Hospital Referral Region Level Research Articles

Geographic Variation in Access to Cardiac Rehabilitation

BackgroundThere is marked geographic variation in cardiac rehabilitation (CR) initiation, ranging from 10% to 40% of eligible patients at the state level. The potential causes of this variation, such as patient access to CR centers, are not well studied. ObjectivesThe authors sought to determine how access to CR centers affects CR initiation in Medicare beneficiaries. MethodsThe authors used Medicare files to identify CR-eligible Medicare beneficiaries and calculate CR initiation rates at the hospital referral region (HRR) level. We used linear regression to evaluate the percent variation in CR initiation accounted for by CR access across HRRs. We then employed geospatial hotspot analysis to identify CR deserts, or counties in which patient load per CR center is disproportionately high. ResultsA total of 1,133,657 Medicare beneficiaries were eligible for CR from 2014 to 2017, of whom 263,310 (23%) initiated CR. The West North Central Census Division had the highest adjusted CR initiation rate (35.4%) and the highest density of CR programs (6.58 per 1,000 CR-eligible Medicare beneficiaries). Density of CR programs accounted for 21.2% of geographic variation in CR initiation at the HRR level. A total of 40 largely urban counties comprising 14% of the United States population age ≥65 years had disproportionately low CR access and were identified as CR deserts. ConclusionsA substantial proportion of geographic variation in CR initiation was related to access to CR programs, with a significant amount of the U.S. population living in CR deserts. These data invite further study on interventions to increase CR access.

Growth in health information exchange with ACO market penetration.

First, to assess whether hospitals expand the network breadth of their health information exchange (HIE) partners after joining an accountable care organization (ACO). Second, to analyze whether this HIE network expansion effect varies across markets with differing levels of ACO penetration. Difference-in-differences analyses of US nonfederal acute care hospitals, 2014-2017. We used data from the American Hospital Association Annual Survey and Information Technology Supplement to measure hospital ACO participation, HIE network breadth (defined as number of different partner types), and ACO market penetration at the hospital referral region level. We implemented a difference-in-differences model to estimate changes in hospitals' HIE network breadth with ACO participation in different years. We estimate these effects combined across all markets and stratified by markets with high and low ACO market penetration. In combined analyses, HIE breadth increased by 0.35 partner types with ACO participation, a 30.7% increase (P < .001). In stratified analyses, this effect was larger for hospitals in high-ACO penetration markets (0.41 partner types, a 32.0% increase; P < .001) and smaller for hospitals in low-ACO penetration markets (0.25 partner types, a 24.8% increase; P < .05). We found dynamic effects of ACO adoption illustrating an immediate effect in high-ACO penetration markets and a 2-year delayed effect in low-ACO penetrationmarkets. Hospitals that joined ACOs increased their HIE breadth, but this effect was heterogenous across markets and across time. Our findings illustrate a "network effect," with large, immediate effects in HIE breadth following ACO participation in high-ACO penetration markets and smaller, delayed effects in low-ACO penetrationmarkets.

Association Between Radiation Oncologist Density and Medicare Spending

The accessibility of radiation oncology services impacts the likelihood of radiation therapy receipt during cancer care. The density of radiation oncologists (ROs) varies nationally, impacting the geographic access to radiation therapy. We aimed to assess the relationship between RO density and Medicare spending to better evaluate this impact of this relationship.We used the Physician and Other Supplier Public Use File from the Centers for Medicare & Medicaid Services to ascertain the total Medicare reimbursements to each provider marked as a "Radiation Oncologist" for the year 2017. We then placed each radiation oncologist within a Hospital Referral Region (HRR), designed by the Dartmouth Atlas to represent regional healthcare markets for tertiary medical care, using a publicly available zip code-to-HRR crosswalk from the Dartmouth Atlas. We summed the total Medicare reimbursements to ROs in each HRR and compared this to the total Medicare reimbursements (part A+B) in each HRR for the year 2017, as reported by the Dartmouth Atlas group. After winsorization of the top and bottom 2% of HRRs by RO density, linear regression was used to evaluate the relationship between RO density and percentage of Medicare expenditure on RO. Modeling without a constant was used as in an HRR without an RO, there can be no RO services billed.We identified 4,533 ROs in the United States that received a total of $1.38 billion in Medicare reimbursements in 2017. This represented 0.5% of total Medicare reimbursements in 2017. There were 17.0 ROs per 100,000 Medicare enrollees in the US in 2017. On an HRR level, there was an average of 15.4 ROs per 100,000 Medicare enrollees (range 0 - 139.4, standard deviation 10.6). On linear regression, there was a positive relationship between the percentage of Medicare spending on RO and the number of ROs per 100,000 Medicare enrollees: for every additional RO per 100,000 Medicare enrollees, an additional 0.027% (95% CI = 0.025% - 0.030%; P < 0.001) of Medicare expenditures in a given HRR were spent on RO.Using density of RO by HRR as a proxy for access to care, this analysis suggests that with increasing access to care, an increasing proportion of Medicare dollars are spent on RO services at the HRR level.

