, Somers VK, et al. CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease. J Clin Sleep Med. 2022;18(1):39-45.

CPAP adherence is associated with reduced risk for stroke among older adult Medicare beneficiaries with obstructive sleep apnea.

STUDY OBJECTIVES: To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on risk of stroke among a nationally representative sample of older adults with obstructive sleep apnea. METHODS: We performed a retrospective cohort study among Medicare beneficiaries aged ≥ 65 years who were newly diagnosed with obstructive sleep apnea and had initiated CPAP (2009-2013). Monthly indicators of CPAP adherence included charges for machines, masks, or supplies and were summed over a 25-month follow-up to create a CPAP adherence variable. Stroke was modeled as a function of CPAP adherence using generalized estimating equations. RESULTS: We found that 5,757 beneficiaries met the inclusion criteria and were included in the final sample. Of these, 407 (7%) experienced stroke. After adjusting for demographic and clinical characteristics, CPAP adherence was associated with a reduced risk of stroke (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99) over 25 months, indicating a 2% reduction in risk of stroke for each month of CPAP adherence. When sensitivity analyses were performed to stratify results by time since the first CPAP charge, the protective effect remained significant for the 12- and 6-month but not the 3-month outcome models. CONCLUSIONS: In this national analysis of older adult Medicare beneficiaries with obstructive sleep apnea, CPAP adherence was associated with significantly reduced risk of stroke.

CPAP adherence reduces cardiovascular risk among older adults with obstructive sleep apnea.

STUDY OBJECTIVES: To examine (1) the impact of adherence to continuous positive airway pressure (CPAP) therapy on risk for cardiovascular (CVD) events among a nationally representative sample of older adults with obstructive sleep apnea (OSA), and (2) the heterogeneity of this effect across subgroups defined by race, sex, and socioeconomic status. METHODS: We conducted a retrospective cohort study among Medicare beneficiaries aged ≥ 65 years with OSA (2009-2013). Monthly indicators of CPAP adherence (charges for machines, masks, or supplies) were summed over 25 months to create a CPAP adherence variable. New CVD events (ischemic heart disease, cardiac and peripheral procedures) were modeled as a function of CPAP adherence using generalized estimating equations. Heterogeneity of the effect of CPAP on new CVD events was evaluated based on race, sex, and socioeconomic status. RESULTS: Among 5024 beneficiaries diagnosed with OSA who initiated CPAP, 1678 (33%) demonstrated new CVD events. Following adjustment for demographic and clinical characteristics, CPAP adherence was associated with reduced risk of new CVD events (hazard ratio 0.95; 95% confidence interval 0.94, 0.96) over 25 months. When analyses were stratified by time since the first CPAP charge, the protective effect remained significant for the 12- and 6-month, but not 3-month, outcome models. No significant differences were observed in the protective effect of CPAP based on race, sex, or socioeconomic status. CONCLUSIONS: In this national study of older adult Medicare beneficiaries with OSA, CPAP adherence was associated with greatly reduced risk for CVD events. This risk reduction was consistent across race, sex, and socioeconomic subgroups.

Lower socioeconomic status and co-morbid conditions are associated with reduced continuous positive airway pressure adherence among older adult medicare beneficiaries with obstructive sleep apnea.

STUDY OBJECTIVES: To examine rates of adherence to continuous positive airway pressure (CPAP) therapy among a representative sample of older adult Medicare beneficiaries with obstructive sleep apnea (OSA), and to identify demographic and health-related factors associated with CPAP adherence. METHODS: Using a 5% sample of Medicare claims data, we utilized Medicare policy and CPAP machine charges as a proxy for CPAP adherence. A cumulative logit model was used to identify demographic, medical, and psychiatric predictors of CPAP adherence status. RESULTS: Of beneficiaries who initiated CPAP (n = 3,229), 74.9% (n = 2,417) met the so-called "90-day Medicare adherence criteria," but only 58.8% of these individuals (n = 1,420) continued to use CPAP throughout the entire 13-month rent-to-own period. Anxiety, anemia, fibromyalgia, traumatic brain injury, and lower socioeconomic status (SES) were all associated with reduced CPAP adherence. CONCLUSIONS: These results provide the first national estimates of CPAP adherence among older adult Medicare beneficiaries in the United States. In addition, findings highlight the salience of medical and psychiatric comorbidity, as well as SES, as important markers of CPAP adherence among older adults in the United States. Future studies should seek to evaluate interventions to improve CPAP adherence among older adults of lower SES.

