Hospitalization In Medicare Beneficiaries Research Articles

Medical Therapy Before, During and After Hospitalization in Medicare Beneficiaries With Heart Failure and Diabetes: Get With The Guidelines – Heart Failure Registry

Patients hospitalized with heart failure (HF) and diabetes mellitus (DM) are at risk for worsening clinical status. Little is known about the frequency of therapeutic changes during hospitalization. We characterized the use of medical therapies before, during and after hospitalization in patients with HF and DM. We identified Medicare beneficiaries in Get With The Guidelines-Heart Failure (GWTG-HF) hospitalized between July 2014 and September 2019 with Part D prescription coverage. We evaluated trends in the use of 7 classes of antihyperglycemic therapies (metformin, sulfonylureas, GLP-1RA, SGLT2-inhibitors, DPP-4 inhibitors, thiazolidinediones, and insulins) and 4 classes of HF therapies (evidence-based β-blockers, ACEi or ARB, MRA, and ARNI). Medication fills were assessed at 6 and 3 months before hospitalization, at hospital discharge and at 3 months post-discharge. Among 35,165 Medicare beneficiaries, the median age was 77 years, 54% were women, and 76% were white; 11,660 (33%) had HFrEF (LVEF ≤ 40%), 3700 (11%) had HFmrEF (LVEF 41%-49%), and 19,805 (56%) had HFpEF (LVEF ≥ 50%). Overall, insulin was the most commonly prescribed antihyperglycemic after HF hospitalization (n = 12,919, 37%), followed by metformin (n = 7460, 21%) and sulfonylureas (n = 7030, 20%). GLP-1RA (n = 700, 2.0%) and SGLT2i (n = 287, 1.0%) use was low and did not improve over time. In patients with HFrEF, evidence-based beta-blocker, RASi, MRA, and ARNI fills during the 6 months preceding HF hospitalization were 63%, 62%, 19%, and 4%, respectively. Fills initially declined prior to hospitalization, but then rose from 3 months before hospitalization to discharge (beta-blocker: 56%-82%; RASi: 51%-57%, MRA: 15%-28%, ARNI: 3%-6%, triple therapy: 8%-20%; P < 0.01 for all). Prescription rates 3 months after hospitalization were similar to those at hospital discharge. In-hospital optimization of medical therapy in patients with HF and DM is common in participating hospitals of a large US quality improvement registry.

Abstract 14383: Medical Therapy Before, During, and After Hospitalization in Medicare Beneficiaries With Heart Failure and Diabetes: The Get With the Guidelines - Heart Failure Registry

Introduction: Patients with heart failure with reduced ejection fraction (HFrEF) and diabetes mellitus (DM) are at risk for worsening HF events, yet little is known about therapeutic changes surrounding hospitalization. We aimed to characterize use of medical therapies before, during, and after hospitalization for HF. Methods: We identified Medicare beneficiaries in the GWTG-HF registry with HFrEF and DM who were hospitalized between July 2016 and September 2017 and had Part D prescription coverage for ≥6 months before and ≥3 months after hospital discharge. Medication fills for evidence-based HFrEF and antihyperglycemic therapies were assessed at 6 and 3 months before hospitalization, at hospital discharge, and 3 months post-discharge. Results: Among 3,272 Medicare beneficiaries with HFrEF and DM, mean age was 77±7y, 41% were women, and 15% were Black. Overall, 92%, 56%, 28%, and 6% were prescribed β-blocker, ACEi/ARB, MRA, and ARNI at discharge. Rates of all therapies were higher at discharge than immediately prior to hospitalization, though rates of β-blocker and ACEi/ARB use declined 3-months post-discharge. ‘Triple therapy’ (ACEI/ARB/ARNI+β-blocker+MRA) was prescribed in 9% prior to hospitalization and 20-21% at discharge and early-post-discharge. After hospitalization, insulin was prescribed most frequently (35%), followed by metformin (21%), sulfonylureas (19%), and DPP4i (11%), while GLP-1RA (2%) and SGLT2i (0.5%) use was infrequent. Modest changes in antihyperglycemic therapies were observed pre- vs. post-hospitalization, including an increase in insulin from 32% to 35% and decrease in metformin from 26% to 21% and SGLT2i from 0.8% to 0.5%. Conclusions: Despite modest improvements in use of evidence-based therapies for HFrEF during and shortly after hospitalization for HF, only 1 out of 5 patients are treated with comprehensive medical therapy. Early adoption in 2016-2017 of SGLT2i was low in a high-risk population with comorbid HFrEF and DM.

