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1.
Am Surg ; 85(10): 1079-1082, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657298

RESUMO

The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AVG (P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure (P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Diálise Renal/estatística & dados numéricos , Especialidades Cirúrgicas/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Idoso , Feminino , Cirurgia Geral/estatística & dados numéricos , Humanos , Masculino , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Razão de Chances , Sistema de Registros , Estudos Retrospectivos , Cirurgiões/classificação , Cirurgia Torácica/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
3.
Am Heart J ; 207: 19-26, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30404047

RESUMO

BACKGROUND: A key quality metric for Accountable Care Organizations (ACOs) is the rate of hospitalization among patients with heart failure (HF). Among this patient population, non-HF-related hospitalizations account for a substantial proportion of admissions. Understanding the types of admissions and the distribution of admission types across ACOs of varying performance may provide important insights for lowering admission rates. METHODS: We examined admission diagnoses among 220 Medicare Shared Savings Program ACOs in 2013. ACOs were stratified into quartiles by their performance on a measure of unplanned risk-standardized acute admission rates (RSAARs) among patients with HF. Using a previously validated algorithm, we categorized admissions by principal discharge diagnosis into: HF, cardiovascular/non-HF, and noncardiovascular. We compared the mean admission rates by admission type as well as the proportion of admission types across RSAAR quartiles (Q1-Q4). RESULTS: Among 220 ACOs caring for 227,356 patients with HF, the median (IQR) RSAARs per 100 person-years ranged from 64.5 (61.7-67.7) in Q1 (best performers) to 94.0 (90.1-99.9) in Q4 (worst performers). The mean admission rates by admission types for ACOs in Q1 compared with Q4 were as follows: HF admissions: 9.8 (2.2) vs 14.6 (2.8) per 100 person years (P < .0001); cardiovascular/non-HF admissions: 11.1 (1.6) vs 15.9 (2.6) per 100 person-years (P < .0001); and noncardiovascular admissions: 42.7 (5.4) vs 69.6 (11.3) per 100 person-years (P < .0001). The proportion of admission due to HF, cardiovascular/non-HF, and noncardiovascular conditions was 15.4%, 17.5%, and 67.1% in Q1 compared with 14.6%, 15.9%, and 69.4% in Q4 (P < .007). CONCLUSIONS: Although ACOs with the best performance on a measure of all-cause admission rates among people with HF tended to have fewer admissions for HF, cardiovascular/non-HF, and noncardiovascular conditions compared with ACOs with the worst performance (highest admission rates), the largest difference in admission rates were for noncardiovascular admission types. Across all ACOs, two-thirds of admissions of patients with HF were for noncardiovascular causes. These findings suggest that comprehensive approaches are needed to reduce the diverse admission types for which HF patients are at risk.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Insuficiência Cardíaca/epidemiologia , Admissão do Paciente/estatística & dados numéricos , Organizações de Assistência Responsáveis/classificação , Organizações de Assistência Responsáveis/normas , Idoso , Algoritmos , Análise de Variância , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Comorbidade , Feminino , Insuficiência Cardíaca/diagnóstico , Hospitalização/estatística & dados numéricos , Humanos , Classificação Internacional de Doenças , Masculino , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/normas , Assistência Centrada no Paciente/estatística & dados numéricos , Distribuição por Sexo , Fatores de Tempo , Estados Unidos
4.
Popul Health Manag ; 22(2): 162-168, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-29957155

RESUMO

The US health care system faces rising costs related to population aging, among other factors. One aspect of the high costs related to aging is Medicare outpatient therapy expenditures, which in 2010 totaled $5.642B for ∼4.7 million beneficiaries. Given the magnitude of these costs and the need to maximize value, this study developed and tested a predictive model of outpatient therapy costs. Retrospective analysis was performed on electronic medical record data from October 31, 2014-September 30, 2016 for 15,468 Medicare cases treated by physical therapists associated with a large, national rehabilitation provider. The analysis was a multiple linear regression of cost per case by 27 predictor variables: age group, sex, recent hospitalization, community vs. facility residence, the 10 states served, time from admission to initial evaluation, initial functional limitation reporting level, functional limitation reporting category, and 9 chronic conditions. The model was designed to be predictive and includes only variables available at the start of a case. The model was statistically significant (P < .0001) but explained only 7.4% of the variance in cost. Of the predictor variables, 16 had statistically significant effects. Those most highly predictive included state in which service was provided (8 of the 16 effects), and 3 variables indicating physical functioning at initial evaluation (initial functional limitation category and level, and residence in community vs. facility). There is need for more research focusing on the effects of specific types of treatment, and also for a more proactive model for outpatient therapy reimbursement that emphasizes prevention as well as treatment.


