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Journal of General Internal Medicine Jun 2024Low neighborhood socioeconomic status is associated with adverse health outcomes, but its association with health care costs in older adults is uncertain.
BACKGROUND
Low neighborhood socioeconomic status is associated with adverse health outcomes, but its association with health care costs in older adults is uncertain.
OBJECTIVES
To estimate the association of neighborhood Area Deprivation Index (ADI) with total, inpatient, outpatient, skilled nursing facility (SNF), and home health care (HHC) costs among older community-dwelling Medicare beneficiaries, and determine whether these associations are explained by multimorbidity, phenotypic frailty, or functional impairments.
DESIGN
Four prospective cohort studies linked with each other and with Medicare claims.
PARTICIPANTS
In total, 8165 community-dwelling fee-for-service beneficiaries (mean age 79.2 years, 52.9% female).
MAIN MEASURES
ADI of participant residence census tract, Hierarchical Conditions Category multimorbidity score, self-reported functional impairments (difficulty performing four activities of daily living), and frailty phenotype. Total, inpatient, outpatient, post-acute SNF, and HHC costs (US 2020 dollars) for 36 months after the index examination.
KEY RESULTS
Mean incremental annualized total health care costs adjusted for age, race/ethnicity, and sex increased with ADI ($3317 [95% CI 1274 to 5360] for the most deprived vs least deprived ADI quintile, and overall p-value for ADI variable 0.009). The incremental cost for the most deprived vs least deprived ADI quintile was increasingly attenuated after separate adjustment for multimorbidity ($2407 [95% CI 416 to 4398], overall ADI p-value 0.066), frailty phenotype ($1962 [95% CI 11 to 3913], overall ADI p-value 0.22), or functional impairments ($1246 [95% CI -706 to 3198], overall ADI p-value 0.29).
CONCLUSIONS
Total health care costs are higher for older community-dwelling Medicare beneficiaries residing in the most socioeconomically deprived areas compared to the least deprived areas. This association was not significant after accounting for the higher prevalence of phenotypic frailty and functional impairments among residents of socioeconomically deprived neighborhoods.
PubMed: 38937364
DOI: 10.1007/s11606-024-08875-8 -
Journal of General Internal Medicine Jun 2024Following the Centers for Medicare and Medicaid Services' approval of the Acute Hospital Care at Home waiver, an increasing number of health care organizations launched...
BACKGROUND
Following the Centers for Medicare and Medicaid Services' approval of the Acute Hospital Care at Home waiver, an increasing number of health care organizations launched Home Hospital (HH) programs in the USA. Ongoing barriers include access to HH expertise and a standard, comprehensive set of implementation tools. We created the HH Early Adopters Accelerator to bring together a network of health care organizations to develop tools ("knowledge products") necessary for HH implementation.
OBJECTIVE
To demonstrate the feasibility of the Accelerator approach for generating and implementing relevant, high-quality knowledge products.
DESIGN
Mixed methods evaluation of the Accelerator. Surveys and qualitative interviews of Accelerator participants were conducted. Surveys elicited feedback on the knowledge products, including time spent on development, perceived utility and quality, and implementation success. The qualitative interviews gathered more in-depth information on topics covered in the surveys.
PARTICIPANTS
Eighteen healthcare organizations and 105 individuals participated in the Accelerator.
KEY RESULTS
The Accelerator reached its goal and developed 20 knowledge products in 32 working weeks (more efficient than expected). Participants agreed that the knowledge products were useful (developers: 98.1%; stakeholders: 93.8%), of high quality (developers: 96.8%), and would improve patient care if implemented in their HH program (developers: 91.7%; stakeholders: 91.2%). Two thirds (66.7%) of the participating organizations who had implemented knowledge products at 3 months continued utilizing knowledge products in their HH program at 1 year. Agreement that knowledge products improve patient care persisted (92% strongly agreed or agreed) at 1 year. Several programs created new tools, policies, and workflows as a result of implementing the knowledge products.
CONCLUSIONS
The Accelerator created high-quality, comprehensive knowledge products that healthcare organizations found useful for safe HH implementation 1 year later. The Accelerator approach can feasibly help healthcare organizations safely bridge the gap between innovation and standard practice.
PubMed: 38937363
DOI: 10.1007/s11606-024-08869-6 -
Journal of General Internal Medicine Jun 2024In 2023, approximately 650,000 people experienced homelessness (PEH) nightly in the United States, the highest number recorded in the country's history. This alarming...
