Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 4.894
Filtrar
1.
Mayo Clin Proc ; 95(1): 57-68, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31902429

RESUMO

OBJECTIVE: To investigate the relationship of body mass index (BMI) with short- and long-term outcomes after transcatheter aortic valve replacement (TAVR). PATIENTS AND METHODS: The relationship between BMI and baseline characteristics and procedural characteristics was assessed for 31,929 patients who underwent TAVR between November 1, 2011, and March 31, 2015, from the STS/ACC TVT Registry. Registry data on 20,429 patients were linked to the Centers for Medicare and Medicaid Services to assess the association of BMI with 30-day and 1-year mortality using multivariable Cox proportional hazards models. The effect of BMI on mortality was also assessed with BMI as a continuous variable. Restricted cubic regression splines were used to model the effect of BMI and to determine appropriate cut points of BMI. RESULTS: Among 31,929 patients, 806 (2.5%) were underweight (BMI, <18.5 kg/m2), 10,755 (33.7%) had normal weight (BMI, 18.5- 24.9 kg/m2), 10,691 (33.5%) were overweight (BMI, 25.0-29.9 kg/m2), 5582 (17.5%) had class I obesity (BMI, 30.0-34.9 kg/m2), 2363 (7.4%) had class II obesity (BMI, 35.0-39.9 kg/m2), and 1732 (5.4%) had class III obesity (BMI, ≥40 kg/m2). Patients in various BMI categories were different in most baseline and procedural characteristics. On multivariable analysis, compared with normal-weight patients, underweight patients had higher mortality at 30 days and at 1 year after TAVR (hazard ratio [HR], 1.35; 95% CI, 1.02-1.78 and HR, 1.41; 95% CI, 1.17-1.69, respectively), whereas overweight patients and those with class I and II obesity had a decreased risk of mortality at 1 year (HR, 0.88; 95% CI, 0.81-0.95, HR, 0.80; 95% CI, 0.72-0.89, and HR, 0.84; 95% CI, 0.72-0.98, respectively). For BMI of 30 kg/m2 or less, each 1-kg/m2 increase was associated with a 2% and 4% decrease in the risk of 30-day and 1-year mortality, respectively; for BMI greater than 30 kg/m2, a 1-kg/m2 increase was associated with a 3% increased risk of 30-day mortality but not with 1-year mortality. CONCLUSION: Results of this large registry study evaluating the relationship of BMI and outcomes after TAVR support the existence of an obesity paradox among patients with severe aortic stenosis undergoing TAVR.


Assuntos
Estenose da Valva Aórtica , Índice de Massa Corporal , Obesidade , Substituição da Valva Aórtica Transcateter , Idoso , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/cirurgia , Correlação de Dados , Feminino , Humanos , Efeitos Adversos de Longa Duração/mortalidade , Masculino , Medicare/estatística & dados numéricos , Mortalidade , Obesidade/diagnóstico , Obesidade/epidemiologia , Modelos de Riscos Proporcionais , Sistema de Registros/estatística & dados numéricos , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia
2.
BMJ ; 368: l6831, 2020 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-31941686

RESUMO

OBJECTIVES: To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. DESIGN: Retrospective cohort study. SETTING: Medicare claims data for 2008-16 in the United States. PARTICIPANTS: Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia-conditions included in the US Hospital Readmissions Reduction Program. MAIN OUTCOME MEASURES: Post-discharge 30 day mortality according to patients' 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. RESULTS: 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (-0.09% to -0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. CONCLUSIONS: The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.