Assuntos
Assistência Ambulatorial , Serviços de Assistência Domiciliar , Medicare Part B , Modalidades de Fisioterapia , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/economia , Assistência Ambulatorial/métodos , Assistência Ambulatorial/estatística & dados numéricos , Feminino , Serviços de Assistência Domiciliar/economia , Serviços de Assistência Domiciliar/estatística & dados numéricos , Humanos , Masculino , Medicare Part B/economia , Medicare Part B/estatística & dados numéricos , Pessoa de Meia-Idade , Modalidades de Fisioterapia/economia , Modalidades de Fisioterapia/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia
5.
Arch Phys Med Rehabil ; 100(1): 78-85, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30179590

RESUMO

OBJECTIVE: To determine if there was a change in the number of outpatient physical therapy (PT) and occupational therapy (OT) visits for Medicare beneficiaries, and in the number of beneficiaries receiving extended courses of >12 therapy visits, after the Jimmo vs Sebelius settlement. DESIGN: Cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS) comparing calendar years 2011-2012 to 2014-2015. SETTING: Community in-home survey. PARTICIPANTS: Medicare Part-B recipients who received outpatient PT/OT (N=1183, median age 70.8) during pre-Jimmo settlement (2011-2012) and post-Jimmo settlement (2014-2015) time periods. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Number of therapy visits/patient/year and number of subjects who received >12 therapy visits/year estimated by linear and logistic regressions controlling for potential confounders (age, body mass index [BMI], and geographic region). RESULTS: The unadjusted median number of therapy visits/year increased from 7 to 8 after the settlement. Linear regression estimated a 1.02 increase in the number of therapy visits after the settlement (95% confidence interval [CI] 0.23, 1.80; P=.01). The odds of having >12 therapy visits/year increased (odds ratio=1.41; 95% CI 1.02,1.96; P=.04). We observed a significant interaction between race and the effect of the settlement on the odds of having >12 therapy visits (OR 3.64; 95% CI 1.58, 8.39). Non-Hispanic white subjects saw an increase in utilization while a combined group of black, Hispanic and Asian subjects' utilization declined. CONCLUSION: Utilization of outpatient PT/OT changed after the 2013 Jimmo settlement. Further research is needed to determine the effect on patient outcomes and cost.


Assuntos
Medicare Part B/estatística & dados numéricos , Terapia Ocupacional/estatística & dados numéricos , Pacientes Ambulatoriais/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Modalidades de Fisioterapia/estatística & dados numéricos , Afro-Americanos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Grupos de Populações Continentais/estatística & dados numéricos , Estudos Transversais , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Modelos Lineares , Masculino , Razão de Chances , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Estudos Retrospectivos , Estados Unidos
6.
Am J Ophthalmol ; 195: 110-120, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30081016

RESUMO

PURPOSE: We conducted a secondary analysis of a randomized, placebo-controlled trial to test if hormone therapy (HT) altered the risk of open-angle glaucoma (OAG), and if the risk reduction varied by race. DESIGN: Secondary analysis of randomized controlled trial data. METHODS: We linked Medicare claims data to 25 535 women in the Women's Health Initiative. Women without a uterus were randomized to receive either oral conjugated equine estrogens (CEE 0.625 mg/day) or placebo, and women with a uterus received oral CEE and medroxyprogesterone acetate (CEE 0.625 mg/day + MPA 2.5 mg/day) or placebo. We used Cox proportional hazards models to calculate hazard ratios (HR) and 95% confidence interval. RESULTS: After exclusion of women with prevalent glaucoma or without claims for eye care provider visits, the final analysis included 8102 women (mean age = 68.5 ± 4.8 years). The OAG incidence was 7.6% (mean follow-up = 11.5 ± 5.2 years; mean HT duration = 4.4 ± 2.3 years). Increased age (P trend = .01) and African-American race (HR = 2.69, 95% CI = 2.13-3.42; white as a reference) were significant risk factors for incident OAG. We found no overall benefit of HT in reducing incident OAG (HR = 1.01, 95% CI = 0.79-1.29 in the CEE trial, and HR = 1.05, 95% CI = 0.85-1.29 in the CEE + MPA trial). However, race modified the relationship between CEE use and OAG risk (P interaction = .01), and risk was reduced in African-American women treated with CEE (HR = 0.49, 95% CI = 0.27-0.88), compared to placebo. Race did not modify the relation between CEE + MPA use and OAG risk (P interaction = .68). CONCLUSIONS: Analysis suggests that HT containing estrogen, but not a combination of estrogen and progesterone, reduces the risk of incident OAG among African-American women. Further investigation is needed.


