Medicare Beneficiaries Research Articles

Ten-Year Follow-Up of Mitral Valve Replacement With the Epic Porcine Valve in a Medicare Population

BackgroundBioprosthetic surgical mitral valve replacement (SMVR) remains an important treatment option in the era of transcatheter valve interventions. This study presents 10-year clinical outcomes of Medicare beneficiaries who underwent SMVR with a contemporary low-profile mitral porcine valve. MethodsThis was a single-arm observational study using Medicare fee-for-service claims data. Deidentified patients undergoing SMVR with the Epic mitral valve (Abbott) in the United States between January 1, 2008 and December 31, 2019 were selected by International Classification of Diseases, Ninth and Tenth Revision procedure codes and then linked to a manufacturer device tracking database. All-cause mortality, heart failure (HF) rehospitalization, and mitral valve reintervention (surgical or transcatheter valve-in-valve) were evaluated at 10 years by using the Kaplan-Meier method. ResultsAmong 75,739 Medicare beneficiaries undergoing SMVR during the study period, 14,015 received the Epic mitral valve (Abbott), 76.5% (10,720) of whom had underlying HF. The mean age was 74 ± 8 years. Survival at 10 years in patients without preoperative HF was 40.4% (95% CI, 37.4%-43.4%) compared with 25.4% (95% CI ,23.8%-27.0%) for patients with HF (P < .001). The 10-year freedom from HF rehospitalization was 51.3% (95% CI, 49.4%-53.1%). Freedom from mitral valve reintervention was 91.4% (95% CI, 89.7%-92.7%) at 10 years. ConclusionsThis real-world nationwide study of Medicare beneficiaries receiving the Epic mitral valve demonstrates >90% freedom from all-cause valve reintervention and >50% freedom from HF rehospitalization at 10 years after implantation. Long-term survival and HF rehospitalization in this population with mitral valve disease treated with SMVR was found to be affected by underlying HF.

Progression of frailty and cardiovascular outcomes among Medicare beneficiaries.

Frailty is associated with adverse cardiovascular outcomes independent of age and comorbidities, yet the independent influence of frailty progression on cardiovascular outcomes remains uncertain. To determine whether frailty progression is associated with adverse cardiovascular outcomes, independent of baseline frailty and age, we evaluated all Medicare Fee-for-Service beneficiaries ≥65 years at cohort inception with continuous enrollment from 2003 to 2015. Linear mixed effects models, adjusted for baseline frailty and age, were used to estimate change in a validated claims-based frailty index (CFI) over a 5-year period. Survival analysis was used to examine frailty progression and risk of adverse health outcomes. There were 8.9 million unique patients identified, mean age 77.3 ± 7.2 years, 58.7% female, 10.9% non-White race. In total, 60% had frailty progression and 40% frailty regression over median follow-up of 2.4 years. Compared to those with frailty regression, when adjusting for age and baseline CFI, those with frailty progression had a significantly greater risk of incident major adverse cardiovascular and cerebrovascular events (MACCE) (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.31-1.31), all-cause mortality (HR 1.34, 95% CI 1.34-1.34), acute myocardial infarction (HR 1.08, 95% CI 1.07-1.09), heart failure exacerbation (HR 1.30, 95% CI 1.29-1.30), ischemic stroke (HR 1.14, 95% CI 1.14-1.15). There was also a graded increase in risk of each outcome with more rapid progression, as well as significantly fewer days alive at home (DAH) with more rapid progression compared to the slowest progression group (270.4 ± 112.3 vs. 308.6 ± 93.0 days, rate ratio 0.88, 95% CI 0.87-0.88, p < 0.001). In this large, nationwide sample of older Medicare beneficiaries, frailty progression, independent of age and baseline frailty, was associated with fewer DAH and a graded risk of MACCE, all-cause mortality, myocardial infarction, heart failure, and ischemic stroke compared to those with frailty regression.

Trends in use of intensive care during hospitalizations at the end-of-life among older adults with advanced cancer.