Assuntos
Unidades de Observação Clínica/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Insuficiência Cardíaca , Infarto do Miocárdio , Pneumonia , Cuidados Semi-Intensivos , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Revisão da Utilização de Seguros , Masculino , Sobremedicalização/prevenção & controle , Medicare/estatística & dados numéricos , Mortalidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/mortalidade , Pneumonia/terapia , Estudos Retrospectivos , Cuidados Semi-Intensivos/métodos , Cuidados Semi-Intensivos/organização & administração , Cuidados Semi-Intensivos/tendências , Estados Unidos/epidemiologia
3.
J Surg Res ; 246: 123-130, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31569034

RESUMO

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Fixação de Fratura/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Fraturas da Coluna Vertebral/cirurgia , Organizações de Assistência Responsáveis/economia , Idoso , Idoso de 80 Anos ou mais , Grupos de Populações Continentais/estatística & dados numéricos , Redução de Custos/economia , Redução de Custos/estatística & dados numéricos , Grupos Étnicos , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/economia , Gastos em Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/organização & administração , Mortalidade Hospitalar , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/estatística & dados numéricos , Fatores Socioeconômicos , Fraturas da Coluna Vertebral/economia , Estados Unidos/epidemiologia
4.
J Surg Res ; 245: 81-88, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31404894

RESUMO

BACKGROUND: Delayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. METHODS: The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. RESULTS: 412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). CONCLUSIONS: ED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Ferimentos não Penetrantes/terapia , Escala Resumida de Ferimentos , Adolescente , Adulto , Idoso , Feminino , Hospitais Comunitários/estatística & dados numéricos , Hospitais Universitários/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Medição de Risco/métodos , Análise de Sobrevida , Estados Unidos , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade , Adulto Jovem
5.
Medicine (Baltimore) ; 98(49): e18082, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31804317

RESUMO

OBJECTIVES: Our study provides phase-specific cost estimates for pancreatic cancer based on stage and treatment. We compare treatment costs between the different phases and within the stage and treatment modality subgroups. METHODS: Our cohort included 20,917 pancreatic cancer patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed between 2000 and 2011. We allocated costs into four phases of care-staging (or surgery), initial, continuing, and terminal- and calculated the total, cancer-attributable, and patient-liability costs in 2018 US dollars. We fit linear regression models using log transformation to determine whether costs were predicted by age and calendar year. RESULTS: Monthly cost estimates were high during the staging and surgery phases, decreased over the initial and continuing phases, and increased during the three-month terminal phase. Overall, the linear regression models showed that cancer-attributable costs either remained stable or increased by year, and either were unaffected by age or decreased with older age; continuing phase costs for stage II patients increased with age. CONCLUSIONS: Our estimates demonstrate that pancreatic cancer costs can vary widely by stage and treatment received. These cost estimates can serve as an important baseline foundation to guide resource allocation for cancer care and research in the future.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Neoplasias Pancreáticas/economia , Neoplasias Pancreáticas/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Modelos Lineares , Masculino , Medicare/estatística & dados numéricos , Modelos Econométricos , Estadiamento de Neoplasias , Programa de SEER , Assistência Terminal/economia , Estados Unidos
7.
MMWR Morb Mortal Wkly Rep ; 68(43): 961-966, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31671084

RESUMO

Diabetes affects approximately 12% of the U.S. adult population and approximately 25% of adults aged ≥65 years. From 2009 to 2017, there was no significant change in diabetes prevalence overall or among persons aged 65-79 years (1). However, these estimates were based on survey data with <5,000 older adults. Medicare administrative data sets, which contain claims for millions of older adults, afford an opportunity to explore both trends over time and heterogeneity within an older population. Previous studies have shown that claims data can be used to identify persons with diagnosed diabetes (2). This study estimated annual prevalence and incidence of diabetes during 2001-2015 using Medicare claims data for beneficiaries aged ≥68 years and found that prevalence plateaued after 2012 and incidence decreased after 2006. In 2015 (the most recent year estimated) prevalence was 31.6%, and incidence was 3.0%. Medicare claims can serve as an important source of data for diabetes surveillance for the older population, which can inform prevention and treatment strategies.