In 2023, approximately 650,000 people experienced homelessness (PEH) nightly in the United States, the highest number recorded in the country's history. This alarming statistic has made homelessness a key issue in the 2024 elections, especially with the White House's goal to reduce homelessness by 25% by 2025. Despite efforts and investments, homelessness remains a persistent public health challenge. The recent inclusion of street medicine services in Center for Medicare and Medicaid Services (CMS) billing codes represents a significant step forward. Street medicine, defined by CMS as healthcare provided in non-permanent locations to unsheltered individuals, now qualifies for Medicare reimbursement. This policy change, alongside state-level initiatives, aims to improve healthcare access for the unhoused, particularly older adults. However, challenges remain in establishing adequate fee schedules and integrating care management. Despite these obstacles, the integration of healthcare and housing services is crucial for addressing homelessness effectively, promoting stability, and improving health outcomes for PEH. This manuscript explores the history, practical guidance, and potential impacts of these developments on homelessness and public health.
PubMed: 38937362
DOI: 10.1007/s11606-024-08880-x -
Journal of General Internal Medicine Jun 2024The available data on anticoagulation therapy in real-world primary care settings for atrial fibrillation (AF) patients at high risk of stroke is limited.
BACKGROUND
The available data on anticoagulation therapy in real-world primary care settings for atrial fibrillation (AF) patients at high risk of stroke is limited.
OBJECTIVE
To evaluate anticoagulation therapy and elucidate the factors associated with the selection between direct oral anticoagulants (DOACs) and warfarin.
DESIGN AND PARTICIPANTS
This is a retrospective cohort study that included patients ≥ 18 years old at a large primary care outpatient group, a network of twenty clinics in the northeast United States between January 4, 2021 - January 4, 2023.
MAIN MEASURES
Oral anticoagulation therapy in AF patients with high risk of stroke (CHADS-VASc score of ≥ 2 in men or ≥ 3 in women).
KEY RESULTS
Among the 3,118 adult patients with AF and high risk of stroke (median age 77.90, IQR 71.66-84.50 years; male 57.6%), we found that older age (aOR 1.40, p = 0.003), greater BMI (25-29.9: aOR 1.32, p = 0.048; ≥ 30 aOR 1.42, p = 0.010), and taking more than five medications (aOR 2.28, p < 0.001) were more likely to be on an oral anticoagulant. Among those taking an OAC, having Medicare as the sole coverage (aOR 0.53, p = 0.032), male gender (aOR 0.69, p = 0.011), worse renal function (aOR 0.80, p = 0.021), and higher CHADS-VASc score (aOR 0.88, p = 0.024) are more likely to be on warfarin than a DOAC. Patients taking more than five medications daily (6-10 medications: aOR 1.92, p = 0.013; ≥ 16: aOR = 2.10, p = 0.006) were more likely to be on an anticoagulant and may receive a DOAC over warfarin.
CONCLUSIONS
AF with high stroke risk adult patients are more likely to be on an oral anticoagulant if they are older, having BMI ≥ 25, or taking more than five medications. Medicare as the sole coverage, male gender, worse renal function, and higher CHADS-VASc scores are factors associated with greater warfarin usage, while patients taking over five daily medications are more likely to be prescribed DOACs.
PubMed: 38937360
DOI: 10.1007/s11606-024-08871-y -
Heart Rhythm Jun 2024Traditional post-approval study (PAS) designs have been accepted by regulatory authorities to fulfill post-marketing requirements for cardiac leads but they have several...
BACKGROUND
Traditional post-approval study (PAS) designs have been accepted by regulatory authorities to fulfill post-marketing requirements for cardiac leads but they have several limitations.
OBJECTIVES
The authors conducted a proof-of-concept study of alternative methods that utilize real-world data (RWD) to evaluate lead safety in large patient populations.
METHODS
Abbott patient device databases were linked with Medicare Fee-For-Service (FFS) claims to identify lead complications among patients implanted with Abbott Optisure™ lead. A 1:1 comparison between the PAS method and RWD method of detecting mechanical lead-related complication events was conducted in 444 PAS subjects who were enrolled in Medicare FFS. Agreement between methods was evaluated using McNemar's test and Cohen's kappa. Survival free from complications at 3 years was compared between the PAS and RWD cohorts using an equivalence acceptance criterion of ±2.5%.
