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2.
Support Care Cancer ; 29(7): 3921-3932, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33389087

RESUMO

BACKGROUND: Rather than early hospice enrollment, most Medicare beneficiaries receive "usual care" in the last months of life, outside of the hospice setting. While care intensity during the last weeks of life has been studied extensively, patterns of symptom management services (SMS) and/or cancer-directed therapies (CDT) received over a 6-month end-of-life period have not. METHODS: This retrospective study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify decedents diagnosed with lung cancer at age ≥ 66 years between January 2007 and December 2013 who survived ≥ 6 months from diagnosis. Medicare claims identified receipt of SMS and/or CDT. We created monthly indicators for care content (SMS-only, CDT-only, or both; otherwise full-month hospice or inpatient/skilled nursing). Multinomial logistic regression estimated associations between sociodemographics and comorbidity, with care content in the final month. RESULTS: Between 6 and 1 months before death, full-month hospice and inpatient/skilled nursing increased; CDT decreased from 31.9 to 18.5%; SMS increased from 86.6 to 97.7%. Relative to full-month hospice, the percentage of patients receiving SMS-only was higher for males, unmarried, younger age, and higher comorbidity; the percentage receiving CDT was also higher for males, unmarried, and younger age, but decreased with increasing comorbidity and over calendar time. CONCLUSION: Among lung cancer decedents observed in the outpatient, nonhospice setting, SMS receipt increased and was nearly universal as death approached. CDT diminished dramatically over the end-of-life period. Associations between sociodemographic characteristics and care setting suggest differences in care preferences or access barriers. Claims represent an important resource for characterizing end-of-life care patterns.


Assuntos
Neoplasias Pulmonares/economia , Neoplasias Pulmonares/terapia , Medicare/normas , Assistência Terminal/economia , Idoso , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos
3.
Tex Med ; 116(8): 43-44, 2020 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-32866277

RESUMO

First, the bad news: Physicians need to take some serious time between now and Jan 1, 2021, to study changes that are coming to Medicare outpatient evaluation and management (E&M) codes - changes most private insurers likely will follow. Now the good news: The changes should reduce the amount of documentation needed with each patient.


Assuntos
Medicare/normas , Pacientes Ambulatoriais , Padrões de Prática Médica/economia , Avaliação de Sintomas/normas , Documentação , Controle de Formulários e Registros , Humanos , Seguro Saúde , Visita a Consultório Médico/economia , Reembolso de Incentivo , Estados Unidos
4.
J Nurs Adm ; 50(7-8): 395-401, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32701644

RESUMO

OBJECTIVE: The aim of this study was to explore the relationship between a hospital's Magnet recognition status, tenure, and its performance in the Hospital Value-Based Purchasing (HVBP) program. BACKGROUND: Previous studies have sought to determine associations between quality of care provided in inpatient setting and the Magnet Recognition Program; however, no study has done so using the most recent (FY2017) iteration of the HVBP program, nor determined the influence a hospital's Magnet designation tenure has on HVBP scores. METHOD: This study used a cross-sectional study design of 2686 hospitals using propensity score matching to reduce bias and improve comparability. RESULTS: Magnet-designated hospitals were associated with higher total performance, process of care and patient experience of care scores, and lower efficiency score. No association was identified between the length of time hospitals have been Magnet designated. CONCLUSION: Findings suggest non-Magnet status hospitals need to consider implementing the principles of Magnet into their culture or participation in the Magnet Recognition Program to provide higher quality of care.


Assuntos
Hospitais/estatística & dados numéricos , Medicare/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Aquisição Baseada em Valor/normas , Estudos Transversais , Bases de Dados Factuais , Humanos , Pontuação de Propensão , Melhoria de Qualidade , Estados Unidos
5.
Med Care ; 58(8): 734-743, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32692140