Assuntos
Diabetes Mellitus/epidemiologia , Medicare/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Prevalência , Estados Unidos/epidemiologia
8.
Medicine (Baltimore) ; 98(46): e17960, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31725657

RESUMO

Despite near universal health coverage under Medicare, racial disparities persist in the treatment of diffuse large B-cell lymphoma (DLBCL) among older patients in the United States. Studies evaluating DLBCL outcomes often treat socioeconomic status (SES) measures as confounders, potentially introducing biases when SES factors are mediators of disparities in cancer treatment.To examine differences in DLBCL treatment, we performed causal mediation analyses of SES measures, including: metropolitan statistical area (MSA) of residence; census-tract poverty level; and private Medicare supplementation using the Surveillance, Epidemiology and End Results-Medicare linked database between 2001 and 2011. In this retrospective cohort study of DLBCL patients ages 66+ years, we conducted a series of multivariable logistic regression analyses estimating odds ratios (OR) and 95% confidence intervals (CI) relating chemo- and/or immuno-therapy treatment and each SES measure, comparing non-Hispanic (NH)-black, Hispanic/Latino, and Asian/Pacific Islander (API) to NH-white patients.Compared to NH-white patients, racial/ethnic minority patients had lower odds of receiving chemo- and/or immuno-therapy treatment (NH-black: OR 0.84, 95% CI 0.65, 1.08; API: OR 0.80, 95% CI 0.64, 1.01; Hispanic/Latino: OR 0.78, 95% CI 0.64, 0.96) and higher odds of lacking private Medicare supplementation and residence within an urban MSA and poor census tracts. Adjustment for SES measures as confounders nullified observed racial differences. In causal mediation analyses, between 31% and 38% of race/ethnicity differences were mediated by having private Medicare supplementation.Providing equitable access to Medicare supplementation may reduce disparities in receipt of chemo- and/or immuno-therapy treatment in older DLBCL patients.


Assuntos
Grupos de Populações Continentais/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Linfoma Difuso de Grandes Células B/terapia , Afro-Americanos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Americanos Asiáticos , Grupo com Ancestrais do Continente Europeu , Feminino , Hispano-Americanos , Humanos , Imunoterapia/métodos , Modelos Logísticos , Linfoma Difuso de Grandes Células B/etnologia , Linfoma Difuso de Grandes Células B/patologia , Masculino , Medicare/estatística & dados numéricos , Estadiamento de Neoplasias , Características de Residência , Estudos Retrospectivos , Programa de SEER , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos
9.
Health Serv Res ; 54(6): 1214-1222, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31742688

RESUMO

IMPORTANCE: It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. OBJECTIVES: Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. DATA SOURCES: The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017-2018 (response rates = 47 percent and 48 percent). STUDY DESIGN: Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. PRINCIPAL FINDINGS: ACO-affiliated practices feed back clinician-level information and use it for quality improvement and compensation on more performance domains than non-ACO-affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. CONCLUSION: ACO-affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.


Assuntos
Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/estatística & dados numéricos , Compensação e Reparação , Planos de Pagamento por Serviço Prestado/economia , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Padrões de Prática Médica/economia , Padrões de Prática Médica/estatística & dados numéricos , Humanos , Medicare/economia , Medicare/estatística & dados numéricos , Estados Unidos
10.
BMC Health Serv Res ; 19(1): 837, 2019 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-31727168

RESUMO

BACKGROUND: The Hospital Readmissions Reduction Program (HRRP) was established by the 2010 Patient Protection and Affordable Care Act (ACA) in an effort to reduce excess hospital readmissions, lower health care costs, and improve patient safety and outcomes. Although studies have examined the policy's overall impacts and differences by hospital types, research is limited on its effects for different types of vulnerable populations. The aim of this study was to analyze the impact of the HRRP on readmissions for three targeted conditions (acute myocardial infarction, heart failure, and pneumonia) among four types of vulnerable populations, including low-income patients, patients served by hospitals that serve a high percentage of low-income or Medicaid patients, and high-risk patients at the highest quartile of the Elixhauser comorbidity index score. METHODS: Data on patient and hospital information came from the Nationwide Readmission Database (NRD), which contained all discharges from community hospitals in 27 states during 2010-2014. Using difference-in-difference (DD) models, linear probability regressions were conducted for the entire sample and sub-samples of patients and hospitals in order to isolate the effect of the HRRP on vulnerable populations. Multiple combinations of treatment and control groups and triple difference (DDD) methods were used for testing the robustness of the results. All models controlled for the patient and hospital characteristics. RESULTS: There have been statistically significant reductions in readmission rates overall as well as for vulnerable populations, especially for acute myocardial infarction patients in hospitals serving the largest percentage of low-income patients and high-risk patients. There is also evidence of spillover effects for non-targeted conditions among Medicare patients compared to privately insured patients. CONCLUSIONS: The HRRP appears to have created the right incentives for reducing readmissions not only overall but also for vulnerable populations, accruing societal benefits in addition to previously found reductions in costs. As the reduction in the rate of readmissions is not consistent across patient and hospital groups, there could be benefits to adjusting the policy according to the socioeconomic status of a hospital's patients and neighborhood.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricos , Humanos , Medicare/economia , Patient Protection and Affordable Care Act , Readmissão do Paciente/economia , Avaliação de Programas e Projetos de Saúde , Estados Unidos
11.
Health Serv Res ; 54(6): 1184-1192, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31657002

