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2.
Med Care ; 59(3): 273-279, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33480659

RESUMO

BACKGROUND: Evidence-based health promotion programs can help older adults manage chronic conditions and address behavioral risk factors, and translating these interventions to population-scale impact depends on reaching people outside of clinical settings. Area Agencies on Aging (AAAs) have emerged as important delivery sites for health promotion programs, but the impacts of their expanded role in delivering these interventions remain unknown. OBJECTIVE: The objective of this study was to test whether evidence-based health promotion programs implemented by AAAs from 2008 to 2016 influenced health care use and spending by older adults and to examine how agencies' organizational capacity for implementation influenced these population-level impacts. RESEARCH DESIGN: We used panel regression models to examine how the expansion of health promotion programs offered by AAAs over the course of 2008-2016 was associated with a change in health care use and spending by older adults in counties served by the AAAs. We examined impact separately for high capacity and low capacity agencies. RESULTS: Across the full sample of AAAs, beginning to offer any health promotion program in the AAA was associated a with 0.94% percentage point reduction in potentially avoidable nursing home use in counties covered by the AAA (95% confidence interval=-1.58, -0.29), equivalent to a 6.5% change. Expanding the breadth of programs offered by the AAA was also associated with a significant reduction in potentially avoidable nursing home use. Stratified analysis showed that reductions in potentially avoidable nursing home use were evident only in places where the AAA had high implementation capacity. Expansion of health promotion programs offered by AAAs was not associated with the change in county-level hospital readmission rates, ambulatory care sensitive hospitalizations, or Medicare spending per beneficiary. CONCLUSIONS: AAAs are an example of community-based organizations that can contribute to health care policy goals such as cost containment. Organizational development support may be needed to extend their ability to effect change in more regions of the country.


Assuntos
Redes Comunitárias/organização & administração , Comportamentos Relacionados com a Saúde , Educação em Saúde/organização & administração , Promoção da Saúde/organização & administração , Idoso , Envelhecimento , Feminino , Humanos , Masculino , Medicare/organização & administração , Saúde da População , Avaliação de Programas e Projetos de Saúde , Qualidade de Vida , Estados Unidos
3.
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
4.
Ann Surg ; 272(4): 612-619, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32932318

RESUMO

OBJECTIVE: To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time. SUMMARY BACKGROUND DATA: Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90). METHODS: Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012-2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90. RESULTS: PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion versus nonexpansion states (-5.9% vs -4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (-3.9% vs -5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs -14.0%, P = 0.013). CONCLUSIONS: Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.


Assuntos
Economia Hospitalar , Reforma dos Serviços de Saúde , Patient Protection and Affordable Care Act , Segurança do Paciente , Humanos , Medicaid/organização & administração , Pessoas sem Cobertura de Seguro de Saúde , Medicare/organização & administração , Provedores de Redes de Segurança/economia , Estados Unidos
5.
Medicine (Baltimore) ; 99(38): e22245, 2020 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-32957371

RESUMO

BACKGROUND: CMS recently decided to produce private "healthcare disparities reports" that include dual eligibility (DE) as the sole stratifying variable used to assess pneumonia readmission disparities. RESEARCH DESIGN: We measure the relationship between DE status and readmissions, both with and without conceptually relevant social risk factors, including air pollution, severe housing problems, and food insecurity, using data from county- and hospital-level readmission rates, DE status, and social risk factors. RESULTS: At the county level, the relationship between DE status and readmissions is partially confounded by at least three social risk factors. DE populations vary widely across hospitals, creating unequal between-hospital comparisons. CONCLUSIONS: Because of differences in the DE population, between-hospital comparisons could be misleading using a methodology that stratifies by DE only. We suggest viable alternatives to sole-factor stratification to properly account for social risk factors and better isolate quality differences that might yield readmission rate inequities. IMPLICATIONS: CMS's healthcare disparities reports provided to hospitals are limited by relying exclusively on DE proportion as the measure of social risk, undercutting the power of quality measurement and its related incentives to close or minimize healthcare inequities.