RESUMO

BACKGROUND: Under the Affordable Care Act, the Centers for Medicare and Medicaid Services has greatly expanded inpatient fee-for-value programs including the Hospital Value-based Purchasing (HVBP) program. Existing evidence from the HVBP program is mixed. There is a need for a systematic review of the HVBP program to inform discussions on how to improve the program's effectiveness. OBJECTIVE: To review and summarize studies that evaluated the HVBP program's impact on clinical processes, patient satisfaction, costs and outcomes, or assessed hospital characteristics associated with performance on the program. DESIGN: We searched the MEDLINE/PubMed, Scopus, ProQuest database for literature published between January 2013 and July 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS: Of 988 studies reviewed, 33 studies that met the selection criteria were included. A small group of studies (n=7) evaluated the impact of the HVBP program, and no impact on processes or patient outcomes was reported. None of the included studies evaluated the effect of HVBP program on health care costs. Other studies (n=28) evaluated the hospital characteristics associated with HVBP performance, suggesting that safety-net hospitals reportedly performed worse on several quality and cost measures. Other hospital characteristics' associations with performance were unclear. CONCLUSIONS: Our findings suggest that the current HVBP does not lead to meaningful improvements in quality of care or patient outcomes and may negatively affect safety-net hospitals. More rigorous and comprehensive adjustment is needed for more valid hospital comparisons.


Assuntos
Medicare/economia , Aquisição Baseada em Valor/normas , Humanos , Medicare/normas , Medicare/tendências , Patient Protection and Affordable Care Act/economia , Patient Protection and Affordable Care Act/normas , Patient Protection and Affordable Care Act/tendências , Avaliação de Programas e Projetos de Saúde , Estados Unidos , Aquisição Baseada em Valor/tendências
6.
AJNR Am J Neuroradiol ; 41(7): 1160-1164, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32554420

RESUMO

In the 2020 Final Rule, the Center for Medicare & Medicaid Services adopted a new coding structure and accepted the substantial increase in valuation for office/outpatient Evaluation and Management codes set to begin in 2021. Given budget neutrality requirements, the projected increase in reimbursement will require a reduction in the conversion factor to offset such increases. The aim is to inform neuroradiologists the impact of these proposed changes on reimbursement and the profession.


Assuntos
Centers for Medicare and Medicaid Services, U.S./normas , Codificação Clínica/normas , Reembolso de Seguro de Saúde/normas , Medicare/normas , Humanos , Pacientes Ambulatoriais , Radiologistas , Estados Unidos
7.
Circ Cardiovasc Qual Outcomes ; 13(4): e005977, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32228065

RESUMO

BACKGROUND: Medicare patients with coronary artery disease (CAD) have been a significant focus of value-based payment programs for outpatient practices. Physicians and policymakers, however, have voiced concern that value-based payment programs may penalize practices that serve vulnerable populations. This study evaluated whether outpatient practices that serve socioeconomically disadvantaged populations have worse CAD outcomes, and if this reflects the delivery of lower-quality care or rather, patient and community factors beyond the care provided by physician practices. METHODS AND RESULTS: Retrospective cohort study of Medicare fee-for-service patients ≥65 years with CAD at outpatient practices participating in the the Practice Innovation and Clinical Excellence registry from January 1, 2010 to January 1, 2015. Outpatient practices were stratified into quintiles by the proportion of most disadvantaged patients-defined by an area deprivation score in the highest 20% nationally-served at each practice site. Prescription of guideline recommended therapies for CAD as well as clinical outcomes (emergency department presentation for chest pain, hospital admission for unstable angina or acute myocardial infarction [AMI], 30-day readmission after AMI, and 30-day mortality after AMI) were evaluated by practice-level socioeconomic disadvantage with hierarchical logistic regression models, using practices serving the fewest socioeconomically disadvantaged patients as a reference. The study included 453 783 Medicare fee-for-service patients ≥65 years of age with CAD (mean [SD] age, 75.3 [7.7] years; 39.7% female) cared for at 271 outpatient practices. At practices serving the highest proportion of socioeconomically disadvantaged patients (group 5), compared with practices serving the lowest proportion (group 1), there was no significant difference in the likelihood of prescription of antiplatelet therapy (odds ratio [OR], 0.94 [95% CI, 0.69-1.27]), ß-blocker therapy if prior myocardial infarction or left ventricular ejection fraction <40% (OR, 0.97 [95% CI, 0.69-1.35]), ACE (angiotensin-converting enzyme) inhibitor or angiotensin receptor blocker if left ventricular ejection fraction <40% and/or diabetes mellitus (OR, 0.93 [95% CI, 0.74-1.19]), statin therapy (OR, 0.88 [95% CI, 0.68-1.14]), or cardiac rehabilitation (OR, 0.45 [95% CI, 0.20-1.00]). Patients cared for at the most disadvantaged-serving practices (group 5) were more likely to be admitted for unstable angina (adjusted OR, 1.46 [95% CI, 1.04-2.05]). There was no significant difference in the likelihood of emergency department presentation for chest pain or hospital admission for AMI between practices. Thirty day mortality rates after AMI were higher among patients at the most disadvantaged-serving practices (aOR, 1.31 [95% CI, 1.02-1.68]), but 30-day readmission rates did not differ. All associations were attenuated after additional adjustment for patient-level area deprivation index. CONCLUSIONS: Physician outpatient practices that serve the most socioeconomically disadvantaged patients with CAD perform worse on some clinical outcomes, despite providing similar guideline-recommended care as other practices, and consequently could fare poorly under value-based payment programs. Social factors beyond care provided by outpatient practices may partly explain worse outcomes. Policymakers should consider accounting for socioeconomic disadvantage in value-based payment programs initiatives that target outpatient practices.


