Centers For Medicare Research Articles

Impact of Early Admission Surveys on Physicians' Communication Skills on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Scores: A Quality Improvement Initiative.

Introduction Effective communication between doctors and patients is one of the 19 core questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Positive patient experiences, as reflected in HCAHPS scores, are associated with higher quality of care, reduced mortality, and fewer readmissions. These scores also influence a hospital's financial bonuses or penalties from the Centers for Medicare & Medicaid Services. Methods This quality improvement (QI) initiative evaluated how early surveys of patients' feedback on doctors' communication skills during admission impacted discharge communication scores. The approach involved promptly sharing patients' feedback with physicians and focusing on improving communication skills for those with less-than-perfect scores. Results This QI initiative involved 41 patients. By surveying patients early during admission and addressing communication issues for those with less-than-perfect scores, the percentage of patients achieving a perfect score on all survey questions increased from 18 (43.9%) at admission to 34 (82.9%) at discharge. The largest improvement was seen in perfect scores for doctors' explanations of patients' conditions, which rose from 59% at admission to 90% at discharge. Conversely, the increase in perfect scores for doctors' respectful treatment was smaller, rising from 88% at admission to 98% at discharge. Conclusion Surveying patients about their doctors' communication skills early in admission to identify those with less-than-perfect scores and improving communication for this group resulted in a 39% increase in satisfaction with doctors' communication.

Treatment patterns, healthcare resource utilization, and costs in Medicare patients with diffuse large B-cell lymphoma: a retrospective claims analysis (2015–2020)

Aims To understand treatment patterns, healthcare resource utilization (HCRU), and the economic burden of diffuse large B-cell lymphoma (DLBCL) in elderly adults in the US. Materials and methods This retrospective database analysis utilized US Centers for Medicare and Medicaid Services Medicare fee-for-service administrative claims data from 2015 to 2020 to describe DLBCL patient characteristics, treatment patterns, HCRU, and costs among patients aged ≥66 years. Patients were indexed at DLBCL diagnosis and required to have continuous enrollment from 12 months pre-index until 3 months post-index. HCRU and costs (USD 2022) are reported as per-patient per-month (PPPM) estimates. Results A total of 11,893 patients received ≥1-line (L) therapy; 1,633 and 391 received ≥2 L and ≥3 L therapies, respectively. Median (Q1, Q3) age at 1 L, 2 L, and 3 L initiation, respectively, was 76 (71, 81), 77 (72, 82), and 77 (72, 82) years. The most common therapy was R-CHOP (70.9%) for 1 L and bendamustine ± rituximab for 2 L (18.7%) and 3 L (17.4%). CAR T was used by 14.8% of patients in 3 L. Overall, 39.6% (1 L), 42.1% (2 L), and 47.8% (3 L) of patients had all-cause hospitalizations. All-cause mean (median [Q1–Q3]) costs PPPM during each line were $22,060 ($20,121 [$16,676–$24,597]) in 1 L, $30,027 ($20,868 [$13,416–$31,016]) in 2 L, and $47,064 ($25,689 [$15,555–$44,149]) in 3 L, with increasing costs driven primarily by inpatient expenses. Total all-cause 3 L mean (median [Q1–Q3]) costs PPPM for patients with and without CAR T were $153,847 ($100,768 [$26,534–$253,630]) and $28,466 ($23,696 [$15,466–$39,107]), respectively. Conclusions No clear standard of care exists in 3 L therapy for older adults with relapsed/refractory DLBCL. The economic burden of DLBCL intensifies with each progressing line of therapy, thus underscoring the need for additional therapeutic options.

The exponential growth of nonsurgeons performing fusions for low-back pain.