Assuntos
Definição da Elegibilidade , Disparidades em Assistência à Saúde , Medicaid/organização & administração , Medicare/organização & administração , Determinantes Sociais da Saúde , Poluição do Ar/efeitos adversos , Abastecimento de Alimentos , Habitação , Humanos , Readmissão do Paciente , Pneumonia/terapia , Fatores de Risco , Estados Unidos
6.
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
7.
Milbank Q ; 98(3): 847-907, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32697004

RESUMO

Policy Points Concerns have been raised about risk selection in the Medicare Shared Savings Program (MSSP). Specifically, turnover in accountable care organization (ACO) physicians and patient panels has led to concerns that ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels. We find no evidence that changes in ACO patient populations explain savings estimates from previous evaluations through 2015. We also find no evidence that ACOs systematically manipulated provider composition or billing to earn bonuses. The modest savings and lack of risk selection in the original MSSP design suggest opportunities to build on early progress. Recent program changes provide ACOs with more opportunity to select providers with lower-risk patients. Understanding the effect of these changes will be important for guiding future payment policy. CONTEXT: The Medicare Shared Savings Program (MSSP) establishes incentives for participating accountable care organizations (ACOs) to lower spending for their attributed fee-for-service Medicare patients. Turnover in ACO physicians and patient panels has raised concerns that ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels. METHODS: We conducted three sets of analyses of Medicare claims data. First, we estimated overall MSSP savings through 2015 using a difference-in-differences approach and methods that eliminated selection bias from ACO program exit or changes in the practices or physicians included in ACO contracts. We then checked for residual risk selection at the patient level. Second, we reestimated savings with methods that address undetected risk selection but could introduce bias from other sources. These included patient fixed effects, baseline or prospective assignment, and area-level MSSP exposure to hold patient populations constant. Third, we tested for changes in provider composition or provider billing that may have contributed to bonuses, even if they were eliminated as sources of bias in the evaluation analyses. FINDINGS: MSSP participation was associated with modest and increasing annual gross savings in the 2012-2013 entry cohorts of ACOs that reached $139 to $302 per patient by 2015. Savings in the 2014 entry cohort were small and not statistically significant. Robustness checks revealed no evidence of residual risk selection. Alternative methods to address risk selection produced results that were substantively consistent with our primary analysis but varied somewhat and were more sensitive to adjustment for patient characteristics, suggesting the introduction of bias from within-patient changes in time-varying characteristics. We found no evidence of ACO manipulation of provider composition or billing to inflate savings. Finally, larger savings for physician group ACOs were robust to consideration of differential changes in organizational structure among non-ACO providers (eg, from consolidation). CONCLUSIONS: Participation in the original MSSP program was associated with modest savings and not with favorable risk selection. These findings suggest an opportunity to build on early progress. Understanding the effect of new opportunities and incentives for risk selection in the revamped MSSP will be important for guiding future program reforms.


Assuntos
Redução de Custos , Custo Compartilhado de Seguro/economia , Medicare/economia , Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/organização & administração , Organizações de Assistência Responsáveis/estatística & dados numéricos , Idoso , Redução de Custos/economia , Redução de Custos/métodos , Redução de Custos/estatística & dados numéricos , Custo Compartilhado de Seguro/métodos , Custo Compartilhado de Seguro/estatística & dados numéricos , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Medicare/organização & administração , Estados Unidos
9.
Sr Care Pharm ; 35(7): 331, 2020 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-32600512

RESUMO

The Centers for Medicare & Medicaid Services (CMS) and other federal agencies are busy churning out regulations and guidance documents in response to the COVID-19 crisis. CMS now requires plans to waive cost sharing for COVID-19-related immunizations, testing, and treatment and suspend utilization review requirements related to drug-supply limits unless these limits are related to patient safety.


