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1.
J Gen Intern Med ; 2020 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-32333312

RESUMO

BACKGROUND: Prescription opioid overprescribing is a focal point for legislators, but little is known about opioid prescribing patterns of primary care nurse practitioners (NPs) and physician assistants (PAs). OBJECTIVE: To identify prescription opioid overprescribers by comparing prescribing patterns of primary care physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs). DESIGN: Retrospective, cross-sectional analysis of Medicare Part D enrollee prescription data. PARTICIPANTS: Twenty percent national sample of 2015 Medicare Part D enrollees. MAIN MEASURES: We identified potential opioid overprescribing as providers who met at least one of the following: (1) prescribed any opioid to > 50% of patients, (2) prescribed ≥ 100 morphine milligram equivalents (MME)/day to > 10% of patients, or (3) prescribed an opioid > 90 days to > 20% of patients. KEY RESULTS: Among 222,689 primary care providers, 3.8% of MDs, 8.0% of NPs, and 9.8% of PAs met at least one definition of overprescribing. 1.3% of MDs, 6.3% of NPs, and 8.8% of PAs prescribed an opioid to at least 50% of patients. NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. CONCLUSIONS: Most NPs/PAs prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs. Efforts to reduce opioid overprescribing should include targeted provider education, risk stratification, and state legislation.

2.
JAMA Netw Open ; 2(12): e1916646, 2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31800069

RESUMO

Importance: Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. Objective: To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). Design, Setting, and Participants: This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019. Exposures: Inpatient rehabilitation received in IRFs vs SNFs. Main Outcomes and Measures: Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Results: Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses. Conclusions and Relevance: In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

3.
JAMA Intern Med ; 2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31764937

RESUMO

Importance: The working schedules of hospitalists vary widely. Discontinuous schedules, such as 24 hours on and 48 hours off, result in several hospitalists providing care during a patient's hospital stay. Poor continuity of care during hospitalization may be associated with poor patient outcomes. Objective: To determine whether admitted patients receiving care from hospitalists with more discontinuous schedules experience worse outcomes. Design, Setting, and Participants: This retrospective cohort study used conditional models to assess Medicare claims data for 114 777 medical admissions of patients with a 3-day to 6-day length of stay from January 1, 2014, through November 30, 2016, who received all general medical care from hospitalists in 229 hospitals in Texas. Data were analyzed from November 2018 to June 2019. Exposures: For each admission, the weighted mean of schedule continuity for the treating hospitalists, assessed as the percentage of all their working days in that year that were part of a block of 7 or more consecutive working days, was calculated. Main Outcomes and Measures: The primary outcome was patient mortality in the 30 days after discharge. Secondary outcomes were readmission rates and Medicare costs in the 30 days after discharge, and discharge destination. Results: Of the 114 777 patient admissions, the mean (SD) age was 79.9 (8.3) years, and 70 047 (61.0%) were women. For admissions in the lowest quartile for continuity of hospitalist schedules, the hospitalists providing care worked 0% to 30% of their total working days as part of a block of 7 or more consecutive days vs 67% to 100% for hospitalists providing care for patients in the highest quartile for continuity. Patient characteristics were not associated with the continuity of working schedules for the hospitalist(s) providing care. In conditional logistic regression models, admitted patients cared for by hospitalists in the highest quartile of schedule continuity (vs the lowest quartile) had lower 30-day mortality after discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.81-0.95), lower readmission rates (aOR, 0.94; 95% CI, 0.90-0.99), higher rates of discharge to the home (aOR, 1.08; 95% CI, 1.03-1.13), and lower 30-day postdischarge costs (-$223; 95% CI, -$441 to -$7). The results were similar across a range of different methods for defining continuity of hospitalist schedules and selecting the cohort. Conclusions and Relevance: Hospitalist schedules vary widely. Admitted patients receiving care from hospitalists with schedules that promote inpatient continuity of care may experience better outcomes of hospitalization.