High-intensity end-of-life (EOL) care, marked by admission to intensive care units (ICUs) or in-hospital death, can be costly and burdensome. Recent trends in use of ICUs, life-sustaining treatments (LSTs), and noninvasive ventilation (NIV) during EOL hospitalizations among older adults with advanced cancer and patterns of in-hospital death are unknown. We used SEER-Medicare data (2003-2017) to identify beneficiaries with advanced solid cancer (summary stage 7) who died within 3 years of diagnosis. We identified EOL hospitalizations (within 30 days of death), classifying them by increasing intensity of care into: (1) without ICU; (2) with ICU but without LST (invasive mechanical ventilation, tracheostomy, gastrostomy, acute dialysis) or NIV; (3) with ICU and NIV but without LST; and (4) with ICU and LST use. We constructed a multinomial regression model to evaluate trends in risk-adjusted hospitalization, overall and across hospitalization categories, adjusting for sociodemographics, cancer characteristics, comorbidities, and frailty. We evaluated trends in in-hospital death across categories. Of 226,263 Medicare beneficiaries with advanced cancer, 138,305 (61.1%) were hospitalized at EOL [Age, Mean (SD):77.9(7.1) years; 45.5% female]. Overall, EOL hospitalizations remained high throughout, from 78.1% (95% CI: 77.4, 78.7) in 2004 to 75.5% (95% CI: 74.5, 76.2) in 2017. Hospitalizations without ICU use decreased from 49.3% (95% CI: 48.5, 50.2) to 35.0% (95% CI: 34.2, 35.9) while hospitalizations with more intensive care increased, from 23.7% (95% CI: 23.0, 24.4) to 28.7% (95% CI: 27.9, 29.5) for ICU without LST or NIV, 0.8% (95% CI: 0.6, 0.9) to 3.8% (95% CI: 3.4, 4.1) for ICU with NIV but without LST, and 4.3% (95% CI: 4.0, 4.7) to 8.0% (95% CI: 7.5, 8.5) for ICU with LST use. Among those who experienced in-hospital death, the proportion receiving ICU care increased from 46.5% to 65.0%. Among older adults with advanced cancer, EOL hospitalization rates remained stable from 2004-2017. However, intensity of care during EOL hospitalizations increased as evidenced by increasing use of ICUs, LSTs, and NIV.

Gender Representation in the ECT Workforce in the United States From 2013 to 2021: A Medicare Physician Data Analysis.

Electroconvulsive therapy (ECT) is an effective treatment for a range of psychiatric disorders. Although much research has examined what patients receive ECT, there is less research describing those physicians who provide ECT services. This study examines the ECT workforce in the United States by analyzing publicly available Medicare billing records. Data regarding the providers performing ECT were accessed from the Medicare Physician and Other Supplier Data for the years 2013 through 2021 based on those physicians who billed the ECT procedural code 90870. During the study period, 1402 physicians performed ECT in at least 1 calendar year on a minimum of 11 Medicare beneficiaries, representing 3.9% of the 36,116 psychiatrists who billed Medicare during this period. Female physicians made up 39% of psychiatrists overall who bill Medicare, but 23% of psychiatrists billing for ECT. Fifty percent of billed ECT treatments were performed by 12% of ECT doctors; among these high-volume ECT providers, 16% were female. Only a small subset of psychiatrists who bill Medicare provide ECT services, and female physicians are under-represented in the ECT workforce and among high-volume ECT providers. Improving workforce equity and with it access to ECT requires further study of psychiatric training and practice environment that may impose barriers on female participation as ECT providers.

Cardiovascular Disease Patterns, Mortality, and Hospitalization Trends in Adults Over 18: Insights From the Behavioral Risk Factor Surveillance System Database.