Assuntos
Terapia de Reposição de Estrogênios , Glaucoma de Ângulo Aberto/etnologia , Idoso , Método Duplo-Cego , Terapia de Reposição de Estrogênios/estatística & dados numéricos , Estrogênios Conjugados (USP)/administração & dosagem , Grupos Étnicos , Feminino , Humanos , Incidência , Medicare Part B/estatística & dados numéricos , Acetato de Medroxiprogesterona/administração & dosagem , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de Risco , Estados Unidos/epidemiologia , Saúde da Mulher
7.
JAMA Ophthalmol ; 136(7): 738-745, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29800973

RESUMO

Importance: Considerable variation exists with respect to the profiles of patients who receive cataract surgery in the United States. Objective: To identify patient characteristics associated with receiving cataract surgery within the US Medicare and Veterans Health Administration (VHA) populations. Design, Setting, and Participants: In this population-based retrospective cohort study of 3 073 465 patients, Medicare and VHA patients with a cataract diagnosis between January 1, 2002, and January 1, 2012, were identified from the 2002-2012 Medicare Part B files (5% sample) and the VHA National Patient Care Database. Patient age, sex, race/ethnicity, region of residence, Charlson Comorbidity Index (CCI) scores, and comorbidities were recorded. Cataract surgery at 1 and 5 years after diagnosis was identified. Data analysis was performed from July 1, 2016, to July 1, 2017. Main Outcomes and Measures: Odds ratios (ORs) of cataract surgery for selected patient characteristics. Results: The study sample included 1 156 211 Medicare patients (mean [SD] age, 73.7 [7.0] years) and 1 917 254 VHA patients (mean [SD] age, 66.8 [10.2] years) with a cataract diagnosis. Of the 1 156 211 Medicare patients, 407 103 (35.2%) were 65 to 69 years old, 683 036 (59.1%) were female, and 1 012 670 (87.6%) were white. Of the 1 917 254 VHA patients, 905 455 (47.2%) were younger than 65 years, 1 852 158 (96.6%) were male, and 539 569 (28.1%) were white. A greater proportion of Medicare patients underwent cataract surgery at 1 year (Medicare: 213 589 [18.5%]; VHA: 120 196 [6.3%]) and 5 years (Medicare: 414 586 [35.9%]; VHA: 240 884 [12.6%]) after diagnosis. Factors associated with the greatest odds of surgery at 5 years were older age per 5-year increase (Medicare: OR, 1.24 [95% CI, 1.23-1.24]; VHA: OR, 1.18 [95% CI, 1.17-1.18]), residence in the southern United States vs eastern United States (Medicare: OR, 1.38 [95% CI, 1.36-1.40]; VHA: OR, 1.40 [95% CI, 1.38-1.41]), and presence of chronic pulmonary disease (Medicare: OR, 1.26 [95% CI, 1.24-1.27]; VHA: OR, 1.40 [95% CI, 1.38-1.41]). Within Medicare, female sex was associated with greater odds of surgery at 5 years (OR, 1.14; 95% CI, 1.13-1.15). Higher CCI scores (CCI score ≥3 vs 0-2) were associated with increased odds of surgery among VHA but not Medicare patients at 5 years (Medicare: OR, 0.94 [95% CI, 0.92-0.95]; VHA: OR, 1.24 [95% CI, 1.23-1.36]). Black race vs white race was associated with decreased odds of cataract surgery 5 years after diagnosis (Medicare: OR, 0.79 [95% CI, 0.78-0.81]; VHA: OR, 0.75 [95% CI, 0.73-0.76]). Conclusions and Relevance: Within both groups, older age, residence in the southern United States, and presence of chronic pulmonary disease were associated with increased odds of cataract surgery. Findings from this study suggest that few disparities exist between the types of patients receiving cataract surgery who are in Medicare vs the VHA, although it is possible that a smaller proportion of VHA patients receive surgery compared with Medicare patients.