Adoption of New Risk Stratification Technologies Within US Hospital Referral Regions and Association With Prostate Cancer Management

The clinical decisions that arise from prostate magnetic resonance imaging (MRI) and genomic testing in patients with prostate cancer are not well understood. To evaluate the association between regional uptake of prostate MRI and genomic testing and observation vs treatment for prostate cancer. This retrospective cohort study of commercial insurance claims for prostate MRI and genomic testing included 65 530 patients 40 to 89 years of age newly diagnosed with prostate cancer from July 1, 2012, through June 30, 2019. Patient- and regional-level use of prostate MRI and genomic testing. Observation vs definitive treatment for prostate cancer. Patient-level analyses examined the association between receipt of testing or residing in a hospital referral region (HRR) that adopted testing and observation. In regional-level analyses, the dependent variable was the change in the proportion of patients observed for prostate cancer at the HRR level between 2 periods: July 1, 2012, to June 30, 2014, and July 1, 2017, to June 20, 2019. The independent study variables included HRR-level changes in the proportion of men undergoing prostate MRI and genomic testing between these periods, and the models were adjusted for contextual factors associated with prostate cancer care and socioeconomic status. This study identified 65 530 patients, including 27 679 in the early period (mean [SD] age, 58.0 [5.9] years) and 37 851 in the late period (mean [SD] age, 59.0 [5.7] years). Use of prostate MRI increased significantly from 7.2% (95% CI, 6.9%-7.5%) to 16.7% (95% CI, 16.3%-17.1%) from the early to late period. Use of genomic testing increased significantly from 1.3% (95% CI, 1.1%-1.4%) to 12.7% (95% CI, 12.3%-13.0%) from the early to late period. Compared with the lowest, the highest HRR quartiles of prostate MRI and genomic testing uptake were associated with an adjusted 4.1% (SE, 1.1%; P < .001) and 2.5% (SE, 1.1%; P = .03) absolute increase in the proportion of patients receiving observation, respectively. In this cohort study, uptake of prostate MRI and genomic testing was associated with increased use of initial observation vs treatment for prostate cancer. Marked geographic variation supports the need for further patient-level research to optimize the dissemination and outcome of testing.

PD50-07 TIME TRENDS AND GEOGRAPHIC VARIABILITY IN PREOPERATIVE MRI FOR PROSTATE CANCER AND ITS ASSOCIATION WITH SURGICAL MARGIN STATUS IN THE UNITED STATES