Assuntos
Assistência Ambulatorial/normas , Doença da Artéria Coronariana/terapia , Medicare/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Classe Social , Determinantes Sociais da Saúde/normas , Seguro de Saúde Baseado em Valor , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/economia , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/mortalidade , Planos de Pagamento por Serviço Prestado/normas , Feminino , Disparidades em Assistência à Saúde/normas , Humanos , Masculino , Medicare/economia , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Padrões de Prática Médica/normas , Indicadores de Qualidade em Assistência à Saúde/economia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Determinantes Sociais da Saúde/economia , Resultado do Tratamento , Estados Unidos , Seguro de Saúde Baseado em Valor/economia
8.
Med Care ; 58(8): 710-716, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32265354

RESUMO

OBJECTIVES: We can learn something about how Veterans value the Veterans Health Administration (VHA) versus community providers by observing Veterans' choices between VHA and Medicare providers after they turn 65. For a cohort of Veterans who were newly age-eligible for Medicare, we estimated the change in VHA reliance (VHA outpatient visits divided by total VHA and Medicare visits) associated with specific events: receiving a life-threatening diagnosis, having a Medicare-paid hospitalization, or moving further from the VHA. RESEARCH DESIGN: A longitudinal cohort study of VHA and Medicare administrative data. SUBJECTS: A total of 5932 VHA users who completed a health survey in 1999 and became age-eligible for Medicare from 1998 to 2000 were followed through 2016. PRINCIPAL FINDINGS: More Veterans chose to rely on the VHA than Medicare (64% vs. 36.%). For a VHA-reliant Veteran, a Medicare-paid hospital stay was associated with a decrease of 7.8 percentage points (pps) (P<0.001) in VHA reliance in the subsequent 12 months, but by 36 months reliance increased to near prehospitalization levels (-1.5 pps; P=0.138). Moving further from the VHA, or receiving a diagnosis of cancer, heart failure, or renal failure had no significant association with subsequent VHA reliance; however, a diagnosis of dementia was associated with a decrease in VHA reliance (-8.6 pps; P=0.026). CONCLUSIONS: A significant majority of newly Medicare-eligible VHA users voted with their feet in favor of sustaining the VHA as a provider of comprehensive medical care for Veterans. These VHA-reliant Veterans maintained their reliance even after receiving a life-threatening diagnosis, and after experiencing Medicare-provided hospital care.


Assuntos
Medicare/normas , United States Department of Veterans Affairs/normas , Veteranos/estatística & dados numéricos , Idoso , Estudos de Coortes , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Estudos Longitudinais , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Estados Unidos , United States Department of Veterans Affairs/estatística & dados numéricos
9.
Circ Cardiovasc Qual Outcomes ; 13(3): e006180, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32148101

