Claims-based Outcomes Research Articles

Comparison of Class-Specific Side Effects Across Preventative Pharmacologic Therapies for Kidney Stone Disease.

Clinical guidelines recommend monitoring for metabolic derangements while on preventive pharmacologic therapy for kidney stone disease. The study objective was to compare the frequency of side effects among patients receiving alkali citrate, thiazides, and allopurinol. Using claims data from working-age adults with kidney stone disease (2008-2019), we identified those with a new prescription for alkali citrate, thiazide, or allopurinol within 12 months after their index stone-related diagnosis or procedure. We fit multivariable logistic regression models, adjusting for cohort characteristics like comorbid illness and medication adherence, to estimate 2-year measured frequencies of claims-based outcomes of acute kidney injury, falls/hip fracture, gastritis, abnormal liver function tests/hepatitis, hypercalcemia, hyperglycemia/diabetes, hyperkalemia, hypokalemia, hyponatremia, and hypotension. Our cohort consisted of 1776 (34%), 2767 (53%), and 677 (13%) patients prescribed alkali citrate, thiazides, or allopurinol, respectively. Comparing unadjusted rates of incident diagnoses, thiazides compared to alkali citrate and allopurinol were associated with the highest rates of hypercalcemia (2.3% vs 1.5% and 1.0%, respectively, P = .04), hypokalemia (6% vs 3% and 2%, respectively, P < .01), and hyperglycemia/diabetes (17% vs 11% and 16%, respectively, P < .01). No other differences with the other outcomes were significant. In adjusted analyses, compared to alkali citrate, thiazides were associated with a higher odds of hypokalemia (OR=2.01, 95% CI 1.44-2.81) and hyperglycemia/diabetes (OR=1.52, 95% CI 1.26-1.83), while allopurinol was associated with a higher odds of hyperglycemia/diabetes (OR=1.34, 95% CI 1.02-1.75). These data provide evidence to support clinical guidelines that recommend periodic serum testing to assess for adverse effects from preventive pharmacologic therapy.

Associations of sex, Alzheimer's disease and related dementias, and days alive and at home among older Medicare beneficiaries recovering from hip fracture.

Males constitute 25% of older adults who experience hip fractures in the United States; a concerning upward trend given poorer health and outcomes among male survivors. Male sex is associated with worse cognitive performance after hip fracture, impacting participation in rehabilitation and long-term outcomes especially for those with Alzheimer's disease or related dementias (ADRD). However, little research has evaluated whether sex differences in post-fracture recovery are greater among those living with ADRD. Data were drawn from 2010 to 2017 Medicare fee-for-service beneficiaries aged 65 years and older who survived hospitalization for hip fracture (n = 69,581). The primary outcome was days alive and at home (DAAH), a validated patient-centered claims-based outcome calculated as 365 days from fracture minus days in hospital, nursing home, rehabilitation facility, emergency department, or time after death. Multivariable Poisson regressions with an interaction term between sex and ADRD status were to model the association between DAAH and ADRD in the 12 months post hip fracture, adjusting for demographics, injury severity, chronic disease burden, and hospital-level fixed effects. Compared to females, males were younger and had more comorbidities at the time of fracture. Among survivors, males with ADRD spent a mean of 160.7 DAAH compared to 228.4 for males without ADRD, 177.8 for females with ADRD, and 248.0 for females without ADRD. In adjusted analyses, males without ADRD spent 8.2% fewer DAAH compared to females (rate ratio [RR] = 0.92, 95% CI 0.92-0.92). This relative sex difference increased significantly when comparing those living with ADRD, with males spending an additional 3.3% fewer DAAH (interaction RR = 0.96, 95% CI 0.96-0.97). Males spend fewer DAAH after hip fracture than females, and this difference increases modestly for males living with ADRD compared to females. This suggests that cognitive impairment may be a small but significant contributor to sex-based differences observed during hip fracture recovery.