You have accessJournal of UrologyProstate Cancer: Detection & Screening V (PD50)1 Sep 2021PD50-07 TIME TRENDS AND GEOGRAPHIC VARIABILITY IN PREOPERATIVE MRI FOR PROSTATE CANCER AND ITS ASSOCIATION WITH SURGICAL MARGIN STATUS IN THE UNITED STATES Alexander Putnam Cole, Xi Chen, Francesco Giganti, Veeru Kasivisvanathan, Logan Briggs, Khalid Alkhatib, Mark Emberton, Caroline Moore, Stuart R Lipsitz, Nancy L Keating, and Quoc-Dien Trinh Alexander Putnam ColeAlexander Putnam Cole More articles by this author , Xi ChenXi Chen More articles by this author , Francesco GigantiFrancesco Giganti More articles by this author , Veeru KasivisvanathanVeeru Kasivisvanathan More articles by this author , Logan BriggsLogan Briggs More articles by this author , Khalid AlkhatibKhalid Alkhatib More articles by this author , Mark EmbertonMark Emberton More articles by this author , Caroline MooreCaroline Moore More articles by this author , Stuart R LipsitzStuart R Lipsitz More articles by this author , Nancy L KeatingNancy L Keating More articles by this author , and Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002072.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The use of MRI for diagnosis and staging of prostate cancer has seen large increases in recent decades. While MRI benefits diagnosis, staging, and risk stratification, evidence about its impact on surgical outcomes is limited. We assessed temporal trends and geographic variability in the use of MRI before prostatectomy among a large, nationally representative cohort of older men and assessed the impact of preoperative MRI on surgical outcomes. METHODS: Using the SEER/Medicare linked dataset, we identified men aged ≥66 years with localized prostate cancer treated with radical prostatectomy from 2004-2015 in the United States. The main independent variable was receipt of an MRI within 90 days prior to surgery. Within each hospital referral region (HRR), we calculated the proportion of men receiving preoperative MRI. To decrease the effect of unmeasured confounders, a clustered two-stage instrumental variable analysis was performed using HRR-level intensity of MRI use as the instrument and surgical margin as the main outcome variable. Secondary outcomes included complications at 30 and 90 days after surgery and receipt of additional prostate-cancer directed therapies at 6 months. RESULTS: A total of 22,814 men were identified who received prostatectomy from 2004-2015 in 72 HRRs. The proportion of men receiving a pre-operative MRI increased from 2.8% in 2004 to 19.3% in 2015 and ranged from 0.0% to 67.4% across HRRs. Our instrumental variables analysis revealed a statistically significant association between HRR level intensity of preoperative MRI and lower odds of positive surgical margin (OR 0.776, 95% CI 0.623 to 0.966) but higher odds of additional prostate cancer directed treatments within six months (OR 1.262, 95% CI 1.101-1.446). CONCLUSIONS: Receipt of preoperative MRI has increased during the study period with considerable geographic variability. Receipt of preoperative MRI was associated with lower odds of positive surgical margin, but greater odds of short-term additional cancer directed therapies. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e854-e854 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander Putnam Cole More articles by this author Xi Chen More articles by this author Francesco Giganti More articles by this author Veeru Kasivisvanathan More articles by this author Logan Briggs More articles by this author Khalid Alkhatib More articles by this author Mark Emberton More articles by this author Caroline Moore More articles by this author Stuart R Lipsitz More articles by this author Nancy L Keating More articles by this author Quoc-Dien Trinh More articles by this author Expand All Advertisement Loading ...

Disparities in the Geographic Distribution of Neurosurgeons in the United States: A Geospatial Analysis

Large disparities in access to neurosurgical care are known, but there are limited data on whether geographic distribution of the neurosurgery workforce potentially plays a role in these disparities. The goal of this study was to identify the geographic distribution of neurosurgeons in the United States and to study the association of the per capita workforce distribution with socioeconomic characteristics of the population. The number of practicing neurosurgeons in the United States in 2016 was obtained from the 2017-2018 American Medical Association Masterfile contained within the Area Health Resource File. The association of the number of neurosurgeons per 100,000 population with socioeconomic characteristics was assessed through linear regression analysis at Hospital Referral Region (HRR) level. The median number of neurosurgeons per capita across all HRRs was 1.47 neurosurgeons per 100,000 population (interquartile range, 1.02-2.27). Bivariable analysis showed that greater supply of neurosurgeons was positively associated with regional levels of college education, median income, and median age. The number of neurosurgeons per capita at the HRR level was negatively associated with unemployment, poverty, and percent uninsured. Regions characterized by low socioeconomic status have fewer neurosurgeons per capita in the United States. Low income, low number of college graduates, and high unemployment rate are associated with fewer numbers of neurosurgeons per capita. Further research is needed to determine if these geographic workforce disparities contribute to poor access to quality neurosurgical care.

