Carrier File Research Articles

CLINICIAN TYPE AND SETTING OF CARE DELIVERED TO MEDICARE BENEFICIARIES WITH DEMENTIA IN THE U.S

Abstract Improving care coordination for persons living with dementia (PLWD) requires understanding of the types of clinicians delivering care and the settings in which they practice. We identified all beneficiaries with dementia in traditional Medicare in 2019. We used the Medicare Carrier file—i.e., where bills for care provided by individual clinicians are recorded—to identify clinicians providing care to PLWD, which we then linked to the National Plan & Provider Enumeration System (NPPES). Using the Carrier and NPPES files, we characterized the workforce providing care to PLWD, including specialty and licensure (e.g., primary care physician, neurologist, nurse practitioner), setting of care delivery, and whether the clinician included a dementia diagnosis in the billing information. Overall, 1,934,318 PLWD received care from 783,225 unique clinicians. The most common settings of care were office (74.8% of PLWD), emergency room (63.9%), inpatient hospital (52.1%), and skilled nursing facility (37.1%). 87.0% of PLWD received care from a primary care physician, 62.9% from a nurse practitioner, and 33.1% from a physician assistant. Among all the clinicians that care for PLWD, 20.3% are primary care physicians, 15.3% nurse practitioners, and 9.0% physician assistants. 2.4% are psychiatrists, 1.7% neurologist, and just 0.5% are geriatric subspecialist physicians. For clinicians providing care to PLWD, the majority provide care in the outpatient setting, followed by hospital-based care. Programs to improve care coordination for PLWD, such as GUIDE Model programs, must account for delivery across multiple health care settings, recognizing that geriatric subspecialists comprise an extremely small proportion of the PLWD-serving workforce.

UroARC: A novel surgical risk calculator for older adults undergoing pelvic organ prolapse and stress urinary incontinence surgery.

Surgeries for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are commonly performed in older adults, many of whom are also frail. A surgical risk calculator for older adults undergoing POP/SUI surgeries that incorporates frailty, a factor known to increase the risk of surgical complications, would be helpful for preoperative counseling but currently does not exist. Medicare Carrier, Outpatient, and MedPAR files were examined for beneficiaries undergoing POP and SUI surgery between 2014 and 2016. A total of 15 POP/SUI categories were examined. The Claims-Based Frailty Index (CFI), a validated measure of frailty in Medicare data, and Charlson Comorbidity Index were deconstructed into their individual variables, and individual variables were entered into stepwise logistic regression models to determine which variables were most highly predictive of 30-day complications and 1-year mortality. To verify the prognostic accuracy for each model for surgical complications of interest, calibration curves and tests of model fit, including C-statistic, Brier scores, and Spiegelhalter p values, were determined. In total, 108 479 beneficiaries were included. Among these, 4.7% had CFI scores consistent with mild to severe frailty (CFI≥0.25). A total of 13 prognostic variable categories were found to be most highly predictive of postoperative complications. Calibration curves for each outcome of interest showed models were well-fit. Most models demonstrated high c-statistic values (≥0.7) and high Spiegelhalter p values (≥0.9), indicating good model calibration and excellent discrimination, and low Brier scores (<0.02), indicating high model accuracy. Urologic surgery for older Adults Risk Calculator serves as a novel surgical risk calculator that is readily accessible to both patients and clinicians that specifically factors in components of frailty. Furthermore, this calculator accounts for the heterogeneity of an aging population and can assist in individualized surgical decision-making for these common procedures.