State- and County-Level Geographic Variation in Opioid Use Disorder, Medication Treatment, and Opioid-Related Overdose Among Medicaid Enrollees

The opioid crisis disproportionately affects Medicaid enrollees, yet little systematic evidence exists regarding how prevalence of and health care utilization for opioid use disorder (OUD) vary across geographical areas. To characterize state- and county-level variation in claims-based prevalence of OUD and rates of medication treatment for OUD and OUD-related nonfatal overdose among Medicaid enrollees. This cross-sectional study used data from the Transformed Medicaid Statistical Information System Analytic Files from January 1, 2016, to December 31, 2018. Participants were Medicaid enrollees with or without OUD in 46 states; Washington, DC; and Puerto Rico who were aged 18 to 64 years and not dually enrolled in Medicare. The analysis was conducted between September 2022 and April 2023. Calendar-year OUD prevalence. The main outcomes were claims-based measures of OUD prevalence and rates of medication treatment for OUD and opioid-related nonfatal overdose. Individual records were aggregated at the state and county level, and variation was assessed within and across states. Of the 76 390 817 Medicaid enrollee-year observations included in our study (mean [SD] enrollee age, 36.5 [1.6] years; 59.0% female), 2 280 272 (3.0%) had a claims-based OUD (mean [SD] age, 38.9 [3.6] years; 51.4% female). Of enrollees with OUD, 41.2% were eligible due to Medicaid expansion, 46.4% had other substance use disorders, 55.8% had mental health conditions, 55.2% had claims indicating some form of OUD medication, and 5.8% had claims indicating an overdose during a calendar year. Claims-based outcomes exhibited substantial variation across states: OUD prevalence ranged from 0.6% in Arkansas and Puerto Rico to 9.7% in Maryland, rates of OUD medication treatment ranged from 17.7% in Kansas to 82.8% in Maine, and rates of overdose ranged from 0.3% in Mississippi to 10.5% in Illinois. Pronounced variation was also found within states (eg, OUD prevalence in Maryland ranged from 2.2% in Prince George's County to 21.6% in Cecil County). In this cross-sectional study of Medicaid enrollees from 2016 to 2018, claims-based prevalence of OUD and rates of OUD medication treatment and opioid-related overdose varied substantially across and within states. Further research appears to be needed to identify important factors influencing this variation.

Esketamine nasal spray for major depressive disorder with acute suicidal ideation or behavior: description of treatment access, utilization, and claims-based outcomes in the United States

AimsTo describe real-world esketamine nasal spray access and use as well as healthcare resource use (HRU) and costs among adults with evidence of major depressive disorder (MDD) with suicidal ideation or behavior (MDSI).MethodsAdults with ≥1 claim for esketamine nasal spray and evidence of MDSI 12 months before/on the date of esketamine initiation (index date) were selected from Clarivate’s Real World Data product (01/2016–03/2021). Patients initiated esketamine on/after 03/05/2019 (esketamine approval for treatment-resistant depression; later approved for MDSI on 08/05/2020) were included in the overall cohort. Esketamine access (measured as approved/abandoned/rejected claims) and use were described post-index; HRU and healthcare costs (2021 USD) were described over 6 months pre- and post-index.ResultsAmong 269 patients in the overall cohort with esketamine pharmacy claims, 46.8% had the first pharmacy claim approved, 38.7% had it rejected, and 14.5% abandoned their claim; 169 patients were initiated on esketamine in the overall cohort (mean age 40.9 years, 62.1% female); 45.0% had ≥8 esketamine treatment sessions (recommended per label) with a mean [median] of 85.0 [58.5] days from index to 8th session (per label 28 days). Among 115 patients with ≥6 months of data post-index, in the 6-month pre- and post-index, respectively, 37.4 and 19.1% had all-cause inpatient admissions, 42.6 and 33.9% had emergency department visits, 92.2 and 81.7% had outpatient visits; mean ± standard deviation all-cause monthly total healthcare costs were $8,371±$15,792 and $6,486±$7,614, respectively.LimitationsThis was a descriptive claims-based analysis; no formal statistical comparisons were performed due to limited sample size as data covered up to 24 months of esketamine use in the US clinical setting.ConclusionsNearly half of patients experience access issues with first esketamine nasal spray treatment session. All-cause HRU and healthcare costs trend lower in the 6 months after relative to 6 months before esketamine initiation.