RESULTS
There were 1,171 PAS patients and 5,804 Medicare FFS patients who received an Optisure™ lead between August 27, 2014 - June 14, 2016. Patients were followed through December 31, 2018. Complete agreement was found between PAS-reported and claims-detected complications (McNemar's p-value=1.00, Cohen's Kappa = 1.0). Survival free from complications at 3 years using the RWD method was 98.4% (95% CL: 98.0%-98.7%), which was within the acceptable range of the PAS 98.4% (95% CL: 97.6%-99.0%).
CONCLUSION
These results show a close agreement between RWD-detected and PAS-reported lead complication rates, which highlight the potential benefits of RWD-based methods to enhance the generation of clinical evidence for lead safety.
PubMed: 38936445
DOI: 10.1016/j.hrthm.2024.06.045 -
Billed advance care planning visits may be occurring among older adults with high risk of mortality.Archives of Gerontology and Geriatrics Jun 2024Advance care planning (ACP) is a process that helps people prepare to make decisions about their future medical care.
CONTEXT
Advance care planning (ACP) is a process that helps people prepare to make decisions about their future medical care.
OBJECTIVES
We sought to understand who was received billed ACP visits and measure the association with health care utilization, cost, and mortality.
METHODS
We used a randomly sampled 20 % cohort of Medicare fee-for-service (FFS) beneficiaries' files to conduct a retrospective cohort study. Beneficiaries with a billed ACP visit were matched to controls using a 2-stage propensity score matching process that included assigning a pseudo-ACP visit date for controls. Outcomes included healthcare utilization, mortality, and total medical cost per month. We used descriptive statistics for univariate analysis and fit multilevel logistic regression, multilevel linear regression, or Cox regression models.
RESULTS
We identified 183,513 beneficiaries who received any billed ACP visit and 550,539 matched controls. Of those who had a ACP visit, the mean age was 76.5 years and high-risk comorbidities were common: 16 % dementia, 10 % congestive heart failure, 10 % cancer. Beneficiaries who had an ACP visit had slightly more health care utilization than controls. Beneficiaries who had an ACP visit were more likely to die (3.1% vs. 1.0 %, p < 0.01, OR=3.0, 95 %CI 2.9-3.2) in the unadjusted and adjusted analyses compared to matched controls. Total monthly medical costs were 33 % higher among beneficiaries who had an ACP visit.
CONCLUSION
Our results suggest that ACP visits may be preferentially utilized amongst individuals with higher risk of mortality. There may be an opportunity to increase ACP visits among older adults at lower risk for mortality.
KEY MESSAGE
This article suggests that ACP visits are likely targeted to older adults with a higher risk of mortality than those at lower risk of mortality suggesting an opportunity to reach people before they are facing end-of-life decisions.
PubMed: 38936316
DOI: 10.1016/j.archger.2024.105526 -
JCO Precision Oncology Jun 2024Patients with hereditary cancer syndromes (HCS) have a high lifetime risk of developing cancer. Historically underserved populations have lower rates of genetic...
PURPOSE
Patients with hereditary cancer syndromes (HCS) have a high lifetime risk of developing cancer. Historically underserved populations have lower rates of genetic evaluation. We sought to characterize demographic factors that are associated with undergoing HCS evaluation in an urban safety-net patient population.
METHODS
All patients who met inclusion criteria for this study from 2016 to 2021 at an urban safety-net hospital were included in this analysis. Inclusion criteria were pathologically confirmed breast, ovarian/fallopian tube, colon, pancreatic, and prostate cancers. Patients also qualified for hereditary breast and ovarian cancers or Lynch syndrome on the basis of National Comprehensive Cancer Network guidelines. Institutional review board approval was obtained. Demographic and oncologic data were collected through retrospective chart review. Univariable and multivariable logistic regression models were constructed.
RESULTS
Of the 637 patients included, 40% underwent genetic testing. Variables associated with receiving genetic testing on univariable analysis included patients living at the time of data collection, female sex, Latinx ethnicity, Spanish language, family history of cancer, and referral for genetic testing. Patients identifying as Black, having Medicare, having pancreatic or prostate cancer, having stage IV disease, having Eastern Cooperative Oncology Group (ECOG) prognostic score ≥1, having medium or high Charlson comorbidity index, with current or previous cigarette use, and with previous alcohol use were negatively associated with testing. On multivariable modeling, family history of cancer was positively associated with testing. Patients identifying as Black, having colon or prostate cancer, and having ECOG score of 2 had significantly lower association with genetic testing.