UroARC: A Novel Surgical Risk Calculator for Older Adults Undergoing Suprapubic Tube Placement

ObjectivesTo develop a surgical risk calculator for older adults undergoing suprapubic tube (SPT) placement that specifically factors in frailty, a key predictor of surgical risk in this vulnerable and heterogenous population. MethodsMedicare MedPAR, Outpatient, and Carrier files for beneficiaries undergoing SPT placement between 2014-2016 were examined. The Claims-Based Frailty Index (CFI), a validated measure of frailty, was used to calculate baseline frailty for each beneficiary. Stepwise regression models were used for each variable within the CFI and Charlson Comorbidity Index to determine the variables most highly predictive of postoperative complications. The most highly predictive variables were then combined into parsimonious categories. To ensure the prognostic accuracy for each outcome, calibration curves and tests of model fit, including C-statistics, Brier scores, and Spiegelhalter p-values were calculated. ResultsA total of 26,999 beneficiaries were included. Among these, 39.1% were pre-frail, 36.8% were mildly frail, and 12.3% were moderately-to-severely frail. Thirteen prognostic variable categories were deemed highly predictive of postoperative complications of interest. All models demonstrated low Brier scores, indicating high model accuracy, and high C-statistic and Spiegelhalter p-values, consistent with excellent model discrimination and calibration, respectively. Excellent model fit was seen on calibration curves for each outcome. ConclusionsUroARC is a novel surgical tool for older adults undergoing SPT placement that specifically factors in frailty. This risk calculator has high accuracy, calibration, and discrimination, and serves as a valuable resource to patients and clinicians for those undergoing consideration for SPT placement.

A proposed method for identifying Interfacility transfers in Medicare claims data.

To develop a method of consistently identifying interfacility transfers (IFTs) in Medicare Claims using patients with ST-Elevation Myocardial Infarction (STEMI) as an example. 100% Medicare inpatient and outpatient Standard Analytic Files and 5% Carrier Files, 2011-2020. Observational, cross-sectional comparison of patient characteristics between proposed and existing methods. We limited to patients aged 65+ with STEMI diagnosis using both proposed and existing methods. We identified 62,668 more IFTs using the proposed method (86,128 versus 23,460). A separately billable interfacility ambulance trip was found for more IFTs using the proposed than existing method (86% vs. 79%). Compared with the existing method, transferred patients under the proposed method were more likely to live in rural (p < 0.001) and lower income (p < 0.001) counties and were located farther away from emergency departments, trauma centers, and intensive care units (p < 0.001). Identifying transferred patients based on two consecutive inpatient claims results in an undercount of IFTs and under-represents rural and low-income patients.

A Review on Image Steganography Techniques

In contemporary times, the exploration of digital multimedia has transformed it into a reliable medium for secure communication. Steganography, the art of concealed communication through mediums like images, has emerged as a pivotal approach, countered by the opposing method of steganalysis for detecting embedded data. This review delves into diverse methodologies examined by researchers, elucidating the primary objective of image steganography—to safeguard data messages from illicit access. The essence lies in discreetly transferring embedded secure data to the target destination without detection by unauthorized users. While various carrier file formats can be employed, digital images, owing to their widespread use on the global Internet, become the preferred medium. The realm of steganographic methodologies encompasses a broad spectrum, varying in complexity, each with its distinct strengths and weaknesses. This exploration underscores the dynamic landscape of image steganography, affirming the ongoing pursuit of effective methods to protect information from unauthorized access through covert channels. The review article provides an overview of various methodologies employed by researchers in the field of image steganography. It emphasizes the significance of using digital images as carrier files due to their prevalence on the worldwide Internet. The content acknowledges the complexity of steganographic methods and highlights that each method has its own strengths and weaknesses. Overall, the discussion underscores the importance of exploring and analyzing these methodologies to enhance the effectiveness of image steganography in secure communication.

Use of Muscle Relaxants After Surgery in Traditional Medicare Part D Enrollees.

Surgeons have come under increased scrutiny for postoperative pain management, particularly for opioid prescribing. To decrease opioid use but still provide pain control, nonopioid medications such as muscle relaxants are being used, which can be harmful in older adults. However, the prevalence of muscle relaxant prescribing, trends in use over time, and risk of prolonged use are unknown. Using a 20% representative Medicare sample, we conducted a retrospective analysis of muscle relaxant prescribing to patients ≥ 65 years of age. We merged patient data from Medicare Carrier, MedPAR, and Outpatient Files with Medicare Part D for the years 2013-2018. A total of 14 surgical procedures were included to represent a wide range of anatomic regions and specialties. The study cohort included 543,929 patients. Of the cohort, 8111 (1.5%) received a new muscle relaxant prescription at discharge. Spine procedures accounted for 12% of all procedures but 56% of postoperative prescribing. Overall, the rate of prescribing increased over the time period (1.4-2.0%, p < 0.001), with increases in prescribing primarily in the spine (7-9.6%, p < 0.0001) and orthopedic procedure groups (0.9-1.4%, p < 0.0001). Of patients discharged with a new muscle relaxant prescription, 10.7% had prolonged use. The use of muscle relaxants in the postoperative period for older adults is low, but increasing over time, especially in ortho and spine procedures. While pain control after surgery is crucial, surgeons should carefully consider the risks of muscle relaxant use, especially for older adults who are at higher risk for medication-related problems.