Paying for Nursing Home Quality: An Elusive But Important Goal.

Paying for Nursing Home Quality: An Elusive But Important Goal.

IMPROVING DEMENTIA CARE THROUGH DIGITAL CAREGIVER EMPOWERMENT: DURABLE CLAIMS-BASED OUTCOMES DEMONSTRATED IN A PRAGMATIC REAL-WORLD TRIAL.

The Ceresti Digital Caregiver Empowerment Program (DCEP) was deployed to 164 family caregivers of Medicare Advantage patients with ADOD. The primary objective of this pragmatic trial was to demonstrate that increasing the knowledge, skills and confidence of family caregivers (e.g., spouses, adult children) via personalized education, proactive coaching and remote monitoring-delivered via an app on a dedicated tablet computer-reduces avoidable patient hospitalizations. Durability of claims-based outcomes was also studied. Caregiver engagement, caregiver satisfaction and caregiver mental health were also tracked METHODS: Patients were included in the claims analysis if their caregiver was enrolled in the DCEP for at least 45 days. Patient outcomes were compared to outcomes from a 3:1 propensity matched comparison group, post-index, from the DCEP start date to the end of claims. Comparison group members were matched to enrollees on demographics, pre-index utilization and costs, and other factors, including the patient's frailty index. The first 30-days post-index were deemed a "transition" period. The impact of the DCEP was determined by comparing the 6-month pre-index averages to outcomes from the 30-day post-index period using the "difference-in-differences" approach (Figure 1). The index date for program enrollees was their DCEP start date. For matched comparison group patients, the index date was the program start date of the enrollee to whom the comparison group member is matched. The DCEP was personalized for each caregiver/patient dyad using predictive models applied to claims data. Table 1 summarizes statistically significant (p-values < 0.05) monthly reductions in utilization and costs for patients enrolled > 45 days, and enrolled high utilizers enrolled > 45 days (PMPM = per member/patient per month). High utilizers are patients with at least one hospitalization or two ED visits in the prior 24 months. Results were durable through 9 months post-index (Figure 3). Empowering family caregivers of patients with ADOD in a personalized DCEP provides durable reductions in patient hospitalizations and medical costs.

Design, test, validate: development of a novel & robust analytic framework and econometric model using administrative claims data.

As health care expenditures continue to rise, policy makers and payers are assessing whether the cost of virtual care programs are justified by their outcomes. Ceresti has developed a novel, robust analytic approach and econometric model to assess the efficacy and overall value of virtual care programs. The methodology uses an administrative claims-based, analytic and statistical framework that accurately identifies and measures reduction in costs and services (including potential savings from avoiding other costly downstream events) attributable to deployed virtual care programs. The analytic framework and econometric model were developed for and validated in a pragmatic trial in a Medicare-aged population. A total of 164 subjects were enrolled in the trial sponsored by a leading Medicare Advantage plan and Ceresti Health. The pragmatic trial compared changes in patient outcomes between program enrollees (DCEP "Care Recipients") and a matched comparison group using a "difference-in-differences" approach. General Matching criteria included: Age Gender Geographic region Aligned index dates between Care Recipients and the comparison group During the 6 month pre-index period matching criteria included: Charlson Comorbidity Index number of condition-specific medical claims presence of a skilled nursing facility claim emergency department (ED) visits and costs inpatient hospital admissions and costs costs for nursing or assisted living, office visits and other outpatient services Costs and service utilization of Care Recipients and the matched comparator group were extracted from an administrative claims database. Total medical and inpatient costs were captured during the pre- and post-index periods for the active and comparator arms. The frequency of ED visits, inpatient admissions, and 30-day readmissions were calculated per patient per month. The change in costs and visit frequency that Care Recipients incurred > 30 days post-index to the end of the study was compared to the change experienced by the matched comparator controls. The analytic model detected statistically significant pre-, post-efficacy across health-related and economic outcomes. The analytic and statistical framework validated in this trial overcomes the challenge of attributing claims-based outcomes to virtual care interventions, and contribute to the methods available to accurately measure the value of virtual care programs in Medicare-aged populations.