This study aimed to report changes in utilization and payment trends of low-back pain (LBP) interventions and the impact of nonsurgeon interventionalists on these changes. Medicare Part B national summary data files were used to gather annual utilization and Centers for Medicare and Medicaid Services (CMS) payment data for LBP interventions from 2000 to 2021. Healthcare Common Procedure Coding System (HCPCS) codes were grouped as decompression, spinal fusion, sacroiliac (SI) joint fusion, epidural steroid injections (ESIs), physical therapy (PT), and chiropractic manipulation (Chiro). The total allowed services and payments were collected for each HCPCS group. CMS provider-level files, available from 2013 to 2021, were used to collect neurosurgeon, orthopedic surgeon, and nonsurgeon interventionalist (interventional radiology and pain management) data for each surgical HCPCS code group (decompression, spinal fusion, and SI joint fusion). The United States Consumer Price Index was used to adjust for inflation. From 2000 to 2021, there were 339,720,725 Medicare-approved interventions and payments of approximately $21 billion for LBP (percentage of cumulative payments: 41.8% Chiro, 16.5% ESI, 14.4% spinal fusion, 14.3% PT, 10.2% decompression, and 0.4% SI joint fusion). In a subgroup analysis, spinal fusions for Medicare patients were performed by orthopedic surgeons (59.2%), neurosurgeons (40.6%), and nonsurgeon interventionalists (< 1%) from 2013 to 2021. From 2013 to 2021, neurosurgeon and orthopedic surgeon fusion utilization each grew by < 3% and associated Medicare payments to each specialty declined by 1% each year. During the same period, nonsurgeon interventionalist utilization grew 26% each year and associated Medicare payments to nonsurgeon interventionalists for spine fusions grew 62% each year. In a subgroup analysis, SI joint fusions for Medicare patients were performed by orthopedic surgeons (50.7%), neurosurgeons (24.8%), and nonsurgeon interventionalists (24.5%) from 2018 to 2021. Neurosurgeon utilization of SI joint fusion declined by 1% each year and associated Medicare payments to this group grew 2% each year. Orthopedic surgeon utilization of SI joint fusion declined 1% and associated Medicare payments to this group grew 4% each year. Nonsurgeon interventionalist use of SI joint fusions grew 415% and payments grew 435% each year. The substantial growth in Medicare payments for surgical LBP interventions is disproportionally driven by nonsurgeon interventionalists. The exponential growth of nonsurgeon interventionalists performing spinal fusion surgeries, particularly SI joint fusions, largely accounts for the significant increase in Medicare expenditures.

Recent Medicare Billing Trends of Hospitals and Surgeons for Revision Hip and Knee Total Joint Arthroplasty: Is the Value of a Surgeon’s Work Decreasing?

BackgroundRevision hip and knee total joint arthroplasty (TJA) is associated with higher health care costs and work burden than primary TJAs. However, previous studies demonstrated a decrease in the value of reimbursements for revision TJA, causing concerns for hospitals and surgeons regarding the financial sustainability of these resource-expensive procedures. This study aimed to investigate the Medicare billing trends of hospitals and surgeons for revision TJA between 2017 and 2022. MethodsMedicare claims and payments for revision TJA were identified from the Centers for Medicare and Medicaid Services Part A and B databases. Hospital claims for revision TJA were identified through Diagnostic-Related Groups (467, 468). Surgeon claims were identified using Current Procedural Terminology codes for revision hip (27134, 27137, 27138) and knee (27486, 27487) TJA. Yearly charges, reimbursements, and markup ratios (MR = charge/reimbursement) were analyzed. All monetary values were adjusted to the 2022 U.S. dollars. ResultsA total of 43,125 surgeons and 152,974 hospital claims were included in this study. From 2017 to 2022, the total volume of revision TJA decreased by 19.4%. Hospital reimbursements remained relatively unchanged, with a decrease of 1.4%, while hospital charges increased by 11.8%, resulting in a 13.3% increase in the MR. For surgeons, reimbursements decreased by 13.8%, and charges decreased by 11.0%, leading to a 3.3% increase in the MR. The proportion of surgeon reimbursement to hospital reimbursement decreased from 8.5 to 7.5%. ConclusionsThe comparison of the billing trends of hospitals and surgeons showed the relatively stable value of hospital reimbursement while the value of surgeon reimbursement continued to decline, implying the decreasing fiscal value of physicians’ work. The study suggests the need for sustainable financial incentives for surgeons performing revision TJA and strategies to control hospital charges to alleviate financial burdens and improve patient access to revision TJA.

Prevalence and Practice Characteristics of Advanced Practice Providers in Upper-Extremity Surgery, 2013–2021

This study evaluated the prevalence, characteristics, and reimbursement of advanced practice providers, including nurse practitioners and physician assistants, who provide care related to the diagnosis and treatment of diseases and conditions of the hand, wrist, and upper extremities in the United States from 2013 to2021. Our analysis was a retrospective cohort study evaluating the diagnostic, procedural, and therapeutic services provided by advanced practice providers from 2013 to 2021 using the Medicare Provider Utilization and Payment Data Public Use Files from the Centers for Medicare and Medicare Services. The reported provider type and billing codes were used to identify health care professionals providing upper-extremity care such as ordering radiographs, applying casts and splints, and performing procedures on the hand, wrist, or other anatomic regions of the upper extremity. Trends over the study period and available data about services provided were analyzed. From 2013 to 2021, providers of upper-extremity care included 19,525 (64.7%) doctor of medicine or doctor of osteopathic medicine upper-extremity surgeons, 7,612 (25.2%) physician assistants, and 3,042 (10.1%) nurse practitioners. The nonsurgeon providers were more likely to be women and provide care in micropolitan areas with less than 50,000 people compared with upper-extremity surgeons. Overall, the number of advanced practice providers who billed for upper-extremity care increased by 170.9% from 1,965 in 2013 to 5,324 in 2021. Based on these trends, the growth of APPs providing upper-extremity care is expected to continue. There is a growing prevalence of advanced practice providers in upper-extremity care, and this trend is expected to continue. With a growing need for upper-extremity care and predicted shortages in the surgeon workforce, the scope of practice and integration of advanced practice providers merits further discussion and evaluation.

