An examination of Alzheimer's disease case definitions using Medicare claims and survey data.

BACKGROUND: The prevalence and expenditure estimates of Alzheimer's disease (AD) from studies using one data source to define cases vary widely. The objectives of this study were to assess agreement between AD case definitions classified with Medicare claims and survey data and to provide insight into causes of widely varied expenditure estimates. METHODS: Data were obtained from the 1999-2004 Medicare Current Beneficiary Survey linked with Medicare claims (n = 57,669). Individuals with AD were identified by survey, diagnosis, use of an AD prescription medicine, or some combination thereof. We also explored how much health care and drug expenditures vary by AD case definition. RESULTS: The prevalence of AD differed significantly by case definition. Using survey report alone yielded more cases (n = 1,994 or 3.46%) than diagnosis codes alone (n = 1,589 or 2.76%) or Alzheimer's medication use alone (n = 1,160 or 2.01%). Agreement between case definitions was low, with kappa coefficients ranging from 0.37 to 0.40. Per capita health expenditures ranged from $16,547 to $24,937, and drug expenditures ranged from $2,303 to $3,519, depending on how AD was defined. CONCLUSIONS: Different information sources yield widely varied prevalence and expenditure estimates. Although claims data provided a more objective means for identifying AD cases, survey report identified more cases, and pharmacy data also are an important source for case ascertainment. Using any single source will underestimate the prevalence and associated cost of AD. The wide range of AD cases identified by using different data sources demands caution interpreting cost-of-illness studies using single data sources.

The Local Food Environment and Food Security: The Health Behavior Role of Social Capital.

Food politics and economic forces may determine the macro conditions for food supply, but the local environment has the most substantial impact on population health. Food security is determined not only by the basic availability of food, but also by social, economic, and cultural factors influencing dietary behaviors. This paper investigates the role of social institutions, specifically social capital, in affecting food security by proposing a theoretical linkage between social capital and health behavior, and an illustrative case is provided. Social capital, defined as the value of the bonding, bridging, and linking relationships between people, is well demonstrated to be related to health. Many mechanisms link social capital to health, including shared access to food and nutritional behaviors. Further, social capital influences health through social status and race. This paper further investigates the links between minority status, food security, social capital, and health. The analysis draws on empirical work in North Carolina with community gardens, faith communities, the local food environment, and other social capital-related variables. By investigating the nature of local food security, particularly for minority populations, this analysis allows for better integration of local conditions with global food politics.

Correction: Who Treats Patients with Diabetes and Compensated Cirrhosis.

[This corrects the article DOI: 10.1371/journal.pone.0165574.].

Who Treats Patients with Diabetes and Compensated Cirrhosis.

BACKGROUND: Increasingly, patients with multiple chronic conditions are being managed in patient-centered medical homes (PCMH) that coordinate primary and specialty care. However, little is known about the types of providers treating complex patients with diabetes and compensated cirrhosis. OBJECTIVE: We examined the mix of physician specialties who see patients dually-diagnosed with diabetes and compensated cirrhosis. DESIGN: Retrospective cross-sectional study using 2000-2013 MarketScan® Commercial Claims and Encounters and Medicare Supplemental Databases. PATIENTS: We identified 22,516 adults (≥ 18 years) dually-diagnosed with diabetes and compensated cirrhosis. Patients with decompensated cirrhosis, HIV/AIDS, or liver transplantation prior to dual diagnosis were excluded. MAIN MEASURES: Physician mix categories: patients were assigned to one of four physician mix categories: primary care physicians (PCP) with no gastroenterologists (GI) or endocrinologists (ENDO); GI/ENDO with no PCP; PCP and GI/ENDO; and neither PCP nor GI/ENDO. Health care utilization: annual physician visits and health care expenditures were assessed by four physician mix categories. KEY RESULTS: Throughout the 14 years of study, 92% of patients visited PCPs (54% with GI/ENDO and 39% with no GI/ENDO). The percentage who visited PCPs without GI/ENDO decreased 22% (from 63% to 49%), while patients who also visited GI/ENDO increased 71% (from 25% to 42%). CONCLUSIONS: This is the first large nationally representative study to document the types of physicians seen by patients dually-diagnosed with diabetes and cirrhosis. A large proportion of these complex patients only visited PCPs, but there was a trend toward greater specialty care. The trend toward co-management by both PCPs and GI/ENDOs suggests that PCMH initiatives will be important for these complex patients. Documenting patterns of primary and specialty care is the first step toward improved care coordination.

Association of hospitalist presence and hospital-level outcome measures among Medicare patients.

BACKGROUND: Hospitalists have been shown to lower patient costs through better resource utilization and decreased length of stay, but it is unclear whether hospitalists are associated with quality of care. We examined the association between the presence of hospitalists and 30-day predicted excess all-cause hospital mortality and readmissions among Medicare patients admitted to a hospital with any of 3 conditions: heart failure, acute myocardial infarction, and pneumonia. METHODS: Using national hospital-level, case mix-adjusted, risk-standardized, 30-day all-cause excess mortality and readmission data from the Centers for Medicare and Medicaid Services, we used descriptive and bivariate statistics to illustrate trends across hospitals. Using multivariable ordinary least squares regression to control for hospital-level characteristics, we then estimated the association between the presence of hospitalists and predicted hospital mortality and readmission. RESULTS: After multivariable adjustment, the presence of hospitalists was associated with lower probability of readmission for all 3 target conditions. No significant associations for any of the target conditions were found in all-cause mortality models. CONCLUSIONS: Hospitalists are already integral to the delivery of inpatient care at most institutions. This study, however, showed an association at the national level of the presence of hospitalists with an important and timely quality measure: reduction of readmission rates. Future research is indicated to explore specific causation pathways for the impact of hospitalists on quality of care.