Comparing Public Quality Ratings for Joint Commission Accredited and Non-Joint Commission Accredited Home Health Agencies: A Replication Study

This was a descriptive replication study comparing 2083 home health agencies accredited by The Joint Commission (TJC) and 8695 non-TJC-accredited home health agencies over a 3-year period using the Centers for Medicare and Medicaid Services Home Health Compare data set. Metrics included the star ratings and 17 quality measures. A longitudinal model was used to determine differences between TJC-accredited and non-TJC-accredited organizations on the quality measures. Categorical differences in star ratings were analyzed using a Cochran-Mantel-Haenszel test. TJC-accredited home health agencies had better average ratings than non-TJC-accredited home health agencies for each of the 3 years (3.4 vs 3.2, p &lt; .001). When categories were collapsed to evaluate differences, the analysis revealed that a significantly larger proportion of TJC-accredited facilities were clustered within the higher ratings (41% for TJC-accredited vs 32% for non-TJC-accredited), and fewer TJC-accredited organizations were clustered within the lower ratings (22% for TJC-accredited vs 30% for non-TJC-accredited; p &lt; .001). Two claims-based outcome measures (hospitalization and emergency room visits) were consistent with the original study in which TJC-accredited home health organizations had statistically significant lower rates across all 3 years studied, compared to non-TJC-accredited HHAs. This replication study validates and extends the generalizability of the findings from the original study.

Real-World and Clinical Trial Data in Relapsed/Refractory Multiple Myeloma (RRMM): Evaluating Treatment Duration and Comparing Effectiveness and Efficacy

Real-World and Clinical Trial Data in Relapsed/Refractory Multiple Myeloma (RRMM): Evaluating Treatment Duration and Comparing Effectiveness and Efficacy

Uncovering the Blind Spot of Clinical Trials: First Report of Baseline Characteristics of Newly Diagnosed (ND) and Relapsed/Refractory (RR) Multiple Myeloma (MM) Patients (Pts) in Insight-MM, a Global, Prospective, Observational Study

Uncovering the Blind Spot of Clinical Trials: First Report of Baseline Characteristics of Newly Diagnosed (ND) and Relapsed/Refractory (RR) Multiple Myeloma (MM) Patients (Pts) in Insight-MM, a Global, Prospective, Observational Study

Novel Claims-Based Outcome Phenotypes in Survivors of Pediatric Traumatic Brain Injury.

For children hospitalized with acute traumatic brain injury (TBI), to use postdischarge insurance claims to identify: (1) healthcare utilization patterns representative of functional outcome phenotypes and (2) patient and hospitalization characteristics that predict outcome phenotype. Two pediatric trauma centers and a state-level insurance claim aggregator. A total of 289 children, who survived a hospitalization after TBI between 2009 and 2014, were in the hospital trauma registry, and had postdischarge insurance eligibility. Retrospective cohort study. Unsupervised machine learning to identify phenotypes based on postdischarge insurance claims. Regression analyses to identify predictors of phenotype. Median age 5 years (interquartile range 2-12), 29% (84/289) female. TBI severity: 30% severe, 14% moderate, and 60% mild. We identified 4 functional outcome phenotypes. Phenotypes 3 and 4 were the highest utilizers of resources. Morbidity burden was highest during the first 4 postdischarge months and subsequently decreased in all domains except respiratory. Severity and mechanism of injury, intracranial pressure monitor placement, seizures, and hospital and intensive care unit lengths of stay were phenotype predictors. Unsupervised machine learning identified postdischarge phenotypes at high risk for morbidities. Most phenotype predictors are available early in the hospitalization and can be used for prognostic enrichment of clinical trials targeting mitigation or treatment of domain-specific morbidities.