Background Cardiovascular diseases (CVDs), including coronary artery disease, heart attacks, strokes, and hypertension, are the leading cause of global morbidity and mortality. Despite advancements in diagnostic techniques, treatment protocols, and public health initiatives, the prevalence of CVD continues to rise. Hence, understanding trends of predisposing factors for CVD and current treatment modalities such as medication use and frequency of hospitalization is essential for developing effective interventions and improving public health strategies. This study leverages Behavioral Risk Factor Surveillance System (BRFSS) data to analyze these trends among adults older than 18 years. Methods Data were sourced from the BRFSSdatabase, analyzing CVD patterns from 2019 to 2021. The study included adults with high cholesterol or blood pressure, coronary heart disease, stroke, and heart failure. Data analysis utilized age-adjusted prevalence, mortality, and hospitalization rates. Results The analysis of the BRFSS data revealed several key trends in CVD patterns from 2019 to 2021. There was a statistically significant increase (p<0.05) in the age-adjusted prevalence of adults taking medication for high cholesterol, rising from 28.9% to 31%, and for controlling high blood pressure, increasing from 57.7% to 60.4%. From 2019 to 2021, coronary heart disease mortality increased from 360,900 to 382,820, while stroke deaths rose from 150,005 to 162,890. Trends show rising mortality for both conditions despite missing data for some years. Mortality rates for coronary heart disease and stroke also rose and were statistically significant (p<0.05), with coronary heart disease mortality increasing from 88 to 92.8 cases per 100,000, and stroke mortality from 37 to 41.1 cases per 100,000.Hospitalization rates for heart failure among Medicare beneficiaries aged 65 and older initially decreased in 2020, likely due to the COVID-19 pandemic impacting hospital admissions, but rose again in 2021 as healthcare-seeking behaviors normalized.Significant gender and racial disparities were observed, with higher mortality rates among males (127.4 per 100,000) and Black, non-Hispanic individuals (110.5 per 100,000). Conclusions This study highlights the increasing medication use for cholesterol and blood pressure among adults older than 18 years, yet mortality rates for coronary heart disease and stroke persist. Significant gender and racial disparities in medication use and mortality rates were observed. These findings underscore the need for targeted public health intervention towards improving medication adherence and addressing social determinants of health, to reduce CVD burden and enhance health equity across diverse populations.

Telehealth Infrastructure, Accountable Care Organization, and Medicare Payment for Patients with Alzheimer's Disease and Related Dementia Living in Socially Vulnerable Areas.

Background: Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer's disease and related dementias (ADRD). Objective: This study aimed to test whether telehealth for care coordination and Accountable Care Organization (ACO) enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. Methods: The study used the merged data set of 2020 Centers for Medicare and Medicaid Services Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the Center for Medicare and Medicaid Service's Social Vulnerability Index (SVI), and the American Hospital Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. Cross-sectional analyses and generalized linear models (GLM) were implemented. Analyses were implemented from November 2023 to February 2024. Results: Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The GLM regression results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was -$1,766.2 (95% confidence interval: -$2,576.4 to -$976). Conclusions: Our results suggested that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas.

Injurious Fall Risk Differences Among Older Adults With First-Line Depression Treatments

One-third of older adults in the US have depression, often treated with psychotherapy and antidepressants. Previous studies suggesting an increased risk of falls and related injuries (FRI) associated with antidepressant use may be affected by confounding by indication or immortal time bias. To evaluate the association between FRI risk and first-line treatments in older adults with depression. This cohort study used a target trial emulation framework with a cloning-censoring-weighting approach with Medicare claims data from 2016 to 2019. Participants included fee-for-service beneficiaries aged 65 years or older with newly diagnosed depression. Data were analyzed from October 1, 2023, to March 31, 2024. First-line depression treatments including psychotherapy, sertraline, escitalopram, citalopram, mirtazapine, duloxetine, trazodone, fluoxetine, bupropion, paroxetine, and venlafaxine. One-year FRI rate, restricted mean survival time (RMST), and adjusted hazard ratio (aHR) with 95% CI. Among 101 953 eligible beneficiaries (mean [SD] age, 76 [8] years), 63 344 (62.1%) were female, 7404 (7.3%) were Black individuals, and 81 856 (80.3%) were White individuals. Compared with the untreated group, psychotherapy use was not associated with FRI risk (aHR, 0.94 [95% CI, 0.82-1.17]), while other first-line antidepressants were associated with a decreased FRI risk (aHR ranged from 0.74 [95% CI, 0.59-0.89] for bupropion to 0.83 [95% CI, 0.67-0.98] for escitalopram). The FRI incidence ranged from 63 (95% CI, 53-75) per 1000 person-year for those treated with bupropion to 87 (95% CI, 83-90) per 1000 person-year for those who were untreated. The RMST ranged from 349 (95% CI, 346-350) days for those who were untreated to 353 (95% CI, 350-356) days for those treated with bupropion. In this cohort study of older Medicare beneficiaries with depression, first-line antidepressants were associated with a decreased FRI risk compared with untreated individuals. These findings provide valuable insights into their safety profiles, aiding clinicians in their consideration for treating depression in older adults.