RESUMO

OBJECTIVE: To investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. DATA SOURCES AND STUDY SETTING: Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee-for-service beneficiaries. STUDY DESIGN: We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment. PRINCIPAL FINDINGS: From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1-day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4-1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8-1.0), lower total Medicare payment for the 90-day episode after hospital discharge ($396; 95% CI 361-431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149-210, P < .001), offsetting the lower payment for the shorter index SNF stay. CONCLUSIONS: Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Hospitalização/economia , Tempo de Internação/economia , Medicare/economia , Alta do Paciente/economia , Instituições de Cuidados Especializados de Enfermagem/economia , Cuidados Semi-Intensivos/economia , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Cuidados Semi-Intensivos/estatística & dados numéricos , Estados Unidos
12.
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
13.
Med Care ; 57(12): 984-989, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31584462

RESUMO

INTRODUCTION: The Medicare Annual Wellness Visit (AWV) is a preventive care visit introduced in 2011 as part of the Affordable Care Act provided without cost to beneficiaries. The AWV is associated with higher preventive services utilization. Although AWV utilization increased during 2011-2013, utilization was lower among ethnoracial minority beneficiaries who may benefit the most. OBJECTIVES: To determine if AWV utilization disparities have persisted using the most recent data available. RESEARCH DESIGN: The authors analyzed AWV utilization in 2011-2013 and 2015-2016 by beneficiary-reported race and ethnicity, adjusting for potential confounders. SUBJECTS: Weighted sample of 78,639,501 fee-for-service Medicare beneficiaries aged 66 years and older who participated in the Medicare Current Beneficiary Survey 2011-2013 or 2015-2016. MEASURES: AWV utilization was identified using Medicare claims. RESULTS: AWV utilization increased from 8.1% to 23.0% of all beneficiaries between 2011 and 2016. Compared with non-Hispanic white beneficiaries, utilization was significantly lower among non-Hispanic Black and non-Hispanic other race beneficiaries in both the minimally and fully-adjusted models. Hispanic/Latino beneficiaries had lower utilization in the minimally adjusted model, but not in the fully-adjusted model. In 2016, compared with non-Hispanic white beneficiaries, AWV utilization was 10.2 points lower for non-Hispanic black, 11.6 points lower for Hispanic/Latino, and 8.6 points lower for non-Hispanic other race beneficiaries, and these differences were attenuated after adjusting for all covariates to 6.8 points lower, 9.4 points lower, and 7.2 points lower, respectively. CONCLUSIONS: The AWV has the potential to increase the use of preventive care, improve health, and reduce ethnoracial disparities among Medicare beneficiaries, but realizing these goals will require increasing utilization by minority groups. If ethnoracial minority beneficiaries had used the AWV at the same rate as non-Hispanic white beneficiaries during the study period, then ~1.6 million additional AWVs would have been used.