A best-worst scaling experiment to identify patient-centered claims-based outcomes for evaluation of pediatric antipsychotic monitoring programs.

ObjectiveThis article employs a best‐worst scaling (BWS) experiment to identify the claims‐based outcomes that matter most to patients and other relevant parties when evaluating pediatric antipsychotic monitoring programs in the United States.Data SourcesPatients and relevant parties, with pediatric antipsychotic oversight and treatment experience, completed a BWS experiment, including policymakers (n = 31), foster care alumni (n = 28), caseworkers (n = 23), prescribing clinicians (n = 32), and caregivers (n = 18).Study DesignRespondents received surveys with a scenario on antipsychotic monitoring programs and ranked 11 candidate claims‐based outcomes as most and least important for program evaluation.Data AnalysisStratified by respondent group, best‐worst scores were calculated to identify the relative importance of the claims‐based outcomes. A conditional logit examined whether candidate outcomes for safety, quality, and unintended consequences were preferred over reduction in antipsychotic treatment, the outcome used most often to evaluate antipsychotic monitoring programs.Principal FindingsSafety indicators (eg, antipsychotic co‐pharmacy, cross‐class polypharmacy, higher than recommended doses) ranked among the top three candidate outcomes across respondent groups and were an important complement to antipsychotic treatment reduction. Foster care alumni prioritized “antipsychotic treatment reduction” and “increased psychosocial treatment.” Caseworkers, prescribers, and caregivers prioritized “increased follow‐up after treatment initiation.” Potential unintended consequences of an antipsychotic monitoring program ranked lowest, including increased use of other psychotropic medication classes (as a substitute), increased psychiatric hospital stays, and increased emergency room utilization. Results of the conditional logit model found only caregivers significantly preferred other indicators over antipsychotic treatment reduction, preferring improvements in follow‐up care (5.78) and psychosocial treatment (4.53) and reduction in prescriptions of higher than recommended doses (3.64).ConclusionsThe BWS experiment supported rank ordering of candidate claims‐based outcomes demonstrating the opportunity for future studies to align outcomes used in antipsychotic monitoring program evaluations with community preferences, specifically by diversifying metrics to include safety and quality indicators.

Use of Administrative Claims to Assess Outcomes and Treatment Effect in Randomized Clinical Trials for Transcatheter Aortic Valve Replacement

Background: Whether passively collected data can substitute for adjudicated outcomes to reproduce the magnitude and direction of treatment effect observed in cardiovascular clinical trials is not well known. Methods: We linked adults ≥65 years of age in the HiR (US CoreValve Pivotal High Risk) and SURTAVI trials (Surgical or Transcatheter Aortic Valve Replacement in Intermediate-Risk Patients) to 100% Medicare inpatient claims, January 1, 2011, to December 31, 2016. Primary (eg, death and stroke) and secondary trial end points were compared across treatment arms (eg, transcatheter aortic valve replacement [TAVR] versus surgical aortic valve replacement [SAVR]) using trial-adjudicated outcomes versus outcomes derived from claims at 1 year (HiR) or 2 years (SURTAVI). Results: Among 600 linked HiR participants (linkage rate, 80.0%), the rate of the trial’s primary end point of all-cause mortality occurred in 13.7% of patients receiving TAVR and 16.4% of patients receiving SAVR at 1 year by using both trial data (hazard ratio, 0.84 [95% CI, 0.65–1.09]; P =0.33) and claims data (hazard ratio, 0.86 [95% CI, 0.66–1.11]; P =0.34; interaction P value=0.80). Noninferiority of TAVR relative to SAVR was seen by using both trial- and claims-based outcomes ( P noninferiority &lt;0.001 for both). Among 1005 linked SURTAVI trial participants (linkage rate, 60.5%), the trial’s primary end point was 12.9% for TAVR and 13.1% for SAVR using trial data (hazard ratio, 1.08 [95% CI, 0.79–1.48]; P =0.90), and 11.3% for TAVR and 12.5% for SAVR patients using claims data (hazard ratio, 1.02 [95% CI, 0.73–1.41]; P =0.58; interaction P value=0.89). TAVR was noninferior to SAVR when compared using both trial and claims ( P non inferiority &lt;0.001 for both). Rates of procedural secondary outcomes (eg, aortic valve reintervention, pacemaker rates) were more closely concordant between trial and claims data than nonprocedural outcomes (eg, stroke, bleeding, cardiogenic shock). Conclusions: In the HiR and SURTAVI trials, ascertainment of trial primary end points using claims reproduced both the magnitude and direction of treatment effect in comparison with adjudicated event data, but nonfatal and nonprocedural secondary outcomes were not as well reproduced. Use of claims to substitute for adjudicated outcomes in traditional trial treatment comparisons may be valid and feasible for all-cause mortality and certain procedural outcomes but may be less suitable for other end points.