Development of the UroARC Surgical Calculator: A Novel Risk Calculator for Older Adults Undergoing Surgery for Bladder Outlet Obstruction.

Bladder outlet obstruction (BOO) is common in older adults. Many older adults who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty. A clinical tool that builds on frailty to predict surgical outcomes for the spectrum of BOO procedures would be helpful to aid in surgical decision-making but does not currently exist. Medicare beneficiaries undergoing BOO surgery from 2014 to 2016 were identified and analyzed using the Medicare MedPAR, Outpatient, and Carrier files. Eight different BOO surgery categories were created. Baseline frailty was calculated for each beneficiary using the Claims-Based Frailty Index (CFI). All 93 variables in the CFI and the 17 variables in the Charlson Comorbidity Index were individually entered into stepwise logistic regression models to determine variables most highly predictive of complications. Similar and duplicative variables were combined into categories. Calibration curves and tests of model fit, including C statistics, Brier scores, and Spiegelhalter P values, were calculated to ensure the prognostic accuracy for postoperative complications. In total, 212,543 beneficiaries were identified. Approximately 42.5% were prefrail (0.15 ≤ CFI < 0.25), 8.7% were mildly frail (0.25 ≤ CFI < 0.35), and 1.2% were moderately-to-severely frail (CFI ≥0.35). Using stepwise logistic regression, 13 distinct prognostic variable categories were identified as the most reliable predictors of postoperative outcomes. Most models demonstrated excellent model discrimination and calibration with high C statistic and Spiegelhalter P values, respectively, and high accuracy with low Brier scores. Calibration curves for each outcome demonstrated excellent model fit. This novel risk assessment tool may help guide surgical prognostication among this vulnerable population.

Mental Health Treatment Among Nursing Home Residents With Alzheimer's Disease and Related Dementias

ObjectivesTo examine the prevalence of mental health treatment among nursing home (NH) long-stay residents with Alzheimer's disease and related dementias (ADRD) and explore factors associated with utilization. DesignRetrospective cohort study. Minimum Data Set data (April 2017–September 2018), Medicare Master Beneficiary Summary File, Part B Carrier file and Part D prescription file were used to identify mental illness and ADRD diagnoses, patient characteristics, and mental health treatment. Setting and ParticipantsAll US Medicare- or Medicaid-certified NHs. Fee-for-service Medicare beneficiaries aged 65 and older who had a quarterly or annual Minimum Data Set assessment with ADRD and were enrolled in Medicare Parts B and D. Two cohorts: residents with both ADRD and psychiatric disorders; residents with ADRD only. MethodsPrimary outcomes: receipt of (1) any mental health treatment (medication or psychotherapy); (2) any psychotherapy in a calendar quarter. Secondary outcomes: antipsychotics, antidepressants, hypnotics, antiepileptics, short-session ( ≤ 30 minutes), long-session ( ≥ 45 minutes), and family/group psychotherapy. Covariates included predisposing, enabling characteristics, and needs factors. Generalized Estimating Equation models of quarterly data, nested within patients, were estimated for each outcome among each cohort. ResultsAnalyses included 1,913,945 resident-quarter observations from 503,077 unique NH long-stay residents. Overall, 68.5% of NH long-stay residents with ADRD have psychiatric disorders; of these, 85% received mental health treatment. African American or Hispanic residents were less likely to use antidepressants. African American residents or residents living in rural locations were less likely to receive long-session psychotherapy. Hispanic residents were more likely to receive long-session psychotherapy. Residents in minority groups were more likely to receive group/family psychotherapy. Conclusions and ImplicationsMost of NH long-stay residents with ADRD had psychiatric disorders and most of them received treatment. Antidepressants or long-session psychotherapy were less likely to be provided to African American residents. Factors that determine the efficacy of mental health treatment and reasons for the racial disparities require further exploration.