RESUMO

BACKGROUND: To combat the high cost and increasing burden of quality reporting, the Medicare Payment Advisory (MedPAC) has recommended using claims data wherever possible to measure clinical quality. In this article, we use a cohort of Medicare beneficiaries with heart failure with reduced ejection fraction and existing quality metrics to explore the impact of changes in quality metric methodology on measured quality performance, the association with patient outcomes, and hospital rankings. METHODS AND RESULTS: We used 100% Medicare Parts A and B and a random 40% sample of Part D from 2008 to 2015 to create (1) a cohort of 295 494 fee-for-service beneficiaries with ≥1 hospitalization for heart failure with reduced ejection fraction and (2) a cohort of 1079 hospitals with ≥11 heart failure with reduced ejection fraction admissions in 2014 and 2015. We used Part D data to calculate ß-blocker use after discharge and ß-blocker use over time. We then varied the quality metric methodologies to explore the impact on measured performance. We then used multivariable time-to-event analyses to explore the impact of metric methodology on the association between quality performance and patient outcomes and Kendall's Tau to describe impact of quality metric methodology on hospital rankings. We found that quality metric methodology had a significant impact on measured quality performance. The association between quality performance and readmissions was sensitive to changes in methodology but the association with 1-year mortality was not. Changes in quality metric methodology also had a substantial impact on hospital quality rankings. CONCLUSIONS: This article highlights how small changes in quality metric methodology can have a significant impact on measured quality performance, the association between quality performance and utilization-based outcomes, and hospital rankings. These findings highlight the need for standardized quality metric methodologies, better case-mix adjustment and cast further doubt on the use of utilization-based outcomes as quality metrics in chronic diseases.


Assuntos
Demandas Administrativas em Assistência à Saúde , Antagonistas Adrenérgicos beta/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Alta do Paciente/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Volume Sistólico , Função Ventricular Esquerda , Antagonistas Adrenérgicos beta/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Confiabilidade dos Dados , Bases de Dados Factuais , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Medicare/normas , Readmissão do Paciente/normas , Melhoria de Qualidade/normas , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
10.
Health Serv Res ; 55(2): 277-287, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32037552

RESUMO

OBJECTIVE: To determine the correlation between hospital 30-day risk-standardized readmission rates (RSRRs) in elderly adults and those in nonelderly adults and children. DATA SOURCES/STUDY SETTING: US hospitals (n = 1760 hospitals admitting adult patients and 235 hospitals admitting both adult and pediatric patients) in the 2013-2014 Nationwide Readmissions Database. STUDY DESIGN: Cross-sectional analysis comparing 30-day RSRRs for elderly adult (≥65 years), middle-aged adult (40-64 years), young adult (18-39 years), and pediatric (1-17 years) patients. PRINCIPAL FINDINGS: Hospital elderly adult RSRRs were strongly correlated with middle-aged adult RSRRs (Pearson R2 .69 [95% confidence interval (CI) 0.66-0.71]), moderately correlated with young adult RSRRs (Pearson R2 .44 [95% CI 0.40-0.47]), and weakly correlated with pediatric RSRRs (Pearson R2 .28 [95% CI 0.17-0.38]). Nearly identical findings were observed with measures of interquartile agreement and Kappa statistics. This stepwise relationship between age and strength of correlation was consistent across every hospital characteristic. CONCLUSIONS: Hospital readmission rates in elderly adults, which are currently used for public reporting and hospital comparisons, may reflect broader hospital readmission performance in middle-aged and young adult populations; however, they are not reflective of hospital performance in pediatric populations.


Assuntos
Guias como Assunto , Medicaid/normas , Medicare/normas , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/normas , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/normas , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
11.
Health Serv Res ; 55(1): 54-62, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31835283

RESUMO

OBJECTIVE: To estimate the impact of opting-out from Medicare supervision requirements for certified registered nurse anesthetists (CRNAs) on anesthesiologists' work patterns. DATA SOURCES/STUDY SETTING: Secondary data from two national surveys of anesthesiologists and the Area Health Resource File. STUDY DESIGN: We use a matching difference-in-difference regression which contrasts the change in work patterns for anesthesiologists in California, which dropped supervision requirements, to the change for similar anesthesiologists. Key outcome variables include the number of weekly hours worked, the type of work done, and type of care delivery teams. DATA COLLECTION/EXTRACTION METHODS: Self-reported national survey data drawn from members of the American Society of Anesthesiologists. PRINCIPAL FINDINGS: Anesthesiologists in California saw no change in time spent working or time spent supervising CRNAs. There was a decrease in direct care clinical work hours along with a shift in working more in intraoperative care, a decrease in postoperative care, and an increase in the percentage of cases supervising residents. CONCLUSIONS: Anesthesiologists had small but real responses to California's decisions to opt-out of the physician supervision requirement for CRNAs, doing more work in intraoperative care and less outside of the operating room. Total hours worked saw no change.