The effects of CenteringPregnancy group prenatal care on postpartum visit attendance and contraception use

ObjectiveWe examined whether Medicaid-enrolled women in CenteringPregnancy group prenatal care had higher rates of (1) postpartum visit attendance and (2) postpartum uptake of contraceptives, compared to women in individual prenatal care. Study designWe linked birth certificates and Medicaid claims for women receiving group prenatal care in 18 healthcare practices and applied preferential-within cluster propensity score methods to identify a comparison group, accounting for the nested data structure by practice. We examined five standardized, claims-based outcomes: postpartum visit attendance; contraception within 3 days; and any contraception, long-acting reversible contraception (LARC), and permanent contraception within eight weeks. We assessed outcomes using logistic regression for two treatment levels: (1) any group attendance compared to no group attendance and (2) attendance at five or more group sessions to at least five prenatal care visits, including crossovers attending fewer than five group sessions (minimum threshold analysis). ResultsWomen attending at least five group sessions had higher rates of postpartum visit attendance (71.5% vs. 67.5%, p < .05). Women with any group attendance (N = 2834) were more likely than women with individual care only (N = 13,088) to receive contraception within 3 days (19.8% vs. 16.9%, p < .001) and to receive a LARC within eight weeks’ postpartum (18.0% vs. 15.2%, p < .001). At both treatment levels, group participants were less likely to elect permanent contraception (5.9% vs. 7.8%, p < 0.001). Women meeting the five-visit group threshold were not more likely to initiate contraception or LARCs within 8 weeks’ postpartum. ConclusionParticipation in at least five group compared to five individual prenatal care visits is associated with greater rates of postpartum visit attendance. Additional engagement and education in group prenatal care may influence postpartum visit attendance. ImplicationsPlanning for postpartum care and contraception during prenatal care is an important strategy for connecting women to postpartum healthcare. Regardless of prenatal care model, women have low uptake of contraception in the postpartum period. Increased use of group prenatal care with its scheduled family planning discussion may help to increase postpartum contraceptive uptake. This benefit is dependent on availability of postpartum contraception options.

Abstract TP307: Validation of a Machine Learning Approach to Determine Stroke Severity of Patients Diagnosed With Stroke in Claims Data