Image Steganography

Abstract: Steganography is the art of hiding the fact that communication is taking place, by hiding by information in other information. Many different carrier file formats can be used, but digital images are the most popular because of their frequency on the Internet. For hiding secret information in images, there exists a large variety of stenographic techniques some are more complex than others and all of them have respective strong and weak points. This project intends to give an overview of image steganography, its uses and techniques. It also supports steganography in Audio files. For a more secure approach, the project encrypts the message using secret key and then sends it to the receiver. The receiver then decrypts the message

The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease.

Background: In 2014, the Affordable Care Act Medicaid Expansion (ME) increased Medicaid eligibility for adults with an income level up to 138% of the federal poverty level. In this study, we examined the impact of ME on mortality and amputation in patients with peripheral artery disease (PAD). Methods: The 100% MedPAR and Part-B Carrier files from 2011 to 2018 were queried to identify all fee-for-service Medicare beneficiaries with PAD using International Classification of Diseases codes. Our primary exposure was whether a state had adopted the ME on January 1, 2014. Our primary outcomes were the change in all-cause 1-year mortality and leg amputation. We used a state-level difference-in-differences (DID) analysis to compare the rates of the primary outcomes among patients who were in states (including the District of Columbia) who adopted ME (n = 25) versus those who were in states that did not (n = 26). We performed a subanalysis stratifying by sex, race, region, and dual-eligibility status. Results: Over the 8-year period, we studied 37,743,929 patients. The average unadjusted 1-year mortality decreased from 2011 to 2018 in both non-ME (9.5% to 8.7%, p < 0.001) and ME (9.1% to 8.3%, p < 0.001) states. The average unadjusted 1-year amputation rate did not improve in either the non-ME (0.86% to 0.87%, p = 0.17) or ME (0.69% to 0.69%, p = 0.65) states. Across the entire cohort, the DID model revealed that ME did not lead to a significant change in mortality (p = 0.15) or amputation (p = 0.34). Conclusion: Medicaid Expansion was not associated with reduced mortality or leg amputation in Medicare beneficiaries with PAD.

Concealment of Secret Information in Digital LSB Steganography in Colour and Grey Scale Images

Modern communication system needs an exceptional way of security, especially on computer networks. The network security is becoming more paramount as the number of data being exchanged on the internet increases. Steganography is the art of hiding information in a cover image without causing statistically significant variations to the cover image. Different types of carrier file formats can be used, but digital images are the most popular ones because of their frequency on the internet. This research work gives an overview of image steganography, it’s uses and techniques, basically, to store confidential information within images such as details of working strategy, secret missions, criminal and confidential information in various organizations that work for national security such as military, FBI, DSS, Nigerian police etc. The desktop application has been developed that incorporates Advanced Encryption Standard for encryption of the original message, and Spatially Desynchronized Steganography Algorithm for hiding the text file inside the image. Least Significant Bit (LSB) technique was used in hiding messages in an image. The system enhanced the LSB technique by randomly dispersing the bits of the message in the image and thus making it harder for steganalyst to extract the original message. Keywords:. LSB, Cryptography, Encryption, Image Processing, Security

Robust steganographic framework for securing sensitive healthcare data of telemedicine using convolutional neural network

