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2.
MMWR Morb Mortal Wkly Rep ; 70(7): 245-249, 2021 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-33600384

RESUMO

On March 13, 2020, the United States declared a national emergency concerning the novel coronavirus disease 2019 (COVID-19) outbreak (1). In response, many state and local governments issued shelter-in-place or stay-at-home orders, restricting nonessential activities outside residents' homes (2). CDC initially issued guidance recommending postponing routine adult vaccinations, which was later revised to recommend continuing to administer routine adult vaccines (3). In addition, factors such as disrupted operations of health care facilities and safety concerns regarding exposure to SARS-CoV-2, the virus that causes COVID-19, resulted in delay or avoidance of routine medical care (4), likely further affecting delivery of routine adult vaccinations. Medicare enrollment and claims data of Parts A (hospital insurance), B (medical insurance), and D (prescription drug insurance) were examined to assess the change in receipt of routine adult vaccines during the pandemic. Weekly receipt of four vaccines (13-valent pneumococcal conjugate vaccine [PCV13], 23-valent pneumococcal polysaccharide vaccine [PPSV23], tetanus-diphtheria or tetanus-diphtheria-acellular pertussis vaccine [Td/Tdap], and recombinant zoster vaccine [RZV]) by Medicare beneficiaries aged ≥65 years during January 5-July 18, 2020, was compared with that during January 6-July 20, 2019, for the total study sample and by race and ethnicity. Overall, weekly administration rates of the four examined vaccines declined by up to 89% after the national emergency declaration in mid-March (1) compared with those during the corresponding period in 2019. During the first week following the national emergency declaration, the weekly vaccination rates were 25%-62% lower than those during the corresponding week in 2019. After reaching their nadirs of 70%-89% below 2019 rates in the second to third week of April 2020, weekly vaccination rates gradually began to recover through mid-July, but by the last study week were still lower than were those during the corresponding period in 2019, with the exception of PPSV23. Vaccination declined sharply for all vaccines studied, overall and across all racial and ethnic groups. While the pandemic continues, vaccination providers should emphasize to patients the importance of continuing to receive routine vaccinations and provide reassurance by explaining the procedures in place to ensure patient safety (3).


Assuntos
/epidemiologia , Medicare/estatística & dados numéricos , Pandemias , Vacinação/estatística & dados numéricos , Vacinas/administração & dosagem , Idoso , Humanos , Estados Unidos/epidemiologia
3.
Medicine (Baltimore) ; 100(7): e24838, 2021 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-33607853

RESUMO

ABSTRACT: More than 70% of tuberculosis (TB) cases diagnosed in the United States (US) occur in non-US-born persons, and this population has experienced less than half the recent incidence rate declines of US-born persons (1.5% vs 4.2%, respectively). The great majority of TB cases in non-US-born persons are attributable to reactivation of latent tuberculosis infection (LTBI). Strategies to expand LTBI-focused TB prevention may depend on LTBI positive non-US-born persons' access to, and ability to pay for, health care.To examine patterns of health insurance coverage and usual sources of health care among non-US-born persons with LTBI, and to estimate LTBI prevalence by insurance status and usual sources of health care.Self-reported health insurance and usual sources of care for non-US-born persons were analyzed in combination with markers for LTBI using 2011-2012 National Health and Nutrition Examination Survey (NHANES) data for 1793 sampled persons. A positive result on an interferon gamma release assay (IGRA), a blood test which measures immunological reactivity to Mycobacterium tuberculosis infection, was used as a proxy for LTBI. We calculated demographic category percentages by IGRA status, IGRA percentages by demographic category, and 95% confidence intervals for each percentage.Overall, 15.9% [95% confidence interval (CI) = 13.5, 18.7] of non-US-born persons were IGRA-positive. Of IGRA-positive non-US-born persons, 63.0% (95% CI = 55.4, 69.9) had insurance and 74.1% (95% CI = 69.2, 78.5) had a usual source of care. IGRA positivity was highest in persons with Medicare (29.1%; 95% CI: 20.9, 38.9).Our results suggest that targeted LTBI testing and treatment within the US private healthcare sector could reach a large majority of non-US-born individuals with LTBI. With non-US-born Medicare beneficiaries' high prevalence of LTBI and the high proportion of LTBI-positive non-US-born persons with private insurance, future TB prevention initiatives focused on these payer types are warranted.