Assuntos
Extração de Catarata/estatística & dados numéricos , Assistência à Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , United States Department of Veterans Affairs/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Catarata/diagnóstico , Estudos de Coortes , Feminino , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Estados Unidos/epidemiologia
8.
Am J Manag Care ; 24(2): e59-e60, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-29461852

RESUMO

OBJECTIVES: Price markups are a major cause of healthcare inflation and financial harm to patients, especially those who are self-paying or covered by commercial insurance. STUDY DESIGN: Retrospective analysis of publicly-available information on Medicare physician payments, representing 100% of Part B services provided to fee-for-service beneficiaries during calendar year 2014. METHODS: Outcomes were markup ratios for oncology services, defined as the ratio of submitted charges to the amount reimbursed by Medicare. For example, the overall cost-to-charge ratio for all Medicare-reimbursed services in 2013 was 3.4, or a 240% charge markup. RESULTS: Our analysis included oncology services provided by 3248 hospitals in all 50 states. There was significant variation in markup ratios by hospital across oncology specialty: radiology (median = 3.7; interquartile range [IQR], 3.1-4.5), hematology/oncology (median = 2.3; IQR, 1.8-2.9), medical oncology (median = 2.4; IQR, 1.8-3.0), pathology (median = 4.1; IQR 3.1-5.1), and radiation oncology (median = 3.6; IQR, 2.9-4.5). Higher markups were associated with for-profit status for medical oncology services (coefficient, 0.29; 95% CI, 0.12-0.45) and prestige status for radiology (0.53; 95% CI, 0.15-0.92) and pathology (0.65; 95% CI, 0.20-1.09) services. CONCLUSIONS: High markups exist for oncology services, and further legislation is needed to protect patients from highly variable pricing and to address disparities in access to high-quality cancer care.


Assuntos
Assistência Ambulatorial/economia , Planos de Pagamento por Serviço Prestado/economia , Gastos em Saúde/estatística & dados numéricos , Oncologia/economia , Medicare Part B/estatística & dados numéricos , Custos e Análise de Custo , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos
9.
Ophthalmology ; 125(7): 984-993, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29433851

RESUMO

PURPOSE: To identify associations between systemic medications and primary open-angle glaucoma (POAG) requiring a procedure using United States insurance claims data in a hypothesis-generating study. DESIGN: Database study. PARTICIPANTS: In total, 6130 POAG cases (defined as patients with POAG undergoing a glaucoma procedure) were matched to 30 650 controls (defined as patients undergoing cataract surgery but without a coded glaucoma diagnosis, procedure, or medication) by age, gender, and region of residence. METHODS: Participant prescription drug use was calculated for the 5-year period before the glaucoma procedure or cataract surgery. Separately for individual generic drugs and drug classes, logistic regression was used to assess the association with POAG status. This was done across all generic drugs and drug classes that were prescribed in at least 1% of cases and controls. Analyses were adjusted for age, sex, region of residence, employment status, insurance plan type, and the total number of drugs prescribed. MAIN OUTCOME MEASURES: Odds ratio (OR) and 95% confidence intervals (CIs) for the association between each drug or drug class and POAG. RESULTS: The median age of participants was 72 years, and 52% were women. We tested for associations of POAG with 423 drug classes and 1763 generic drugs, resulting in a total of 2186 statistical tests and a Bonferroni-adjusted significance threshold of P < 2.3 × 10-5. Selective serotonin reuptake inhibitors (SSRIs) were strongly associated with a reduced risk of POAG (OR, 0.70; 95% CI, 0.64-0.76; P = 1.0 × 10-15); the most significant drug in this class was citalopram (OR, 0.66; 95% CI, 0.57-0.77; P = 1.2 × 10-7). Calcium channel blockers were strongly associated with an increased risk of POAG (OR, 1.26; 95% CI, 1.18-1.35; P = 1.8 × 10-11); the most significant drug in this class was amlodipine (OR, 1.27; 95% CI, 1.18-1.37; P = 5.9 × 10-10). CONCLUSIONS: We present data documenting potential associations of SSRIs and calcium channel blockers with POAG requiring a procedure. Further research may be indicated to better evaluate any associates of serotonin metabolism or calcium channels in glaucoma, or establish whether the associations are due to variations in the patterns for prescribing these drugs.