AbstractData is the key element that runs the modern society. Large amounts of data are being released day by day as a result of many activities. The digital data is transferred through the Internet which may be vulnerable to attacks while transmitting. Especially, the medical data is observed to be of at most importance. Thus, the security of the data should be preserved while communicating through the Internet. Many techniques have been evolved for securing the data, such as Encryption which makes the data not understandable by others and techniques such as Steganography, which hides the data inside other file or document. Traditional methods of Steganography‐like LSB substitution are subjected to risks of manipulation of carrier image and poor embedding capabilities. In light of this, the authors introduce a Convolutional Neural Network‐based image steganography method that operates on DICOM images which conceals the sensitive medical data in the carrier file, thereby increasing the privacy of the sensitive data. The data considered here is brain MRI scan images. The Prep Net, Hiding Net and Reveal Net networks, each with distinct number of convolution layers are used to build the model. The sensitive data is firstly segmented to detect the Region of Interest (ROI) and then the combination of sensitive data and the carrier image are fed to the Prep Net to manipulate sensitive images in such a form that it can easily fit inside the carrier image. The Hiding Net takes the result of Prep Net and embeds the sensitive image inside the carrier image to form a stego image. The Reveal Net takes the result of Hiding Net image and then extracts the sensitive image with minimal loss. The dataset contains medical images of DICOM format taken from open source platform Kaggle that contains 3500 images of 2 classes. The results obtained show that the proposed model achieves 20 percent better output compared to traditional LSB methods. As a result, the potential for hiding the data will be expanded, as well as its security.

Abstract P388: Higher Social Vulnerability Was Associated With Less Community-Based Rehabilitation Utilization After Stroke

Background: Timely rehabilitation care significantly improves function and mobility after stroke, but barriers exist in access and utilization. The impact of neighborhood social determinants of health is not fully understood. Our study aims to estimate the association between Social Vulnerability Index (SVI), a measure of a community's need for support, and post-stroke rehabilitation utilization. Methods: This study is an observational, secondary analysis of the COMprehensive Post-Acute Stroke Services study, a pragmatic trial conducted in 41 North Carolina hospitals from 2016-2019. This analysis included 4765 individuals (51.2% female; 74.8% Whites; mean age 69.9) discharged directly home after stroke and linked to administrative claims. Utilization of physical or occupational therapy was obtained from outpatient, carrier file and home health claims. Geocoded participant addresses were linked to 2018 summary SVI percentile ranking and its four sub-domains at the Census tract level. Generalized estimation equations with cluster of Census tract and hospital were used to estimate the association between quintiles of SVIs and incidence proportion of rehabilitation use within 30 days. Covariates included patients’ socio-demographics, clinical characteristics, and comorbidities. Results: The overall proportion of rehabilitation use by 30 days was 38.6%, ranging from 34.6-46.5% across SVI quintiles. In multivariable analysis, quintiles of higher summary SVI were associated with lower rehabilitation use compared with the least vulnerable quintile (RD and 95% CI, Q5 vs Q1: -0.098 [-0.147 to -0.049]; Table). There was a significant decreasing trend across quintiles (P-trend &lt; 0.001). Similar results were observed for SVI sub-domains except for minority status and language. Conclusion: Higher social vulnerability was associated with less post-stroke rehabilitation use. The finding is useful to identify communities for targeted interventions to improve access and utilization to rehabilitation.

Review on various image protection methods

The security of information exchange over email and other web-based means is rather low, and there is the risk of interception when it comes to confidential information (e.g., credit card info). Therefore, online users should be ensured of the security and privacy of their web interactions. Despite the remarkable benefits of the Internet in the modern era and its contribution to digital communication, the information security of open networks has become an important issue due to its heavy costs. Several approaches have been used to address this issue, particularly through information hiding and encryption in system security strategies. Cryptography is the process of information encryption, and steganography refers to information hiding. These methods have proven quite effective in maintaining information security. Cryptography involves making changes to confidential information, which prevents their readability by eavesdroppers, which could also be considered a technique of original text to cipher text. On the other hand, steganography entirely hides confidential information from unauthorized users using multiple carrier formats, including audio, video, protocol, and images. Given the availability of digital images, they are often employed as carrier files online. Other approaches to image steganography are also common and have specific limitations and advantages. The present study aimed to review different methods of image cryptography and steganography and compare the studies in this regard so as to determine which the best, specific and accurate methods of information security.