Assuntos
Anestesiologistas/psicologia , Atenção à Saúde/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Medicare/normas , Enfermeiras Anestesistas/legislação & jurisprudência , Enfermeiras Anestesistas/normas , Salas Cirúrgicas/normas , Adulto , Anestesiologistas/normas , Atitude do Pessoal de Saúde , California , Atenção à Saúde/legislação & jurisprudência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas/legislação & jurisprudência , Estados Unidos
12.
Prof Case Manag ; 25(1): 26-36, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31764714

RESUMO

PURPOSE OF STUDY: The study's purpose was to identify hospital programs, organizational characteristics, and levels of nursing involvement in hospital programs that contribute significantly to reductions in readmission rates and reimbursement penalties for hospital systems in upstate New York. PRIMARY PRACTICE SETTING: Hospitals located in upstate New York. METHODOLOGY AND SAMPLE: No sampling technique was employed because the cohort included hospitals located in upstate New York. Hospitals in upstate New York were selected (N = 94), representing 53 counties ranging between metropolitan and rural status. Using an ex post facto design within the framework of the ecological and synergy models, organizational characteristics of hospital systems and educational levels of nursing involvement in hospital programs were analyzed and coded. Independent-samples t tests, analysis of variance, and Pearson correlation tests were conducted. RESULTS: Organizational programs that reduce various hospital readmission rates and reimbursement penalties for hospitals in upstate New York are (1) certified home health agencies; (2) telehealth; (3) house calls; (4) advanced practice nurses on care management interdisciplinary discharge teams; and (4) increasing the number of hospital readmission reduction programs (HRRPs) utilized. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Hospitals should.


Assuntos
Guias como Assunto , Medicare/estatística & dados numéricos , Medicare/normas , Alta do Paciente/estatística & dados numéricos , Alta do Paciente/normas , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/normas , Humanos , New York , Avaliação de Programas e Projetos de Saúde , Estados Unidos
13.
Healthc (Amst) ; 8(1): 100364, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31155480

RESUMO

BACKGROUND: Older adults with cardiometabolic conditions are typically seen by multiple providers. Management by multiple providers may compromise care continuity and increase health expenditures for older adults, which may partly explain the inverse association between continuity and Medicare expenditures found in prior studies. This study sought to examine whether all-cause admission, outpatient expenditures or total expenditures were associated with the number of prescribers of cardiometabolic medications. METHODS: Medicare fee-for-service beneficiaries with diabetes (n = 100,191), hypertension (n = 299,949) or dyslipidemia (n = 243,598) living in 10 states were identified from claims data. The probability of an all-cause hospital admission in 2011 was estimated via logistic regression and Medicare (outpatient, total) expenditures in 2011 were estimated using generalized linear models, both as a function of the number of prescribers in 2010. Regressions were adjusted for demographic characteristics, Medicaid status, number of prescriptions, and 17 chronic conditions. RESULTS: In all three cohorts, older adults with more prescribers in 2010 had modestly higher adjusted odds of all-cause inpatient admission than older adults with a single prescriber. Compared to a single prescriber, outpatient and total expenditures in 2011 were 3-10% higher for older adults with diabetes and multiple prescribers, 2-6% higher for older adults with hypertension and multiple prescribers, and 2-5% higher for older adults with dyslipidemia and multiple prescribers. CONCLUSIONS AND IMPLICATIONS: These results provide some evidence that older adults with multiple prescribers also have modestly higher Medicare utilization than those with a single prescriber; thus care continuity may impact patient utilization. LEVEL OF EVIDENCE: Level III (retrospective cohort analysis).


Assuntos
Continuidade da Assistência ao Paciente/normas , Custos de Cuidados de Saúde/estatística & dados numéricos , Medicare/normas , Idoso , Estudos de Coortes , Continuidade da Assistência ao Paciente/economia , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Dislipidemias/economia , Dislipidemias/terapia , Feminino , Humanos , Hipertensão/economia , Hipertensão/terapia , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
14.
Health Serv Res ; 55(2): 273-276, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31880314