Assuntos
Assistência à Saúde/economia , Emigrantes e Imigrantes/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Tuberculose Latente/epidemiologia , Adolescente , Adulto , Idoso , Criança , Estudos Transversais , Assistência à Saúde/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde , Humanos , Incidência , Cobertura do Seguro/tendências , Testes de Liberação de Interferon-gama/métodos , Tuberculose Latente/diagnóstico , Tuberculose Latente/prevenção & controle , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Mycobacterium tuberculosis/imunologia , Inquéritos Nutricionais/métodos , Prevalência , Estados Unidos/epidemiologia , Adulto Jovem
4.
Health Aff (Millwood) ; 40(1): 146-155, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33400571

RESUMO

Medicare's Skilled Nursing Facility Value-Based Purchasing Program, which awards value-based incentive payments based on hospital readmissions, distributed its first two rounds of incentives during fiscal years 2019 and 2020. Incentive payments were based on achievement or improvement scores-whichever was better. Incentive payments were as low as -2.0 percent in both program years and as high as +1.6 percent in FY 2019 and +3.1 percent in FY 2020. In FY 2019, 26 percent of facilities earned positive incentives and 72 percent earned negative incentives, compared with 19 percent positive and 65 percent negative incentives in FY 2020. Larger, rural, and not-for-profit facilities were more likely to earn positive incentives, as were those with the highest registered nurse staffing levels. Although these findings indicate the potential to reward high-quality care at skilled nursing facilities, intended and unintended outcomes of this new value-based purchasing program should be monitored closely for possible program refinements, particularly in light of the disproportionate impacts of coronavirus disease 2019 (COVID-19) on nursing facilities.


Assuntos
Medicare , Motivação , Readmissão do Paciente/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Aquisição Baseada em Valor/estatística & dados numéricos , Humanos , Medicare/economia , Medicare/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Instituições de Cuidados Especializados de Enfermagem/economia , Estados Unidos
5.
J Surg Oncol ; 123(4): 1023-1029, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33497477

RESUMO

BACKGROUND: To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients. METHODS: Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database. RESULTS: In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average $183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients. CONCLUSION: Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type.


Assuntos
Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde/estatística & dados numéricos , Seguradoras/estatística & dados numéricos , Medicare/estatística & dados numéricos , Terapia Neoadjuvante/economia , Protectomia/economia , Neoplasias Retais/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Seguimentos , Humanos , Seguro Saúde , Masculino , Pessoa de Meia-Idade , Prognóstico , Neoplasias Retais/epidemiologia , Neoplasias Retais/terapia , Estudos Retrospectivos , Taxa de Sobrevida , Estados Unidos/epidemiologia , Adulto Jovem
6.
J Urol ; 205(1): 199-205, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32808855