Assuntos
Medicamentos Genéricos/administração & dosagem , Glaucoma de Ângulo Aberto/epidemiologia , Medicamentos sob Prescrição/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Bloqueadores dos Canais de Cálcio/administração & dosagem , Bases de Dados Factuais , Feminino , Glaucoma de Ângulo Aberto/diagnóstico , Humanos , Revisão da Utilização de Seguros , Pressão Intraocular/fisiologia , Masculino , Medicare Part B/estatística & dados numéricos , Pessoa de Meia-Idade , Razão de Chances , Inibidores de Captação de Serotonina/administração & dosagem , Tonometria Ocular , Estados Unidos , Campos Visuais/fisiologia
10.
AJR Am J Roentgenol ; 210(4): 816-820, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29446681

RESUMO

OBJECTIVE: Previously published reports have shown that coronary CT angiography (CCTA) is a more efficient method of diagnosis than myocardial perfusion imaging (MPI) and stress echocardiography for patients presenting to emergency departments (EDs) with acute chest pain. In light of this evidence, the objective of this study was to examine recent trends in the use of these techniques in EDs. MATERIALS AND METHODS: The nationwide Medicare Part B databases for 2006-2015 were the data source. The Current Procedural Terminology, version 4, codes for CCTA, MPI, and stress echocardiography were selected. Medicare place-of-service codes were used to determine procedure volumes in EDs. Medicare specialty codes were used to ascertain how many of these examinations were interpreted by radiologists, cardiologists, and other physicians as a group. RESULTS: From 2006 to 2015, there was essentially no change in the number of MPI examinations performed in EDs for patients using Medicare (22,342 in 2006, 22,338 in 2015) or in the number of stress echocardiograms (3544 in 2006, 3520 in 2015). By contrast, the number of CCTA examinations increased rapidly, from 126 in 2006 to 1919 in 2015 (compound annual growth rate, 35%). Despite this rapid growth, patients in EDs underwent 11.6 times as many MPI as CCTA examinations in 2015. In that last year of the study, radiologists interpreted 78% of ED MPI and 83% of ED CCTA examinations. CONCLUSION: Use of CCTA in EDs has increased rapidly, but far more MPI examinations are still being performed. This finding suggests that recently acquired evidence is not yet being fully acted upon.


Assuntos
Dor no Peito/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Idoso , Current Procedural Terminology , Ecocardiografia sob Estresse , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Medicare Part B/estatística & dados numéricos , Estados Unidos
11.
AJR Am J Roentgenol ; 210(2): 364-368, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29220208

RESUMO

OBJECTIVE: The objective of our study was to use a new modality and body region categorization system to assess changing utilization of noninvasive diagnostic imaging in the Medicare fee-for-service population over a recent 20-year period (1994-2013). MATERIALS AND METHODS: All Medicare Part B Physician Fee Schedule services billed between 1994 and 2013 were identified using Physician/Supplier Procedure Summary master files. Billed codes for diagnostic imaging were classified using the Neiman Imaging Types of Service (NITOS) coding system by both modality and body region. Utilization rates per 1000 beneficiaries were calculated for families of services. RESULTS: Among all diagnostic imaging modalities, growth was greatest for MRI (+312%) and CT (+151%) and was lower for ultrasound, nuclear medicine, and radiography and fluoroscopy (range, +1% to +31%). Among body regions, service growth was greatest for brain (+126%) and spine (+74%) imaging; showed milder growth (range, +18% to +67%) for imaging of the head and neck, breast, abdomen and pelvis, and extremity; and showed slight declines (range, -2% to -7%) for cardiac and chest imaging overall. The following specific imaging service families showed massive (> +100%) growth: cardiac CT, cardiac MRI, and breast MRI. CONCLUSION: NITOS categorization permits identification of temporal shifts in noninvasive diagnostic imaging by specific modality- and region-focused families, providing a granular understanding and reproducible analysis of global changes in imaging overall. Service family-level perspectives may help inform ongoing policy efforts to optimize imaging utilization and appropriateness.


Assuntos
Diagnóstico por Imagem/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Idoso , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Estados Unidos
12.
Ophthalmology ; 124(9): 1290-1295, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28499746