RESUMO

OBJECTIVE: To compare readmission rates as measured by the Centers for Medicare and Medicaid Services and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) methods. DATA SOURCES: 20 percent sample of national Medicare data for patients undergoing cystectomy, colectomy, abdominal aortic aneurysm (AAA) repair, and total knee arthroplasty (TKA) between 2010 and 2014. STUDY DESIGN: Retrospective cohort study comparing 30-day readmission rates. DATA COLLECTION/EXTRACTION METHODS: Patients undergoing cystectomy, colectomy, abdominal aortic aneurysm repair, and total knee arthroplasty between 2010 and 2014 were identified. PRINCIPAL FINDINGS: Cystectomy had the highest and total knee arthroplasty had the lowest readmission rate. The NSQIP measure reported significantly lower rates for all procedures compared to the CMS measure, which reflects an immortal-time bias. CONCLUSIONS: We found significantly different readmission rates across all surgical procedures when comparing CMS and NSQIP measures. Longer length of stay exacerbated these differences. Uniform outcome measures are needed to eliminate ambiguity and synergize research and policy efforts.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Alta do Paciente/normas , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/normas , Melhoria de Qualidade/normas , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/cirurgia , Artroplastia do Joelho/economia , Artroplastia do Joelho/estatística & dados numéricos , Viés , Colectomia/economia , Colectomia/estatística & dados numéricos , Feminino , Humanos , Masculino , Medicare/economia , Medicare/normas , Medicare/estatística & dados numéricos , Razão de Chances , Melhoria de Qualidade/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
15.
J Oncol Pharm Pract ; 26(2): 279-285, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30943846

RESUMO

INTRODUCTION: Novel oral oncolytic agents have become the standard of care and first-line therapies for many malignancies. However, issues impacting access to these drugs are not well explored. As part of a quality improvement project in a large tertiary academic institution, we aim to identify potential barriers that delay treatment for patients who are prescribed novel oral oncolytics. METHODS: This was a retrospective review of adults who were newly prescribed a novel oral oncolytic for Food and Drug Administration-approved indications at a single tertiary care center. Patients were identified via electronic prescription data (e-Scribe). Demographics, insurance information, and prescription dates were extracted from the electronic medical record and pharmacy claims data. Statistical analyses were performed to determine whether time-to-receipt was associated with insurance category, pharmacy transfers, cost assistance, and drug prescribed. RESULTS: Of the 270 successfully filled prescriptions, the mean time-to-receipt was 7.3 ± 10.3 days (range: 0-109 days). Patients with Medicare experienced longer time-to-receipt (9.1 ± 13.1 days) compared to patients with commercial insurance (4.4 ± 3.3). Uninsured patients experienced the longest time-to-receipt (15.7 ± 7.8 days) overall. Pharmacy transfers and cost assistance programs were also significantly associated with longer time-to-receipt. Ten prescriptions remained unfilled 90 days after the study period and were considered abandoned. CONCLUSION: Insurance has a significant effect on the time-to-receipt of newly prescribed novel oral oncolytics. Pharmacy transfers and applying for cost assistance are also associated with longer wait times for patients. Our retrospective analysis identifies areas of improvement for future interventions to reduce wait times for patients receiving novel oral oncolytics.


Assuntos
Antineoplásicos/administração & dosagem , Neoplasias/tratamento farmacológico , Assistência Farmacêutica/normas , Honorários por Prescrição de Medicamentos/normas , Melhoria de Qualidade/normas , Administração Oral , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/economia , Prescrições de Medicamentos/economia , Prescrições de Medicamentos/normas , Feminino , Humanos , Masculino , Medicare/economia , Medicare/normas , Medicare/tendências , Pessoa de Meia-Idade , Neoplasias/economia , Neoplasias/epidemiologia , Assistência Farmacêutica/economia , Assistência Farmacêutica/tendências , Honorários por Prescrição de Medicamentos/tendências , Estudos Retrospectivos , Tempo para o Tratamento , Estados Unidos/epidemiologia
16.
JAMA Netw Open ; 2(12): e1917559, 2019 12 02.
Artigo em Inglês | MEDLINE | ID: mdl-31834398