RESUMO

PURPOSE: We compared short and long-term outcomes between nursing home residents and matched community dwelling older adults undergoing surgery for pelvic organ prolapse. MATERIALS AND METHODS: This retrospective cohort study evaluates women 65 years old or older undergoing different types of pelvic organ prolapse repairs (anterior/posterior, apical and colpocleisis) between 2007 and 2012 using Medicare claims and the Minimum Data Set for Nursing Home Residents. Long-stay nursing home residents were identified and propensity score matched (1:2) to community dwelling older individuals based on procedure type, age, race and Charlson score. Generalized estimating equation models were created to determine the relative risk of hospital length of stay 3 or more days, 30-day complications and 1-year mortality between the 2 groups. Kaplan-Meier curves were created comparing 1-year mortality between groups. RESULTS: There were 799 nursing home residents and 1,598 matched community dwelling older adults who underwent pelvic organ prolapse surgery and were included in our analyses. Nursing home residents demonstrated statistically significant increased risk for hospital length of stay 3 or more days (38.9% vs 18.6%, adjusted RR 2.1, 95% CI 1.8-2.4), 30-day complications (15.1% vs 3.8%, aRR 3.9, 95% CI 2.9-5.3) and 1-year mortality (11.1% vs 3.2%, aRR 3.5, 95% CI 2.5-4.8) compared to community dwelling older adults. Kaplan-Meier curves illustrated similar survival findings at 1 year (11.1%, 95% CI 9.0-13.3 vs 3.2%, 95% CI 2.3-4.1, p <0.0001). CONCLUSIONS: Despite matching on several characteristics, nursing home residents demonstrated worse short and long-term outcomes compared to community dwelling older adults, suggesting other key vulnerabilities exist that contribute additional surgical risk in this population.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Vida Independente/estatística & dados numéricos , Casas de Saúde/estatística & dados numéricos , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Medicare/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia
7.
Med Care ; 59(1): 6-12, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32925454

RESUMO

BACKGROUND: US hospitals are penalized for excess 30-day readmissions and mortality for select conditions. Under the Centers for Medicare and Medicaid Services policy, readmission prevention is incentivized to a greater extent than mortality reduction. A strategy to potentially improve hospital performance on either measure is by improving nursing care, as nurses provide the largest amount of direct patient care. However, little is known as to whether achieving nursing excellence, such as Magnet status, is associated with improved hospital performance on readmissions and mortality. OBJECTIVE: The purpose of this study was to examine the relationship between hospitals' Magnet status and performance on readmission and mortality rates for Medicare beneficiaries. RESEARCH DESIGN: This is a cross-sectional analysis of Medicare readmissions and mortality reduction programs from 2013 to 2016. A propensity score-matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals. SUBJECTS: The sample was comprised of 3877 hospitals. MEASURES: The outcome measures were 30-day risk-standardized readmission and mortality rates. RESULTS: Following propensity score matching on hospital characteristics, we found that Magnet hospitals outperformed non-Magnet hospitals in reducing mortality; however, Magnet hospitals performed worse in reducing readmissions for acute myocardial infarction, coronary artery bypass grafting, and stroke. CONCLUSIONS: Magnet hospitals performed better on the Hospital Value-Based Purchasing Mortality Program than the Hospital Readmissions Reduction Program. The results of this study suggest the need for The Magnet Recognition Program to examine the role of nurses in postdischarge activities as a component of its evaluation criteria.


Assuntos
Hospitais/normas , Medicare , Mortalidade/tendências , Infarto do Miocárdio/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/normas , Acidente Vascular Cerebral/epidemiologia , Estudos Transversais , Hospitais/estatística & dados numéricos , Humanos , Medicare/economia , Medicare/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Alta do Paciente , Readmissão do Paciente/tendências , Acidente Vascular Cerebral/mortalidade , Estados Unidos/epidemiologia , Aquisição Baseada em Valor/organização & administração , Aquisição Baseada em Valor/normas
8.
Med Care ; 59(1): 22-28, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32925460

RESUMO

BACKGROUND/OBJECTIVES: Nearly 38 million Americans have hearing loss. Understanding how sensory deficits such as hearing loss, which limit communication, impact satisfaction has implications for Medicare value-based reimbursement mechanisms. The aim of this study was to characterize the association of functional hearing loss and dissatisfaction with quality of health care over the past year among Medicare beneficiaries. METHODS: Cross-sectional study of satisfaction with quality of health care among Medicare beneficiaries with self-reported trouble hearing from the 2015 Medicare Current Beneficiaries Survey. There were 11,441 Medicare beneficiaries representing a 48.6 million total weighted nationally representative sample. RESULTS: Forty-eight percent of Medicare beneficiaries reported a little or a lot of trouble hearing. Medicare beneficiaries with a little trouble hearing (odds ratio=1.496; 95% confidence interval, 1.079-2.073; P=0.016) and a lot of trouble hearing (odds ratio=1.769; 95% confidence interval, 1.175-2.664; P=0.007) had 49.6% and 76.9% higher odds of being dissatisfied with the quality of their health care over the previous year, respectively. CONCLUSIONS: Medicare beneficiaries with functional hearing loss had higher odds of dissatisfaction with health care over the past year compared to those without functional hearing loss. Given Medicare's reliance on patient satisfaction as a value-based measure for hospital reimbursement, interventions to address hearing loss in the health care system are needed.


