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1.
Female Pelvic Med Reconstr Surg ; Publish Ahead of Print2021 Jan 04.
Artigo em Inglês | MEDLINE | ID: mdl-33411454

RESUMO

OBJECTIVE: We evaluated patterns of outpatient visits seen for urinary incontinence (UI) among women 65 years or older in the Nurses' Health Study and the general Medicare population. We were interested in understanding whether nurses, with high health literacy, may receive more care for UI than the general population. METHODS: Medicare Fee for Service claims data for women aged 66-91 years were compared for Nurses' Health Study participants (n = 3,213) and a propensity-matched sample from general Medicare Fee for Service beneficiaries (n = 3,213) with 1 or more outpatient evaluation and management visits for UI in 2012. We examined the mean number of outpatient visits for UI and the type of provider seen, using t tests and χ2 tests. Providers were categorized as specialist and nonspecialist providers using taxonomy codes. RESULTS: The percentage of women 65 years or older who had an outpatient visits for UI over 12 months was 6.4% in the Nurses' Health Study cohort and 5.4% in the general population. The mean number of office visits for UI in 2012 was similar between nurses and the matched general population (mean = 1.8 vs 1.8; P = 0.3). A small percentage of women saw both nonspecialists and specialists for UI (9.3% in the Nurses' Health Study and 10.0% in the Center for Medicare Services cohorts). CONCLUSIONS: We found that less than 7% of older women had outpatient evaluation of UI symptoms during a 12-month period, despite UI being very common in this age group. This was similar in nurses and the general population, suggesting that even high health care literacy does not increase UI care seeking.

2.
Phys Ther ; 100(10): 1862-1871, 2020 09 28.
Artigo em Inglês | MEDLINE | ID: mdl-32949237

RESUMO

OBJECTIVE: Although Medicare assessment files will include Standardized Patient Assessment Data Elements from 2016 forward, lack of uniformity of functional data prior to 2016 impedes longitudinal research. The purpose of this study was to create crosswalks for postacute care assessment measures and the basic mobility and daily activities scales of the Activity Measure for Post-Acute Care (AM-PAC) and to test their accuracy and validity in development and validation datasets. METHODS: This cross-sectional study is a secondary analysis of AM-PAC, the Inpatient Rehabilitation Facility Patient Assessment Instrument, the Minimum Data Set, and the Outcome and Assessment Information Set data from 300 adults receiving rehabilitation recruited from 6 health care networks in 1 metropolitan area. Rasch analysis was used to co-calibrate items from the 3 measures onto the AM-PAC metric and to create look-up tables to create estimated AM-PAC (eAM-PAC) scores. Mean scores and correlation and agreement between actual and estimated scores were examined in the development dataset. Scores were estimated in a cohort of Medicare beneficiaries with hip, humerus and radius fractures. Correlations between eAM-PAC and Functional Independence Measure motor scores were examined. Differences in mean eAM-PAC scores were evaluated across groups of known differences (age, fracture type, dementia). RESULTS: Strong correlations were found between actual and eAM-PAC scores in the development dataset. Moderate to strong correlations were found between the eAM-PAC basic mobility and Functional Independence Measure motor scores in the validation dataset. Differences in basic mobility scores across known groups were statistically significant and appeared to be clinically important. Differences between mean daily activities scores were statistically significant but appeared not to be clinically important. CONCLUSION: Although further testing is warranted, the basic mobility crosswalk appears to provide valid scores for aggregate analysis of Medicare postacute care data. IMPACT: This study reports on a method to take data from different Medicare administrative data sources and estimate scores on 1 scale. This approach was applied separately for data related to basic mobility and to daily activities. This may allow researchers to overcome challenges with using Medicare administrative data from different sources.