Steganographic Techniques for High-Capacity Covert Communication in Images and Videos

Steganography is the art of concealing information within other data to obscure the transmission process. Digital photos are the preferred carrier files due to their ubiquity online. Various steganography techniques exist for hiding sensitive data in video frames, each with distinct strengths and weaknesses. Some applications require total invisibility for critical information, while others can accommodate larger secret messages. Our project conceals messages within visuals, enabling users to select replacement bits instead of employing less secure LSB substitution. Data transmission, the process of sending data from source to destination, often involves slower mediums like coaxial cables and twisted pair wires, which can result in data leaks or losses. To address these issues, fiber optics are employed. Fiber optics transmited data as light beams, minimizing data leakage and incorporating security measures. In our proposed system, we enhance fiber optic encryption through the use of images. Key Words: Steganography, data concealment, digital photos, steganography techniques, data invisibility, LSB substitution, data transmission, coaxial cables, twisted pair wires, fiber optics, data security, image encryption.

Primary Care Physician Follow-Up and 30-Day Readmission After Emergency General Surgery Admissions

The benefit of primary care physician (PCP) follow-up as a potential means to reduce readmissions in hospitalized patients has been found in other medical conditions and among patients receiving high-risk surgery. However, little is known about the implications of PCP follow-up for patients with an emergency general surgery (EGS) condition. To evaluate the association between PCP follow-up and 30-day readmission rates after hospital discharge for an EGS condition. This cohort study used data from the Centers for Medicare & Medicaid Services Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files for beneficiaries aged 66 years or older who were hospitalized with an EGS condition that was managed operatively or nonoperatively between September 1, 2016, and November 30, 2018. Eligible patients were enrolled in Medicare fee-for-service, admitted through the emergency department with a primary diagnosis of an EGS condition, and received a general surgery consultation during the admission. Data were analyzed between July 11, 2022, and June 5, 2023. Follow-up with a PCP within 30 days after hospital discharge for the index admission. The primary outcome was readmission within 30 days after discharge for the index admission. An inverse probability weighted regression model was used to estimate the risk-adjusted association of PCP follow-up with 30-day readmission. The secondary outcome was readmission within 30 days after discharge stratified by treatment type (operative vs nonoperative treatment) during their index admission. The study included 345 360 Medicare beneficiaries (mean [SD] age, 74.4 [12.0] years; 187 804 females [54.4%]) hospitalized with an EGS condition. Of these, 156 820 patients (45.4%) had a follow-up PCP visit, 108 544 (31.4%) received operative treatment during their index admission, and 236 816 (68.6%) received nonoperative treatment. Overall, 58 253 of 332 874 patients (17.5%) were readmitted within 30 days after discharge for the index admission. After risk adjustment and propensity weighting, patients who had PCP follow-up had 67% lower odds of readmission (adjusted odds ratio [AOR], 0.33; 95% CI, 0.31-0.36) compared with patients without PCP follow-up. After stratifying by treatment type, patients who were treated operatively during their index admission and had subsequent PCP follow-up within 30 days after discharge had 79% reduced odds of readmission (AOR, 0.21; 95% CI, 0.18-0.25); a similar association was seen among patients who were treated nonoperatively (AOR, 0.36; 95% CI, 0.34-0.39). Infectious conditions, heart failure, acute kidney failure, and chronic kidney disease were among the most frequent diagnoses prompting readmission overall and among operative and nonoperative treatment groups. In this cohort study, follow-up with a PCP within 30 days after discharge for an EGS condition was associated with a significant reduction in the adjusted odds of 30-day readmission. This association was similar for patients who received operative care or nonoperative care during their index admission. In patients aged 66 years or older with an EGS condition, primary care coordination after discharge may be an important tool to reduce readmissions.