Assuntos
Comunicação , Perda Auditiva Funcional/psicologia , Medicare/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Atividades Cotidianas , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Autorrelato , Fatores Sexuais , Inquéritos e Questionários , Estados Unidos
9.
Med Care ; 59(1): 46-52, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33027238

RESUMO

BACKGROUND: As the population with human immunodeficiency virus (HIV) continues to age, the need for nursing home (NH) care is increasing. OBJECTIVES: To assess whether NH's experience in treating HIV is related to outcomes. RESEARCH DESIGN: We used claims and assessment data to identify individuals with and without HIV who were admitted to NHs in 9 high HIV prevalent states. We classified NHs into HIV experience categories and estimate the effects of NH HIV experience on patient's outcomes. We applied an instrumental variable using distances between each individual's residence and NHs with different HIV experience. SUBJECTS: In all, 5,929,376 admissions for those without HIV and 53,476 admissions for residents with HIV. MEASURES: Our primary outcomes were 30-day hospital readmissions, likelihood of becoming a long stay resident, and 180-day mortality posthospital discharge. RESULTS: Residents with HIV tended to have poorer outcomes than residents without HIV, regardless of the NH they were admitted to. Residents with HIV admitted to high HIV experience NHs were more likely to be readmitted to the hospital than those admitted to NHs with lower HIV experience (19.6% in 0% HIV NHs, 18.7% in 05% HIV NHs and 22.9% in 5%-50% HIV NHs). CONCLUSIONS: Residents with HIV experience worse outcomes in NHs than residents without HIV. Increased HIV experience was not related to improved outcomes.


Assuntos
Infecções por HIV/enfermagem , Revisão da Utilização de Seguros/estatística & dados numéricos , Casas de Saúde/estatística & dados numéricos , Avaliação de Resultados da Assistência ao Paciente , Readmissão do Paciente/estatística & dados numéricos , Idoso , Feminino , Infecções por HIV/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Estados Unidos
10.
Med Care ; 59(1): 77-81, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33201083

RESUMO

BACKGROUND: Breast cancer patients of low socioeconomic status (SES) have worse survival than more affluent women and are also more likely to undergo surgery in low-volume facilities. Since breast cancer patients treated in high-volume facilities have better survival, regionalizing the care of low SES patients toward high-volume facilities might reduce SES disparities in survival. OBJECTIVE: We leverage a natural experiment in New York state to examine whether a policy precluding payment for breast cancer surgery for New York Medicaid beneficiaries undergoing surgery in low-volume facilities led to reduced SES disparities in mortality. RESEARCH DESIGN: A multivariable difference-in-differences regression analysis compared mortality of low SES (dual enrollees, Medicare-Medicaid) breast cancer patients to that of wealthier patients exempt from the policy (Medicare only) for time periods before and after the policy implementation. SUBJECTS: A total of 14,183 Medicare beneficiaries with breast cancer in 2006-2008 or 2014-2015. MEASURES: All-cause mortality at 3 years after diagnosis and Medicaid status, determined by Medicare administrative data. RESULTS: Both low SES and Medicare-only patients had better 3-year survival after the policy implementation. However, the decline in mortality was larger in magnitude among the low SES women than others, resulting in a 53% smaller SES survival disparity after the policy after adjustment for age, race, and comorbid illness. CONCLUSION: Regionalization of early breast cancer care away from low-volume centers may improve outcomes and reduce SES disparities in survival.