Assuntos
Pessoas com Deficiência/reabilitação , Cuidados Semi-Intensivos/métodos , Inquéritos e Questionários/normas , Atividades Cotidianas , Adulto , Estudos Transversais , Avaliação da Deficiência , Feminino , Humanos , Masculino , Medicare , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Psicometria/estatística & dados numéricos , Recuperação de Função Fisiológica , Estados Unidos , Caminhada
3.
Cancer Med ; 9(5): 1911-1921, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31925998

RESUMO

BACKGROUND: We calculated the performance of National Cancer Institute (NCI)/National Comprehensive Cancer Network (NCCN) cancer centers' end-of-life (EOL) quality metrics among minority and white decedents to explore center-attributable sources of EOL disparities. METHODS: We conducted a retrospective cohort study of Medicare beneficiaries with poor-prognosis cancers who died between April 1, 2016 and December 31, 2016 and had any inpatient services in the last 6 months of life. We attributed patients' EOL treatment to the center at which they received the preponderance of EOL inpatient services and calculated eight risk-adjusted metrics of EOL quality (hospice admission ≤3 days before death; chemotherapy last 14 days of life; ≥2 emergency department (ED) visits; intensive care unit (ICU) admission; or life-sustaining treatment last 30 days; hospice referral; palliative care; advance care planning last 6 months). We compared performance between patients across and within centers. RESULTS: Among 126,434 patients, 10,119 received treatment at one of 54 NCI/NCCN centers. In aggregate, performance was worse among minorities for ED visits (10.3% vs 7.4%, P < .01), ICU admissions (32.9% vs 30.4%, P = .03), no hospice referral (39.5% vs 37.0%, P = .03), and life-sustaining treatment (19.4% vs 16.2%, P < .01). Despite high within-center correlation for minority and white metrics (0.61-0.79; P < .01), five metrics demonstrated worse performance as the concentration of minorities increased: ED visits (P = .03), ICU admission (P < .01), no hospice referral (P < .01), and life-sustaining treatments (P < .01). CONCLUSION: EOL quality metrics vary across NCI/NCCN centers. Within center, care was similar for minority and white patients. Minority-serving centers had worse performance on many metrics.

4.
Am J Obstet Gynecol ; 222(2): 163.e1-163.e8, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31449803

RESUMO

BACKGROUND: Urinary incontinence subtypes often differ by symptom severity and treatment profiles; in particular, mixed urinary incontinence is generally associated with worse symptoms and less successful treatment. Yet, limited information exists on the natural history of different urinary incontinence subtypes, which could help to better identify and treat patients prior to development of more intractable disease. OBJECTIVE: To evaluate the onset of urinary incontinence subtypes, and transitions between subtypes over 8 years, using 2 large cohorts of middle-aged and older women with incident urinary incontinence. MATERIALS AND METHODS: We identified 10,349 women with incident urinary incontinence (stress, urgency, and mixed subtypes) from the Nurses' Health Study and the Nurses' Health Study II who were 41-83 years of age, using repeated mailed questionnaires. We defined stress urinary incontinence as leakage with coughing, sneezing, or activity; urgency urinary incontinence as urine loss with a sudden feeling of bladder fullness or when a toilet was inaccessible; and mixed urinary incontinence when women reported that stress and urgency symptoms occurred equally. In subsequent questionnaires 4 and 8 years later, we continued to track symptom severity and subtypes. In addition, to obtain predicted probabilities of urinary incontinence subtypes 4 years and 8 years after urinary incontinence onset, we used multivariable-adjusted generalized estimating equations with a multinomial outcome. RESULTS: At urinary incontinence onset in 2004-2005, 56% of women reported stress urinary incontinence symptoms, 23% reported urgency urinary incontinence symptoms, and 21% reported mixed urinary incontinence symptoms. Women with stress urinary incontinence or urgency urinary incontinence at onset were likely to report the same urinary incontinence type 4 and 8 years later (stress urinary incontinence at onset: 70% and 60% reported stress urinary incontinence at years 4 and 8, respectively; urgency urinary incontinence at onset: 68% and 64% reported urgency urinary incontinence at years 4 and 8, respectively). Nonetheless, for both stress and urgency urinary incontinence, women with more severe symptoms at onset were more likely to progress to mixed urinary incontinence. Women with mixed urinary incontinence at onset had more variation over time, although the largest subset continued to report mixed urinary incontinence (45% reported mixed urinary incontinence at year 4; 43% reported mixed urinary incontinence at year 8). Few women across all urinary incontinence subtypes reported resolution of symptoms over 4-8 years of follow-up (4-12%). When considering the likelihood of remaining with or progressing to mixed urinary incontinence over follow-up, according to age, body mass index, and urinary incontinence severity, we found that older and younger women had similar predicted probability of remaining with or progressing to mixed urinary incontinence (eg, women <60 years of age at onset with severe mixed urinary incontinence had a 54% (95% confidence interval, 53-55) probability of mixed urinary incontinence 8 years later, vs 57% (95% confidence interval, 56-58) of women ≥70 years of age with severe mixed urinary incontinence at onset). Obese women were somewhat more likely to progress to mixed urinary incontinence regardless of urinary incontinence type at onset (eg, women with body mass index <25 kg/m2 at onset with severe stress urinary incontinence had a 30% predicted probability of mixed urinary incontinence 8 years after onset, vs 36% of women with body mass index of 30+ kg/m2 at onset with severe stress urinary incontinence). CONCLUSION: Most women with incident stress and urgency urinary incontinence continued to experience similar subtype symptoms over 8 years. However, obese women and those with more severe symptoms were more likely to remain with or progress to mixed urinary incontinence.