A cross-sectional study of trauma certification and hospital referral region diversity: A system theory approach

BackgroundThere are clear racial/ethnic disparities in the trauma care service delivery. However, no study has examined the relationships between structural determinants of trauma care designations (L-I through L-IV) or verification and social factors of the surrounding health region in the U.S. ObjectiveThis study examined the relationship between U.S. community segregation in a hospital referral region (HRR) and hospitals’ attainment of trauma certification and trauma designation L-I/II. MethodsTwo-year retrospective analysis of 2,348 acute hospitals that participated in the Hospital Value-Based Purchasing (HVBP) Program. Multivariate Poisson and 1:2 matching ratio using Propensity Score Matching regressions were used. Our primary variables were composite segregation scores for each county—aggregated to the HRR level (n=303)—and hospital performance on the HVBP Program. ResultsSegregated HRRs are 69% and 40% less likely to have an increase in the number of hospitals with trauma care designations L-I/II and trauma certification, respectively. Our matching ratio showed that hospitals with trauma certification or hospitals with trauma care designations L-I/II were more likely to be within HRRs with lower community diversity. ConclusionOur findings highlight that system disparities exist in trauma care. Research is needed to determine if other factors, such as resource allocation and reimbursement distribution, impact the availability of trauma facilities.

Barriers to hospital electronic public health reporting and implications for the COVID-19 pandemic.

We sought to identify barriers to hospital reporting of electronic surveillance data to local, state, and federal public health agencies and the impact on areas projected to be overwhelmed by the COVID-19 pandemic. Using 2018 American Hospital Association data, we identified barriers to surveillance data reporting and combined this with data on the projected impact of the COVID-19 pandemic on hospital capacity at the hospital referral region level.Our results find the most common barrier was public health agencies lacked the capacity to electronically receive data, with 41.2% of all hospitals reporting it. We also identified 31 hospital referral regions in the top quartile of projected bed capacity needed for COVID-19 patients in which over half of hospitals in the area reported that the relevant public health agency was unable to receive electronic data.Public health agencies’ inability to receive electronic data is the most prominent hospital-reported barrier to effective syndromic surveillance. This reflects the policy commitment of investing in information technology for hospitals without a concomitant investment in IT infrastructure for state and local public health agencies.

Association of 21-Gene Assay (OncotypeDX) Testing and Receipt of Chemotherapy in the Medicare Breast Cancer Patient Population Following Initial Adoption

BackgroundOur objective was to investigate why early studies regarding adoption of the 21-gene recurrence score (RS) assay did not show an initial reduction in the number of patients with breast cancer receiving real-world chemotherapy. Materials and MethodsWe addressed 2 sources of confounding suspected in previous studies: (1) the early time frame during the initial adoption phase of the RS assay, and (2) suspected selective, increased administration to patients more likely to have been chemotherapy candidates. To address selective use during initial adoption, we used updated SEER-Medicare data from 2004 and 2011. To address individual selection bias, we examined whether RS test utilization was negatively associated with rates of local chemotherapy use assessed at the hospital referral region level using conventional ordinary least squares and instrumental variable approaches to adjust for selection bias. ResultsA total of 26,009 patients met inclusion criteria. Assay use was associated with a decrease in absolute percentage use of chemotherapy of 4.5% (95% confidence interval [CI], 3.2%-5.7%), which was even more pronounced in sensitivity analyses limited to later study years (2008-2011), with a decrease of 6.8% (95% CI, 5.3%-8.3%). Instrumental variable models yielded similar point estimates but were insufficiently powered to draw conclusions. ConclusionReceipt of the 21-gene assay was associated with decreased utilization of chemotherapy by 2008.

The Distribution of Colorectal Surgeons in the United States

BackgroundSurgical resection is a mainstay of colorectal cancer treatment, and prior studies have shown improved outcomes in patients undergoing surgery for colorectal cancer by colorectal surgical specialists compared with nonspecialized surgeons. Here, we examine the geographic distribution of colorectal surgeons in the United States and its relationship with sociodemographic characteristics of the served population. MethodsThe Area Health Resource File from 2017 to 2018 was used to identify the number and location of colorectal surgeons practicing throughout the United States and sociodemographic characteristics at the county and hospital referral region (HRR) level. The main outcomes of interest were the density of colorectal surgeons per 100,000 population and associations with sociodemographic characteristics at the county and HRR level based on multivariable linear regression. ResultsIn multivariable analysis, regions with higher proportion of nonwhite individuals and college-educated individuals had significantly more colorectal surgeons per 100,000 population, whereas regions with higher proportions of uninsured individuals had significantly fewer colorectal surgeons per 100,000 population at both the county and HRR levels. ConclusionsGeographic and sociodemographic variability exists in the distribution of colorectal surgeons in the United States. Such variability may be contributing to disparities in access to specialized colorectal care.