Assuntos
Neoplasias da Mama , Disparidades em Assistência à Saúde , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Fatores Socioeconômicos , Idoso , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/mortalidade , Feminino , Humanos , New York , Estados Unidos
11.
Med Care ; 59(1): 29-37, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33298706

RESUMO

BACKGROUND: Hospital-based acute care [emergency department (ED) visits and hospitalizations] that is preventable with high-quality outpatient care contributes to health care system waste and patient harm. OBJECTIVE: To test the hypothesis that an ED-to-home transitional care intervention reduces hospital-based acute care in chronically ill, older ED visitors. RESEARCH DESIGN: Convergent, parallel, mixed-methods design including a randomized controlled trial. SETTING: Two diverse Florida EDs. SUBJECTS: Medicare fee-for-service beneficiaries with chronic illness presenting to the ED. INTERVENTION: The Coleman Care Transition Intervention adapted for ED visitors. MEASURES: The main outcome was hospital-based acute care within 60 days of index ED visit. We also assessed office-based outpatient visits during the same period. RESULTS: The Intervention did not significantly reduce return ED visits or hospitalizations or increase outpatient visits. In those with return ED visits, the Intervention Group was less likely to be hospitalized than the Usual Care Group. Interview themes describe a cycle of hospital-based acute care largely outside patients' control that may be difficult to interrupt with a coaching intervention. CONCLUSIONS AND RELEVANCE: Structural features of the health care system, including lack of access to timely outpatient care, funnel patients into the ED and hospital admission. Reducing hospital-based acute care requires increased focus on the health care system rather than patients' care-seeking decisions.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviços de Assistência Domiciliar , Medicare/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Cuidado Transicional/estatística & dados numéricos , Idoso , Doença Crônica/terapia , Feminino , Florida , Hospitalização , Humanos , Masculino , Medicare/economia , Atenção Primária à Saúde , Estados Unidos
12.
Ann Intern Med ; 174(2): 200-208, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33347769

RESUMO

BACKGROUND: Under the Bundled Payments for Care Improvement (BPCI) program, bundled paymtents for lower-extremity joint replacement (LEJR) are associated with 2% to 4% cost savings with stable quality among Medicare fee-for-service beneficiaries. However, BPCI may prompt practice changes that benefit all patients, not just fee-for-service beneficiaries. OBJECTIVE: To examine the association between hospital participation in BPCI and LEJR outcomes for patients with commercial insurance or Medicare Advantage (MA). DESIGN: Quasi-experimental study using Health Care Cost Institute claims from 2011 to 2016. SETTING: LEJR at 281 BPCI hospitals and 562 non-BPCI hospitals. PATIENTS: 184 922 patients with MA or commercial insurance. MEASUREMENTS: Differential changes in LEJR outcomes at BPCI hospitals versus at non-BPCI hospitals matched on propensity score were evaluated using a difference-in-differences (DID) method. Secondary analyses evaluated associations by patient MA status and hospital characteristics. Primary outcomes were changes in 90-day total spending on LEJR episodes and 90-day readmissions; secondary outcomes were postacute spending and discharge to postacute care providers. RESULTS: Average episode spending decreased more at BPCI versus non-BPCI hospitals (change, -2.2% [95% CI, -3.6% to -0.71%]; P = 0.004), but differences in changes in 90-day readmissions were not significant (adjusted DID, -0.47 percentage point [CI, -1.0 to 0.06 percentage point]; P = 0.084). Participation in BPCI was also associated with differences in decreases in postacute spending and discharge to institutional postacute care providers. Decreases in episode spending were larger for hospitals with high baseline spending but did not vary by MA status. LIMITATION: Nonrandomized studies are subject to residual confounding and selection. CONCLUSION: Participation in BPCI was associated with modest spillovers in episode savings. Bundled payments may prompt hospitals to implement broad care redesign that produces benefits regardless of insurance coverage. PRIMARY FUNDING SOURCE: Leonard Davis Institute of Health Economics at the University of Pennsylvania.