Assuntos
Incontinência Urinária por Estresse/fisiopatologia , Incontinência Urinária de Urgência/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Progressão da Doença , Feminino , Humanos , Estudos Longitudinais , Pessoa de Meia-Idade , Obesidade/epidemiologia , Índice de Gravidade de Doença , Incontinência Urinária por Estresse/complicações , Incontinência Urinária por Estresse/epidemiologia , Incontinência Urinária de Urgência/complicações , Incontinência Urinária de Urgência/epidemiologia
5.
Soc Sci Med ; 240: 112570, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31585377

RESUMO

Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care).


Assuntos
Redes Comunitárias/classificação , Assistência à Saúde/classificação , Segregação Social/tendências , Assistência Terminal/estatística & dados numéricos , Grupo com Ancestrais do Continente Africano/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Redes Comunitárias/normas , Redes Comunitárias/estatística & dados numéricos , Grupos de Populações Continentais/estatística & dados numéricos , Assistência à Saúde/normas , Assistência à Saúde/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde , Humanos , Masculino , Assistência Terminal/métodos
6.
J Am Geriatr Soc ; 67(8): 1582-1589, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31287929

RESUMO

OBJECTIVES: As key team members caring for people with advanced illness, nurses teach patients and families about managing their illnesses and help them to understand their options. Our objective was to determine if nurses' personal healthcare experience with serious illness and end-of-life (EOL) care differs from the general population as was shown for physicians. DESIGN: Observational propensity-matched cohort study. SETTING: Fee-for-service Medicare. PARTICIPANTS: Nurses' Health Study (NHS) and a random 20% national sample of Medicare beneficiaries aged 66 years or older with Alzheimer's disease and related dementias (ADRD) or congestive heart failure (CHF) diagnosed in the hospital. MEASUREMENTS: Characteristics of care during the first year after diagnosis and the last 6 months of life (EOL). RESULTS: Among 57 660 NHS participants, 7380 had ADRD and 5375 had CHF; 3227 ADRD patients and 2899 CHF patients subsequently died. Care patterns in the first year were similar for NHS participants and the matched national sample: hospitalization rates, emergency visits, and preventable hospitalizations were no different in either disease. Ambulatory visits were slightly higher for NHS participants than the national sample with ADRD (13.1 vs 12.5 visits; P < .01) and with CHF (13.7 vs 12.5; P < .001). Decedents in the NHS and national sample had similar acute care use (hospitalization and emergency visits) in both diseases, but those with ADRD were less likely to use life-prolonging treatments such as mechanical ventilation (10.9% vs 13.5%; P = .001), less likely to die in a hospital with a stay in the intensive care unit (10.4% vs 12.1%; P = .03), and more likely to use hospice (58.9% vs 54.8%; P < .001). CHF at the EOL results were similar. CONCLUSIONS: Nurses with newly identified serious illness experience similar care as the general Medicare population. However, at EOL, nurses are more likely to choose less aggressive treatments than the patients for whom they care. J Am Geriatr Soc 67:1582-1589, 2019.