Sharing Social Needs Data Across Sectors: Lessons From the Centers for Medicare and Medicaid Services Innovation Center's Accountable Health Communities Model.

Health-related social needs (HRSNs), like unstable housing, inability to afford utilities, food insecurity, unreliable transportation, and lack of personal safety, profoundly affect people's health and well-being. Between 2017 and 2022, awardees of the Accountable Health Communities Model (AHC) addressed the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services. Using and sharing HRSN data between clinical and community partners was a critical component of these efforts. This article shares findings from focus groups and interviews with 19 AHC awardees and seven of their partners. It explores the following:1. Whether sharing HRSN data with clinical partners informed clinical care2. Successes and challenges related to sharing data with community-based organizations (CBOs) and clinical partners3. How awardees collected and used HRSN data to advance health equityHalf of awardees interviewed documented HRSNs in electronic health records and shared aggregated HRSN data with CBOs. HRSN data enabled some clinicians to adjust patient care, although most were uncertain about how to do so. Participants described how sharing HRSN data with communities informs program and funding priorities to improve equity. However, CBOs noted that they had limited incentive to participate in data-sharing platforms. Our work highlights opportunities to provide guidance to clinicians on how to use HRSN screening results in care, standardize HRSN screening results in electronic health records, and co-create data-sharing initiatives with CBOs and patients to ensure meaningful participation.

Trends in payments for facility and surgeon professional fees for shoulder surgeries performed at ambulatory surgery centers

It has previously been demonstrated that utilization of ambulatory surgery centers (ASCs) results in cost savings and improved outcomes. Despite these benefits, Medicare reimbursement for professional fees at ASCs are decreasing over time. In this study, we sought to analyze the discrepancy between facility fee and professional fee reimbursements for ASCs by Medicare for common shoulder procedures over time. We hypothesized that professional fees for shoulder procedures would decrease over the study period while facility fees kept pace with inflation. Current Procedural Terminology (CPT) codes were used to identify shoulder specific procedures approved for ASCs by Centers for Medicare and Medicaid Services (CMS). Procedures were grouped into arthroscopic and open categories. Publicly available data from CMS was accessed via the Medicare Physician Fee Schedule Lookup Tool and used to determine professional fee payments from 2018-2024. Additionally, Medicare ASC Payment Rates files were accessed to determine facility fee reimbursements to ASCs from 2018-2024. Descriptive statistics were used to calculate means and percent change over time. Compound annual growth rates (CAGR) were calculated and discrepancies in inflation were corrected for using the Consumer Price Index. The Benjamini and Hochberg method was used to correct P values in the setting of multiple comparisons. A total of 33 common shoulder procedures were included for analysis (10 arthroscopic codes and 23 open codes). Reimbursements for facility fees have remained significantly higher than corresponding professional fees for both open and arthroscopic procedures (p<0.01). On average, facility fee reimbursements for common shoulder surgeries have risen on an annual basis in a manner consistent with inflation (p=0.838). However, professional fees for these procedures have experienced a nearly uniform decline over the study period both nominally and in inflation-adjusted dollars (p=0.064 and p=0.005, respectively). Facility fee payments for outpatient approved shoulder surgeries have matched or outpaced inflation. Over the same time period, professional fee reimbursements for surgeons are consistently decreasing, both in absolute and inflation-adjusted dollars. Reform to the physician fee schedule is necessary to ensure that Medicare patients retain access to high-quality physician care.

The comprehensive value of the modern vascular surgeon to the orthopedic surgery service

ObjectiveOrthopedic surgery is among the highest compensated specialties in modern practice. Vascular surgeons are consulted frequently during orthopedic operations, however, the comprehensive value of the vascular surgery service to the safe delivery of orthopedic care has not been characterized previously. MethodsElectronic medical records were retrospectively queried for all operations performed by orthopedic surgeons requiring operative vascular surgical consultation from June 2013 to December 2023. Data were collected on case-specific details, reasons for consultation, and total charges. Work relative value units were calculated for each primary orthopedic procedure using the Centers for Medicare and Medicaid Services physician fee schedule. ResultsA total of 952 operative vascular surgery consultations were required over the study period. Consults were requested by 56 orthopedic surgeons across all eight orthopedic subspecialties at our institution. Operative vascular consultation was requested across 108 different procedure types. A total of 94 consults (9.9%) were emergent, intraoperative requests, with the remaining 858 consults (90.1%) occurring in the preoperative setting. The most common causes for consultation included surgical exposure (n = 832 [87.4%]), inadvertent bleeding (n = 44 [4.6%]), need for bypass (n = 12 [1.3%]), and acute limb ischemia (n = 11 [1.2%]). Total charges for all operative consultations exceeded $91.5 million, and the calculated total work relative value units for all primary orthopedic procedures was 19,384.5. A total of 54 cases (5.7%) occurred after hours, on a weekend, or both. ConclusionsVascular surgeons are integral to the provision of orthopedic surgical services, inclusive of all orthopedic subspecialties, for both the prevention and treatment of iatrogenic vascular injury. The around-the-clock availability of a vascular surgeon enables the orthopedic surgery department to generate significant revenue for the hospital system. These findings are important to the ongoing discussions regarding the value and compensation of the modern vascular surgeon.