Cost of ovarian cancer by the phase of care in the United States

BackgroundOvarian cancer is associated with delayed diagnosis and poor survival; thus, interest is high in identifying predictive and prognostic biomarkers and novel therapeutic agents.Although the costs of ovarian cancer care are likely to increase as newer, more effective, but more expensive treatment regimens become available, information on the current costs of care for ovarian cancer—across the care continuum from diagnosis to the end of life—are lacking. ObjectiveThis study aimed to estimate real-world mean and median costs of ovarian cancer care within the first 5 years after diagnosis by patients’ phase of care, age, race/ethnicity, and geographic region. Study DesignWe performed a retrospective cohort study of ovarian cancer patients diagnosed between January 1, 2015 and December 31, 2020. We used claims data from Optum’s de-identified Clinformatics® Data Mart database, which includes inpatient, outpatient, and prescription claims for commercial insurance and Medicare beneficiaries nationwide. Cost of ovarian cancer care were calculated for the start of care (ie, the first 6 months), continuing care (ie, period between the initial and end-of-life care), and end-of-life care (ie, the last 6 months) phases and reported in 2021 U.S. dollar amounts. Ovarian cancer care costs were stratified by age, race/ethnicity, and geographic region. Due to the skewed nature of cost data, the mean cost data were log-transformed for modelling. Ordinary least-squares regression was conducted on the log costs, adjusting for patient categorical age, race/ethnicity, and geographic region. ResultsA total of 7913 patients were included in the analysis. The mean cost per year for ovarian cancer care was >$200,000 during the start of care, between $26,000 and $88,000 during the continuing care phase, and >$129,000 during the end-of-life care phase. There were statistically significant associations between age and costs during each phase of care. Compared to younger patients, older patients incurred higher costs during the continuing care phase and lower costs during the end-of-life care phase. Geographic differences in the costs of ovarian cancer care were also noted regardless of the phase of care. There were no associations between cost and race/ethnicity in our cohort. ConclusionsOvarian cancer care costs are substantial and vary by the phase of care, age category, and geographic region. As more effective but expensive treatment options for ovarian cancer become available with potential survival benefit, sustainable interventions to reduce the cost of care for ovarian cancer will be needed throughout the cancer care continuum.

Post-Acute Transitions for Traditional Medicare Beneficiaries with Serious Mental Illness

Post-Acute Transitions for Traditional Medicare Beneficiaries with Serious Mental Illness

The Neurologist's Guide to Drug Pricing in the United States.

As newer, innovative neurology drugs enter the US health care system, neurologists should consider the cost of these treatments in addition to their efficacy, safety, and tolerability. To do so thoughtfully requires an understanding of how prescription drugs are priced in the United States. The process of drug pricing is linked to the distribution supply chain and the many stakeholders involved. Stakeholders include pharmaceutical manufacturers; wholesalers; pharmacies; pharmacy benefit managers; payers, including health insurers; hospital systems; neurologists and other clinicians; and patients. Drug pricing has taken center stage as the Inflation Reduction Act of 2022 has set maximum out-of-pocket expenses for Medicare beneficiaries for the first time in the program's history and limits drug price increases for a select group of Medicare Part D drugs. This article describes the US drug distribution supply chain and its stakeholders and introduces key drug pricing terms; a brief description of how rebates are generally estimated will also be discussed. Finally, as newer neurology outpatient drugs enter the market, the "value" of drugs will be described through cost-effectiveness terminology and their utility for the clinical neurologist.