Introduction: The National Institutes of Health Stroke Scale (NIHSS) scores are often not readily available in structured claims databases. We have previously demonstrated that a machine learning model can be used to determine proxies for NIHSS scores. Our current work focuses on creating a model applicable across different databases to validate our approach and enable further outcome studies. Methods: We identified 1,415 eligible hospital-admitted patients in the Optum® de-identified Integrated Claims-EMR database who were diagnosed with ischemic or hemorrhagic stroke, or a transient ischemic attack and had NIHSS scores in medical notes. These patients were split into a training (N=1,192) set for model development and a hold-out test (N=223) set to evaluate model performance. Furthermore, model performance was externally validated using the 286 eligible stroke patients in IBM’s Claims-EMR database (CED). Potential predictors for stroke severity included relevant procedures, diagnoses, patient demographics, and information about the patient hospital stay. Results: The optimal model, a random forest model, achieved a coefficient of determination (R 2 ) between the actual and predicted NIHSS scores in the hold-out Optum dataset of 0.48 and of 0.42 in the secondary CED dataset. The final model incorporated a total of 47 predictors. The strongest predictors included transient ischemic attack diagnosis, length of hospital stay, critical care procedures, patient age, and hemiplegia diagnosis. Conclusion: This study shows that machine learning can be used to determine proxies for NIHSS scores across different real-world databases. Ultimately, this will enable large claims-based outcome studies involving stroke severity to improve our understanding of how stroke severity affects healthcare utilization, total cost of care, and the financial impact on the larger community.

Use of Medicare Claims to Identify Adverse Clinical Outcomes After Mitral Valve Repair.

Clinical event committees are commonly employed for event validation in clinical studies, but little is known about the comparative performance of administrative claims data versus clinician-triggered event adjudication for ascertainment of adverse events in structural heart disease studies. Medicare claims were linked to 418 patients >65 years of age who underwent transcatheter mitral valve repair (MitraClip) for severe mitral regurgitation from 2007 to 2013 as part of the EVEREST II (Endovascular Valve Edge-to-Edge Repair Study II) High-Risk Registry or the REALISM (Real World Expanded Multicenter Study of the MitraClip System) Continued-Access Registry. Each registry adjudicated mortality, heart failure hospitalization, renal failure, ventilation, and bleeding/transfusion within 1 year. Concordance of claims-based outcomes with events was assessed in 3 ways: 1-year occurrence, cumulative incidence, and synchrony of first events. For event occurrence, positive predictive value (PPV) of claims versus adjudication was the highest for mortality (PPV=97%) and heart failure hospitalization (PPV=69%) but lower for bleeding (PPV=40%) and renal failure (PPV=19%). Whereas claims-based cumulative incidence for mortality, heart failure hospitalization, and renal failure were consistent with clinician-triggered adjudication, incidence curves for bleeding events and ventilation diverged, with claims identifying a greater number of events. When events were detected by both methods, however, over 75% of event dates matched exactly. Mitral valve reinterventions were identified through claims with perfect sensitivity and specificity relative to physician adjudication. Ascertainment of mortality, heart failure hospitalization, and renal failure was highly concordant between physician adjudication and administrative claims. Further work is necessary to determine the role of administrative claims in event ascertainment in both prospective and retrospective studies of structural heart disease.

Community-based wellness and prevention programs: the role of medicare.

Community-based wellness and prevention programs: the role of medicare.

Classification accuracy of claims-based methods for identifying providers failing to meet performance targets.

Quality assessment is critical for healthcare reform, but data sources are lacking for measurement of many important healthcare outcomes. With over 49 million people covered by Medicare as of 2010, Medicare claims data offer a potentially valuable source that could be used in targeted health care quality improvement efforts. However, little is known about the operating characteristics of provider profiling methods using claims-based outcome measures that may estimate provider performance with error. Motivated by the example of screening mammography performance, we compared approaches to identifying providers failing to meet guideline targets using Medicare claims data. We used data from the Breast Cancer Surveillance Consortium and linked Medicare claims to compare claims-based and clinical estimates of cancer detection rate. We then demonstrated the performance of claim-based estimates across a broad range of operating characteristics using simulation studies. We found that identification of poor performing providers was extremely sensitive to algorithm specificity, with no approach identifying more than 65% of poor performing providers when claims-based measures had specificity of 0.995 or less. We conclude that claims have the potential to contribute important information on healthcare outcomes to quality improvement efforts. However, to achieve this potential, development of highly accurate claims-based outcome measures should remain a priority.