The impact of policy and technology infrastructure on telehealth utilization.

The COVID-19 outbreak resulted in an unprecedented surge in telehealth utilization. However, the effects of policy enactment on utilization remain understudied in the literature. Our research examines the impact of policy mandates relating to federal incentive programs on telehealth utilization across states during the pandemic by considering technology infrastructure, such as broadband penetration and equipment possession. This study also considers the impact of political orientation and control factors, including income attributes, on telehealth utilization. Considering telehealth utilization in the Medicare program as a test case, this study employed the partial least square and structural equation model to analyze data from the Centers for Medicare & Medicaid Services, the American Community Survey, and the Microsoft Airband Project to draw inferences. Our study finds that telehealth legislation, broadband penetration, political orientation, and control factors have a direct significant impact on telehealth utilization, whereas incentive programs and equipment possession have an indirect impact through broadband penetration.

Geographic Variation of Prevalence of Alzheimer's Disease and Related Dementias in Central Appalachia.

Alzheimer's disease and related dementias (ADRD) prevalence varies geographically in the United States. To assess whether the geographic variation of ADRD in Central Appalachia is explained by county-level sociodemographics or access to care. Centers for Medicare and Medicaid Services Public Use Files from 2015- 2018 were used to estimate county-level ADRD prevalence among all fee-for-service (FFS) beneficiaries with≥1 inpatient, skilled nursing facility, home health agency, hospital outpatient or Carrier claim with a valid ADRD ICD-9/10 code over three-years in Central Appalachia (Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia). Negative binomial regression was used to estimate prevalence overall, by Appalachian/non-Appalachian designation, and by rural/urban classification. Models were then adjusted for county-level: 1) FFS demographics (age, gender, and Medicaid eligibility), comorbidities; 2) population sociodemographics (race/ethnicity, education, aging population distribution, and renter-occupied housing); and 3) diagnostic access (PCP visits, neurology visits, and imaging scans). Across the 591 counties in the Central Appalachian region, the average prevalence of ADRD from 2015- 2018 was 11.8%. ADRD prevalence was modestly higher for Appalachian counties both overall (PR: 1.03; 95% CI: 1.02, 1.04) and after adjustment (PR: 1.02; 95% CI: 1.00, 1.03) compared to non-Appalachian counties. This difference was similar among rural and urban counties (p = 0.326) but varied by state (p = 0.004). The relative variation in ADRD prevalence in the Appalachian region was smaller than hypothesized. The case mixture of the dual eligible population, accuracy of the outcome measurement, and impact of educational attainment in this region may contribute to this observation.

Assessing geographical variation in economic disadvantage and dermatological care access in Florida

This study aims to quantify the relationship between economic disadvantage and access to dermatological care in Florida in order to advocate for tailored healthcare policies. Identifying underserved geographic communities can guide policymakers in implementing strategies to enhance accessibility to care in these areas. Using data from the Centers for Medicare &amp; Medicaid Services (CMS) and the US Census, this study analyzed dermatologist density across 920 Florida zip codes. Economic disadvantage was assessed using the distressed community index (DCI), a metric that stratifies zip codes into 5 levels of economic well-being. Statistical analyses, including the Kruskal-Wallis test, were conducted to assess disparities. Findings revealed significant differences in the number of providers by DCI quintile (p&lt;.001) and urban/rural designation (p&lt;.001). Lower deprivation areas were more likely to have providers, with 33.2% of the least deprived quintile having at least one provider compared to 11.8% in the most deprived quintile. Urban areas were more likely to have at least one provider (p&lt;.001), with 36.6% of urban zip codes having providers versus 1.1% of rural ones. Zip codes with at least one provider had significantly higher total population (p&lt;.001). These findings highlight the need for targeted interventions to address geographic disparities in the provision of dermatologic care, particularly in economically disadvantaged and rural areas of Florida. Considering the state’s high sun exposure rates and associated skin cancer risks, ensuring accessible dermatology services across all zip codes, regardless of socioeconomic status, is imperative for public health.

Alzheimer's Disease Anti-Amyloid Immunotherapies: Imaging Recommendations and Practice Considerations for ARIA Monitoring.