4.
JAMA Netw Open ; 2(11): e1915638, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31730188

RESUMO

Importance: Patients qualifying for Medicare disability have the highest rates of opioid use compared with older Medicare beneficiaries and commercial insurance beneficiaries. Research on opioid overdose deaths in this population can help identify appropriate interventions. Objective: To assess the rate of opioid overdose death and to identify its associated risk factors. Design, Setting, and Participants: This cohort study included a 20% national sample of Medicare enrollees aged 21 to 64 years whose initial Medicare entitlement was based on disability and who resided in 50 US states and Washington, DC, in 2012 to 2016. Data analyses were performed from March 15, 2019, through September 23, 2019. Exposures: Fifty-five chronic or potentially disabling conditions were selected from the Centers for Medicare & Medicaid Services Chronic Disease Data Warehouse. Main Outcomes and Measures: Opioid overdose death rate estimated from Medicare National Death Index linkage data. Results: Among 1 766 790 Medicare enrollees younger than 65 years who qualified for Medicare because of disability, the mean (SD) age was 52.2 (10.2) years, and 866 914 (49.1%) were women. These enrollees represent 14.9% (95% CI, 14.9%-15.0%) of the entire Medicare population and accounted for 80.8% (95% CI, 78.9%-82.7%) of opioid overdose deaths among all Medicare enrollees. Opioid overdose mortality in this population increased from 57.4 per 100 000 (95% CI, 53.9-61.0 per 100 000) in 2012 to 77.6 per 100 000 (95% CI, 73.5-81.8 per 100 000) in 2016. Results from the stepwise logistic regression model revealed that 3 categories of conditions are associated with opioid overdose death: substance abuse, psychiatric diseases, and chronic pain. Among the 11.1% (95% CI, 11.0%-11.2%) of adults with disability who had all 3 conditions, the rate of opioid overdose death was 363.7 per 100 000 (95% CI, 326.7-402.6 per 100 000), which is 23.4 times higher than the rate for individuals with none of the conditions (15.5 per 100 000; 95% CI, 11.6-20.1 per 100 000). Conclusions and Relevance: This study identifies differences in opioid overdose mortality among subgroups of Medicare enrollees younger than 65 years who qualify for Medicare because of disability. Understanding the heterogeneity of medical and psychiatric conditions associated with opioid use and misuse is key to developing specific, data-driven interventions targeted to each subgroup of high-risk populations.

5.
Med Care ; 57(11): 905-912, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31568165

RESUMO

BACKGROUND: It is unclear whether Medicare data can be used to identify type and degree of collaboration between primary care providers (PCPs) [medical doctors (MDs), nurse practitioners, and physician assistants] in a team care model. METHODS: We surveyed 63 primary care practices in Texas and linked the survey results to 2015 100% Medicare data. We identified PCP dyads of 2 providers in Medicare data and compared the results to those from our survey. Sensitivity, specificity, and positive predictive value (PPV) of dyads in Medicare data at different threshold numbers of shared patients were reported. We also identified PCPs who work in the same practice by Social Network Analysis (SNA) of Medicare data and compared the results to the surveys. RESULTS: With a cutoff of sharing at least 30 patients, the sensitivity of identifying dyads was 27.8%, specificity was 91.7%, and PPV 72.2%. The PPV was higher for MD-nurse practitioner/physician assistant pairs (84.4%) than for MD-MD pairs (61.5%). At the same cutoff, 90% of PCPs identified in a practice from the survey were also identified by SNA in the corresponding practice. In 5 of 8 surveyed practices with at least 3 PCPs, about ≤20% PCPs identified in the practices by SNA of Medicare data were not identified in the survey. CONCLUSIONS: Medicare data can be used to identify shared care with low sensitivity and high PPV. Community discovery from Medicare data provided good agreement in identifying members of practices. Adapting network analyses in different contexts needs more validation studies.


Assuntos
Assistência à Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Equipe de Assistência ao Paciente/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Interpretação Estatística de Dados , Assistência à Saúde/métodos , Humanos , Colaboração Intersetorial , Profissionais de Enfermagem/estatística & dados numéricos , Assistentes Médicos/estatística & dados numéricos , Médicos de Atenção Primária/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Texas , Estados Unidos
6.
Health Serv Res ; 54(6): 1223-1232, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31576566