Assuntos
Doença de Alzheimer/enfermagem , Insuficiência Cardíaca/enfermagem , Enfermeiras e Enfermeiros/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Assistência Terminal/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço Prestado , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare , Pontuação de Propensão , Estados Unidos
7.
J Urol ; 202(2): 333-338, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30865568

RESUMO

PURPOSE: The aims of this investigation were to examine how often outpatient visits addressing urinary incontinence in women with self-reported incontinence symptoms occur and to explore characteristics associated with an outpatient visit for incontinence. MATERIALS AND METHODS: We studied the records of 18,576 women from the Nurses' Health Study who were 65 years old or older, reported prevalent incontinence symptoms in 2012 on a mailed questionnaire and were linked with Medicare utilization data. We compared demographic, personal and clinical characteristics in women with and without claims for outpatient visits for urinary incontinence. In logistic regression models we controlled for potential confounding factors, including age, race, parity, body mass index, medical comorbidities, smoking status, health seeking behavior, disability, physical function and geographic region. RESULTS: In this linkage between symptom report and insurance claims data we found that only 16% of older women with current incontinence symptoms also had an outpatient visit addressing incontinence in the prior 2 years. In multivariable adjusted models severe vs slight incontinence (OR 3.75, 95% CI 3.10-4.53) and urgency vs stress incontinence (OR 1.80, 95% CI 1.56-2.08) were the strongest predictors of undergoing outpatient evaluation. CONCLUSIONS: Overall only a small percent of women who report urinary incontinence symptoms also have medical outpatient visits for incontinence, which is a marker of care seeking. Our study highlights the discordance between the high prevalence of incontinence in older women and the lack of clinical assessment despite symptoms even among nurses with high health care literacy.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Incontinência Urinária , Idoso , Idoso de 80 Anos ou mais , Autoavaliação Diagnóstica , Feminino , Humanos , Incontinência Urinária/diagnóstico , Incontinência Urinária/terapia
8.
J Am Geriatr Soc ; 67(1): 29-36, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30291742

RESUMO

OBJECTIVES: To examine prostate-specific antigen (PSA) screening practice change in subgroups of men defined in guidelines and in various regions and to identify factors associated with change in screening practices. DESIGN: Observational study using serial cross-sections, 2003 to 2013. SETTING: National fee-for-service Medicare. PARTICIPANTS: Men aged 68 and older eligible for prostate cancer screening. MEASUREMENTS: National PSA screening practices in men aged 68 and older from 2003 to 2013 and change in regional screening rates in men aged 75 and older. RESULTS: The PSA screening rate in men aged 68 and older was 17.2% in 2003, 22.3% in 2008, and 18.6% in 2013 (p < .001 for all differences); rates ended slightly lower than rates in 2003 only in men 80 and older. Racial disparities in screening became less pronounced over this period. In men aged 75 and older, change in regional screening rates varied widely, with absolute rates growing by 15 per 100 enrollees in some areas and declining by the same amount in others. Areas with high social capital, a measure associated with diffusion of new ideas, were more likely to decline; malpractice intensity and managed care penetration had no effect. CONCLUSION: Studying Medicare enrollees over time, we found little reduction in PSA screening and even increases according to race and in some regions. The heterogeneous changes across regions suggest that consistent reduction in the use of low-value care may require change strategies that go beyond evidence and guidelines to include monitoring and feedback on performance. J Am Geriatr Soc 67:29-36, 2019.


Assuntos
Detecção Precoce de Câncer/tendências , Utilização de Procedimentos e Técnicas/tendências , Antígeno Prostático Específico/análise , Neoplasias da Próstata/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Detecção Precoce de Câncer/economia , Planos de Pagamento por Serviço Prestado/economia , Planos de Pagamento por Serviço Prestado/tendências , Humanos , Masculino , Medicare/economia , Medicare/tendências , Utilização de Procedimentos e Técnicas/economia , Neoplasias da Próstata/economia , Estados Unidos
9.
J Womens Health (Larchmt) ; 27(12): 1466-1473, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30118370

RESUMO

Background: To better understand health habits in older nurses versus the general population, we sought to determine whether the demographics, health care utilization, and Medicare spending by the Nurses' Health Study (NHS) participants enrolled in Medicare and a matched sample of Medicare beneficiaries meaningfully differed. Materials and Methods: Analytic cohorts included a random 20% sample of Medicare beneficiaries continuously enrolled in fee for service (FFS) Medicare that were propensity matched to the NHS participants continuously enrolled in FFS Medicare in a single year (2012). Matching was based upon preselected demographic factors and health status, using a nearest-neighbor matching algorithm to obtain a 1:1 match without replacement. Healthcare utilization and spending were compared between the two groups; we also stratified findings by number of chronic comorbidities. Results: Similar rates of utilization of primary care and most outpatient services. However, NHS participants had slightly higher rates of cancer screening, specialist care, and inpatient surgery were observed. When stratified by comorbidity status, the largest differences in utilization and spending were found in women with no comorbidity. Conclusions: The modest differences in observed healthcare utilization and spending suggest that older healthcare professionals may access care in fairly similar ways to the general population, and that health status may be a more important determinant of utilization and spending than health profession in older age groups.