Diagnostic rate estimation from Medicare records: Dependence on claim numbers and latent clinical features

ObjectiveInternational Classification of Disorders version 10 (ICD-10) codes contribute heavily to healthcare data. Medicare claims and other data-sources are used to constitute study populations and appraise healthcare processes. How variability in claims-per-beneficiary impacts diagnostic determinations is inadequately understood. The objective of this study is so assess distributional properties of Medicare claims, and examine claim rates impact on code utilization and rate determinations. MethodsThe study population was Medicare beneficiaries aged 75–79.99 with claim(s) in the 5% standard analytical Carrier and Outpatient files, alive and participating in Medicare part B for all 12 months of 2017. Medicare beneficiary files were processed to create records containing all ICD-10 codes specified, key demographics, Part B and vital status, and the total claims for each 2017 beneficiary. Claim number cohorts were characterized. ResultsBeneficiaries meeting inclusion criteria totaled 221,625, these having 7,617,503 claims; 96.4% had between 1 and 120 claims. Median claims were 24 for males (females 25); modal claims were 11 (13). Average distinct codes per beneficiary increased with claims number. The assignment of ICD-10 codes, i.e., ‘diagnostic rate estimates’ (DRE), increased as claim numbers increased for most codes among those most commonly utilized. For some conditions, mostly benign and age-related, DREs plateaued as claim numbers increased. For other conditions, typically associated with clinical acuity, e.g., chest pain, DREs increased steeply with claims. ConclusionsOlder adult Medicare beneficiaries aged 75–80 exhibited varying claims activity over the course of a year. Although DRE dependence on claim numbers varies across ICD-10 codes, rate estimates are higher for beneficiaries with claim numbers above the median.

MP24-14 URORISK: A NOVEL SURGICAL RISK CALCULATOR FOR BLADDER OUTLET PROCEDURES IN OLDER ADULTS

You have accessJournal of UrologyCME1 Apr 2023MP24-14 URORISK: A NOVEL SURGICAL RISK CALCULATOR FOR BLADDER OUTLET PROCEDURES IN OLDER ADULTS Farnoosh Nik-Ahd, Shoujun Zhao, Lufan Wang, W. John Boscardin, and Anne M. Suskind Farnoosh Nik-AhdFarnoosh Nik-Ahd More articles by this author , Shoujun ZhaoShoujun Zhao More articles by this author , Lufan WangLufan Wang More articles by this author , W. John BoscardinW. John Boscardin More articles by this author , and Anne M. SuskindAnne M. Suskind More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003249.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bladder outlet obstruction (BOO) is common in older adults. As such, many who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty and other comorbidities. No risk calculator for BOO surgery that factors in frailty exists. We developed the first risk calculator for BOO surgeries that includes components of frailty and comorbidity to predict the risk of common complications. METHODS: Medicare beneficiaries undergoing BOO surgery from 2014-2016 were examined using Medicare MedPAR, Outpatient, and Carrier files. Pre-procedure frailty was quantified for each subject using the 93-item Claims-Based Frailty Index (CFI). Each variable in the Charlson Comorbidity Index and CFI was extrapolated into stepwise logistic regression models to determine variables most predictive of surgical complications. The most prognostic variables were grouped into 13 categories. C-statistics, Brier scores, Spiegelhalter p values and model fit curves were calculated to assess model fit. RESULTS: A total of 212,543 subjects were included. BOO surgeries included transurethral resection of the prostate, GreenLight Laser Therapy, transurethral incision of the bladder neck, holmium laser enucleation of the prostate, transurethral microwave thermotherapy, transurethral incision of the prostate, UroLift, and transurethral needle ablation. Most subjects were white (88%), with CFI scores that were not frail (CFI<0.15, N=101,282, 48%) or pre-frail (0.15≤CFI<0.25, N=10,559, 39%). Variables most predictive of complications were congestive heart failure, primary malignancy, secondary or metastatic malignancy, pneumonia/influenza in the past year, neurodegenerative/neurologic diseases, dementia/psychiatric conditions and substance use, renal disease, chronic liver disease, anemias/platelets disorders, chronic lung disease, coronary artery disease, venous/lymphatic/thrombotic disorders, and stroke. Model fit for any complication within 30 days of surgery is shown (Figure). CONCLUSIONS: This is the first risk calculator for BOO surgery that includes predictors of frailty and comorbidity to individualize risk calculation among older adults. This serves as an effective and widely-applicable tool to help guide patient counseling and clinical decision-making. Source of Funding: NIH-NIA R01AG058616 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e323 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Farnoosh Nik-Ahd More articles by this author Shoujun Zhao More articles by this author Lufan Wang More articles by this author W. John Boscardin More articles by this author Anne M. Suskind More articles by this author Expand All Advertisement PDF downloadLoading ...