Outcomes of Post‐Acute Care in Home Health Versus a Skilled Nursing Facility in Medicare Beneficiaries with Dementia

Research ObjectiveTo compare the outcomes of post‐acute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with dementia. Despite the fact that both post‐acute care use and dementia are highly prevalent in the Medicare population, very few studies have compared the outcomes of different post‐acute care settings for patients with dementia, leaving patients, caregivers, and clinicians uncertain how to make optimal decisions around hospital discharge.Study DesignRetrospective analysis of secondary data using an instrumental variable design to compare outcomes of HH versus SNF following an acute hospitalization. We used a 100% sample of Medicare inpatient, outpatient, and post‐acute care claims and assessment data from January 1, 2015 to December 31, 2016 and used differential distance between home health and SNF as the instrumental variable to account for nonrandom allocation of patients (F‐statistic: 26.5). Outcomes included unplanned 30‐day readmission, 30‐ and 100‐day mortality, and a composite measure of readmission and mortality to address competing risks. Our analysis adjusted for beneficiary characteristics and year of analysis, included fixed effects for hospital and year, and adjusted for clustering at the hospital level.Population StudiedWe used MedPAR to identify hospitalizations and Minimum Data Set and Outcome and Assessment Information Set assessments to identify SNF and HH stays following hospital discharge. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or were enrolled in hospice. We identified dementia using validated diagnostic codes with a three‐year look‐back. We also measured demographics, comorbidities, characteristics of the index hospital stay, prior health care utilization, and both cognitive and physical function on admission to post‐acute care.Principal FindingsOur sample included 1,369,192 beneficiaries with a diagnosis of dementia; 404,539 (29.5%) received HH, while 964,653 (70.5%) went to SNF. The cohort was older (mean age 83), approximately 70% were cognitively impaired on SNF admission, and only 30.4% of patients were independent in Activities of Daily Living. Overall, 16.1% were readmitted to the hospital and 5.9% died within 30 days, while 19.5% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two post‐acute care settings. These findings were similar when the analysis was stratified by degree of cognitive impairment.ConclusionsIn a sample of more than 1.6 million Medicare beneficiaries discharged to post‐acute care following hospitalization, use of home health services and SNF were equivalent in terms of unplanned readmissions and 30‐ and 100‐day mortality. These are important findings given more than 7 in 10 Medicare beneficiaries with dementia are currently discharged to SNF for post‐acute care at much higher cost than HH, and the prevalence of both dementia and post‐acute care use are increasing in the United States.Implications for Policy or PracticeOur findings suggest HH may provide similar outcomes at lower cost following hospitalization for Medicare beneficiaries with a diagnosis of dementia, and that home‐based models of care may provide increased post‐acute care value.Primary Funding SourceUniversity of Pennsylvania Institute on Aging.

Economic burden of hospitalizations of Medicare beneficiaries with heart failure.

ObjectiveThe objective of this study was to assess the costs associated with the hospitalization and the cumulative 30-, 60-, and 90-day readmission rates in a cohort of Medicare beneficiaries with heart failure (HF).MethodsThis was a retrospective, observational study based on data from the national 5% sample of Medicare beneficiaries. Inpatient data were gathered for Medicare beneficiaries with at least one HF-related hospitalization between July 1, 2005, and December 31, 2011. The primary end point was the average per-patient cost of hospitalization for individuals with HF. Secondary end points included the cumulative rate of hospitalization, the average length of hospital stay, and the cumulative 30-, 60-, and 90-day readmission rates.ResultsData from 63,678 patients with a mean age of 81.8 years were included in the analysis. All costs were inflated to $2,015 based on the medical care component of the Consumer Price Index. The mean per-patient cost of an HF-related hospitalization was $14,631. The mean per-patient cost of a cardiovascular (CV)-related or all-cause hospitalization was $16,000 and $15,924, respectively. The cumulative rate of all-cause hospitalization was 218.8 admissions per 100 person-years, and the median length of stay for HF-related, CV-related, and all-cause hospitalizations was 5 days. Also, 22.3% of patients were readmitted within 30 days, 33.3% were readmitted within 60 days, and 40.2% were readmitted within 90 days.ConclusionThe costs associated with hospitalization for Medicare beneficiaries with HF are substantial and are compounded by a high rate of readmission.