Assuntos
Serviços de Saúde para Idosos/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Enfermeiras e Enfermeiros/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Feminino , Avaliação Geriátrica/métodos , Serviços de Saúde para Idosos/economia , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Revisão da Utilização de Seguros , Masculino , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , Valores de Referência , Medição de Risco , Estados Unidos
11.
Cancer Epidemiol ; 50(Pt A): 68-75, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28822325

RESUMO

INTRODUCTION: Prostate and breast cancer screening in older patients continue to be controversial. Balancing the desire for early detection with avoidance of over-diagnosis has led to competing and contradictory guidelines for both practices. Despite similarities, it is not known how these screening practices are related at the regional level. In this study, we examined how screening PSA and mammography are related within healthcare regions, and, to better understand what may be driving these practices, whether they are associated with local intensity of care. METHODS: We performed a retrospective cross-sectional study of fee-for-service Medicare beneficiaries in 2012. For each of 306 hospital referral regions (HRRs), we calculated rates of PSA screening for men aged ≥68 years, as well as rates of screening mammography for women aged ≥75 years, adjusted for age and race. Additionally, we determined regional rates of "healthcare intensity", including spending on tests and procedures, and intensity of end-of-life care. Pearson correlations of adjusted rates were calculated within HRRs. RESULTS: The mean adjusted rate of PSA screening was 22%. The mean age of screened and unscreened patients was 75.0 and 77.4 years, respectively (p<0.0001). The mean adjusted rate of screening mammography was 23%; mean ages of screened and non-screened women were 79.95 and 83.67, respectively (p<0.0001). HRR-level PSA screening rates were independent of screening mammography rates (r=0.06, p=0.31). PSA screening rates were associated with spending on testing and procedures (r=0.42, p<0.0001) and various measures of intensity of EOL care (e.g. r=0.40, p<0.0001 for mechanical ventilator use). Screening mammography had low correlation with both health care spending and EOL care intensity measures (all r-values <0.3). CONCLUSIONS: Regional rates of PSA screening rates were independent of screening mammography, thus these practices appear to be driven by different factors. Unlike mammography, PSA screening was associated with local enthusiasm for testing and treatment. Efforts to reduce over-testing should contemplate these practices differently, and future research should examine the factors motivating these screening practices.


Assuntos
Neoplasias da Mama/diagnóstico , Detecção Precoce de Câncer/normas , Hospitais/normas , Guias de Prática Clínica como Assunto/normas , Neoplasias da Próstata/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/epidemiologia , Estudos Transversais , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Masculino , Mamografia , Medicare , Determinação de Necessidades de Cuidados de Saúde , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/epidemiologia , Programas Médicos Regionais , Estudos Retrospectivos , Estados Unidos/epidemiologia
12.
Health Aff (Millwood) ; 36(7): 1309-1317, 2017 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-28679819

RESUMO

Health care spending is generally highest among people who need both complex medical care and long-term services and supports, such as adults dually eligible for Medicare and Medicaid. Understanding how different types of complex patients use services over time can inform policies that target this population. High combined Medicare and Medicaid spending are found in two distinct groups of high-cost dual eligibles: older beneficiaries who are nearing the end of life, and younger beneficiaries with sustained need for functional supports. However, both groups have high hospitalization costs. Among high-cost dual eligibles living in the community, those who are older spend less on home and community-based services than those who are younger. Greater use of such services might provide stable support in the last year or two of life, when illness and functional decline accelerate. Tailored approaches to each population's distinct needs could yield care of increased value to patients and their families, with the potential to lower costs if patients' needs can be met with fewer stays in short-term inpatient facilities.