RESUMO

PURPOSE: To quantify Medicare beneficiary proximity to his or her yttrium-aluminum-garnet (YAG) laser capsulotomy-providing ophthalmologist and optometrist in Oklahoma by calculating driving distances and times. DESIGN: Cross-sectional cohort study using 2014 Oklahoma Medicare 100% and 5% data sets and Google Maps distance and travel time application programming interfaces. PARTICIPANTS: U.S. fee-for-service Medicare beneficiaries and Oklahoma ophthalmologist and optometrist laser capsulotomy providers. METHODS: The 2014 Medicare Provider Utilization and Payment Limited 100% and 5% datasets from the Centers for Medicare and Medicaid (CMS) were obtained to identify the office street addresses of Oklahoma ophthalmologists and optometrists who submitted claims to Medicare for a YAG laser capsulotomy, and the county addresses of the corresponding Medicare beneficiaries who received the laser capsulotomy. The shortest travel distances and travel times between the beneficiary and the laser provider were calculated by using Google Maps distance and travel time application programming interfaces. MAIN OUTCOME MEASURES: Beneficiary driving distances and times to his or her YAG laser capsulotomy-providing Oklahoma ophthalmologist and optometrist. RESULTS: In 2014, 90 (57%) of 157 Oklahoma ophthalmologists and 65 (13%) of 506 Oklahoma optometrists submitted a total of 7521 and 3751 YAG laser capsulotomy claims to Medicare, respectively. By using the Medicare Limited 5% dataset, there was no difference in driving distance between beneficiaries who received a laser capsulotomy from an ophthalmologist (median, 39 miles; interquartile range [IQR], 13-113 miles) compared with an optometrist (median, 46 miles; IQR, 13-125 miles; P = 0.93) or in driving time to an ophthalmologist (median, 47 minutes; IQR, 19-110 minutes) compared with an optometrist (median, 50 minutes; IQR, 17-117 minutes; P = 0.76). CONCLUSIONS: For Medicare beneficiaries, there was no difference in geographic access to YAG laser capsulotomy whether performed by an Oklahoma ophthalmologist or optometrist as determined by calculated driving distances and times.


Assuntos
Condução de Veículo/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Oftalmologistas/estatística & dados numéricos , Optometristas/estatística & dados numéricos , Capsulotomia Posterior , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Lasers de Estado Sólido/uso terapêutico , Masculino , Medicare Part B/estatística & dados numéricos , Oklahoma/epidemiologia , Capsulotomia Posterior/estatística & dados numéricos , Fatores de Tempo , Viagem/estatística & dados numéricos , Estados Unidos
13.
Ann Fam Med ; 15(1): 63-67, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-28376462

RESUMO

PURPOSE: Variation in end-of-life care in the United States is frequently driven by the health care system. We assessed the association of primary care physician involvement at the end of life with end-of-life care patterns. METHODS: We analyzed 2010 Medicare Part B claims data for US hospital referral regions (HRRs). The independent variable was the ratio of primary care physicians to specialist visits in the last 6 months of life. Dependent variables included the rate of hospital deaths, hospital and intensive care use in the last 6 months of life, percentage of patients seen by more than 10 physicians, and Medicare spending in the last 2 years of life. Robust linear regression analysis was used to measure the association of primary care physician involvement at the end of life with the outcome variables, adjusting for regional characteristics. RESULTS: We assessed 306 HRRs, capturing 1,107,702 Medicare Part B beneficiaries with chronic disease who died. The interquartile range of the HRR ratio of primary care to specialist end-of-life visits was 0.77 to 1.21. HRRs with high vs low primary care physician involvement at the end of life had significantly different patient, population, and health system characteristics. Adjusting for these differences, HRRs with the greatest primary care physician involvement had lower Medicare spending in the last 2 years of life ($65,160 vs $69,030; P = .003) and fewer intensive care unit days in the last 6 months of life (2.90 vs 4.29; P <.001), but also less hospice enrollment (44.5% of decedents vs 50.4%; P = .004). CONCLUSIONS: Regions with greater primary care physician involvement in end-of-life care have overall less intensive end-of-life care.


Assuntos
Medicare Part B/estatística & dados numéricos , Atenção Primária à Saúde/economia , Assistência Terminal/estatística & dados numéricos , Idoso , Demografia , Feminino , Geografia , Humanos , Revisão da Utilização de Seguros , Modelos Lineares , Masculino , Médicos de Atenção Primária , Encaminhamento e Consulta , Estados Unidos
14.
Health Aff (Millwood) ; 36(4): 663-670, 2017 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28373332

RESUMO

Imaging is an important cost driver in health care, and its use grew rapidly in the early 2000s. Several studies toward the end of the decade suggested that a leveling off was beginning to occur. In this study we examined more recent data to determine whether the slowdown had continued. Our data sources were the nationwide Medicare Part B databases for the period 2001-14. We calculated utilization rates per 1,000 enrollees for all advanced imaging modalities. We also calculated professional component relative value unit (RVU) rates per 1,000 beneficiaries for all imaging modalities, as RVU values provide a measure of complexity of imaging services and may in some ways be a better reflection of the amount of work involved in imaging. We found that utilization rates and RVU rates grew substantially until 2008 and 2009, respectively, and then began to drop. The downward trend in both rates persisted through 2014. Federal policies appear to have achieved the desired effect of ending the rapid growth of imaging that had been seen in earlier years.