Racial and Ethnic Disparities in Take-Home Methadone Use for Medicare Beneficiaries With Opioid Use Disorder

Racial and Ethnic Disparities in Take-Home Methadone Use for Medicare Beneficiaries With Opioid Use Disorder

Ambient Air Pollution Exposure and Adverse Outcomes Among Medicare Beneficiaries With Heart Failure.

Exposure to fine particulate matter (<2.5 um, particulate matter with an aerodynamic diameter <2.5 microns [PM2.5]) has been implicated in atherogenesis. Limited data in animal studies suggest that PM2.5 exposure leads to myocardial fibrosis and increased incidence of heart failure (HF). Whether PM2.5 is associated with adverse outcomes in patients with preexisting HF has not been widely studied. In this retrospective cohort study, Medicare patients hospitalized with first HF between 2013 and 2020 were identified from the Medicare Provider Analysis and Review Part A 100% files. Patients were linked with integrated estimates of ambient PM2.5 obtained at 1×1 km using the zip code of participants' residence. The study outcomes were all-cause death, HF, and all-cause readmissions burden. A total of 2 599 525 patients were included in this study, with 6 321 731 person-years of follow-up. Mean PM2.5 was 7.3±1.7 μg/m3. Each interquartile range of PM2.5 was associated with 0.9% increased hazard of all-cause death, 4.5% increased hazard of first HF readmission, 3.1% increased risk of HF hospitalization burden, and 5.2% increase in all-cause readmission burden, after adjusting for 11 sociodemographic and medical factors. Subgroup analyses showed that the effects were more pronounced at levels <7 μg/m3 and in patients aged <75 years, Asians, and those residing in rural areas. Ambient air pollution is associated with higher risk of adverse events in Medicare beneficiaries with established HF. These associations persist below the National Air Quality Standards (12 μg/m3), supporting that no threshold effect exists for health effects of air pollution exposure.

Opioid and Nonopioid Analgesic Prescribing Patterns of Hepatologists for Medicare Beneficiaries.

Opioids are commonly prescribed to patients with chronic liver disease, but little is known regarding medication prescribing patterns of hepatologists. Opioid use increased until national guidelines limited opioid prescriptions in early 2016. We aimed to describe rates of opioid and nonopioid analgesics to Medicare beneficiaries by hepatologists from 2013 to 2017 and identify demographic characteristics associated with higher prescribing. Prescription data from 2013 to 2017 by 761 hepatologists identified in the Centers for Medicare and Medicaid Services Part D Public Use File were analyzed. Annual prescription volumes were compared for providers with >10 annual prescriptions of a given drug type. Provider characteristics associated with opioid prescriptions were identified through multivariate logistic regression analyses. The proportion of hepatologists prescribing >10 annual opioid prescriptions decreased from 29% to 20.6%. Median annual opioid prescriptions per hepatologist significantly decreased from 24 to 20. Tramadol remained the most prescribed analgesic. Nonopioid analgesic prescription volume did not increase significantly. Provider characteristics associated with increased opioid prescriptions included male sex, practice location in the South and Midwest (vs West), more years in practice, and a greater proportion of beneficiaries who are white or with low-income subsidy claims. Characteristics associated with fewer prescriptions included non-university-based practice, having a greater proportion of female beneficiaries, and later prescription year. Hepatologists are prescribing less opioids. However, the prevalence of tramadol use and the lack of increase in nonopioid analgesic use highlights the need for advancing the science and training of pain management in chronic liver disease and targeted implementation of nonopioid treatment programs.