Assuntos
Medicare/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Medicina Preventiva/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Grupos de Populações Continentais/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Feminino , Humanos , Masculino , Estados Unidos
14.
Health Serv Res ; 54(6): 1233-1245, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31576563

RESUMO

OBJECTIVE: To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. DATA SOURCE: 2010-2013 Medicare Current Beneficiary Survey. STUDY DESIGN: Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. PRINCIPAL FINDINGS: Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. CONCLUSIONS: Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.


Assuntos
Elegibilidade Dupla ao MEDICAID e MEDICARE , Definição da Elegibilidade/normas , Medicaid/estatística & dados numéricos , Medicaid/normas , Medicare/estatística & dados numéricos , Medicare/normas , Risco Ajustado/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Socioeconômicos , Governo Estadual , Estados Unidos
15.
Public Health Rep ; 134(6): 685-694, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31577517

RESUMO

OBJECTIVE: Emergency departments (EDs) are critical settings for hepatitis C care in the United States. We assessed trends and characteristics of hepatitis C-associated ED visits during 2006-2014. METHODS: We used data from the 2006-2014 Nationwide Emergency Department Sample to estimate numbers, rates, and costs of hepatitis C-associated ED visits, defined by either first-listed diagnosis of hepatitis C or all-listed diagnosis of hepatitis C. We assessed trends by demographic characteristics, liver disease severity, and patients' disposition by using joinpoint analysis, and we calculated the average annual percentage change (AAPC) from 2006 to 2014. RESULTS: During 2006-2014, the rate per 100 000 visits of first-listed and all-listed hepatitis C-associated ED visits increased significantly from 10.1 to 25.4 (AAPC = 13.0%; P < .001) and from 484.4 to 631.6 (AAPC = 3.4%; P < .001), respectively. Approximately 70% of these visits were made by persons born during 1945-1965 (baby boomers); 30% of visits were made by Medicare beneficiaries and 40% by Medicaid beneficiaries. Significant rate increases were among visits by baby boomers (first-listed: AAPC = 13.8%; all-listed: AAPC = 2.6%), persons born after 1965 (first-listed: AAPC = 14.3%; all-listed: AAPC = 9.2%), Medicare beneficiaries (first-listed: AAPC = 18.0%; all-listed: AAPC = 3.9%), and persons hospitalized after ED visits (first-listed: AAPC = 20.0%; all-listed: AAPC = 2.3%; all P < .001). Increasing proportions of compensated cirrhosis were among visits by baby boomers (first-listed: AAPC = 11.5%; all-listed: AAPC = 6.3%). Annual hepatitis C-associated total ED costs increased by 400.0% (first-listed) and 192.0% (all-listed) during 2006-2014. CONCLUSION: Public health efforts are needed to address the growing burden of hepatitis C care in the ED.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Hepatite C/complicações , Hepatite C/epidemiologia , Hospitalização , Idoso , Serviço Hospitalar de Emergência/tendências , Feminino , Pesquisas sobre Serviços de Saúde , Hepacivirus/isolamento & purificação , Hepatite C/diagnóstico , Humanos , Masculino , Medicaid/estatística & dados numéricos , Medicaid/tendências , Medicare/estatística & dados numéricos , Medicare/tendências , Pessoa de Meia-Idade , Estados Unidos
16.
Health Serv Res ; 54(6): 1246-1254, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31595498

RESUMO

OBJECTIVE: To measure strategies of interorganizational collaboration among health care and social service organizations that serve older adults. STUDY SETTING: Twenty Hospital Service Areas (HSAs) in the United States. STUDY DESIGN: We developed and validated a novel scale to characterize interorganizational collaboration, and then tested its application by assessing whether the scale differentiated between HSAs with high vs low performance on potentially avoidable health care use and spending for Medicare beneficiaries. DATA COLLECTION: Health care and social service organizations (N = 173 total) in each HSA completed a 12-item collaboration scale, three questions about collaboration behaviors, and a detailed survey documenting collaborative network ties. PRINCIPAL FINDINGS: We identified two distinguishable subscales of interorganizational collaboration: (a) Aligning Strategy and (b) Coordinating Current Work. Each subscale demonstrated convergent validity with the organization's position in the collaborative network, and with collaboration behaviors. The full scale and Coordinating Current Work subscale did not differentiate high- vs low-performing HSAs, but the Aligning Strategy subscale was significantly higher in high-performing HSAs than in low-performing HSAs (P = .01). CONCLUSIONS: Cross-sector collaboration-and particularly Aligning Strategy-is associated with health care use and spending for older adults. This new survey measure could be used to track the impact of interventions to foster interorganizational collaboration.