With the full FDA approval and centers for Medicare & Medicaid services (CMS) coverage of lecanemab and donanemab, a growing number of practices are offering anti-amyloid immunotherapy to appropriate patients with cognitive impairment (MCI) or mild dementia due to amyloid-positive Alzheimer's disease (AD). The goal of this paper is to provide updated practical considerations for radiologists, including implementation of MR imaging protocols, workflows and reporting and communication practices relevant to anti-amyloid immunotherapy and monitoring for amyloid-related imaging abnormalities (ARIA). Based on consensus discussion within an expanded ASNR Alzheimer's, ARIA, and Dementia study group, we will: (1) summarize the FDA guidelines for evaluation of radiographic ARIA; (2) review the three key MRI sequences for ARIA monitoring and standardized imaging protocols based on ASNR-industry collaborations; (3) provide imaging recommendations for three key patient scenarios; (4) highlight the role of the radiologist in the care team for this population; (5) discuss implementation of MRI protocols to detect ARIA in diverse practice settings; and (6) present results of the 2023 ASNR international neuroradiologist practice survey on dementia and ARIA imaging.ABBREVIATIONS: AD = Alzheimer's disease; ARIA = amyloid-related imaging abnormalities; APOE = apolipoprotein-E; CMS = centers for Medicare & Medicaid services; MCI = mild cognitive impairment.

Integrating Price Benchmarks and Comparative Clinical Effectiveness to Inform the Medicare Drug Price Negotiation Program

ObjectivesBy September 2024, the Centers for Medicare and Medicaid Services (CMS) will publicly report the negotiated prices (Maximum Fair Prices) for the first 10 drugs selected for price negotiation. We estimate initial price offers based on net prices, statutorily defined ceilings, and comparative effectiveness data for the 10 drugs and their therapeutic alternatives. MethodsWe utilized net prices and other price benchmarks for the 10 drugs and their therapeutic alternatives. We searched for data on comparative clinical effectiveness for the primary indications. We outlined a range of plausible initial price offers based on CMS guidance and our interpretation of regulatory intent. ResultsFor ibrutinib and ustekinumab, statutorily defined ceiling prices will likely determine the initial price offers. The integration of net pricing and clinical evidence from comparator branded products will inform the initial price offers for apixaban, empagliflozin, etanercept, and insulin aspart. Rivaroxaban and sacubitril/valsartan have therapeutic alternatives that are generics; therefore, CMS may apply a discount to current net prices. To achieve savings in the negotiation of dapagliflozin and sitagliptin, CMS will have to leverage additional negotiation factors because statutory defined ceilings and net prices of therapeutic alternatives are similar or higher. ConclusionsThis analysis sheds light on important price benchmarks and clinical evidence factors for the determination of the initial price offers. Although we were not able to simulate the offer and counter-offer process, our findings provide a transparent and systematic way to produce initial offers that are consistent with CMS guidance.

Drug Pricing Stewardship from Mark Cuban's Cost Plus Generic Drug Program.

The exceedingly high US spending per capita on prescription medications is mediated, at least in part, by the inefficiencies of existing generic pharmaceutical distribution and reimbursement systems; yet, the extent of potential savings and areas for targeted interventions for generic drug prescribers remains underexplored. We aimed to analyze 2021 Medicare Part D spending on generic drugs in comparison with pricing of a low-cost generic drug program, the Mark Cuban Cost Plus Drug Company (MCCPDC), to gauge the extent of achievable potential savings. In this retrospective, observational study, we performed a systematic analysis of potential Medicare Part D savings when using MCCPDC generic pricing. The 2023 MCCPDC data, as of August 2023, were obtained from the provider's publicly available database. The 2021 Medicare Part D data and prescriber datasets were obtained from the US Centers for Medicare and Medicaid Services. Outcomes included total prescription volume, proportion of drugs with savings, total US dollar Medicare savings, and average weighted price reduction per unit drug. Results were stratified by medical and surgical subspecialties to identify areas for targeted interventions. Subspecialty-wise contribution to total savings versus contribution to total prescription volume was characterized. Total estimated Medicare Part D savings were $8.6 billion using 90-day MCCPDC pricing, with surgical drugs accounting for over $900 million. Nearly 80% of the examined drugs were more price effective through MCCPDC using 90-day supply. Commonly prescribed drugs in cardiology, psychiatry, neurology, transplant surgery, and urology demonstrated the highest estimated absolute savings. The most disproportionate savings relative to prescription volume were observed for drugs in oncology, gynecology, infectious disease, transplant surgery, and colorectal surgery. This study underscores the significant potential for Medicare Part D savings through strategies that address the systemic overpayment for generic medications. We identified key areas for reform as well as specific medical and surgical subspecialties where targeted interventions could yield substantial savings.