CONCLUSION
Uptake of HCS was lower in patients identifying as Black, those with colon or prostate cancer, and those with an ECOG score of 2. Efforts to increase HCS testing in these patients will be important to advance equitable cancer care.
Topics: Humans; Female; Male; Safety-net Providers; Middle Aged; Retrospective Studies; Aged; Early Detection of Cancer; Hospitals, Urban; Adult; Genetic Testing; Neoplastic Syndromes, Hereditary
PubMed: 38935898
DOI: 10.1200/PO.23.00699 -
Ophthalmology Jun 2024
Re: Sabharwal et al.: Early endophthalmitis incidence and risk factors after glaucoma surgery in the Medicare population from 2016 to 2019(Ophthalmology. 2024;131:179-187).
PubMed: 38935042
DOI: 10.1016/j.ophtha.2024.05.020 -
Internal Medicine Journal Jun 2024Effective alcohol and other drugs (AODs) treatment has been proven to increase productivity and reduce costs to the community. Telehealth has previously been proven...
BACKGROUND
Effective alcohol and other drugs (AODs) treatment has been proven to increase productivity and reduce costs to the community. Telehealth has previously been proven effective at delivering AOD treatment in the right settings. Yet, Australia's current Medicare funding restricts telephone consultations.
AIM
We hypothesise that treatment modality influences attendance rates. Specifically, telephone consultations can remove barriers to accessing treatment and, therefore, can increase attendance.
METHODS
We conducted a retrospective audit on our addiction medicine specialist outpatient service from 1 July 2022 to 30 June 2023. A mixed-effects logistic regression model was used to analyse factors associated with attendance rates.
RESULTS
There were 576 participants in the study, and 3354 appointments were booked over the 12-month study period. Of these, 2695 were face-to-face, 541 were telephone and 118 were video. The unadjusted raw attendance rate was highest in the telephone group (87.24%), followed by face-to-face (73.02%) and video (44.92%). After adjusting for covariates, telephone consultation was associated with significantly increased odds of attending compared to face-to-face (odds ratio (OR) = 2.60, 95% confidence interval (CI) = 1.90-3.54, P < 0.001). Video consultation was associated with a 69% reduction in the odds of attending compared to face-to-face (OR = 0.31, 95% CI = 0.019-0.49, P < 0.001).
CONCLUSIONS
While physical attendance may be required for specific clinical care, telephone consultations are associated with increased attendance and can form an important adjunct to delivering addiction treatment. Given the substantial costs of substance use disorders, this could inform government policies and funding priorities to further improve access and treatment outcomes.
PubMed: 38934477
DOI: 10.1111/imj.16462 -
Alzheimer's & Dementia : the Journal of... Jun 2024There is limited evidence about factors related to the timeliness of dementia diagnosis in healthcare settings.
INTRODUCTION
There is limited evidence about factors related to the timeliness of dementia diagnosis in healthcare settings.
METHODS
In five prospective cohorts at Rush Alzheimer's Disease Center, we identified participants with incident dementia based on annual assessments and examined the timing of healthcare diagnoses in Medicare claims. We assessed sociodemographic, health, and psychosocial correlates of timely diagnosis.
RESULTS
Of 710 participants, 385 (or 54%) received a timely claims diagnosis within 3 years prior to or 1 year following dementia onset. In logistic regressions accounting for demographics, we found Black participants (odds ratio [OR] = 2.15, 95% confidence interval [CI]: 1.21 to 3.82) and those with better cognition at dementia onset (OR = 1.48, 95% CI: 1.10 to 1.98) were at higher odds of experiencing a diagnostic delay, whereas participants with higher income (OR = 0.89, 95% CI: 0.81 to 0.97) and more comorbidities (OR = 0.94, 95% CI: 0.89 to 0.98) had lower odds.
DISCUSSION
We identified characteristics of individuals who may miss the optimal window for dementia treatment and support.
HIGHLIGHTS
We compared the timing of healthcare diagnosis relative to the timing of incident dementia based on rigorous annual evaluation. Older Black adults with lower income, higher cognitive function, and fewer comorbidities were less likely to be diagnosed in a timely manner by the healthcare system.
PubMed: 38934297
DOI: 10.1002/alz.14067