Association of Continuous Glucose Monitor Receipt and Diabetes Care Provider Type: A Cohort Study of West Virginia Medicaid Beneficiaries With Type 1 Diabetes.

OBJECTIVE: To compare the prevalence of West Virginia Medicaid (WVM) beneficiaries with type 1 diabetes (T1D) with a WVM administrative claim for continuous glucose monitoring (CGM) supplies by whether they received medical care from a board-certified endocrinologist. METHODS: A total of 1494 WVM beneficiaries aged 20-64 with T1D were retrospectively followed from May 2018 to April 2020. The sample consisted of 2 groups: those receiving medical care from board-certified endocrinologists and those receiving medical care from other providers. CGM prevalence is compared before and after WVM started providing insurance coverage for beneficiaries with T1D to use CGM systems in May 2019 using linear regression with and without adjustments for patient characteristics. RESULTS: Thirty-five percent of beneficiaries received care from a board-certified endocrinologist at any point during the sample period. Post-May 2019, the prevalence of WVM administrative claims for CGM supplies was significantly higher among beneficiaries receiving care from an endocrinologist compared with other providers. CONCLUSIONS: Receiving diabetes care from a board-certified endocrinologist is positively associated with having administrative claims for CGM supplies.

The Impact of the Flint Water Crisis on Fertility.

Flint switched its public water source in April 2014, increasing exposure to lead and other contaminants. We compare the change in the fertility rate and in health at birth in Flint before and after the water switch to the changes in other cities in Michigan. We find that Flint fertility rates decreased by 12 % and that overall health at birth decreased. This effect on health at birth is a function of two countervailing mechanisms: (1) negative selection of less healthy embryos and fetuses not surviving (raising the average health of survivors), and (2) those who survived being scarred (decreasing average health). We untangle this to find a net of selection scarring effect of 5.4 % decrease in birth weight. Because of long-term effects of in utero exposure, these effects are likely lower bounds on the overall effects of this exposure.

Glaucoma, Alzheimer disease and other dementia: a longitudinal analysis.

PURPOSE: To evaluate the risk of developing Alzheimer disease (AD) or other dementia in patients diagnosed with open-angle glaucoma (OAG) in a nationally representative longitudinal sample of elderly persons. METHODS: This retrospective cohort study (January 1, 1994-December 31, 2007) used Medicare 5% claims data. We identified beneficiaries aged 68+ years who had at least two claims with diagnoses of OAG and no Alzheimer or other dementia in 1994, using a 3-year look-back period between 1991 and 1993 (n = 63,235) and beneficiaries matched on age, sex, race, and Charlson index without a diagnosis of OAG throughout the observational period (n = 63,235), using propensity score matching. Using a Cox Proportional Hazards model, we analyzed time to AD diagnosis and time to AD or other dementia diagnosis. RESULTS: Elderly individuals diagnosed with OAG did not have an increased rate of AD and other dementia diagnosis compared to those without OAG during a 14-year follow-up period, even after controlling for relevant covariates present at baseline. CONCLUSIONS: Individuals aged 68+ years diagnosed with OAG have a decreased rate of AD or other dementia diagnosis compared to control patients without an OAG diagnosis. Although OAG and AD are both age-related neurodegenerative diseases, our findings do not support a positive association.

Ocular complications after anti-vascular endothelial growth factor therapy in Medicare patients with age-related macular degeneration.

PURPOSE: To determine longitudinal rates of ocular complications after anti-vascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (AMD) in a nationally representative longitudinal sample. DESIGN: Retrospective, longitudinal case-control study. METHODS: Using the Medicare 5% claims database, diagnoses of neovascular AMD and anti-VEGF injections of ranibizumab, bevacizumab, or pegaptanib were identified from International Classification of Diseases and Current Procedural Terminology procedure codes. Six thousand one hundred fifty-four individuals undergoing anti-VEGF treatment for neovascular AMD (total of 40 903 injections) were compared with 6154 matched controls with neovascular AMD who did not undergo anti-VEGF treatment. Propensity score matching was used to match individuals receiving anti-VEGF injections with controls. Rates of postinjection adverse outcomes (endophthalmitis, rhegmatogenous retinal detachment, retinal tear, uveitis, and vitreous hemorrhage) were analyzed by cumulative incidence and Cox proportional hazards model to control for demographic factors and ocular comorbidities. RESULTS: At the 2-year follow-up, the rates of endophthalmitis per injection (0.09%; P<.01), uveitis (0.11%; P<.01), and vitreous hemorrhage per injection (0.23%; P < .01) were significantly higher in the anti-VEGF treatment group. With Cox proportional hazards modeling, the anti-VEGF treatment group had a 102% higher risk of severe ocular complications overall and a 4% increased risk per injection, both of which were statistically significant (P<.01). CONCLUSIONS: Rates of endophthalmitis, uveitis, and vitreous hemorrhage were higher in the group treated with anti-VEGF injection than in the control group, although these nevertheless were rare in both groups. The overall risk of severe ocular complications was significantly higher in the anti-VEGF treatment group.