A Review of Hospice Characteristics and Patient Outcomes Associated with Exceeding the Medicare Hospice Annual Aggregate Reimbursement Cap (SA517C)

physician and degree of fragmentation with referral to hospice. This model adjusted for resident characteristics, cognition, functional status and diagnosis prior to admission. Results. We captured 130,833 hospitalizations of Medicare beneficiaries with advanced cognitive impairment who were residing in NHs between 2000 and 2010 (mean patient age of 83.6, 68.0% female, 74.3% white, 70.2% one-year mortality). Of the hospitalizations that involved only one type of provider acting as the attending physician, the primary provider for that admission was a non-hospitalist general practitioner, a hospitalist, or a specialist in 67.4%, 25.6% and 7.1% of admissions respectively. Hospitalists had 1.44 increased odds of hospice referral compared to non-hospitalist generalists (95% CI 1.31-1.58). Specialists were not statistically significantly different from non-hospitalist generalist. Conclusion. Hospice referrals for NH residents with ACI are more likely when the attending physician is a hospitalist. Implications for Research, Policy, and Practice. Hospitalists, a growing class of physicians, are more likely to appropriately refer NH residents with a high 1-year mortality to hospice at hospital discharge.

Outcomes of Infection-Related Hospitalization in Medicare Beneficiaries Receiving In-Center Hemodialysis

Infection is a common cause of hospitalization in adults receiving hemodialysis. Limited data are available about downstream events resulting from or following these hospitalizations. Retrospective cohort study using the US Renal Data System. Medicare beneficiaries initiating in-center hemodialysis therapy in 2005 to 2008. Demographics, dual Medicare/Medicaid eligibility, body mass index, comorbid conditions, initial vascular access type, nephrology care prior to dialysis therapy initiation, residence in a care facility, tobacco use, biochemical measures, and type of infection. 30-day hospital readmission or death following first infection-related hospitalization. 60,270 Medicare beneficiaries had at least one hospitalization for infection. Of those who survived the initial hospitalization, 15,113 (27%) were readmitted and survived the 30 days following hospital discharge, 1,624 (3%) were readmitted to the hospital and then died within 30 days of discharge, and 2,425 (4%) died without hospital readmission. Complications related to dialysis access, sepsis, and heart failure accounted for 12%, 9%, and 7% of hospital readmissions, respectively. Factors associated with higher odds of 30-day readmission or death without readmission included non-Hispanic ethnicity, lower serum albumin level, inability to ambulate or transfer, limited nephrology care prior to dialysis therapy, and specific types of infection. In comparison, older age, select comorbid conditions, and institutionalization had stronger associations with death without readmission than with readmission. Findings limited to Medicare beneficiaries receiving in-center hemodialysis. Hospitalizations for infection among patients receiving in-center hemodialysis are associated with exceptionally high rates of 30-day hospital readmission and death without readmission.

Using Statewide Audit and Feedback to Improve Hospital Care in West Virginia

Audit and feedback systems have significantly improved medical care in numerous settings, and they appear to work by stimulating competition rather than through command and control. The West Virginia Medical Institute (WVMI), a Medicare-designated Quality Improvement Organization (QIO), periodically collected quality information on five common conditions (acute myocardial infarction [AMI], heart failure, pneumonia, stroke, and atrial fibrillation) that cause hospitalization in Medicare beneficiaries. All 44 acute care hospitals in West Virginia were offered written and orally presented reports of quality performance from 1998 through 2001. All indicators appeared to improve statewide. Several--for example, aspirin at discharge for AMI patients and pneumococcal vaccine for pneumonia patients--improved by more than 10 absolute percentage points. Fourteen of 15 quality indicators showed significant improvement (p < .05, paired t-test) in all hospitals between the before- and after-feedback periods. Seven of 13 indicators assessed during the entire study in the largest hospitals showed no significant trends in quality before feedback but significant increases (p < .05, chi-square for trend) in the after-feedback period. The quality indicator changes reported can represent important health gains for West Virginia Medicare beneficiaries. Most of the improvement did not occur until after hospitals received feedback.