RESUMO

OBJECTIVE: To develop and validate a claims-based comorbidity score for patients undergoing major surgery, and compare its performance with established comorbidity scores. DATA SOURCE: Five percent Medicare data from 2007 to 2014. STUDY DESIGN: Retrospective cohort study of patients aged ≥65 years undergoing six major operations (N = 99 250). DATA COLLECTION: One-year mortality was the primary outcome. Secondary outcomes were hospital mortality, 30-day mortality, 30-day readmission, and length of stay. The comorbidity score was developed in the derivation cohort (70 percent sample) using logistic regression model. The comorbidity score was calibrated and validated in the validation cohort (30 percent sample), and compared against the Charlson, Elixhauser, and Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) comorbidity scores using c-statistic, net reclassification improvement, and integrated discrimination improvement. PRINCIPAL FINDINGS: In the validation cohort, the surgery-specific comorbidity score was well calibrated and performed better than the Charlson, Elixhauser, and CMS-HCC comorbidity scores for all outcomes; the performance was comparable to the CMS-HCC for 30-day readmission. For example, the surgery-specific comorbidity score (c-statistic = 0.792; 95% CI, 0.785-0.799) had greater discrimination than the Charlson (c-statistic = 0.747; 95% CI, 0.739-0.755), Elixhauser (c-statistic = 0.747; 95% CI, 0.735-0.755), or CMS-HCC (c-statistic = 0.755; 95% CI, 0.747-0.763) scores in predicting 1-year mortality. The net reclassification improvement and integrated discrimination improvement were greater for surgery-specific comorbidity score compared to the Charlson, Elixhauser, and CMS-HCC scores. CONCLUSIONS: Compared to commonly used comorbidity measures, a surgery-specific comorbidity score better predicted outcomes in the surgical population.


Assuntos
Comorbidade , Guias como Assunto , Mortalidade Hospitalar , Classificação Internacional de Doenças/normas , Risco Ajustado/normas , Procedimentos Cirúrgicos Operatórios/classificação , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Modelos Logísticos , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Estados Unidos
8.
Ann Intern Med ; 170(11): 749-755, 2019 06 04.
Artigo em Inglês | MEDLINE | ID: mdl-31108502

RESUMO

Background: Whether readmission rates vary by primary care physician (PCP) is unknown, although federal policy holds PCPs accountable for reducing readmissions. Objective: To determine whether 30-day readmission rates vary by PCP. Design: Retrospective cohort study using marginal models and multilevel logistic regression with 100% of data on Texas Medicare claims from 2008 to 2015. Setting: Texas. Participants: Patients discharged alive between 1 January 2008 and 30 November 2015 who had a PCP in the prior year and whose PCP had at least 50 admissions in the study period. Measurements: Readmission within 30 days of discharge. Follow-up visits with a PCP within 7 days of discharge were also measured. Results: Between 2012 and 2015, the mean risk-standardized rate of 30-day readmissions was 12.9%. Of 4230 PCPs, 1 had a readmission rate that was significantly higher than the mean and none had a significantly lower rate. The 10th and 90th percentiles of PCP readmission rates were 12.4% and 13.4%, respectively, each only 0.5 percentage point different from the mean. The 99th percentile of PCP readmission rates was 14.0%, 1.1 percentage points higher than the mean. Detecting a 1.1-percentage point difference from the mean adjusted readmission rate would require more than 3500 admissions per PCP per year. Limitations: Only fee-for-service Medicare patients in a single state were included. The authors could not account for confounders not included in Medicare databases or classify readmissions as avoidable. Conclusion: Variation in readmission rates among PCPs is very low. Programs holding PCPs accountable for readmissions may prove ineffective. Primary Funding Source: National Institutes of Health.


Assuntos
Readmissão do Paciente/estatística & dados numéricos , Médicos de Atenção Primária , Padrões de Prática Médica , Planos de Pagamento por Serviço Prestado , Política de Saúde , Humanos , Medicare/economia , Médicos de Atenção Primária/economia , Reembolso de Incentivo , Estudos Retrospectivos , Texas , Estados Unidos
10.
J Thorac Dis ; 11(3): 873-881, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31019776