Assuntos
Diagnóstico por Imagem/estatística & dados numéricos , Diagnóstico por Imagem/tendências , Medicare Part B/estatística & dados numéricos , Humanos , Estados Unidos
15.
JAMA Intern Med ; 177(5): 675-682, 2017 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-28288254

RESUMO

Importance: While the substantial variation in health care spending across regions and hospitals is well known, key clinical decisions are ultimately made by physicians. However, the degree to which spending varies across physicians and the clinical consequences of that variation are unknown. Objective: To investigate variation in spending across physicians and its association with patient outcomes. Design, Setting, and Participants: For this retrospective data analysis, we analyzed a 20% random sample of Medicare fee-for-service beneficiaries 65 years and older who were hospitalized with a nonelective medical condition and treated by a general internist between January 1, 2011, and December 31, 2014. We first quantified the proportion of variation in Medicare Part B spending attributable to hospitals, physicians, and patients. We then examined the association between physician spending and patient outcomes, adjusted for patient and physician characteristics and hospital fixed effects (effectively comparing physicians within the same hospital). Our primary analysis focused on hospitalist physicians, whose patients are plausibly quasirandomized within a hospital based on physician work schedule. A secondary analysis focused on general internists overall. To ensure that patient illness severity did not directly affect physician spending estimates, we calculated physicians' spending levels in 2011 through 2012 and examined outcomes of their patients in 2013 and 2014. Exposures: Physicians' adjusted Part B spending level in 2011 through 2012. Main Outcomes and Measures: Patients' 30-day mortality and readmission rates in 2013 and 2014. Results: To determine the amount of variation across physicians we included 485 016 hospitalizations treated by 21 963 physicians at 2837 acute care hospitals for the analysis of hospitalists and 839 512 hospitalizations treated by 50 079 physicians at 3195 acute care hospitals for the analysis of general internists. Variation in spending across physicians within hospital was larger than variation across hospitals (for hospitalists, 8.4% across physicians vs 7.0% across hospitals; for general internists, 10.5% across physicians vs 6.2% across hospitals). Higher physician spending was not associated with lower 30-day mortality (adjusted odds ratio [aOR] for additional $100 in physician spending, 1.00; 95% CI, 0.98-1.01; P = .47) or readmissions (aOR, 1.00; 95% CI, 0.99-1.01; P = .54) for hospitalists within the same hospital. We observed similar patterns among general internists. Conclusions and Relevance: Health care spending varies more across individual physicians than across hospitals. However, higher physician spending is not associated with better outcomes of hospitalized patients. Our findings suggest policies targeting both physicians and hospitals may be more effective in reducing wasteful spending than policies focusing solely on hospitals.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Médicos Hospitalares , Hospitalização/economia , Medicina Interna , Mortalidade , Readmissão do Paciente/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Planos de Pagamento por Serviço Prestado , Humanos , Modelos Logísticos , Medicare Part B/economia , Medicare Part B/estatística & dados numéricos , Análise Multivariada , Razão de Chances , Padrões de Prática Médica/economia , Estudos Retrospectivos , Estados Unidos
16.
J AAPOS ; 21(3): 239-241.e3, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28161340

RESUMO

Disorders of binocular vision that are increasingly prevalent among aged, fee-for-service Medicare beneficiaries are associated with fractures, falls, and musculoskeletal injuries. We evaluate whether strabismus surgery influences the association of injuries in elderly patients with disorders of binocular vision in a 5% random sample of Medicare fee-for-service claims data from 2010 to 2013. There were 22,237 Medicare beneficiaries with a claim that included a diagnosis of a disorder of binocular vision. Of these, the majority had strabismus (49.5%); amblyopia (9.14%), diplopia (53.5%), and nystagmus (2.72%) were also represented. There were 530 patients who underwent strabismus surgery. The unadjusted odds ratio for the association between undergoing strabismus surgery and any of the three musculoskeletal injuries defined above was 0.868 (95% CI, 0.725-1.040; P = 0.13), and the adjusted odds ratio was 1.004 (95% CI, 0.833-1.210; P = 0.97). This study did not reveal a difference in the subsequent risk of musculoskeletal injuries, fractures, or falls in Medicare beneficiaries who underwent surgery. The failure to find an association could represent a true lack of correlation, selection bias, study design using administrative claims data, or a very small effect.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Fraturas Ósseas/epidemiologia , Medicare Part B/estatística & dados numéricos , Sistema Musculoesquelético/lesões , Estrabismo/cirurgia , Transtornos da Visão/epidemiologia , Visão Binocular , Idoso , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço Prestado , Feminino , Humanos , Masculino , Músculos Oculomotores/cirurgia , Razão de Chances , Procedimentos Cirúrgicos Oftalmológicos/estatística & dados numéricos , Estados Unidos , Pessoas com Deficiência Visual/estatística & dados numéricos
17.
J Health Econ ; 51: 84-97, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-28129637