3-Year Outcomes of Balloon-Expandable Valves: 20-mm vs Larger Valves (≥23 mm)

BackgroundA prior Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry–based analysis reported similar 1-year clinical outcomes with small (20-mm) vs large (≥23-mm) balloon-expandable valves (BEV). ObjectivesThe aim of this study was to describe mid-term 3-year clinical outcomes for small vs large BEV and the relationship between discharge echocardiographic mean gradient (MG) and different definitions of prothesis-patient mismatch (PPM) with clinical outcomes. MethodsUsing the TVT Registry with Centers for Medicare and Medicaid Services linkage, a propensity-matched analysis of patients receiving 20- vs ≥23-mm BEVs was performed. Spline curves and Kaplan-Meier plots with adjusted HRs determined the relationship between MG and 3-year mortality. ResultsIn total, 316,091 patients were analyzed; after propensity matching, 8,100 pairs of each group were compared. The 20-mm BEV was associated with higher MGs compared with ≥23-mm BEVs (16.2 ± 7.2 mm Hg vs 11.8 ± 5.7 mm Hg; P < 0.0001). At 3 years, there was no difference in mortality between 20- and ≥23-mm BEVs (31.5% vs 32.5%, respectively; HR: 0.97; 95% CI: 0.90-1.05). Compared with an MG of 10 to 30 mm Hg, an MG <10 mm Hg (HR: 1.25; 95% CI:1.22-1.27) was associated with increased 3-year mortality. Measured severe PPM and predicted no PPM were associated with increased 3-year mortality (33.5% vs 32.9% vs 32.1%; P < 0.0001) and (33.5% vs 31.1% vs 30%; P < 0.0001), respectively. Low MG and severe measured PPM were associated with lower left ventricular ejection fraction (LVEF). ConclusionsPatients with small-prosthesis BEVs (20 mm) had identical 3-year survival as those with larger (≥23-mm) BEV valves. Severe measured PPM and low MG (<10 mm Hg), but not predicted severe PPM, were associated with lower LVEF and increased mortality, suggesting that LVEF is the culprit for worse outcomes.

Administrative Analysis of the Home-Based Older Persons Upstreaming Prevention Physical Therapy Program: A Pilot Observational Study.

Introduction Traditionally, physical therapist (PT) services do not commence until an injury, fall, or health issue has already occurred although there is increasing evidence that preventative programs administered by PTs may decrease the fall risk among elderly individuals.The purpose of this study was to examine billing, reimbursement, and administrative outcomes of the previously established and investigated prevention-based screening and intervention HOP-UP-PT (Home-based Older Persons Upstreaming Prevention-Physical Therapy) program delivered by a physical therapist in the home of older adults after being referred by a community partner. A randomized controlled trial of the HOP-UP-PT program demonstrated an 8-fold reduction in falls for participants at moderate and high fall risk compared to those who did not participate in the program. Methods Aprospective observational study was performed to examine administrative and payment outcomes of HOP-UP-PT participation. Participants were referred into the HOP-UP-PT program via a local community center. Physician authorization for physical therapy participation was obtained for each participant as required for payment under United States' Center for Medicare and Medicaid Services (CMS)guidelines. The HOP-UP-PT program is preventative physical therapy delivered in the person's home with five in person visits (approximately one per month) followed by a monthly telehealth visit and a final in-person visit.Interventions included a balance program, home safety recommendations, health coaching, and addressing individual risks of falling or becoming homebound. A retrospective analysis was performed on the administrative andinsurance payment data from this study which was then analyzed descriptively. Results Six participants with four different insurances completed the 7-month program (mean age=77 years) in 2021. The physical therapy visits were submitted to the participants' Medicare Part B plan. One participant's physical therapy visits were not submitted for payment as the health system did not have an active agreement with that health insurer. Due to the unclear status of telehealth visits in 2021, these services were not submitted to the insurance company for payment.All other PT visits were paid by the insurance companies. The mean amount paid for the initial evaluation code was $102.83 and the mean payment for the ~15 minute treatment codes was $25.90 per unit. Initial pilot data demonstrated a potential for a4.2% positive operating margin when considering salary costs and travel.The mean delay from the initial referral into the HOP-UP-PT program until the physician provided written authorization for physical therapy was 69.7 days. Conclusion This study demonstrated initial evidence that payment for prevention-focused outpatient physical therapist services delivered in the home was feasible, however delays and costsin procuring physician authorization was a substantial barrier to prevention-focused physical therapy. A 4.2% operating margin demonstrated that, when efficiently operated, similar programs are likely to be viable. Furthermore, if telehealth services would have been paid, the operating margin was estimated to increase to 32%. Physical therapists are highly qualified to deliver efficient, effective preventative services which has the potential to reduce falls and institutionalization and subsequent healthcare cost savings.