Older adult US Medicare beneficiaries with untreated obstructive sleep apnea are heavier users of health care than matched control patients.

STUDY OBJECTIVES: To examine the effect of untreated obstructive sleep apnea (OSA) on health care utilization (HCU) and costs among a nationally representative sample of Medicare beneficiaries. METHODS: Our data source was a random 5% sample of Medicare administrative claims data for years 2006-2013. OSA was operationalized as (1) receipt of one or more International Classification of Disease, Version 9, Clinical Modification diagnostic codes for OSA in combination with (2) initiation of OSA treatment with either continuous positive airway pressure or oral appliance (OA) therapy. First, HCU and costs were assessed during the 12 months prior to treatment initiation. Next, these HCU and costs were compared between beneficiaries with OSA and matched control patients without sleep-disordered breathing using generalized linear models. RESULTS: The final sample (n = 287,191) included 10,317 beneficiaries with OSA and 276,874 control patients. In fully adjusted models, during the year prior to OSA diagnosis and relative to matched control patients, beneficiaries with OSA demonstrated increased HCU and higher mean total annual costs ($19,566, 95% confidence interval [CI] $13,239, $25,894) as well as higher mean annual costs across all individual points of service. Inpatient care was associated with the highest incremental costs (ie, greater than control patients; $15,482, 95% CI $8,521, $22,443) and prescriptions were associated with the lowest incremental costs (ie, greater than control patients; $431, 95% CI $339, $522). CONCLUSIONS: In this randomly selected and nationally representative sample of Medicare beneficiaries and relative to matched control patients, individuals with untreated OSA demonstrated increased HCU and costs across all points of service.

Economic aspects of insomnia medication treatment among Medicare beneficiaries.

STUDY OBJECTIVES: To examine economic aspects of insomnia and insomnia medication treatment among a nationally representative sample of older adult Medicare beneficiaries. METHODS: Using a random 5% sample of Medicare administrative data (2006-2013), insomnia was defined using International Classification of Disease, Version 9, Clinical Modification diagnostic codes. Treatment was operationalized as one or more prescription fills for an US Food and Drug Administration (FDA)-approved insomnia medication following diagnosis, in previously untreated individuals. To evaluate the economic impact of insomnia treatment on healthcare utilization (HCU) and costs in the year following insomnia diagnosis, a difference-in-differences approach was implemented using generalized linear models. RESULTS: A total of 23 079 beneficiaries with insomnia (M age = 71.7 years) were included. Of these, 5154 (22%) received one or more fills for an FDA-approved insomnia medication following insomnia diagnosis. For both treated and untreated individuals, HCU and costs increased during the 12 months prior to diagnosis. Insomnia treatment was associated with significantly increased emergency department visits and prescription fills in the year following insomnia diagnosis. After accounting for pre-diagnosis differences between groups, no significant differences in pre- to post-diagnosis costs were observed between treated and untreated individuals. CONCLUSIONS: These results advance previous research into economics of insomnia disorder by evaluating the impact of medication treatment and highlighting important differences between treated and untreated individuals. Future studies should seek to understand why some individuals diagnosed with insomnia receive treatment but others do not, to identify clinically meaningful clusters of older adults with insomnia, and to explore the economic impact of insomnia and insomnia treatment among subgroups of individuals with insomnia, such as those with cardiovascular diseases, mood disorders, and neurodegenerative disease.