RESUMO

Does tort reform reduce defensive medicine and thus healthcare spending? Several (though not all) prior studies, using a difference-in-differences (DiD) approach, find lower Medicare spending for hospital care after states adopt caps on non-economic or total damages ("damage caps"), during the "second" reform wave of the mid-1980s. We re-examine this issue in several ways. We study the nine states that adopted caps during the "third reform wave," from 2002 to 2005. We find that damage caps have no significant impact on Medicare Part A spending, but predict roughly 4% higher Medicare Part B spending. We then revisit the 1980s caps, and find no evidence of a post-adoption drop (or rise) in spending for these caps.


Assuntos
Medicina Defensiva/economia , Responsabilidade Legal , Imperícia/legislação & jurisprudência , Medicina Defensiva/organização & administração , Gastos em Saúde/estatística & dados numéricos , Humanos , Responsabilidade Legal/economia , Imperícia/economia , Medicare Part A/economia , Medicare Part A/estatística & dados numéricos , Medicare Part B/economia , Medicare Part B/estatística & dados numéricos , Estados Unidos
18.
Health Serv Res ; 52(6): 2197-2218, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-27859057

RESUMO

OBJECTIVE: To assess the impact of preferences, socioeconomic status (SES), and supplemental insurance (SI) on racial/ethnic disparities in the probability and use of services at physicians' offices, hospitals, and emergency departments among Medicare beneficiaries enrolled in Part B. RESEARCH DESIGN AND SUBJECTS: This study includes black and white beneficiaries from the 2009-2011 panel of the Medicare Current Beneficiary Survey who were enrolled in Medicare Part B. Logit and negative binomial multivariate regression analysis were used in conjunction with rank-and-replace methods to determine factors influencing utilization and black-white utilization disparities. PRINCIPAL FINDINGS: Among Part B beneficiaries, significant disparities exist for each studied service. Examining contributing factors, 12-19 percent of the black-white health-adjusted difference in the probability of use is explained by differences in SES, whereas differences in the distribution of SI accounts for 20 percent or more. For volume, SES is found to account for 2-11 percent of differences with SI making up another 9-10 percent. CONCLUSIONS: A substantial portion of the difference in black-white beneficiary use of outpatient services is due to SI. Policies aimed at increasing coverage are likely to increase the probability of visits with modest increases in volume.


Assuntos
Afro-Americanos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Medicare Part B/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Fatores Socioeconômicos , Estados Unidos
20.
Ophthalmic Surg Lasers Imaging Retina ; 47(3): 258-67, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26985800

RESUMO

BACKGROUND AND OBJECTIVE: To characterize vascular endothelial growth factor (VEGF) inhibitor treatment patterns in patients with diabetic macular edema (DME) using a Medicare Standard Analytic Files Part B or Outpatient Claims database to understand treatment frequency and DME persistence. PATIENTS AND METHODS: A retrospective analysis of treatment patterns for patients diagnosed with DME receiving their first anti-VEGF injection was performed. RESULTS: The average number of anti-VEGF injection claims for DME per patient rose from 3.1 to 4.6 per year (mean: 4.2). Within 1 year of diagnosis, 46% of patients received their final DME diagnosis (mean: 1.9 anti-VEGF claims), and 65% of patients received their final anti-VEGF treatment for DME. Patients who received treatment for DME through years 2 and 3 submitted a mean of four and 7.2 anti-VEGF claims, respectively. CONCLUSION: VEGF inhibitor treatment was less frequent than in landmark trials, but did resolve DME in a proportion of patients.


Assuntos
Inibidores da Angiogênese/uso terapêutico , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/tratamento farmacológico , Formulário de Reclamação de Seguro/estatística & dados numéricos , Edema Macular/diagnóstico , Edema Macular/tratamento farmacológico , Medicare Part B/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Inibidores da Angiogênese/administração & dosagem , Técnicas de Diagnóstico Oftalmológico , Feminino , Humanos , Injeções Intravítreas , Masculino , Pessoa de Meia-Idade , Retratamento , Estudos Retrospectivos , Estados Unidos , Fator A de Crescimento do Endotélio Vascular/antagonistas & inibidores , Acuidade Visual
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