Severe adverse events after cataract surgery among medicare beneficiaries.

PURPOSE: To determine rates and risk factors associated with severe postoperative complications after cataract surgery and whether they have been changing over the past decade. DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: A total of 221 594 Medicare beneficiaries who underwent cataract surgery during 1994-2006. METHODS: Beneficiaries were stratified into 3 cohorts: those who underwent initial cataract surgery during 1994-1995, 1999-2000, or 2005-2006. One-year rates of postoperative severe adverse events (endophthalmitis, suprachoroidal hemorrhage, retinal detachment) were determined for each cohort. Cox regression analyses determined the hazard of developing severe adverse events for each cohort with adjustment for demographic factors, ocular and medical conditions, and surgeon case-mix. MAIN OUTCOME MEASURES: Time period rates of development of severe postoperative adverse events. RESULTS: Among the 221 594 individuals who underwent cataract surgery, 0.5% (1086) had at least 1 severe postoperative complication. After adjustment for confounders, individuals who underwent cataract surgery during 1994-1995 had a 21% increased hazard of being diagnosed with a severe postoperative complication (hazard ratio [HR] 1.21; 95% confidence interval [CI], 1.05-1.41) relative to individuals who underwent cataract surgery during 2005-2006. Those who underwent cataract surgery during 1999-2000 had a 20% increased hazard of experiencing a severe complication (HR 1.20; 95% CI, 1.04-1.39) relative to the 2005-2006 cohort. Risk factors associated with severe adverse events include a prior diagnosis of proliferative diabetic retinopathy (HR 1.62; 95% CI, 1.07-2.45) and cataract surgery combined with another intraocular surgical procedure on the same day (HR 2.51; 95% CI, 2.07-3.04). Individuals receiving surgery by surgeons with the case-mix least prone to developing a severe adverse event (HR 0.52; 95% CI, 0.44-0.62) had a 48% reduced hazard of a severe adverse event relative to recipients of cataract surgery performed by surgeons with the case-mix most prone to developing such outcomes. CONCLUSIONS: Rates of sight-threatening adverse events after cataract surgery declined during 1994-2006. Future efforts should be directed to identifying ways to reduce severe adverse events in high-risk groups.

Alcohol consumption in early adulthood and schooling completed and labor market outcomes at midlife by race and gender.

OBJECTIVES: We assessed the relation of alcohol consumption in young adulthood to problem alcohol consumption 10 years later and to educational attainment and labor market outcomes at midlife. We considered whether these relations differ between Blacks and Whites. METHODS: We classified individuals on the basis of their drinking frequency patterns with data from the 1982 to 1984 National Longitudinal Survey of Youth 1979 (respondents aged 19-27 years). We assessed alcohol consumption from the 1991 reinterview (respondents aged 26-34 years) and midlife outcomes from the 2006 reinterview (respondents aged 41-49 years). RESULTS: Black men who consumed 12 or more drinks per week at baseline had lower earnings at midlife, but no corresponding relation for Black women or Whites was found. Black men and Black women who consumed 12 or more drinks per week at baseline had lower occupational attainment than did White male non-drinkers and White female non-drinkers, respectively, but this result was not statistically significant. CONCLUSIONS: The relation between alcohol consumption in young adulthood and important outcomes at midlife differed between Blacks and Whites and between Black men and Black women, although Blacks' alcohol consumption at baseline was lower on average than was that of Whites.

Risk of glaucoma among patients with benign essential blepharospasm.

PURPOSE: Debate exists whether intraocular pressure fluctuation is a risk factor for glaucoma. Patients with benign essential blepharospasm (BEB) experience intermittent, ultra-short-term intraocular pressure elevations from frequent blinking and spastic eyelid closure. This article explores the development of incident glaucoma after BEB diagnosis. METHODS: Medicare claims files were used to identify patients with a diagnosis of BEB from 1994 to 2000. An equal-sized control group consisting of patients without BEB was created using one-to-one propensity score matching. The patients with BEB and those in the control group were followed for the development of one of the following main outcome measures: primary open angle glaucoma (POAG), closed angle glaucoma (CAG), or other glaucoma (besides POAG and CAG) over the following 2,190 days. RESULTS: There were 1,350 persons in each group, consisting of 29% men, 94% of whom were white, with a mean age of 76 years. In the unadjusted model, BEB patients did not develop POAG (hazard ratio [HR], 1.159; 95% confidence interval [CI], 0.876-1.534), CAG (HR, 1.477; 95% CI, 0.711-3.066), or other glaucoma (HR, 1.306; 95% CI, 0.904-1.886) more often than controls. Adjusting for age, gender, race, number of visits to the ophthalmologist, and other eye disease, a diagnosis of BEB did not affect the risk of POAG (HR, 1.152; 95% CI, 0.870-1.525), CAG (HR, 1.448; 95% CI, 0.696-3.015), or other glaucoma (HR, 1.296; 95% CI, 0.896-1.873). CONCLUSIONS: BEB is not a risk indicator for POAG, CAG, or other forms of glaucoma.