Association Between Clinician Specialization in Nursing Home Care and Nursing Home Clinical Quality Scores

ImportanceWhile the number of prescribing clinicians (physicians and nurse practitioners) who provide any nursing home care remained stable over the past decade, the number of clinicians who focus their practice exclusively on nursing home care has increased by over 30%. ObjectivesTo measure the association between regional trends in clinician specialization in nursing home care and nursing home quality. DesignRetrospective cross-sectional study. Setting and ParticipantsPatients treated in 15,636 nursing homes in 305 US hospital referral regions between 2013 and 2016. MeasuresClinician specialization in nursing home care for 2012–2015 was measured using Medicare fee-for-service billings. Nursing home specialists were defined as generalist physicians (internal medicine, family medicine, geriatrics, and general practice) or advanced practitioners (nurse practitioners and physician assistants) with at least 90% of their billings for care in nursing homes. The number of clinicians was aggregated at the hospital referral region level and divided by the number of occupied Medicare-certified nursing home beds. Nursing Home Compare quality measure scores for 2013–2016 were aggregated at the HHR level, weighted by occupied beds in each nursing home in the hospital referral region. We measured the association between the number of nursing home specialists per 1000 beds and the clinical quality measure scores in the subsequent year using linear regression. ResultsAn increase in nursing home specialists per 1000 occupied beds in a region was associated with lower use of long-stay antipsychotic medications and indwelling bladder catheters, higher prevalence of depressive symptoms, and was not associated with urinary tract infections, use of restraints, or short-stay antipsychotic use. Conclusions and ImplicationsHigher prevalence of nursing home specialists was associated with regional improvements in 2 of 6 quality measures. Future studies should evaluate whether concentrating patient care among clinicians who specialize in nursing home practice improves outcomes for individual patients. The current findings suggest that prescribing clinicians play an important role in nursing home care quality.

Physician EHR Adoption and Potentially Preventable Hospital Admissions among Medicare Beneficiaries: PanelData Evidence, 2010-2013.

To test for correlation between the growth in adoption of ambulatory electronic health records (EHRs) in the United States during 2010-2013 and hospital admissions and readmissions for elderly Medicare beneficiaries with at least one of four common ambulatory care-sensitive conditions (ACSCs). SK&A Information Services Survey of Physicians, American Hospital Association General Survey and Information Technology Supplement; and the Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013. Fixed effects model estimated the relationship between hospital referral region (HRR) level measures of physician EHR adoption and ACSC admissions and readmissions. Analyzed rates of admissions and 30-day readmissions per beneficiary at the HRR level (restricting the denominator to beneficiaries in our sample), adjusted for differences across HRRs in Medicare beneficiary age, gender, and race. Calculated physician EHR adoption rates as the percentage of physicians in each HRR who report using EHR in ambulatory care settings. Each percentage point increase in market-level EHR adoption by physicians is correlated with a statistically significant decline of 1.06 ACSC admissions per 10,000 beneficiaries over the study period, controlling for the overall time trend as well as market fixed effects and characteristics that changed over time. This finding implies 26,689 fewer ACSC admissions in our study population during 2010 to 2013 that were related to physician ambulatory EHR adoption. This represents 3.2 percent fewer ACSC admissions relative to the total number of such admissions in our study population in 2010. We found no evidence of a correlation between EHR use, by either physicians or hospitals, and hospital readmissions at either the market level or hospital level. This study extends knowledge about EHRs' relationship with quality of care and utilization. The results suggest a significant association between EHR use in ambulatory care settings and ACSC admissions that is consistent with policy goals to improve the quality of ambulatory care for patients with chronic conditions. The null findings for readmissions support the need for improved interoperability between ambulatory care EHRs and hospital EHRs to realize improvements in readmissions.