Effect of village midwife program on contraceptive prevalence and method choice in Indonesia.

Indonesia established its Village Midwife Program in 1989 to combat high rates of maternal mortality. The program's goals were to address gaps in access to reproductive health care for rural women, increase access to and use of family planning services, and broaden the mix of available contraceptive methods. In this study, we use longitudinal data from the Indonesia Family Life Survey to examine the program's effect on contraceptive practice. We find that the program did not affect overall contraceptive prevalence but did affect method choice. Over time, for women using contraceptives, midwives were associated with increased odds of injectable contraceptive use and decreased odds of oral contraceptive and implant use. Although the Indonesian government had hoped that the Village Midwife Program would channel women into using longer-lasting methods, the women's "switching behavior" indicates that the program succeeded in providing additional outlets for and promoting the use of injectable contraceptives.

From the Editor-in-Chief.

This issue of World Health & Population presents papers that have been published online by WHP and are selected here as representative of recent interesting contributions to the journal. Three of the five articles originate from Nigeria, and two of these focus on malaria. The other two articles report on healthcare in South Asian settings - slums in Calcutta (Kolkata) and health facilities planning in the city of Khulna in Bangladesh.

Comparative analysis of cost of endoscopic endonasal minimally invasive and sublabial-transseptal approaches to the pituitary.

BACKGROUND: Two surgical approaches to the pituitary are commonly used: the sublabial-transseptal (SLTS) approach using microscopy and the endonasal endoscopic minimally invasive (MIPS) approach. Although outcomes are similar for both procedures, MIPS has become increasingly prevalent over the last 15 years. Limited cost analysis data comparing the 2 alternatives are available. METHODS: A retrospective analysis of cost and volume data was performed using data from the published literature and University of North Carolina at Chapel Hill (UNC) Hospitals. A sensitivity analysis of the parameters was used to evaluate the uncertainty in parameter estimates. RESULTS: The total cost in real dollars ranges from $11,438 to $12,513 and $18,095 to $21,005 per patient per procedure for MIPS and SLTS, respectively, with a cost difference ranging between $5582 and $9567 per patient per procedure. The sensitivity analysis indicates that the total cost for MIPS is most sensitive to: (1) average length of stay, (2) nursing costs, and (3) number of total complications, whereas the total cost for SLTS is most sensitive to: (1) average length of stay, (2) nursing cost, and (3) operating time. MIPS is less costly than SLTS between 94% and 98% of the time. CONCLUSION: The results indicate that MIPS is less costly than SLTS at a large academic center. Future research should compare the outcomes and quality of life (QoL) associated with the 2 surgeries to improve the data used to determine the cost-effectiveness of MIPS compared to SLTS.

Human resources in healthcare.

This issue of World Health & Population presents papers that have been published online by WHP and are selected here as representative of recent outstanding contributions to the journal. The papers in this issue include research from South and Southeast Asia, Africa and Latin America.

Risk adjustment for Medicare beneficiaries with Alzheimer's disease and related dementias.

OBJECTIVE: To compare prospective risk adjustment measures on their ability to predict expenditures for Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD). METHODS: Data were obtained from the 1999-2004 Medicare Current Beneficiary Survey linked with Medicare claims. Beneficiaries' base-year demographic and health characteristics were used to construct risk adjustment measures, comorbidity measures, functional status measures, and prior expenditures that were used to predict the subsequent year's total and drug expenditures. Adjusted R(2) values, predictive ratios, and receiver operating characteristic curves were used to compare overall predictive power, accuracy of subgroup prediction, and accuracy in identifying beneficiaries with the top 10% of expenditures, respectively. RESULTS: The Centers for Medicare & Medicaid Services-Hierarchical Condition Category (CMS-HCC) and the Chronic Illness and Disability Payment System-Medicare had higher overall and subgroup predictive power for total expenditures compared with other diagnosis-based measures. The Prescription Drug Hierarchical Condition Category (RxHCC) exhibited greater predictive power for drug expenditures than other measures and outperformed other measures in identifying ADRD beneficiaries with extremely high drug expenditures. Adding functional status to single-measure models generally improved predictive power (ie, R(2) value) for overall health expenditures by 2% to 4%, but not for drug expenditures. CONCLUSIONS: The CMS-HCC and the RxHCC measures currently used by CMS are more predictive and accurate than other risk adjustment measures for overall and drug expenditure prediction for beneficiaries with substantial disabilities and comorbidities. Prediction of overall expenditures may be modestly improved for these beneficiaries by using a combined model of these measures and functional status.

From the Editor-in-Chief. World health and population.

This volume of World Health & Population presents papers that have recently been published online by WHP and selected as particularly representative of the diversity and focus of the journal.