Assuntos
Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Medicaid/organização & administração , Medicare/organização & administração , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Betacoronavirus , Infecções por Coronavirus/economia , Infecções por Coronavirus/prevenção & controle , Uso de Medicamentos , Humanos , Pandemias/economia , Pandemias/prevenção & controle , Pneumonia Viral/economia , Pneumonia Viral/prevenção & controle , Estados Unidos
10.
Med Care ; 58(7): 586-593, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32520834

RESUMO

BACKGROUND: Social factors are important drivers of health. However, it is unclear to what extent neighborhood social conditions are associated with total and preventable health care utilization and costs. OBJECTIVES: To examine the association of neighborhood social conditions with total annual and potentially preventable Medicare costs. RESEARCH DESIGN AND SUBJECTS: Retrospective cohort study. Medicare claims data from 2013 to 2014 linked with neighborhood social conditions at the US census block group level of 2013 for 93,429 Medicare fee-for-service and dually eligible patients. MEASURES: Neighborhood social conditions were measured by Area Deprivation Index at the census block group level, categorized into quintiles. Outcomes included total annual and potentially preventable utilization and costs. RESULTS: After adjustment for demographics and comorbidities, patients with the least disadvantaged social conditions had higher total annual Medicare costs [$427; 95% confidence interval (CI), $200-$655] and similar potentially preventable costs (-$23; 95% CI, -$56 to $10) as compared with patients with the intermediate level social conditions. Patients with the most disadvantaged social conditions had similar total Medicare costs (-$22; 95% CI, -$342 to $298) but higher potentially preventable costs ($53; 95% CI, $1-$104) than patients with the intermediate level social conditions. CONCLUSIONS: Disadvantaged neighborhood conditions are associated with lower total annual Medicare costs but higher potentially preventable costs after controlling for demographic, medical, and other patient characteristics. Socioeconomic barriers may limit access and use of primary care and disease management services, resulting in a higher proportion of their health care costs going to potentially preventable care.


Assuntos
Custos de Cuidados de Saúde/normas , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Condições Sociais/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Correlação de Dados , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Medicare/organização & administração , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos
14.
BMC Health Serv Res ; 20(1): 132, 2020 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-32085767

RESUMO

BACKGROUND: Colorectal cancer screening rates remain low, especially among certain racial and ethnic groups and the uninsured and Medicaid insured. Clinics and health care systems have adopted population-based mailed fecal immunochemical testing (FIT) programs to increase screening, and now health insurance plans are beginning to implement mailed FIT programs. We report on challenges to and successes of mailed FIT programs during their first year of implementation in two health plans serving Medicaid and dual eligible Medicaid/Medicare enrollees. METHODS: This qualitative descriptive study gathered data through in-depth interviews with staff and leaders at each health plan (n = 10). The Consolidated Framework for Implementation Research, field notes from program planning meetings between the research team and the health plans, and internal research team debriefs informed interview guide development. Qualitative research staff used Atlas.ti to code the health plan interviews and develop summary themes through an iterative content analysis approach. RESULTS: We identified first-year implementation challenges in five thematic areas: 1) program design, 2) vendor experience, 3) engagement/communication, 4) reaction/satisfaction of stakeholders, and 5) processing/returning of mailed kits. Commonly experienced challenges by both health plans related to the time-consuming nature of the programs to set up, and complexities and delays in working with vendors. We found implementation successes in the same five thematic areas as well as four additional areas of: 1) leadership support, 2) compatibility with the health plan, 3) broader impacts, and 4) collaboration with researchers. Commonly experienced successes included the ability to adapt the mailed FIT program to the individual health plan culture and needs, and the synchronicity between the programs and their organizational missions and goals. CONCLUSIONS: Both health plans successfully adapted mailed FIT programs to their own culture and resources and used their strong quality management resources to maximize success in overcoming the time demands of setting up the program and working with their vendors. Mailed FIT programs administered by health plans, especially those serving Medicaid- and dual eligible Medicaid/Medicare-insured populations, may be an important resource to support closing gaps in colorectal cancer screening among traditionally underserved populations.