Early Physician Follow-Up and Out-of-Hospital Outcomes After Cerebral Aneurysm Treatment in Elderly Patients

The impact of early physician follow-up on out-of-hospital outcomes after cerebral aneurysm treatment has not been studied previously. We investigated the association of early physician follow-up (within 30 days of discharge) with mortality and readmissions for elderly patients undergoing treatment for cerebral aneurysms. We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent treatment for cerebral aneurysms from 2007 to 2012. To control for confounding, we used propensity score conditioning and inverse probability weighting, with mixed effects to account for clustering at the Hospital Referral Region level. Of 8703 patients presenting with unruptured aneurysms, 5673 (65.2%) had early physician follow-up, and 3030 (34.8%) did not. Of 3211 patients with subarachnoid hemorrhage, 1504 (46.8%) had early physician follow-up, and 1707 (53.2%) did not. Propensity score-adjusted analysis demonstrated that patients with unruptured aneurysms who visited a physician within 30 days of discharge had lower 3-month mortality (odds ratio [OR] 0.52; 95% confidence interval [95% CI] 0.36-0.74) but a greater rate of 90-day readmissions (OR 1.14; 95% CI 1.03-1.28). Similarly, early follow-up was associated with lower 3-month mortality (OR, 0.33; 95% CI, 0.24-0.46), and a greater rate of 90-day readmissions (OR 1.79; 95% CI 1.02-3.14) for patients presenting with subarachnoid hemorrhage. In a cohort of Medicare patients undergoing treatment for cerebral aneurysms, we identified an association of early physician follow-up with decreased short-term post-discharge mortality, but increased 90-day readmissions. More studies on the impact of strengthening the post-discharge network on the outcomes of this population are warranted.

Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic and Opioid Use in Younger Medicare Beneficiaries

ObjectiveThe purpose of this study was to determine whether the per-capita supply of doctors of chiropractic (DCs) or Medicare spending on chiropractic care was associated with opioid use among younger, disabled Medicare beneficiaries. MethodsUsing 2011 data, at the hospital referral region level, we correlated the per-capita supply of DCs and spending on chiropractic manipulative therapy (CMT) with several measures of per-capita opioid use by younger, disabled Medicare beneficiaries. ResultsPer-capita supply of DCs and spending on CMT were strongly inversely correlated with the percentage of younger Medicare beneficiaries who had at least 1, as well as with 6 or more, opioid prescription fills. Neither measure was correlated with mean daily morphine equivalents per opioid user or per chronic opioid user. ConclusionsA higher per-capita supply of DCs and Medicare spending on CMT were inversely associated with younger, disabled Medicare beneficiaries obtaining an opioid prescription. However, neither measure was associated with opioid dosage among patients who obtained opioid prescriptions.

The impact of hybrid neurosurgeons on the outcomes of endovascular coiling for unruptured cerebral aneurysms.

OBJECTIVE The impact of combined practices on the outcomes of unruptured cerebral aneurysm coiling remains an issue of debate. The authors investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm coiling. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent endovascular coiling for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding, the authors used propensity score conditioning, with mixed effects to account for clustering at the hospital referral region level. RESULTS During the study period, there were 11,716 patients who underwent endovascular coiling for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 1186 (10.1%) underwent treatment performed by hybrid neurosurgeons, and 10,530 (89.9%) by proceduralists who performed only endovascular coiling. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR 0.84; 95% CI 0.58-1.23), discharge to rehabilitation (OR 1.0; 95% CI 0.66-1.51), 30-day readmission rate (OR 1.07; 95% CI 0.83-1.38), and length of stay (adjusted difference, 0.41; 95% CI -0.26 to 1.09). Higher procedural volume was independently associated with improved outcomes. CONCLUSIONS In a cohort of Medicare patients, the authors did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and LOS between hybrid neurosurgeons and proceduralists performing only endovascular coiling.

Regional-Level Correlations in Inappropriate Imaging Rates for Prostate and Breast Cancers: Potential Implications for the Choosing Wisely Campaign.