RESUMO

Importance: The Improving Medicare Post-Acute Care Transformation Act of 2014 mandated a quality measure of potentially preventable 30-day hospital readmission for inpatient rehabilitation facilities (IRFs). Examining IRF performance nationally may help inform health care quality initiatives for Medicare beneficiaries. Objective: To examine variation in Centers for Medicare & Medicaid Services Quality Reporting Program measures for US facility-level risk-adjusted all-cause and potentially preventable hospital readmission rates after inpatient rehabilitation. Design, Setting, and Participants: This cohort study of Medicare claims data included 454 378 Medicare beneficiaries discharged from 1162 IRFs between June 1, 2013, and July 1, 2015. Data were analyzed March 23, 2018, through June 24, 2019. Main Outcomes and Measures: All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities and the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation. Specifications from the Centers for Medicare & Medicaid Services were followed to identify the cohort, define outcomes, and calculate risk-standardized facility-level rates. Results: Among a cohort of 454 378 patients, the mean (SD) age was 76.2 (10.6) years and 263 546 (58.0%) were women. The all-cause readmission rate was 12.3% (95% CI, 12.2%-12.4%), and the potentially preventable readmission rate was 5.3% (95% CI, 5.3%-5.4%). Across 1162 included IRFs, risk-standardized all-cause readmission rates ranged from 10.1% (95% CI, 8.9%-11.6%) to 15.9% (95% CI, 13.6-18.6%) and potentially preventable readmission rates ranged from 4.3% (95% CI, 3.7%-5.4%) to 7.3% (95% CI, 5.7%-8.3%). Using the All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities, 16 IRFs (1.4%) had 95% CIs above the national mean rate, 1137 IRFs (97.9%) had 95% CIs containing the national mean rate, and 9 IRFs (0.8%) had 95% CIs below the national mean rate. Using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation, 8 IRFs (0.7%) had 95% CIs above the national mean rate, 1153 IRFs (99.2%) had 95% CIs containing the national mean rate, and 1 IRF (0.1%) had a 95% CI below the national mean rate. Conclusions and Relevance: This cohort study found that readmission rates were lower when using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation and further reduced discrimination between facilities compared with the recently discontinued All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities. This finding may indicate there is a lack of room for improvement in readmission rates. Given the rationale of the Centers for Medicare & Medicaid Services for removing measures that fail to discriminate quality performance, this suggests that the current readmission measure should not be implemented as part of the Inpatient Rehabilitation Quality Reporting Program.


Assuntos
Planos de Pagamento por Serviço Prestado , Medicare , Alta do Paciente/normas , Readmissão do Paciente/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Centros de Reabilitação/normas , Cuidados Semi-Intensivos/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Masculino , Medicare/economia , Medicare/normas , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Alta do Paciente/economia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/economia , Readmissão do Paciente/normas , Garantia da Qualidade dos Cuidados de Saúde/métodos , Indicadores de Qualidade em Assistência à Saúde/economia , Centros de Reabilitação/economia , Centros de Reabilitação/estatística & dados numéricos , Estudos Retrospectivos , Risco Ajustado , Cuidados Semi-Intensivos/economia , Cuidados Semi-Intensivos/estatística & dados numéricos , Estados Unidos
17.
BMC Health Serv Res ; 19(1): 818, 2019 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-31703682

RESUMO

BACKGROUND: While Medicare is a federal health insurance program, managed Medicare limits access to healthcare services to networks within states or territories. However, if a natural disaster requires evacuation, displaced patients are at risk of losing coverage for their benefits. Previous literature has discussed the quality of managed Medicare plans within Puerto Rico but has not addressed the adequacy of this coverage if residents are displaced to the continental United States. We explore Hurricane Maria's impact on a resident of Puerto Rico with chronic health problems, and the challenges he faces seeking healthcare in New York. CASE PRESENTATION: A 59-year-old male with a history of diabetes mellitus type II, coronary artery disease, peripheral vascular disease status post right foot amputation, and end-stage kidney disease on hemodialysis was admitted in October of 2017 for chest pain and swelling of legs for 5 days. The patient had missed his last three dialysis sessions after Hurricane Maria forced him to leave Puerto Rico. In examining this patient's treatment, we observe the effect of Hurricane Maria on the medical management of Puerto Rican residents and identify challenges managed Medicare may pose to patients who cross state or territory lines. CONCLUSIONS: We employ this patient's narrative to frame a larger discussion of Puerto Rican managed Medicare and provide additional recommendations for healthcare providers. Moreover, we consider this case in the context of disaster-related continuity of care for patients with complex medical conditions or treatment regimens. To address the gaps in the care of these patients, this article proposes (1) developing system-based approaches for screening displaced patients, (2) increasing the awareness of Special Enrollment Periods related to Medicare among healthcare providers, and (3) creating policy solutions to assure access to care for patients with complex medical conditions.