Assuntos
Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Seguro Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Mecanismo de Reembolso/estatística & dados numéricos , Idoso , Artroplastia de Quadril/estatística & dados numéricos , Artroplastia do Joelho/estatística & dados numéricos , Cuidado Periódico , Planos de Pagamento por Serviço Prestado , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Seguro Saúde/economia , Seguro Saúde/organização & administração , Tempo de Internação/estatística & dados numéricos , Masculino , Medicare/economia , Medicare/organização & administração , Mecanismo de Reembolso/organização & administração , Resultado do Tratamento , Estados Unidos , Programas Voluntários/economia , Programas Voluntários/organização & administração , Programas Voluntários/estatística & dados numéricos
13.
J Surg Res ; 257: 278-284, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32866668

RESUMO

BACKGROUND: Emergency general surgery has higher adverse outcomes than elective surgery. Patients leaving the hospital against medical advice (AMA) have a greater risk for readmission and complications. We sought to identify clinical and demographic characteristics along with hospital factors associated with leaving AMA after EGS operations. METHODS: A retrospective review of the Nationwide Inpatient Sample was performed. All patients who underwent an EGS procedure accounting for >80% of the burden of EGS-related inpatient resources were identified. 4:1 propensity score analysis was conducted. Regression analyses determined predictive factors for leaving AMA. RESULTS: 546,856 patients were identified. 1085 (0.2%) patients who underwent EGS left AMA. They were more likely to be men (59% versus 42%), younger (median age 51 y, IQR [37.61] versus 54, IQR [38.69]), qualify for Medicaid (26% versus 13%) or be self-pay (17% versus 9%), and be within the lowest quartile median household income (40% versus 28%) (all P < 0.05). After applying 4:1 propensity score matching, individuals who were self-pay (OR 3.15, 95% CI 2.44-4.06) or insured through Medicare (OR 2.75, 95% CI 2.11-3.57) and Medicaid (OR 3.58, 95% CI 2.83-4.52) had increased odds of leaving AMA compared with privately insured patients. In addition, history of alcohol (OR 2.21, 95% CI 1.65-2.98), drug abuse (OR 4.54, 95% CI 3.23-6.38), and psychosis (OR 2.31, 95% CI 1.65-3.23) were associated with higher likelihood for leaving AMA. CONCLUSIONS: Patients undergoing EGS have a high risk of complications, and leaving AMA further increases this risk. Interventions to encourage safe discharge encompassing surgical, psychiatric, and socioeconomic factors are warranted to prevent a two-hit effect and compound postoperative risk.


Assuntos
Tratamento de Emergência/efeitos adversos , Cooperação do Paciente/estatística & dados numéricos , Alta do Paciente/normas , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adulto , Fatores Etários , Idoso , Feminino , Humanos , Renda/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Cooperação do Paciente/psicologia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Estados Unidos/epidemiologia
15.
Value Health ; 23(9): 1210-1217, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32940239

RESUMO

OBJECTIVES: Significant literature exists on the effects of medication adherence on reducing healthcare costs, but less is known about the effect of medication adherence among Medicare low-income subsidy (LIS) recipients. This study examined the effects of medication adherence on healthcare costs among LIS recipients with diabetes, hypertension, and/or heart failure. METHODS: This retrospective study analyzed Medicare claims data (2012-2013) linked to the Area Health Resources Files. Using measures developed by the Pharmacy Quality Alliance, adherence to 11 medication classes was studied among patients with 7 possible combinations of the diseases mentioned. Adherence was measured in 8 categories of proportion of days covered (PDC): ≥95%, 90% to <95%, 85% to <90%, 80% to <85%, 75% to <80%, 50% to <75%, 25% to <50%, and <25%. Annual Medicare costs were compared across adherence categories. A generalized linear model was used to control for patient/community characteristics. RESULTS: Among patients with only one disease, such as diabetes, patients with the lowest adherence (PDC < 25%) had $3152/year higher Medicare costs than patients with the highest adherence (PDC ≥ 95%; $11 101 vs $7949; P < .05). The adjusted costs among patients with PDC < 25% was $1893 higher than patients with PDC ≥ 95% ($9919 vs $8026; P < .05). Among patients with multiple chronic conditions, patients' adherence to medications for fewer diseases had higher costs. CONCLUSIONS: Greater medication adherence is associated with lower Medicare costs in the Medicare LIS population. Future policy affecting the LIS program should encourage better medication adherence among patients with chronic diseases.