RESUMO

Background: Lung cancer is the most common cancer killer annually, yet the overall rate of eligible patients who undergo screening with low-dose computed tomography (LDCT) is low. Our goal was to determine factors which were associated with the probability of obtaining lung cancer screening. Methods: The Clinformatics Data Mart (CDM) database, a national commercial health insurance database with over 18,000,000 enrollees, was queried to determine the rate of LDCT screening and factors which influenced receiving LDCT screening. All enrollees between the ages of 55 and 77 from 2016 to 2017 were included. Demographics, history of tobacco exposure and state smoking statistics were recorded. Results: All 8,350,197 enrollees aged 55-77 were included in the study. Among enrollees, the rate of screening increased throughout 2016 and early 2017 and then appeared to stabilize. In the second half of 2017 the LDCT rate was approximately 6 per 1,000 enrollees per year, and was increasing at a slope of 0.1 additional LDCT per 1,000 enrollees per year. There was marked geographic variation, with 5-fold differences in LDCT rates between different regions. There was no correlation between smoking rate and LDCT rate at the state level (r=0.02; P=0.87). Enrollees aged 65-69 were most likely to be screened (OR =1.53; 1.45-1.61) compared to enrollees aged 55-59. Conclusions: The rate of LDCT screening is increasing very slowly with time, and most eligible patients are not screened. Further studies are needed to determine the reasons for low screening rates, and the marked geographic variation.

11.
Mayo Clin Proc Innov Qual Outcomes ; 3(1): 70-77, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30899910

RESUMO

Objective: To describe rates of low-dose computed tomography (LDCT) and all chest computerized tomography (CT) before and after Centers for Medicare and Medicaid Services (CMS) initiated reimbursement and requirements for screening and to describe factors associated with receipt of LDCT. Patients and Methods: Retrospective cross-sectional study of Medicare enrollees aged 55 to 77 in Parts A and B Medicare without HMO enrollment in a 20% national sample (n=3,887,430 in 2010, 4,200,875 in 2015, and 4,145,542 in 2016). The outcomes were receipt of LDCT and any chest CT from January 1, 2010, to December 31, 2016. Other measures included enrollee demographic characteristics and diagnoses, including diagnoses of tobacco use. Results: The number of enrollees aged 55 to 77 with LDCT rose throughout 2015 and early 2016, and then plateaued. In 2016, 0.44% of enrollees, and 2.21% of those with a tobacco-use diagnosis, underwent LDCT screening. There were increases in the rate of any chest CT (LDCT or diagnostic) between January 1, 2010 and December 31, 2016, and most of this was accounted for by LDCTs. Conclusions: Two years after CMS approval for lung cancer screening reimbursement, less than 5% of the Medicare population eligible for screening received LDCT. More work is required to identify and modify the barriers for LDCT screening.

13.
Health Commun ; 34(7): 702-706, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-29373069

RESUMO

Differences exist across breast cancer screening guidelines regarding frequency of screening and age of discontinuation for older women (≥70 years) at average risk for breast cancer. These differences highlight concerns about the benefits and harms of screening, and may negatively impact older women's ability to make informed screening decisions. This study examined preferences for communicating about screening mammography among racially/ethnically diverse, older women. In-depth interviews were conducted with 59 women with no breast cancer history. Non-proportional quota sampling ensured roughly equal numbers on age (70-74 years, ≥75 years), race/ethnicity (non-Hispanic/Latina White, non-Hispanic/Latina Black, Hispanic/Latina), and education (≤high school diploma, >high school diploma). Interviews were audio-recorded, transcribed, and analyzed using NVivo 10. Thematic analyses revealed that rather than being told to get mammograms, participants wanted to hear about the benefits and harms of screening mammography, including overdiagnosis. Participants recommended that this information be communicated via physicians or other healthcare providers, included in brochures/pamphlets, and presented outside of clinical settings (e.g., in senior groups). Results were consistent regardless of participants' age, race/ethnicity, or education. Findings revealed that older women desire information about the benefits and harms of screening mammography, and would prefer to learn this information through discussions with healthcare providers and multiple other formats.