The association between regional norms of clinical practice and appropriateness of care is incompletely understood. Understanding regional patterns of care across diseases might optimize implementation of programs like Choosing Wisely, an ongoing campaign to decrease wasteful medical expenditures. To determine whether regional rates of inappropriate prostate and breast cancer imaging were associated. Retrospective cohort study using the the Surveillance, Epidemiology, and End Results-Medicare linked database. We identified patients diagnosed from 2004 to 2007 with low-risk prostate (clinical stage T1c/T2a; Gleason score, ≤6; and prostate-specific antigen level, <10 ng/mL) or breast cancer (in situ, stage I, or stage II disease), based on Choosing Wisely definitions. In a hospital referral region (HRR)-level analysis, our dependent variable was HRR-level imaging rate among patients with low-risk prostate cancer. Our independent variable was HRR-level imaging rate among patients with low-risk breast cancer. In a subsequent patient-level analysis we used multivariable logistic regression to model prostate cancer imaging as a function of regional breast cancer imaging and vice versa. We identified 9219 men with prostate cancer and 30,398 women with breast cancer residing in 84 HRRs. We found high rates of inappropriate imaging for both prostate cancer (44.4%) and breast cancer (41.8%). In the first, second, third, and fourth quartiles of breast cancer imaging, inappropriate prostate cancer imaging was 34.2%, 44.6%, 41.1%, and 56.4%, respectively. In the first, second, third, and fourth quartiles of prostate cancer imaging, inappropriate breast cancer imaging was 38.1%, 38.4%, 43.8%, and 45.7%, respectively. At the HRR level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates (ρ = 0.35; P < .01). At the patient level, a man with low-risk prostate cancer had odds ratios (95% CIs) of 1.72 (1.12-2.65), 1.19 (0.78-1.81), or 1.76 (1.15-2.70) for undergoing inappropriate prostate imaging if he lived in an HRR in the fourth, third, or second quartiles, respectively, of inappropriate breast cancer imaging, compared with the lowest quartile. At a regional level, there is an association between inappropriate prostate and breast cancer imaging rates. This finding suggests the existence of a regional-level propensity for inappropriate imaging utilization, which may be considered by policymakers seeking to improve quality of care and reduce health care spending in high-utilization areas.

Prescription opioid use among disabled Medicare beneficiaries: intensity, trends, and regional variation.

Prescription opioid use and overdose deaths are increasing in the United States. Among disabled Medicare beneficiaries under the age of 65, the rise in musculoskeletal conditions as qualifying diagnoses suggests that opioid analgesic use may be common and increasing, raising safety concerns. From a 40% random-sample Medicare denominator, we identified fee-for-service beneficiaries under the age of 65 and created annual enrollment cohorts from 2007 to 2011 (6.4 million person-years). We obtained adjusted, annual opioid use measures: any use, chronic use (≥ 6 prescriptions), intensity of use [daily morphine equivalent dose (MED)], and opioid prescribers per user. Geographic variation was studied across Hospital Referral Regions. Most measures peaked in 2010. The adjusted proportion with any opioid use was 43.9% in 2007, 44.7% in 2010, and 43.7% in 2011. The proportion with chronic use rose from 21.4% in 2007 to 23.1% in 2011. Among chronic users: mean MED peaked at 81.3 mg in 2010, declining to 77.4 mg in 2011; in 2011, 19.8% received ≥ 100 mg MED; 10.4% received ≥ 200 mg. In 2011, Hospital Referral Region-level measures varied broadly (5th-95th percentile): any use: 33.0%-58.6%, chronic use: 13.9%-36.6%; among chronic users, mean MED: 45 mg-125 mg; mean annual opioid prescribers: 2.4-3.7. Among these beneficiaries, opioid use was common. Although intensity stabilized, the population using opioids chronically grew. Variation shows a lack of a standardized approach and reveals regions with mean MED at levels associated with overdose risk. Future work should assess outcomes, chronic use predictors, and policies balancing pain control and safety.