Receipt of care and reduction of lower extremity amputations in a nationally representative sample of U.S. Elderly.

OBJECTIVE: To determine effectiveness of receipt of care from podiatrist and lower extremity clinician specialists (LEC specialists) on diabetes mellitus (DM)-related lower extremity amputation. DATA SOURCES: Medicare 5 percent sample claims, 1991-2007. STUDY DESIGN: Individuals with DM-related lower extremity complications (LECs) were followed 6 years. Visits with podiatrists, LEC specialists, and other health professionals were tracked to ascertain whether receipt of such care reduced the hazards of an LEC amputation. DATA COLLECTION: Individuals were stratified based on disease severity, Stage 1--neuropathy, paresthesia, pain in feet, diabetic amyotrophy; Stage 2--cellulitis, charcot foot; Stage 3--ulcer; Stage 4--osteomyelitis, gangrene. PRINCIPAL FINDINGS: Half the LEC sample died within 6 years. More severe lower extremity disease increased risk of death and amputation. Persons visiting a podiatrist and an LEC specialist within a year before developing all stage complications were between 31 percent (ulceration) and 77 percent (cellulitis and charcot foot) as likely to undergo amputation compared with individuals visiting other health professionals. CONCLUSIONS: Individuals with an LEC had high mortality. Visiting both a podiatrist and an LEC specialist in the year before LEC diagnosis was protective of undergoing lower extremity amputation, suggesting a benefit from multidisciplinary care.

One-year outcomes after retinal detachment surgery among medicare beneficiaries.

PURPOSE: To determine longitudinal rates of second retinal detachment operation and postoperative adverse outcomes after retinal detachment surgery in a nationally representative sample of older Americans. DESIGN: Retrospective, longitudinal cohort analysis. METHODS: A total of 9216 Medicare beneficiaries were identified from the Medicare 5% sample who were diagnosed with rhegmatogenous retinal detachment and underwent primary pars plana vitrectomy (PPV), scleral buckle, pneumatic retinopexy, or laser photocoagulation or cryotherapy alone. Rhegmatogenous retinal detachment, PPV, scleral buckle, pneumatic retinopexy, or laser photocoagulation/cryotherapy was ascertained from International Classification of Diseases and Current Procedural Terminology procedure codes. Rates of second retinal detachment operation and postoperative adverse outcomes were analyzed by cumulative incidence and logistic regression to control for prior adverse outcome measures and demographic factors. RESULTS: At 1-year follow-up, the rate of receipt of a second retinal detachment operation for beneficiaries who had undergone primary pneumatic retinopexy was much higher (40.6%, P < .0001) relative to the scleral buckle (19.2%) group. After controlling for demographic variables and ocular comorbidities, pneumatic retinopexy individuals were nearly 3 times more likely to receive a second retinal detachment surgery than scleral buckle individuals. No significant differences exist in risk of second retinal detachment surgery for the PPV compared to the scleral buckle group. Individuals receiving PPV were 2 times more likely to suffer adverse outcomes than were those undergoing scleral buckle. Results were robust in sensitivity analysis. CONCLUSIONS: Rates of second operation were much higher after pneumatic retinopexy than PPV or scleral buckle, and rates of adverse outcomes were higher in PPV, even after controlling for risk factors and demographic variables.

Effects of receipt of guideline-recommended care on onset of diabetic retinopathy and its progression.

OBJECTIVE: To determine whether persons in a community setting diagnosed with diabetes who received recommended patterns of care experience improved vision outcomes over a 3-year time period. DESIGN: Retrospective, longitudinal, cohort analysis. PARTICIPANTS: Persons diagnosed with diabetes mellitus (DM), with no prior diagnosis of diabetic retinopathy (DR; n = 5989) from the Medicare Current Beneficiary Survey (1992-2004). Persons diagnosed with DM were followed up to 3 years. INTERVENTION: Propensity score matching was used to compare vision outcomes between persons who received guideline-recommended care and those who did not. Receipt of recommended levels of care was defined as receiving each of the following services 0.75 times annually on average: physician examination, ophthalmologist or optometrist examination, hemoglobin A1c level, lipid levels, and urinalysis. MAIN OUTCOME MEASURES: Outcome measures were indicators of DR disease progression: no diagnosed DR to diagnosed background DR, proliferative DR, macular edema, proliferative DR complications, and use of a low-vision aid or blindness. RESULTS: Persons with diagnosed diabetes receiving guideline-recommended care experienced earlier onset of background DR (average treatment effects on the treated [ATT] at 3 years, 0.118; 95% confidence interval [CI], -0.005 to 0.240). There were no differences between those receiving recommended care and others in time to onset of proliferative DR, macular edema, or proliferative DR complications. However, persons who received care consistent with recommendations experienced much lower rates of onset of low vision/blindness than did others (ATT at 3 years, -0.109; 95% CI, -0.189 to -0.030). CONCLUSIONS: Low vision/blindness was substantially reduced over a 3-year period among persons diagnosed with DM who received recommended levels of care.