Long-term outcomes of peripheral atherectomy for femoropopliteal endovascular interventions.

The use of atherectomy during peripheral endovascular interventions (PVI) has increased dramatically, but data regarding its safety and effectiveness are lacking. Aims: This study sought to determine the long-term safety of atherectomy in contemporary practice. Methods: Medicare fee-for-service beneficiaries who underwent femoropopliteal artery PVI from 2015-2018 were identified in a 100% sample of inpatient, outpatient, and carrier file data using procedural claims codes. The primary exposure was the use of atherectomy. Inverse probability of treatment weighting was used to adjust for measured differences in patient populations. Kaplan-Meier methods and multivariable Cox proportional hazards regression were used to compare outcomes. Results: Among 168,553 patients who underwent PVI, 59,142 (35.1%) underwent atherectomy. The mean patient age was 77.0±7.6 years, 44.9% were female, 81.9% were white, and 46.7% had chronic limb-threatening ischaemia. Over a median follow-up time of 993 days (interquartile range 319-1,377 days), atherectomy use was associated with no difference in the risk of either the composite endpoint of death and amputation (adjusted hazard ratio [aHR] 0.99, 95% confidence interval [CI]: 0.97-1.01; p=0.19) or of major adverse limb events (aHR 1.02, 95% CI: 0.99-1.05; p=0.26). Patients who underwent atherectomy had a modest reduction in the risk of subsequently undergoing amputation or surgical revascularisation (aHR 0.92, 95% CI: 0.90-0.94; p<0.01) but an increase in the risk of undergoing a subsequent PVI (aHR 1.19, 95% CI: 1.16-1.21; p<0.01). The use of atherectomy during femoropopliteal artery PVI was not associated with an increase in the risk of long-term adverse safety outcomes among patients with peripheral artery disease.

Readmissions and postdischarge mortality by race and ethnicity among Medicare beneficiaries with multimorbidity.

Disparities in readmission risk and reasons they might exist among diverse complex patients with multimorbidity, disability, and unmet social needs have not been clearly established. These characteristics may be underestimated in claims-based studies where individual-level data are limited. We sought to examine the risk of readmissions and postdischarge mortality by race and ethnicity after rigorous adjustment for multimorbidity, physical functioning, and sociodemographic and lifestyle characteristics. We used Health and Retirement Study (HRS) data linked to Medicare claims. To obtain ICD-9-CM diagnostic codes to compute the ICD-coded multimorbidity-weighted index (MWI-ICD) we used Medicare Parts A and B (inpatient, outpatient, carrier) files between 1991-2015. Participants must have had at least one hospitalization between January 1, 2000 and September 30, 2015 and continuous enrollment in fee-for-service Medicare Part A 1-year prior to hospitalization. We used multivariable logistic regression to assess the association of MWI-ICD with 30-day readmissions and mortality 1-year postdischarge. Using HRS data, we adjusted for age, sex, BMI, smoking, physical activity, education, household net worth, and living arrangement/marital status, and examined for effect modification by race and ethnicity. The final sample of 10,737 participants had mean ± SD age 75.9 ± 8.7 years. Hispanic adults had the highest mean MWI-ICD (16.4 ± 10.1), followed by similar values for White (mean 14.8 ± 8.9) and Black (14.7 ± 8.9) adults. MWI-ICD was associated with a higher odds of readmission, and there was no significant effect modification by race and ethnicity. For postdischarge mortality, a 1-point increase MWI-ICD was associated with a 3% higher odds of mortality (OR=1.03, 95% CI: 1.03-1.04), which did not significantly differ by race and ethnicity. Multimorbidity was associated with a monotonic increased odds of 30-day readmission and 1-year postdischarge mortality across all race and ethnicity groups. There was no significant difference in readmission or mortality risk by race and ethnicity after robust adjustment.