Social Determinants of Health and Surgical Desirability of Outcome Ranking in Older Veterans

Evaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement. To measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR). This was a cohort study of US veterans using data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP; 2013-2019) limited to patients aged 65 years or older with inpatient stays between 2 and 30 days, merged with multiple data sources, including Medicare. Race and ethnicity data were retrieved from VASQIP, Medicare and Medicaid beneficiary summary files, the Veterans Health Administration Corporate Data Warehouse, and the United States Veterans Eligibility Trends and Statistics file. Data were analyzed between September 2023 and February 2024. Living in a highly deprived neighborhood (Area Deprivation Index >85), race and ethnicity used as a social construct, rurality, and care fragmentation (percentage of non-VA care days). DOOR is a composite, patient-centered ranking of 26 outcomes ranging from no complication (1, best) to 90-day mortality or near-death complications (6, worst). A series of proportional odds regressions was used to assess the impact of SDOH and care fragmentation adjusted for clinical risk factors, including presentation acuity (presenting with preoperative acute serious conditions and urgent or emergent surgical procedures). The cohort had 93 644 patients (mean [SD] age, 72.3 [6.2] years; 91 443 [97.6%] male; 74 624 [79.7%] White). Veterans who identified as Black (adjusted odds ratio [aOR], 1.06; 95% CI, 1.02-1.10; P = .048) vs White and veterans with higher care fragmentation (per 20% increase in VA care days relative to all care days: aOR, 1.01; 95% CI, 1.01-1.02; P < .001) were associated with worse (higher) DOOR scores until adjusting for presentation acuity. Living in rural geographic areas was associated with better DOOR scores than living in urban areas (aOR, 0.93; 95% CI, 0.91-0.96; P < .001), and rurality was associated with lower presentation acuity (preoperative acute serious conditions: aOR, 0.88; 95% CI, 0.81-0.95; P = .001). Presentation acuity was higher in veterans identifying as Black, living in deprived neighborhoods, and with increased care fragmentation. Veterans identifying as Black and veterans with greater proportions of non-VA care had worse surgical outcomes. VA programs should direct resources to reduce presentation acuity among Black veterans, incentivize veterans to receive care within the VA where possible, and better coordinate veterans' treatment and records between care sources.

Disparities in Use of Novel Diabetes Medications by Insurance: A Nationally Representative Cohort Study.

Minority racial and ethnic populations have the highest prevalence of type 2 diabetes mellitus but lower use of sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1ra), novel medications that reduce morbidity and mortality. Observed disparities may be due to differences in insurance coverage, which have variable cost-sharing, prior authorization, and formulary restrictions that influence medication access. To assess whether racial/ethnic differences in SGLT2i and GLP1ra use differ by payer. Cross-sectional analysis of 2018 and 2019 Medical Expenditure Panel Survey data. Adults ≥ 18years old with diabetes. We defined insurance as private, Medicare, or Medicaid using ≥ 7months of coverage in the calendar year. We defined race/ethnicity as White (non-Hispanic) vs non-White (including Hispanic). The primary outcome was use of ≥ 1 SGLT2i or GLP1ra medication. We used multivariable logistic regression to assess the interaction between payer and race/ethnicity adjusted for cardiovascular, socioeconomic, and healthcare access factors. We included 4997 adults, representing 24.8 million US adults annually with diabetes (mean age 63.6years, 48.8%female, 38.8%non-White; 33.5% private insurance, 56.8% Medicare, 9.8% Medicaid). In our fully adjusted model, White individuals with private insurance had significantly more medication use versus non-White individuals (16.1% vs 8.3%, p < 0.001), which was similar for Medicare beneficiaries but more attenuated (14.7% vs 11.0%, p = 0.04). Medication rates were similar among Medicaid beneficiaries (10.0% vs 9.0%, p = 0.74). Racial/ethnic disparities in novel diabetes medications were the largest among those with private insurance. There was no disparity among Medicaid enrollees, but overall prescription rates were the lowest. Given that disparities vary considerably by payer, differences in insurance coverage may account for the observed disparities in SGLT2i and GLP1ra use. Future studies are needed to assess racial/ethnic differences in novel diabetes use by insurance formulary restrictions and out-of-pocket cost-sharing.

Associations between patient portal use and electronic health record (EHR) data timeliness in type 2 diabetes mellitus care

Abstract Objective Patient data is subject to missingness and errors. Patient portals enable patients managing type 2 diabetes mellitus (T2DM) to review and correct data to avoid retesting, medication errors, and diagnostic mistakes. We examined whether patient portal use was associated with electronic health record (EHR) data timeliness in T2DM care. Research Design and methods We analyzed EHR data from a panel of adult patients to determine whether portal use improved data timeliness. EHR data timeliness is measured as the number of days between patient encounters, accounting for mean attribute update periods, where available EHR attribute updates for T2DM measurements were present, including body mass, weight, glycated hemoglobin A1c, cholesterol, blood pressure, serum creatinine, and smoking status. We performed negative binomial regressions with fixed effects to estimate the association between patient portal use and EHR data timeliness. Sensitivity analyses were conducted using Poisson regressions. Results Nearly a third (31.3%) of patients in our sample actively used the health portal. There were fewer days (111.9 days vs. 136.7 days; p &lt; 0.001) between EHR attribute updates for patients who used health portals compared to patients who did not. Data timeliness was lower among female, non-Hispanic White Medicare beneficiaries. Based on regression analyses, portal use was associated with an expected 3.6 (p &lt; 0.001) percentage point decrease in days between attribute updates, indicating improved EHR timeliness. Conclusion Improving the quality of health information may streamline decision-making in partnership with patients who produce data points across clinical settings. Active use of patient portals and digital health tools in chronic disease care are critical for care management and clinical decision-making, especially for patients managing type 2 diabetes across clinical settings.

Patterns of Infliximab Biosimilar Uptake for Medicare, Medicaid, and Private Insurance from 2016 to 2022.

Biosimilars have the potential to reduce spending on biologic drugs, yet uptake has been slower than anticipated. We investigated how successive introductions of infliximab biosimilars influenced their adoption by major US insurance providers. Data came from the Rheumatology Informatics System for Effectiveness, a national registry with electronic health records from more than 1,100 US rheumatologists. All infliximab administrations (bio-originator or biosimilar) to patients aged ≥18 years from April 2016 to September 2022 were included. We used an interrupted time series to model the effect of each infliximab biosimilar release (infliximab-dyyb, November 2016; infliximab-adba, July 2017; and infliximab-axxq, July 2020) on uptake across Medicare, Medicaid, and private insurers. With the first and second biosimilar releases, biosimilar uptake rose slowly, with average annual increases of ≤5% from 2016 to June 2020 (Medicare 3.2%, Medicaid 5.2%, and private insurance 1.8%). With the third biosimilar release in July 2020, the average annual increase reached 13% for Medicaid and 16.4% for private insurance but remained low for Medicare (5.6%). By September 2022, uptake was higher for Medicaid (43.8%) and private insurance (38.5%) than for Medicare (24%). Our results have two key findings for policy makers. First, our results suggest that one or two biosimilars may not generate enough competition to speed adoption rates for biosimilars. Second, Medicare, which covers most patients receiving biologics nationally, had slow adoption rates even after the third biosimilar was introduced. Policy levers to speed adoption among Medicare beneficiaries are needed.

Correlates of Transitioning from In-Person to Telemedicine Outpatient Neurology Clinic Visits.

Introduction: The COVID-19 pandemic accelerated telemedicine adoption, impacting appointment no-show rates. This study examines neurology appointment preferences among individuals with previous no-shows. Methods: We analyzed transitions between in-person and telemedicine modalities at the Tulane Center for Clinical Neurosciences from August 2020 to February 2021 by race, sex, and insurance type. Logistic regression was used to assess which individual characteristics were associated with switching modalities. Results: A total of 118 patients were included. Transitions to telemedicine visits were significantly higher for female (odds ratio [OR] = 1.868, p = 0.051), Medicaid (OR = 0.433, p = 0.035), and Medicare (OR = 0.228, p = 0.001) beneficiaries compared with males and those with private coverage. Telemedicine to in-person transitions were significantly higher for Medicaid compared with private coverage (OR = 8.133, p = 0.018). Discussion: Females are more likely to switch to telemedicine following an in-person no-show, whereas Medicare beneficiaries are less likely. Medicaid beneficiaries are more likely to revert to in-person appointments. Telemedicine may enhance equitable neurological care, particularly because of its high utilization among females.

Crosswalk Algorithms for Cognitive and Functional Outcomes Among 2013–2018 Medicare Beneficiaries With Dementia

ObjectiveBefore 2019, the Minimum Data Set (MDS) and Outcome and Assessment Information Set (OASIS) had incongruent response categories for rating cognitive impairment and activities of daily living (ADLs), hindering direct comparisons between nursing facilities and home health. We devised rule-based algorithms to compare cognitive impairment and ADL limitations between these 2 care settings among people with Alzheimer's disease and Alzheimer's disease–related dementias (ADRD). DesignA retrospective cohort study. Setting and ParticipantsIncluded fee-for-service Medicare beneficiaries (2013–2018) transitioning from nursing facilities to home health, with 1-year of continuous enrollment, aged ≥65 years, diagnosed ADRD, and with complete MDS discharge and OASIS admission assessments (N = 398,496). MethodsWe identified target phenotypes using the Cognitive Function Scale (CFS) and ADL items from the MDS discharge assessment as reference standards. We compared 6 OASIS-based algorithms for cognitive impairment and 1 for each ADL limitation by estimating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). ResultsThe average age was 83.5 (SD = 7.5) years and 82.3% transitioned from nursing to home health within 3 days. In the MDS discharge assessment, 42.2% had moderate-to-severe cognitive impairment. ADL limitations ranged from 71.4% for feeding to 97.8% for bathing. Compared with the moderate-to-severe cognitive impairment (CFS ≥3) on the MDS, the OASIS cognitive assessment indicating “considerable assistance to total dependence in routine situations” had 24% sensitivity, 94% specificity, 75% PPV, and 63% NPV. The ADL limitation algorithms exhibited high sensitivities (>96%) and PPVs (>94%) except for feeding (Sensitivity: 82%; PPV: 74%). Despite the short time frame between the 2 assessments, the OASIS admission assessment showed a higher prevalence of ADL limitations than the MDS discharge assessment. Conclusions and ImplicationsWe highlighted differences in patient function between post-acute care settings. Our algorithms can help researchers, clinicians, and policymakers standardize patient-centered outcomes for comparative effectiveness research or quality initiatives.

Adverse events in men with advanced prostate cancer treated with androgen biosynthesis inhibitors and androgen receptor inhibitors.

The use of androgen biosynthesis and second-generation androgen receptor inhibitors for advanced prostate cancer is increasing. Because these therapies alter the androgen pathway, they have been associated with cardiometabolic and neurocognitive toxicities. Although their safety profiles have been assessed in clinical trials, real-world data are limited. A 20% sample of national Medicare claims was used to perform a retrospective cohort study of Medicare beneficiaries with advanced prostate cancer treated with androgen biosynthesis (ie, abiraterone) and second-generation androgen receptor inhibitors between 2012 and 2019. Outcomes were assessed after the first fill of either class of drug for the 12-month period after starting therapy. The primary outcome was a hospital admission or emergency department visit for a cardiometabolic event. Secondary outcomes included neurocognitive events and fractures. Multivariable regression was used to assess the association between the class of drug and occurrence of an adverse event. There were 3488 (60%) men started on an androgen biosynthesis inhibitor and 2361 (40%) started on an androgen receptor inhibitor for the first time. Cardiometabolic adverse events were more common in men managed with androgen biosynthesis inhibitor (9.2% vs 7.5%, P = .027). No difference between androgen biosynthesis and androgen receptor inhibitors was observed for neurocognitive events (3.3% vs 3.4%, respectively; P = .71) or fractures (4.2% vs 3.6%, respectively; P = .26). Men with advanced prostate cancer initiating an androgen biosynthesis inhibitor for the first time more commonly had cardiometabolic events than those started on androgen receptor inhibitors. Neurocognitive events and fractures did not differ by drug class.