Assuntos
Tempestades Ciclônicas , Atenção à Saúde/normas , Desastres , Medicare/normas , Múltiplas Afecções Crônicas/terapia , Hispano-Americanos , Humanos , Seguro Saúde , Masculino , Turismo Médico , Pessoa de Meia-Idade , Múltiplas Afecções Crônicas/etnologia , Cidade de Nova Iorque , Aceitação pelo Paciente de Cuidados de Saúde , Porto Rico/etnologia , Refugiados , Diálise Renal , Estados Unidos
18.
J Manag Care Spec Pharm ; 25(12): 1319-1327, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31778613

RESUMO

BACKGROUND: In recent years, value assessment frameworks have been introduced to inform discussions about how to define and assess value in the U.S. health care system. However, there is uncertainty as to how value assessment frameworks and other approaches to achieve value such as outcomes-based contracting are perceived and used in coverage decisions. OBJECTIVE: To understand how U.S. payers determine value in the use of pharmaceuticals and how it differs from payers outside the United States. METHODS: Qualitative in-depth phone interviews with 13 executive-level public and private U.S. managed care representatives and 6 health technology assessment advisors outside the United States were conducted from September to November 2017. RESULTS: Despite various mechanisms used by U.S. payers to assess value, no consistent definitions of value were provided, and U.S. payers felt limited in what they can do to achieve value in pharmaceutical decision making. Value assessment frameworks are not formally considered in formulary and reimbursement decisions but are used as a reference as they become available by most or all U.S. health plans. U.S. payers expressed concerns, including limited control over pharmaceutical pricing and budget caps, and limited ability to use incremental cost per quality-adjusted life-year thresholds. Outcomes-based contracting could have some utility in specific cases where the treatment has a particularly high cost and a clear outcomes measure, but payers indicated that outcomes-based contracts can be difficult to operationalize, and determination of savings was uncertain. Payers outside the United States-who are enabled by government health care bodies, policy tools, and analytical frameworks that have no counterpart in the United States-have a wider array of instruments at their disposal. U.S. payers were largely open to learning from other health care systems outside the United States, particularly the German health care system, where patient-relevant benefit compared with a predetermined treatment comparator is the primary determinant for price negotiations. CONCLUSIONS: Although there is interest in including value assessment frameworks during the decision-making process in the United States, there are significant challenges to operationalizing them. The current environment in the United States restricts payers' ability to make favorable contracts with manufacturers, and changes to the U.S. health system design are needed to facilitate this effort. Adoption of a value assessment framework in Medicare or Medicaid would accelerate adoption of these tools by private payers in the United States. DISCLOSURES: This study was conducted by RTI Health Solutions under the direction of The Pew Charitable Trusts and was funded by The Pew Charitable Trusts. Vekaria is employed by RTI Health Solutions. Reynolds and Coukell are employed by The Pew Charitable Trusts. Brogan and Hogue have nothing to disclose.


Assuntos
Atenção à Saúde/normas , Preparações Farmacêuticas/normas , Orçamentos/normas , Tomada de Decisões , Humanos , Programas de Assistência Gerenciada/normas , Medicare/normas , Farmácia/normas , Avaliação da Tecnologia Biomédica/normas , Estados Unidos
19.
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
20.
Ann Intern Med ; 171(7): ITC49-ITC64, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31569251

RESUMO

This review provides an evidence-based guide for the diagnosis, evaluation, and treatment of patients with asthma. It addresses typical questions that arise in the clinic-based care of patients with asthma and provides a basic and comprehensive resource for asthma care.


Assuntos
Asma/diagnóstico , Asma/terapia , Antiasmáticos/uso terapêutico , Asma/tratamento farmacológico , Asma/etiologia , Diagnóstico Diferencial , Progressão da Doença , Hospitalização , Humanos , Medicaid/normas , Anamnese , Medicare/normas , Educação de Pacientes como Assunto , Exame Físico , Garantia da Qualidade dos Cuidados de Saúde , Encaminhamento e Consulta , Fatores de Risco , Espirometria , Estados Unidos
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