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Health Affairs Scholar Jun 2024Since January 2020, Medicare has covered opioid use disorder (OUD) treatment services at opioid treatment programs (OTPs), the only outpatient settings allowed to...
Since January 2020, Medicare has covered opioid use disorder (OUD) treatment services at opioid treatment programs (OTPs), the only outpatient settings allowed to dispense methadone for treating OUD. This study examined policy-associated changes in Medicare acceptance and the availability of four OUD treatment services (ongoing buprenorphine, HIV/AIDS education, employment services, and comprehensive mental health assessment), by for-profit status, and county-level changes in Medicare-accepting-OTPs access, by sociodemographic characteristics (racial composition, poverty rate, and rurality). Using data from the 2019-2022 National Directory of Drug and Alcohol Abuse Treatment Facilities, we found Medicare acceptance increased from 21.31% in 2018 to 80.76% in 2021. The availability of the four treatment services increased, but no increases were significantly associated with Medicare coverage. While county-level OTP access significantly improved, counties with higher rates of non-White residents experienced an additional average increase of 0.86 Medicare-accepting-OTPs (95% CI, 0.05-1.67) compared to those without higher rates of non-White populations. Overall, Medicare coverage was associated with improved OTP access, not ancillary services.
PubMed: 38938273
DOI: 10.1093/haschl/qxae076 -
Colorectal Disease : the Official... Jun 2024Total (procto)colectomy for ulcerative colitis (UC) is associated with significant morbidity, which is increased in the emergency setting. This study aimed to evaluate...
AIM
Total (procto)colectomy for ulcerative colitis (UC) is associated with significant morbidity, which is increased in the emergency setting. This study aimed to evaluate the outcomes following total (procto)colectomies at a population level within New South Wales (NSW), Australia, and identify case mix and hospital factors associated with these outcomes.
METHODS
A retrospective data linkage study of patients undergoing total (procto)colectomy for UC in NSW over a 19-year period (2001-2020) was performed. The primary outcome was 90-day mortality. The influence of hospital level factors (including annual volume) and patient demographic variables on outcomes was assessed using logistic regression. Temporal trends in annual volume and evidence for centralization were assessed.
RESULTS
In all, 1418 patients (mean 47.0 years [SD 18.7], 58.7% male) underwent total (procto)colectomy during the study period. The overall 90-day mortality rate was 3.2% (emergency 8.6% and elective 0.8%). After adjusting for confounding, increasing age at total (procto)colectomy, higher comorbidity burden, public health insurance (Medicare) status, emergency operation and living outside a major city were significantly associated with increased mortality. Hospital volume was significantly associated with mortality at a univariate level, but this did not persist on multivariate modelling.
CONCLUSIONS
Outcomes of UC patients undergoing total (procto)colectomy in NSW Australia are comparable to international experience. Whilst higher mortality rates are observed in low volume and public hospitals, this appears attributable to case mix and acuity rather than surgical volume alone. However, as inflammatory bowel disease surgery is not centralized in Australia, only one NSW hospital performed >10 UC total (procto)colectomies annually. Variation in mortality according to insurance status and across regional/remote areas may indicate inequality in the availability of specialist inflammatory bowel disease treatment, which warrants further research.
PubMed: 38937922
DOI: 10.1111/codi.17074 -
The Senior Care Pharmacist Jul 2024
Topics: United States; Humans; Centers for Medicare and Medicaid Services, U.S.; Personnel Staffing and Scheduling; Medicaid
PubMed: 38937890
DOI: 10.4140/TCP.n.2024.277 -
Journal of Orthopaedic Surgery and... Jun 2024Innovation has fueled the shift from inpatient to outpatient care for orthopaedic joint arthroplasty. Given this transformation, it becomes imperative to understand what...
BACKGROUND
Innovation has fueled the shift from inpatient to outpatient care for orthopaedic joint arthroplasty. Given this transformation, it becomes imperative to understand what factors help assign care-settings to specific patients for the same procedure. While the comorbidities suffered by patients are important considerations, recent research may point to a more complex determination. Differences in reimbursement structures and patient characteristics across various insurance statuses could potentially influence these decisions.
METHODS
Retrospective binary logistic and ordinary least square (OLS) regression analyses were employed on de-identified inpatient and outpatient orthopaedic arthroplasty data from Albany Medical Center from 2018 to 2022. Data elements included surgical setting (inpatient vs. outpatient), covariates (age, sex, race, obesity, smoking status), Elixhauser comorbidity indices, and insurance status.
RESULTS
Patients insured by Medicare were significantly more likely to be placed in inpatient care-settings for total hip, knee, and ankle arthroplasty when compared to their privately insured counterparts even after Centers for Medicare and Medicaid Services (CMS) removed each individual surgery from its inpatient-only-list (1.65 (p < 0.05), 1.27 (p < 0.05), and 12.93 (p < 0.05) times more likely respectively). When compared to patients insured by the other payers, Medicare patients did not have the most comorbidities (p < 0.05).
CONCLUSIONS
Medicare patients were more likely to be placed in inpatient care-settings for hip, knee, and ankle arthroplasty. However, Medicaid patients were shown to have the most comorbidities. It is of value to note Medicare patients billed for outpatient services experience higher coinsurance rates.
LEVEL OF EVIDENCE
III.
Topics: Humans; Retrospective Studies; Male; Female; Insurance Coverage; United States; Inpatients; Middle Aged; Aged; Medicare; Medicaid; Orthopedic Procedures; Outpatients
PubMed: 38937773
DOI: 10.1186/s13018-024-04734-8 -
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