Geographic variation in health IT and health care outcomes: A snapshot before the meaningful use incentive program began

BackgroundThe 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which includes the Meaningful Use (MU) incentive program, was designed to increase the adoption of health information technology (IT) by physicians and hospitals. Policymakers hope that increased use of health IT to exchange health information will in turn enhance the quality and efficiency of health care delivery. In this study, we analyze the extent to which key outcomes vary based on the levels of health ITness among physicians and hospitals before the HITECH and MU programs led to increases in adoption and changes in use. Our findings provide an important baseline for a future evaluation of the impact of these programs on population-level outcomes. MethodsWe constructed measures of the degree of hospital and physician adoption and use (“health ITness”) at the level of the hospital referral region (HRR). We used data from the 2010 IT Supplement of the American Hospital Association (AHA) Annual Survey of Hospitals to capture hospital health ITness and data from the 2010 survey of ambulatory health care sites produced by SK&A Information Services for the physician measure. We conducted cross-sectional analyses of the relationship between market-level Medicare costs and use and three measures: (1) physician health ITness, (2) hospital health ITness, and (3) an overall measure of health ITness. ResultsIn general, greater levels of physician health ITness are associated with decreasing costs and use. Many of these relationships lose statistical significance, however, when we control for population and market characteristics such as the average age and health status of Medicare beneficiaries, mean household income, and the HMO penetration rate. Several of the relationships also change according to the level of hospital health ITness. ConclusionsOur findings suggest that greater levels of physician health ITness are associated with decreasing costs and use for a number of services, including inpatient costs and stays, imaging services, and lab tests, in 2010. Our health ITness and outcomes measures are aggregated at the HRR level; as such, these results do not suggest that the adoption and use of health IT by individual physicians or hospitals leads to decreases in costs or use for their individual patients. Nevertheless, these baseline findings provide important information to be considered in future research analyzing the impact of HITECH and the MU incentives.

The cost implications of prostate cancer screening in the Medicare population

Recent debate about prostate-specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost of screening. A population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer at the end of 2006 (n = 94,652), was assembled, and they were followed for 3 years to assess the cost of PSA screening and downstream procedures (biopsy, pathologic analysis, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level. Approximately 51.2% of men received PSA screening tests during the 3-year period, with 2.9% undergoing biopsy. The annual expenditures on prostate cancer screening by the national fee-for-service Medicare program were $447 million in 2009 US dollars. The mean annual screening cost at the HRR level ranged from $17 to $62 per beneficiary. Downstream biopsy-related procedures accounted for 72% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI] = 1.07-1.35) and localized cancer (IRR = 1.30, 95% CI = 1.15-1.47). The IRR for regional/metastasized cancer was also elevated, although not statistically significant (IRR = 1.31, 95% CI = 0.81-2.11). Medicare prostate cancer screening-related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis.

Longitudinal Urban-Rural Discrepancies in the US Orthopaedic Surgeon Workforce

It is unclear whether the supply of orthopaedic surgeons can meet the needs of a growing and aging population. This may be especially concerning in rural areas where there are known disparities in overall healthcare provision. We therefore (1) determined urban-rural trends in the US physician and orthopaedic workforce (including the age of that workforce) from 1995 to 2010; (2) geographically mapped the physician and orthopaedic distribution; and (3) examined urban-rural changes in select nonorthopaedic musculoskeletal provider (chiropractor and podiatrist) workforces from 2000 to 2010. County-level provider data from 1995 to 2010 were obtained from the Department of Health and Human Services. This was aggregated to Hospital Referral Regions and ranked by Rural-Urban Continuum Code. Hospital Referral Region-level data were mapped to identify geographic trends. Total physician and orthopaedic surgeon workforce data were averaged across the most urban and rural regions for the study period. There were urban-rural discrepancies in the physician and orthopaedic workforce from 1995 to 2010 with fewer orthopaedic surgeons in rural areas than urban areas (6.52 versus 8.73 per 100,000 in 2010; p=0.001). Furthermore, orthopaedic surgeons in rural areas were older than their urban counterparts, with a workforce age ratio (age>55: age<55 years) of 0.92 versus 0.65 in 2010 (p=0.024). From 2000 to 2010, the rural chiropractor and podiatrist workforces showed tremendous growth of 229.6% and 279.9%, respectively. There were significant urban-rural orthopaedic surgeon workforce discrepancies from 1995 to 2010. Concurrent growth in chiropractor and podiatrist numbers shows significant trends in the musculoskeletal provider workforce that warrant continuing observation and analysis. Level IV, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.