16.
BMJ Open ; 8(6): e022138, 2018 06 14.
Artigo em Inglês | MEDLINE | ID: mdl-29903800

RESUMO

OBJECTIVES: Current research on the perceptions of overdiagnosis or overdetection of breast cancer has largely been conducted outside of the USA and with women younger than 70 years.Therefore, we explored older women's perceptions about the concept of overdetection of breast cancer and its influence on future screening intentions. DESIGN: Mixed-methods analysis using purposive sampling based on race/ethnicity, age and educational level. Semistructured interviews, including two hypothetical scenarios illustrating benefits and harms of screening and overdetection, were analysed using inductive and deductive thematic approaches. An inferential clustering technique was used to assess overall patterns in narrative content by sociodemographic characteristics, personal screening preferences or understanding of overdetection. SETTING: Houston/Galveston, Texas, USA. PARTICIPANTS: 59 English-speaking women aged 70 years and older with no prior history of breast cancer. RESULTS: Very few women were familiar with the concept of overdetection and overtreatment. After the scenarios were presented, half of the women still demonstrated a lack of understanding of the concept of overdetection. Many women expressed suspicion of the concept, equating it to rationing. Women who showed understanding of overdetection were more likely to express an intent to discontinue screening, although 86% of the women stated that hearing about overdetection did not influence their screening decision. Themes identified did not differ by race/ethnicity, education, age or screening preferences. Differences were identified between women who understood overdetection and women who did not (r=0.23, p<0.001). CONCLUSIONS: Many older women did not understand the concept of overdetection, in addition to being suspicious of or resistant to the concept. Providing older women with descriptions of overdetection may not be sufficient to influence screening intentions.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Detecção Precoce de Câncer , Mamografia , Sobremedicalização , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisões , Feminino , Humanos , Entrevistas como Assunto , Programas de Rastreamento , Percepção , Texas
17.
J Am Med Dir Assoc ; 19(10): 896-901, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29691152

RESUMO

OBJECTIVE: Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings. DESIGN: Retrospective cohort study. SETTING: Acute care hospitals. PARTICIPANTS: Medicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge. MEASUREMENTS: 90-day unplanned readmissions. RESULTS: The cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings. CONCLUSIONS: We observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care.


Assuntos
Planos de Pagamento por Serviço Prestado , Alta do Paciente , Readmissão do Paciente/estatística & dados numéricos , Cuidados Semi-Intensivos , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Substituição , Estudos de Coortes , Cuidado Periódico , Feminino , Fraturas do Quadril/epidemiologia , Humanos , Masculino , Medicare , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem , Acidente Vascular Cerebral/epidemiologia , Estados Unidos/epidemiologia
18.
J Am Geriatr Soc ; 66(5): 945-953, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29656382

RESUMO

OBJECTIVES: To examine how an October 2014 Drug Enforcement Administration policy reclassified hydrocodone product from schedule III to II has affected older adults, who are among the largest consumers of prescription opioids in the United States. DESIGN: Retrospective cohort study. SETTING: United States. PARTICIPANTS: A 20% sample of Medicare Part D beneficiaries aged 65 and older from 2013 through 2015 (> 2,500,000 beneficiaries each year) MEASUREMENTS: From January 2013 to December 2015, we calculated the monthly prevalence of opioid prescriptions and the prevalence of individuals who received prescriptions for a 90-day supply or longer (prolonged), as well as hospitalizations related to opioid toxicity in 2013 and 2015. RESULTS: From 2013 to 2015, the proportion of Medicare Part D enrollees who received a hydrocodone prescription in a year decreased from 21.9% to 18.3%. Monthly rates for hydrocodone prescriptions declined significantly in 2014. The risk of receiving prolonged opioid prescriptions decreased by approximately 7% in the multivariable analyses comparing 2015 to 2013 (prevalence ratio=0.93, 95% confidence interval (CI)=0.93-0.94). Medicare enrollees with an original entitlement because of disability or with Medicaid eligibility had smaller decreases in prolonged prescriptions and, unexpectedly, small increases in high-dose prescriptions. Opioid-related hospitalizations did not change significantly, but opioid-related hospitalizations without a documented opioid prescription increased (odds ratio=1.24, 95% CI=1.03-1.50). CONCLUSION: The 2014 change in hydrocodone from schedule III to schedule II was associated with modest decreases in rates of opioid use in the elderly. The unexpected increase in opioid-related hospitalizations without documented opioid prescriptions may represent an increase in illegal use.