Assuntos
Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/métodos , Medicaid/organização & administração , Medicare/organização & administração , Sangue Oculto , Serviços Postais , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Pesquisa Qualitativa , Melhoria de Qualidade/organização & administração , Estados Unidos
15.
BMC Health Serv Res ; 20(1): 77, 2020 Feb 03.
Artigo em Inglês | MEDLINE | ID: mdl-32013969

RESUMO

BACKGROUND: The Affordable Care Act (ACA) was enacted to enhance access to care primarily among nonelderly and low-income populations; however, several provisions addressed key determinants of emergency department (ED) and inpatient visits among Medicare beneficiaries over age 65 years. We take stock of the overall changes in these visits among older Medicare beneficiaries, focusing on those with multiple chronic conditions (MCCs), and provide a nationally representative post-reform update. METHODS: We analyzed a sample of 32,919 older adults (65+) on Medicare from the 2006-2015 Medical Expenditure Panel Survey (MEPS). Using a survey-weighted two-part model, we examined changes in ED visits, inpatient visits, and length of stay (LOS) by MCC status, before (2006-2010), during (2011-2013), and after the ACA (2014-2015). RESULTS: Prior to the ACA, 18.1% of Medicare older adults had ≥1 ED visit, whereas 17.1% had ≥1 inpatient visits, with an average of 5.1 nights/visit. Following ACA reforms, among those with 2+ chronic conditions, the rate of ever having an ED visit increased by 4.3 percentage points [95% confidence intervals [CI]: 2.5, 6.1, p < 0.01], whereas the rate of inpatient visits decreased by 1.4 percentage points [95%CI: - 2.9, 0.2, p < 0.1], after multivariable adjustment. CONCLUSIONS: We found sizable increases in ED visits and nontrivial decreases in inpatient visits among older Medicare beneficiaries with MCCs, underscoring the continuing need for improving access to and quality of care among older adults with MCCs to decrease reliance on the ED and reduce preventable hospitalizations.


Assuntos
Doença Crônica/epidemiologia , Doença Crônica/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Medicare/organização & administração , Multimorbidade , Idoso , Feminino , Reforma dos Serviços de Saúde , Humanos , Masculino , Patient Protection and Affordable Care Act , Estados Unidos/epidemiologia
16.
Milbank Q ; 98(1): 172-196, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31994260

RESUMO

Policy Points Although preventable chronic conditions such as type 2 diabetes carry a significant cost and health burden, few lifestyle interventions have been scaled at a national policy level. The translation of the National Diabetes Prevention Program lifestyle intervention from research to a Medicare-covered service can serve as a model for national adoption of other interventions that have the potential to improve population health. The successful translation of the National Diabetes Prevention Program has depended on the collaboration of government agencies, academic researchers, community-based healthcare providers, payers, and other parties. CONTEXT: Many evidence-based health interventions never achieve national implementation. This article analyzes factors that supported the translation and national implementation of a lifestyle change intervention to prevent or delay type 2 diabetes in individuals with prediabetes. METHODS: We used the Knowledge to Action framework, which was developed to map how science is translated into effective health programs, to examine how the evidence-based intervention from the 2002 Diabetes Prevention Program trial was translated into the Centers for Disease Control and Prevention's large-scale National Diabetes Prevention Program, eventually resulting in payment for the lifestyle intervention as a Medicare-covered service. FINDINGS: Key findings of our analysis include the importance of a collaboration among researchers, policymakers, and payers to encourage early adopters; development of evidence-based, national standards to support widespread adoption of the intervention; and use of public input from community organizations to scale the intervention to a national level. CONCLUSIONS: This analysis offers timely lessons for other high-value, scalable interventions attempting to move beyond the evidence-gathering phase and into translation and institutionalization.


Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Promoção da Saúde/organização & administração , Estilo de Vida , Medicare/organização & administração , Humanos , Desenvolvimento de Programas , Estados Unidos
17.
Trials ; 21(1): 91, 2020 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-31941527

RESUMO

BACKGROUND: Colorectal cancer (CRC) screening rates remain suboptimal, particularly in low-income and underserved populations. Mailed fecal immunochemical testing (FIT) may overcome common barriers to screening; however, the effect of mailed FIT kits may differ across important subpopulations. The goal of the current study was to examine sociodemographic and health-related factors that moderate the effect of an intervention of automated direct mail of FIT kits at health clinics serving low-income populations. METHODS: This study is a secondary analysis of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) study, a cluster-randomized pragmatic trial to increase uptake of CRC screening in patients seen at federally qualified health centers. The intervention involved tools embedded in the electronic medical records to enable participating clinics to mail FIT kits and related materials to eligible participants. We examined the rate of FIT completion by potential moderating characteristics using electronic health record data supplemented by the American Community Survey and the Centers for Medicare & Medicaid Services Geographic Variation datasets, linked via geocoding to patients' addresses. All patients aged 50-75 seen in participating health clinics who were eligible for CRC screening were included. RESULTS: Although not always statistically significant, we saw a consistent pattern of increased FIT return rates among intervention participants compared to control participants across all subgroups studied, with incidence rate ratios (IRRs) generally ranging from 1.25 to 1.50. FIT completion in the intervention group ranged from 15 and 20% across subpopulations, typically three to six percentage points higher than the control group participants. The only moderator with a statistically significant interaction was race: persons of Asian descent showed a twofold response to the intervention (adjusted incidence rate ratio [aIRR] = 2.06, 95% confidence interval 1.41 to 3.00). CONCLUSIONS: Response to a mailed FIT intervention was generally consistent across a wide range of individual and neighborhood-level patient characteristics, including typically underserved patients and those in low-resource communities. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01742065. Registered on 5 December 2012.


Assuntos
Neoplasias do Colo/prevenção & controle , Neoplasias Colorretais/diagnóstico , Fezes/química , Programas de Rastreamento/métodos , Idoso , Estudos de Casos e Controles , Neoplasias Colorretais/epidemiologia , Registros Eletrônicos de Saúde , Feminino , Humanos , Incidência , Masculino , Medicaid/economia , Medicare/organização & administração , Pessoa de Meia-Idade , Serviços Postais , Estados Unidos
18.
Healthc (Amst) ; 8(1): 100406, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31918975

RESUMO

BACKGROUND: Improving care for high-cost patients requires a better understanding of their characteristics and the ability to effectively target interventions. We developed an actionable taxonomy with clinically meaningful patient categories for high-cost Medicare patients-those in the top 10% of total costs. METHODS: A cross-sectional study of a Medicare fee-for-service (FFS) patient cohort in the New York metropolitan area. We merged claims and neighborhood social determinants of health data to map patients into actionable categories. RESULTS: Among 428,024 Medicare FFS patients, we mapped the 42,802 high-cost patients into ten overlapping categories, including: multiple chronic conditions, seriously ill, frail, serious mental illness, single condition with high pharmacy cost, chronic pain, end-stage renal disease (ESRD), single high-cost chronic condition, opioid use disorder, and socially vulnerable. Most high-cost patients had multiple chronic conditions (97.4%), followed by serious illness (53.7%) and frailty (48.9%). Patients with ESRD, who were seriously ill, and who were frail were more likely to be high-cost compared to patients in other categories. 72.7% of high-cost patients fell into multiple categories. CONCLUSIONS: High-cost patients are highly heterogeneous. A patient taxonomy incorporating medical, behavioral, and social characteristics may help providers better understand their characteristics and health needs. IMPLICATIONS: Mapping high-cost patients into clinically meaningful and actionable categories that incorporate medical, behavioral, and social factors could help health systems target interventions. Integrated approaches, including medical care, behavioral health, and social services may be needed to effectively and efficiently care for high-cost patients.


Assuntos
Idoso Fragilizado/estatística & dados numéricos , Medicare/economia , Idoso , Idoso de 80 Anos ou mais , Classificação/métodos , Estudos de Coortes , Feminino , Humanos , Masculino , Medicare/organização & administração , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos
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