Assuntos
Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Definição da Elegibilidade , Gastos em Saúde/estatística & dados numéricos , Cuidados Paliativos/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Medicaid/economia , Medicare/economia , Pessoa de Meia-Idade , Estados Unidos
13.
Phys Ther ; 97(3): 280-289, 2017 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-28340130

RESUMO

Background: Clinical practice guidelines recommend fall risk assessment and intervention for older adults who sustain a fall-related injury to prevent future injury and mobility decline. Objective: The aim of this study was to describe how often Medicare beneficiaries with upper extremity fracture receive evaluation and treatment for fall risk. Design: Observational cohort. Methods: Participants were fee-for-service beneficiaries age 66 to 99 treated as outpatients for proximal humerus or distal radius/ulna ("wrist") fragility fractures. -Participants were studied using Carrier and Outpatient Hospital files. The proportion of patients evaluated or treated for fall risk up to 6 months after proximal humerus or wrist fracture from 2007-2009 was examined based on evaluation, treatment, and diagnosis codes. Time to evaluation and number of treatment sessions were calculated. Logistic regression was used to analyze patient characteristics that predicted receiving evaluation or treatment. Narrow (gait training) and broad (gait training or therapeutic exercise) definitions of service were used. Results: There were 309,947 beneficiaries who sustained proximal humerus (32%) or wrist fracture (68%); 10.7% received evaluation or treatment for fall risk or gait issues (humerus: 14.2%; wrist: 9.0%). Using the broader definition, the percentage increased to 18.5% (humerus: 23.4%; wrist: 16.3%). Factors associated with higher likelihood of services after fracture were: evaluation or treatment for falls or gait prior to fracture, more comorbidities, prior nursing home stay, older age, humerus fracture (vs wrist), female sex, and white race. Limitations: Claims analysis may underestimate physician and physical therapist fall assessments, but it is not likely to qualitatively change the results. Conclusions: A small proportion of older adults with upper extremity fracture received fall risk assessment and treatment. Providers and health systems must advance efforts to provide timely evidence-based management of fall risk in this population.


Assuntos
Acidentes por Quedas , Traumatismos do Braço/terapia , Fraturas Ósseas/terapia , Idoso , Idoso de 80 Anos ou mais , Traumatismos do Braço/etiologia , Estudos de Coortes , Feminino , Fraturas Ósseas/etiologia , Marcha , Humanos , Modelos Logísticos , Masculino , Medicare , Medição de Risco , Estados Unidos
14.
JAMA Intern Med ; 176(9): 1371-8, 2016 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-27454945

RESUMO

IMPORTANCE: Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia. OBJECTIVE: To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia. DESIGN, SETTING, AND PARTICIPANTS: This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1 416 369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included. EXPOSURES: Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles. MAIN OUTCOMES AND MEASURES: Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician). RESULTS: Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22 004 vs $24 371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P < .001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups. CONCLUSIONS AND RELEVANCE: Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.


Assuntos
Continuidade da Assistência ao Paciente/estatística & dados numéricos , Demência/epidemiologia , Planos de Pagamento por Serviço Prestado , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Comorbidade , Estudos Transversais , Demência/terapia , Diagnóstico por Imagem/estatística & dados numéricos , Testes Diagnósticos de Rotina/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Gastos em Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Renda , Masculino , Medicare , Estudos Retrospectivos , Estados Unidos/epidemiologia
15.
J Am Med Dir Assoc ; 17(9): 802-6, 2016 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-27297089

RESUMO

OBJECTIVES: To identify which clinical specialties are most central for care of people with dementia in the community and long-term care (LTC) settings. DESIGN: Cross-sectional analysis. PARTICIPANTS: Fee-for-service Medicare beneficiaries aged ≥65 years with dementia. MEASUREMENTS: Specialty, categorized into primary care (internal or family medicine, geriatrics, or nurse practitioners [NPs]) versus other specialties, of the predominant provider of care (PPC) for each patient, defined by providing the most ambulatory visits. RESULTS: Among 2,598,719 beneficiaries with dementia, 74% lived in the community and 80% had a PPC in primary care. In LTC, 91% had primary care as their PPC compared with 77% in the community (P < .001). Cardiology and neurology were the most frequent specialties. NPs were PPCs for 19% of dementia patients in LTC versus 7% in the community (P < .001). CONCLUSION: It is unknown whether specialists are aware of their central role for many dementia patients' care needs. In LTC, NPs play the lead role as PPCs.


Assuntos
Demência , Casas de Saúde , Especialização , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Assistência de Longa Duração , Masculino , Medicare , Atenção Primária à Saúde , Estados Unidos
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