Assuntos
Diabetes Mellitus Tipo 2/epidemiologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Insuficiência Cardíaca/epidemiologia , Hipertensão/epidemiologia , Medicare/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Diabetes Mellitus Tipo 2/tratamento farmacológico , Insuficiência Cardíaca/tratamento farmacológico , Humanos , Hipertensão/tratamento farmacológico , Medicare/economia , Estudos Retrospectivos , Estados Unidos
17.
Med Care ; 58(10): 853-860, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925414

RESUMO

OBJECTIVE: The objective of this study was to estimate trends in the percentage of Medicare beneficiaries cared for by nurse practitioners from 2012 to 2017, to characterize beneficiaries cared for by nurse practitioners in 2017, and to examine how the percentage of beneficiaries cared for by nurse practitioners varies by practice characteristics. DESIGN: An observational study of 2012-2017 Medicare fee-for-service beneficiaries' ambulatory visits. We computed the percentage of beneficiaries with 1 or more ambulatory visits from nurse practitioners and the percentage of beneficiaries receiving the plurality of their ambulatory visits from a nurse practitioner versus a physician (ie, predominant provider). We compared beneficiary demographics, clinical characteristics, and utilization by the predominant provider. We then characterized the predominant provider by practice characteristics. KEY RESULTS: In 2017, 28.9% of beneficiaries received any care from a nurse practitioner and 8.0% utilized nurse practitioners as their predominant provider-an increase from 4.4% in 2012. Among beneficiaries cared for by nurse practitioners in 2017, 25.9% had 3 or more chronic conditions compared with 20.8% of those cared for by physicians. Beneficiaries cared for in practices owned by health systems were more likely to have a nurse practitioner as their predominant provider compared with those attending practices that were independently owned (9.3% vs. 7.0%). CONCLUSIONS: Nurse practitioners are caring for Medicare beneficiaries with complex needs at rates that match or exceed their physician colleagues. The growing role of nurse practitioners, especially in health care systems, warrants attention as organizations embark on payment and delivery reform.


Assuntos
Medicare/estatística & dados numéricos , Múltiplas Afecções Crônicas/terapia , Profissionais de Enfermagem/tendências , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Médicos de Atenção Primária/tendências , Estados Unidos
18.
PLoS One ; 15(9): e0227783, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32925977

RESUMO

PURPOSE: To quantify differences in the age, gender, race, and clinical complexity of Medicare beneficiaries treated by ophthalmologists and optometrists in each of the United States. DESIGN: Cross-sectional study based on publicly accessible Medicare payment and utilization data from 2012 through 2017. METHODS: For each ophthalmic and optometric provider, demographic information of treated Medicare beneficiaries was obtained from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services (CMS) for the years 2012 through 2017. Clinical complexity was defined using CMS Hierarchical Condition Category (HCC) coding. RESULTS: From 2012 through 2017, ophthalmologists in every state treated statistically significantly older beneficiaries, with the greatest difference (4.99 years in 2014) between provider groups seen in Rhode Island. In most states there was no gender difference among patients treated by the providers but in 46 states ophthalmologists saw a more racially diverse group of beneficiaries. HCC risk score analysis demonstrated that ophthalmologists in all 50 states saw more medically complex beneficiaries and the differences were statistically significant in 47 states throughout all six years. CONCLUSIONS: Although there are regional variations in the characteristics of patients treated by ophthalmologists and optometrists, ophthalmologists throughout the United States manage older, more racially diverse, and more medically complex Medicare beneficiaries.