Assuntos
Analgésicos Opioides/provisão & distribução , Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Hidrocodona/provisão & distribução , Hidrocodona/uso terapêutico , Padrões de Prática Médica , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Medicare Part D , Transtornos Relacionados ao Uso de Opioides , Estudos Retrospectivos , Estados Unidos
19.
J Am Geriatr Soc ; 66(10): 1880-1886, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29656399

RESUMO

OBJECTIVES: To determine how the risk of subsequent long-term care (LTC) placement varies between skilled nursing facilities (SNFs) and the SNF characteristics associated with this risk. DESIGN: Population-based national cohort study with participants nested in SNFs and hospitals in a cross-classified multilevel model. SETTING: SNFs (N=6,680). PARTICIPANTS: Fee-for-service Medicare beneficiaries (N=552,414) discharged from a hospital to a SNF in 2013. MEASUREMENTS: Participant characteristics from Medicare data and the Minimum Data Set. SNF characteristics from Medicare and Nursing Home Compare. Outcome was a stay of 90 days or longer in a LTC nursing home within 6 months of SNF admission. RESULTS: Within 6 months of SNF admission, 10.4% of participants resided in LTC. After adjustments for participant characteristics, the SNF where a participant received care explained 7.9% of the variance in risk of LTC, whereas the prior hospital explained 1.0%. Individuals in SNFs with excellent quality ratings had 22% lower odds of transitioning to LTC than those in SNFs with poor ratings (odds ratio=0.78, 95% confidence interval=0.74-0.84). Variation between SNFs and associations with quality markers were greater in sensitivity analyses limited to individuals least likely to require LTC. Results were essentially the same in a number of other sensitivity analyses designed to reduce potential confounding. CONCLUSION: Risk of subsequent LTC placement, an important and negatively viewed outcome for older adults, varies substantially between SNFs. Individuals in higher-quality SNFs are at lower risk.


Assuntos
Instituição de Longa Permanência para Idosos/estatística & dados numéricos , Assistência de Longa Duração/estatística & dados numéricos , Medicare/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Feminino , Humanos , Masculino , Análise Multinível , Estados Unidos
20.
Semin Thorac Cardiovasc Surg ; 30(3): 350-359, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29549015

RESUMO

Video-assisted thoracoscopic surgery may be associated with less morbidity than open lobectomy or segmentectomy, but some studies have questioned the benefit of thoracoscopic surgery. This study aimed to determine trends and factors associated with patient's likelihood of undergoing thoracoscopic lobectomy or segmentectomy and to compare outcomes with each approach. This retrospective study included adult patients undergoing pulmonary lobectomy or segmentectomy from the American College of Surgeons National Surgical Quality Improvement Project from 2007 to 2015 (n = 14,717). Logistic regression analysis was conducted to determine the association of patient demographics, clinical characteristics, and surgeon specialty with thoracoscopic lobectomy or segmentectomy. Propensity score matching was performed to evaluate outcomes for thoracoscopic and open lobectomy or segmentectomy. Use of thoracoscopic lobectomy or segmentectomy increased from 11.6% in 2007 to 60.6% in 2015 (P< 0.0001). Older patients, females, and Hispanics were more likely to undergo thoracoscopic lobectomy, whereas morbidly obese patients, patients with higher American Society of Anesthesiology class, and patients with 4-6 frailty conditions had a lower likelihood of receiving thoracoscopic lobectomy or segmentectomy. Thoracic surgeons had 57% (odds ratio 1.57, 95% confidence interval 1.36-1.81) higher odds of performing thoracoscopic surgery than other surgeons. Thoracoscopic lobectomy or segmentectomy reduced risk of 30-day mortality (1.0% vs 1.9%; odds ratio 0.51, 95% confidence interval 0.37-0.70) and resulted in shorter length of stay (4 days vs 6 days; Beta coefficient = -0.37, P < 0.0001), and fewer complications. The frequency of thoracoscopic lobectomy or segmentectomy has increased substantially over the last 10 years and now accounts for over half of lobectomies. Video-assisted thoracoscopic surgery showed better outcomes than open lobectomy or segmentectomy.


Assuntos
Pneumonectomia/tendências , Padrões de Prática Médica/tendências , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Cirurgia Torácica Vídeoassistida/tendências , Fatores Etários , Idoso , Comorbidade , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonectomia/efeitos adversos , Pneumonectomia/mortalidade , Pneumonectomia/normas , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/mortalidade , Cirurgia Torácica Vídeoassistida/normas , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
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