Provision of transplant education for patients starting dialysis: Disparities persist

BackgroundAll patients starting dialysis should be informed of kidney transplant as a renal replacement therapy option. Prior research has shown disparities in provision of this information. In this study, we aimed to identify patient sociodemographic and dialysis facility characteristics associated with not receiving transplant information at the time of dialysis initiation. We additionally sought to determine the association of receiving transplant information with waitlist and transplant outcomes. MethodsWe retrospectively analyzed CMS-2728 forms filed from 2007 to 2019. The primary outcome was report of provision of information about transplant on the Centers for Medicare and Medicaid Services Form CMS-2728. For patients not informed at the time of dialysis, we collected the reported reason for not being informed (medically unfit, declined information, unsuitable due to age, psychologically unfit, not assessed, or other). Cox proportional-hazards model estimates were used to study determinants of addition to the waitlist and transplant (secondary outcomes). ResultsFifteen percent of patients did not receive information about transplant (N = 133,414). Non-informed patients were more likely to be older, female, white, and on Medicare. Patients informed about transplant had a shorter time between end-stage renal disease onset and addition to the waitlist; they also spent a shorter time on the waitlist before receiving a transplant. Patients at chain dialysis facilities were more likely to receive information, but this did not translate into higher waitlist or transplant rates. Patients at independent facilities acquired by chains were more likely to be informed but less likely to be added to the waitlist post acquisition. ConclusionsDisparities continue to persist in providing information about transplant at initiation of dialysis. Patients who are not informed have reduced access to the transplant waitlist and transplant. Maximizing the number of patients informed could increase the number of patients referred to transplant centers, and ultimately transplanted. However, policy actions should account for differences in protocols stemming from facility ownership.

Modeling Nursing Home Harms From COVID-19 Staff Furlough Policies

Current guidance to furlough health care staff with mild COVID-19 illness may prevent the spread of COVID-19 but may worsen nursing home staffing shortages as well as health outcomes that are unrelated to COVID-19. To compare COVID-19-related with non-COVID-19-related harms associated with allowing staff who are mildly ill with COVID-19 to work while masked. This modeling study, conducted from November 2023 to June 2024, used an agent-based model representing a 100-bed nursing home and its residents, staff, and their interactions; care tasks; and resident and staff health outcomes to simulate the impact of different COVID-19 furlough policies over 1 postpandemic year. Simulating increasing proportions of staff who are mildly ill and are allowed to work while wearing N95 respirators under various vaccination coverage, SARS-CoV-2 transmissibility and severity, and masking adherence. The main outcomes were staff and resident COVID-19 cases, staff furlough days, missed care tasks, nursing home resident hospitalizations (related and unrelated to COVID-19), deaths, and costs. In the absence of SARS-CoV-2 infection in the study's 100-bed agent-based model, nursing home understaffing resulted in an annual mean (SD) 93.7 (0.7) missed care tasks daily (22.1%), 38.0 (7.6) resident hospitalizations (5.2%), 4.6 (2.2) deaths (0.6%), and 39.7 (19.8) quality-adjusted life years lost from non-COVID-19-related harms, costing $1 071 950 ($217 200) from the Centers for Medicare & Medicaid Services (CMS) perspective and $1 112 800 ($225 450) from the societal perspective. Under the SARS-CoV-2 Omicron variant conditions from 2023 to 2024, furloughing all staff who tested positive for SARS-CoV-2 was associated with a mean (SD) 326.5 (69.1) annual furlough days and 649.5 (95% CI, 593.4-705.6) additional missed care tasks, resulting in 4.3 (95% CI, 2.9-5.9) non-COVID-19-related resident hospitalizations and 0.7 (95% CI, 0.2-1.1) deaths, costing an additional $247 090 (95% CI, $203 160-$291 020) from the CMS perspective and $405 250 (95% CI, $358 550-$451 950) from the societal perspective. Allowing 75% of staff who were mildly ill to work while masked was associated with 5 additional staff and 5 additional resident COVID-19 cases without added COVID-19-related hospitalizations but mitigated staffing shortages, with 475.9 additional care tasks being performed annually, 3.5 fewer non-COVID-19-related hospitalizations, and 0.4 fewer non-COVID-19-related deaths. Allowing staff who were mildly ill to work ultimately saved an annual mean $85 470 (95% CI, $41 210-$129 730) from the CMS perspective and $134 450 (95% CI, $86 370-$182 540) from the societal perspective. These results were robust to increased vaccination coverage, increased nursing home transmission, increased importation of COVID-19 from the community, and failure to mask while working ill. In this modeling study of staff COVID-19 furlough policies, allowing nursing home staff to work with mild COVID-19 illness was associated with fewer resident harms from staffing shortages and missed care tasks than harms from increased COVID-19 transmission, ultimately saving substantial direct medical and societal costs.