Impact of maintenance therapy on hospitalization and expenditures for medicare beneficiaries with chronic obstructive pulmonary disease

Background: Chronic obstructive pulmonary disease (COPD) is associated with high levels of hospitalization and health care expenditures among the aged. Adherence to appropriate maintenance drug regimens has been reported to reduce hospitalization and health care spending in clinical trials. However, little research has been conducted to compare use versus nonuse of these medications in terms of health-related outcomes in routine practice. Objective: The purpose of this study was to compare differences between users and nonusers of maintenance medications in terms of selected outcomes for a nationally representative sample of Medicare beneficiaries with COPD. Methods: The study sample was selected from Medicare Current Beneficiary Surveys conducted between 1997 and 2005. Beneficiaries with COPD who used ≥1 maintenance medication annually were compared with nonusers on 3 claims-based outcomes: any hospitalization, any rehospitalization within 31 days, and total annual Medicare expenditures. Results: The study sample consisted of 6322 Medicare beneficiaries who contributed a total of 9161 person-year observations for analysis. Over the 9-year study period, 39.9% (3659/9161) of the person-year observations were recorded for maintenance medication users, and 60.1% (5502/9161) were recorded for nonusers. Most of the observations for medication users involved beneficiaries who were female (50.1% [1833/3659]), non-Hispanic white (85.4% [3124/3659]), and ≥65 years of age (88.2% [3228/3659]); most of the observations for nonusers involved beneficiaries who were male (51.9% [2855/5502]), non-Hispanic white (82.7% [4550/5502]), and ≥65 years of age (88.1% [4848/5502]). Annually, 40% of the sample filled prescriptions for COPD maintenance medications. In multivariate models, maintenance drug users were less likely than nonusers to be hospitalized (odds ratio [OR] = 0.70; 95% CI, 0.61 to 0.79) or rehospitalized (OR= 0.74; 95% CI, 0.63 to 0.87), and had significantly lower annual Medicare expenditures (−$3916; 95% CI, −$4977 to −$2854). Conclusions: In this comparison of users and nonusers of maintenance medication for COPD, use of maintenance therapy was associated with significantly lower risks of hospitalization and rehospitalization and reduced Medicare expenditures.

Incidence of neuropsychiatric adverse events in influenza patients treated with oseltamivir or no antiviral treatment

The association between neuropsychiatric events and antiviral treatments for influenza has been under scrutiny. In this study, the incidence of neuropsychiatric events in influenza patients dispensed oseltamivir or no antiviral was assessed using a large US medical claims database. Propensity score balanced cohorts from a prior study of influenza patients with and without oseltamivir exposure were expanded and reanalysed in this retrospective study. Patients > or = 1 year with an influenza diagnosis [International Classification of Disease, 9th revision (ICD-9) 487.XX] during the study period (1 November 1999 to 30 April 2005) were identified and grouped into two cohorts: those dispensed oseltamivir [n = 60,267, 60,834 incident cases (ICs)] and those dispensed no-antiviral (n = 175,933, 183,786 ICs). Cohorts were stratified by age: < or = 17 years (oseltamivir, n = 20,501 ICs; no-antiviral, n = 84,871 ICs) and > or = 18 years (oseltamivir, n = 40,333 ICs; no-antiviral, n = 98,915 ICs). Medical claims in the 30 days (overall analysis) or 14 days (stratified analysis) after diagnosis were searched for indications of neuropsychiatric events. Claims-based outcome measures included three hierarchical neuropsychiatric categories: one broad, one restrictive (excluding particular disorders/conditions) and one limited to central nervous system (CNS)-specific disorders. In the overall analysis, no increase in the incidence of claims-based neuropsychiatric events was detected in the patients dispensed oseltamivir vs. those dispensed no antiviral. Claims-based neuropsychiatric events were also reported with a similar frequency in patients < or = 17 years and > or = 18 years who did and did not receive antivirals. In this retrospective cohort study, no increase in claims-based neuropsychiatric events was detected in influenza patients who were and were not exposed to oseltamivir.