Assuntos
Oftalmopatias/terapia , Medicare/estatística & dados numéricos , Oftalmologia/estatística & dados numéricos , Optometria/estatística & dados numéricos , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Fatores Etários , Idoso , Grupos de Populações Continentais/estatística & dados numéricos , Estudos Transversais , Oftalmopatias/diagnóstico , Oftalmopatias/economia , Feminino , Humanos , Masculino , Medicare/economia , Oftalmologistas/economia , Oftalmologistas/estatística & dados numéricos , Oftalmologia/economia , Optometristas/economia , Optometristas/estatística & dados numéricos , Optometria/economia , Padrões de Prática Médica/economia , Fatores Sexuais , Estados Unidos
19.
Milbank Q ; 98(3): 908-974, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32820837

RESUMO

Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment. CONTEXT: Bundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality. METHODS: We examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs. FINDINGS: Medicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change. CONCLUSIONS: Bundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge.


Assuntos
Hospitalização/economia , Medicare/economia , Pacotes de Assistência ao Paciente/economia , Mecanismo de Reembolso , Redução de Custos/economia , Redução de Custos/métodos , Redução de Custos/estatística & dados numéricos , Custos Hospitalares/organização & administração , Custos Hospitalares/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Medicare/organização & administração , Medicare/estatística & dados numéricos , Pacotes de Assistência ao Paciente/estatística & dados numéricos , Mecanismo de Reembolso/economia , Mecanismo de Reembolso/estatística & dados numéricos , Estados Unidos
20.
PLoS One ; 15(8): e0237790, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32810185

RESUMO

This study determined the frequency and factors associated with EGFR testing rates and erlotinib treatment as well as associated survival outcomes in patients with non small cell lung cancer in Kentucky. Data from the Kentucky Cancer Registry (KCR) linked with health claims from Medicaid, Medicare and private insurance groups were evaluated. EGFR testing and erlotinib prescribing were identified using ICD-9 procedure codes and national drug codes in claims, respectively. Logistic regression analysis was performed to determine factors associated with EGFR testing and erlotinib prescribing. Cox-regression analysis was performed to determine factors associated with survival. EGFR mutation testing rates rose from 0.1% to 10.6% over the evaluated period while erlotinib use ranged from 3.4% to 5.4%. Factors associated with no EGFR testing were older age, male gender, enrollment in Medicaid or Medicare, smoking, and geographic region. Factors associated with not receiving erlotinib included older age, male gender, enrollment in Medicare or Medicaid, and living in moderate to high poverty. Survival analysis demonstrated EGFR testing or erlotinib use was associated with a higher likelihood of survival. EGFR testing and erlotinib prescribing were slow to be implemented in our predominantly rural state. While population-level factors likely contributed, patient factors, including geographic location (areas with high poverty rates and rural regions) and insurance type, were associated with lack of use, highlighting rural disparities in the implementation of cancer precision medicine.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Cloridrato de Erlotinib/uso terapêutico , Testes Genéticos/estatística & dados numéricos , Neoplasias Pulmonares/tratamento farmacológico , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Carcinoma Pulmonar de Células não Pequenas/genética , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Análise Mutacional de DNA/economia , Análise Mutacional de DNA/estatística & dados numéricos , Prescrições de Medicamentos/economia , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/economia , Uso de Medicamentos/estatística & dados numéricos , Receptores ErbB/antagonistas & inibidores , Receptores ErbB/genética , Feminino , Testes Genéticos/economia , Disparidades em Assistência à Saúde/economia , Humanos , Kentucky/epidemiologia , Neoplasias Pulmonares/genética , Neoplasias Pulmonares/mortalidade , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Mutação , Pobreza/estatística & dados numéricos , Medicina de Precisão/economia , Medicina de Precisão/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Análise de Sobrevida , Estados Unidos , Adulto Jovem
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