Radiology outpatients’ awareness of their out-of-pocket estimates and hospital price estimator tools in the United States

ObjectivePrice transparency mandates by the Centers for Medicare and Medicaid Services (CMS) were implemented in 2021 for hospitals and 2023 for health plans. We assessed U.S. patients’ awareness of their estimated out-of-pocket cost (OOPC) and hospital price-estimator tool among outpatients undergoing advanced imaging. MethodsEnglish-, Spanish-, and Vietnamese-speaking adults receiving a CT, PET/CT, or MRI at a tertiary academic center between 11/2022 and 03/2023 completed a 15-minute survey. We assessed awareness of OOPC estimates prior to imaging and the hospital price-estimator tool, and factors associated with such awareness using multivariable regression analysis. Results423 patients were included (mean age: 57.1 ± 15.6; 57.4 % female; 55 % White; 21.8 % Hispanic; 18.9 % Asian). Only 10.7 % and 16.8 % were aware of their OOPC before receipt of imaging and center'shospital price-estimator tool, respectively. No patient used the hospital price estimator tool to obtain their OOPC estimate. Annual household income of $50,000 or more (OR: 30.25, 95 % CI: 1.78, 513.79), and having at least one comorbidity (OR: 4.59, 95 % CI: 1.42, 14.79) were associated with a higher probability of knowing OOPC prior to imaging. Patients who experienced financial hardship were less likely to be aware of their OOPC (OR: 0.29, CI: 0.10, 0.86). No significant factors were associated with awareness of hospital price estimator tool in full regression model. ConclusionOur study highlights limited OOPC and price estimator tool awareness, two years post-CMS mandate, with specific demographics more likely to know their OOPC. Our findings emphasize the urgency for targeted interventions to increase price awareness and enhance healthcare decision-making.

What Is the Incidence of and Outcomes After Debridement, Antibiotics, and Implant Retention (DAIR) for the Treatment of Periprosthetic Joint Infections in the AJRR Population?

Debridement, antibiotics, and implant retention (DAIR) is used to manage acute periprosthetic joint infections (PJIs) after total joint arthroplasty (TJA). Given the uncertain success of single or multiple DAIR attempts and possible long-term deleterious effects this treatment can create when trying to treat persistent infection, it is important to understand the frequency with which surgeons in the United States are attempting multiple debridements for PJI and whether those procedures are achieving the desired goal. In the context of the American Joint Replacement Registry (AJRR), we asked: (1) What proportion of patients who undergo DAIR have only one DAIR, and what percentage of those patients have more than one? (2) Of the patients who undergo one or more DAIR procedures, what is the proportion who progress to additional surgical procedures? (3) What is the cumulative incidence of medical or surgical endpoints related to infection on the affected leg (other than additional DAIR procedures)? DAIR procedures to treat PJI, defined by ICD-9/10 and CPT (Current Procedural Technology) codes, reported to the AJRR from 2012 to 2020 were merged with Centers for Medicare and Medicaid Services (CMS) data from 2012 to 2020 to determine the incidence of patients aged 65 and older who underwent additional PJI-related procedures on the same joint. Linking to CMS ensures no loss to follow-up or patient migration to a non-AJRR site. As of 2021, the AJRR captures roughly 35% of all arthroplasty procedures performed in the United States. Of the total 2.2 million procedures in the AJRR, only 0.2% of the procedures were eligible based on our inclusion criteria. Additionally, 61% of the total population is Medicare eligible, and thus, these patients are linked to CMS. Of the 5029 DAIR attempts after a TKA, 46% (2318) were performed in female patients. Similarly, there were a total of 798 DAIR attempts after a THA, and 50% (398) were performed in female patients. For the purposes of decreasing confounding factors, bilateral THAs and TKAs were excluded from the study population. When querying for eligible procedures from 2012 to 2020, the patient population was limited to those 65 years and older, and a subsequent reoperation for infection had to be reported after a primary TJA. This limited the patient population as most infections reported to AJRR resulted in a revision, and we were searching for DAIRs. Although 5827 TJAs were identified as a primary TJA with a subsequent infectious event, more than 65% (3788) of that population did not have a reported event. The following conditions were queried as secondary outcomes after the first DAIR: sepsis, cellulitis, postoperative infection, endocarditis, amputation, knee fusion, resection, drainage, arthrotomy, and debridement. To answer our first and second study questions, we used frequency testing from the available AJRR data. Because of competing risks and issues with incomplete data, we used the cumulative incidence function to evaluate the outcomes specific to study question 3. Of the patients who underwent DAIR, 93% (5406 of 5827) had one DAIR and 8% (421 of 5827) had more than one. Among the DAIR population, at least 35% of TKAs and 38% of THAs were identified as having experienced an additional PJI-related event (an additional surgical procedure on the same joint, sustained an infectious endpoint in the linked CMS-AJRR dataset, or they had died). The cumulative incidence of developing a further medical or surgical condition related to the joint that had the initial DAIR were as follows: 48% (95% CI 42% to 54%) at 8 years after a DAIR following a TKA and 42% (95% CI 37% to 46%) at 4 years after a DAIR following a THA. The timepoints for TKA and THA are different because there are more longitudinal procedure data available for TKAs regarding DAIR procedures than for THAs. In this study, we used data from the AJRR to assess the incidences of single and multiple DAIR attempts and additional surgical- and infection-related sequalae. Continued investigation is required to determine the fate of infected joints that undergo DAIR with regard to ultimate patient outcome. Future cross-sectional studies using large datasets are necessary to assess functional outcomes and determine the risk of persistent infection after DAIR more precisely. Level III, therapeutic study.