Assuntos
Comportamento Cooperativo , Relações Interinstitucionais , Medicare/organização & administração , Reprodutibilidade dos Testes , Serviço Social/organização & administração , Inquéritos e Questionários/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Serviço Social/estatística & dados numéricos , Estados Unidos
17.
Health Serv Res ; 54(6): 1326-1334, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31602637

RESUMO

OBJECTIVE: To evaluate whether changes in diagnosis assignment explain reductions in 30-day readmission for patients with pneumonia following the Hospital Readmission Reduction Program (HRRP). DATA SOURCES: 100 percent MedPAR, 2008-2015. STUDY DESIGN: Retrospective cohort study of Medicare discharges in HRRP-eligible hospitals. Outcomes were 30-day readmission rates for pneumonia under a "narrow" definition (used for the HRRP until October 2015; n = 2 288 644) and a "broad" definition that included certain diagnoses of sepsis and aspiration pneumonia (used since October 2015; n = 3 618 215). We estimated changes in 30-day readmissions in the pre-HRRP period (January 2008-March 2010), the HRRP implementation period (April 2010-September 2012), and the HRRP penalty period (October 2012-June 2015). PRINCIPAL FINDINGS: Under the narrow definition, adjusted annual readmission rates changed by +0.07 percentage points (pp) during the pre-HRRP period (95% CI: -0.03 pp, +0.18 pp), -1.07 pp during HRRP implementation (95% CI: -1.15 pp, -0.99 pp), and -0.09 pp during the penalty period (95% CI: -0.18 pp, -0.00 pp). Under the broad definition, 30-day readmissions changed by +0.21 pp during the pre-HRRP period (95% CI: +0.12 pp, +0.30 pp), -1.28 pp during HRRP implementation (95% CI: -1.35 pp, -1.21 pp), and -0.09 pp during the penalty period (95% CI: -0.16 pp, -0.02 pp). CONCLUSIONS: Changes in the coding of inpatient pneumonia admissions do not explain readmission reduction following the HRRP.


Assuntos
Codificação Clínica/normas , Hospitalização/estatística & dados numéricos , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/classificação , Estudos de Coortes , Humanos , Estudos Retrospectivos , Estados Unidos
18.
Health Serv Res ; 54(5): 971-980, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31506956

RESUMO

OBJECTIVE: To estimate the relationship between breach remediation efforts and hospital care quality. DATA SOURCES: Department of Health and Human Services' (HHS) public database on hospital data breaches and Medicare Compare's public data on hospital quality measures for 2012-2016. MATERIALS AND METHODS: Data breach data were merged with the Medicare Compare data for years 2012-2016, yielding a panel of 3025 hospitals with 14 297 unique hospital-year observations. STUDY DESIGN: The relationship between breach remediation and hospital quality was estimated using a difference-in-differences regression. Hospital quality was measured by 30-day acute myocardial infarction mortality rate and time from door to electrocardiogram. PRINCIPAL FINDINGS: Hospital time-to-electrocardiogram increased as much as 2.7 minutes and 30-day acute myocardial infarction mortality increased as much as 0.36 percentage points during the 3-year window following a breach. CONCLUSION: Breach remediation efforts were associated with deterioration in timeliness of care and patient outcomes. Thus, breached hospitals and HHS oversight should carefully evaluate remedial security initiatives to achieve better data security without negatively affecting patient outcomes.


Assuntos
Segurança Computacional/estatística & dados numéricos , Segurança Computacional/normas , Confidencialidade/normas , Registros Eletrônicos de Saúde/normas , Hospitais/normas , Medicare/normas , Qualidade da Assistência à Saúde/normas , Registros Eletrônicos de Saúde/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Medicare/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estados Unidos
19.
World Neurosurg ; 132: e14-e20, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31521753

RESUMO

OBJECTIVE: Age and comorbidity burden of patients going anterior cervical discectomy and fusion (ACDF) have increased significantly over the past 2 decades, resulting in increased expenditures. Non-home discharge after ACDF contributes to increased direct and indirect costs of postoperative care. The purpose of this study was to identify independent prognostic factors for discharge disposition in patients undergoing ACDF. METHODS: A retrospective review was conducted at 5 medical centers to identify patients undergoing ACDF for degenerative conditions. The primary outcome was non-home discharge. Additional outcomes considered included discharge to rehabilitation and home discharge with services. Bivariate and multivariable analyses were used to identify independent prognostic factors for non-home discharge. RESULTS: Of 2070 patients undergoing ACDF, 114 (5.5%) had non-home discharge and 63 (3.0%) had discharge to inpatient rehabilitation. Factors independently associated with non-home discharge included older age, marital status, Medicare insurance, Medicaid insurance, previous spine surgery, myelopathy, preoperative comorbidities (hemiplegia/paraplegia, congestive heart failure, cerebrovascular accident), anemia, and leukocytosis. C-statistic for the overall model was 0.85. Results were relatively similar for patients younger than the age of 65 years as well as for discharge to inpatient rehabilitation and discharge home with services. CONCLUSIONS: Numerous sociodemographic and clinical characteristics influence the risk of non-home discharge and discharge to inpatient rehabilitation in patients undergoing ACDF. Policy makers and payers should consider these factors when determining appropriate preoperative adjustment for risk-based reimbursements.


Assuntos
Vértebras Cervicais/cirurgia , Discotomia Percutânea/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Fusão Vertebral/estatística & dados numéricos , Adulto , Fatores Etários , Comorbidade , Feminino , Humanos , Degeneração do Disco Intervertebral/reabilitação , Degeneração do Disco Intervertebral/cirurgia , Masculino , Estado Civil , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos/epidemiologia
20.
Bone Joint J ; 101-B(9): 1081-1086, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474135

RESUMO

AIMS: The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon's cases and the total time spent in the operating theatre per day. MATERIALS AND METHODS: A retrospective analysis was performed on the Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) on all primary elective TKAs performed at the New England Baptist Hospital between January 2013 and June 2016. Using theatre records, episodes were categorized into days where a surgeon performed overlapping and nonoverlapping lists. Clinical outcomes, economic outcomes, and demographic factors were calculated. A regression model controlling for the patient-specific factors was used to compare groups. Total orthopaedic cases and aggregate time spent operating (time between skin incision and closure) were also compared. RESULTS: A total of 3633 TKAs were performed (1782 on nonoverlapping days; 1851 on overlapping days). There were no differences between the two groups for length of inpatient stay, payments, mortality, emergency room visits, or readmission during the 90-day postoperative period. The overlapping group had 0.74 fewer skilled nursing days (95% confidence interval (CI) -0.26 to -1.22; p < 0.01), and 0.66 more home health visits (95% CI 0.14 to 1.18; p = 0.01) than the nonoverlapping group. On overlapping days, surgeons performed more cases per day (5.01 vs 3.76; p < 0.001) and spent more time operating (484.55 minutes vs 357.17 minutes; p < 0.001) than on nonoverlapping days. CONCLUSION: The study shows that the practice of alternating operating theatres for TKA has no adverse effect on the clinical outcome or economic utilization variables measured. Furthermore, there is opportunity to increase productivity with alternating theatres as surgeons with overlapping cases perform more cases and spend more time operating per day. Cite this article: Bone Joint J 2019;101-B:1081-1086.


Assuntos
Artroplastia do Joelho/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Duração da Cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/economia , Boston/epidemiologia , Bases de Dados Factuais/estatística & dados numéricos , Eficiência Organizacional/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Humanos , Tempo de Internação , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Salas Cirúrgicas/organização & administração , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos/epidemiologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA