Medicare Cohorts Research Articles

Contemporary Analysis of Reexcision and Conversion to Mastectomy Rates and Associated Healthcare Costs for Women Undergoing Breast-Conserving Surgery

PurposeThis study was designed to provide a comprehensive and up-to-date understanding of population-level reoperation rates and incremental healthcare costs associated with reoperation for patients who underwent breast-conserving surgery (BCS).MethodsThis is a retrospective cohort study using Merative™ MarketScan® commercial insurance data and Medicare 5% fee-for-service claims data. The study included females aged 18–64 years in the commercial cohort and females aged 18 years and older in the Medicare cohort, who underwent initial BCS for breast cancer in 2017–2019. Reoperation rates within a year of the initial BCS and overall 1-year healthcare costs stratified by reoperation status were measured.ResultsThe commercial cohort included 17,129 women with a median age of 55 (interquartile range [IQR] 49–59) years, and the Medicare cohort included 6977 women with a median age of 73 (IQR 69–78) years. Overall reoperation rates were 21.1% (95% confidence interval [CI] 20.5–21.8%) for the commercial cohort and 14.9% (95% CI 14.1–15.7%) for the Medicare cohort. In both cohorts, reoperation rates decreased as age increased, and conversion to mastectomy was more prevalent among younger women in the commercial cohort. The mean healthcare costs during 1 year of follow-up from the initial BCS were $95,165 for the commercial cohort and $36,313 for the Medicare cohort. Reoperations were associated with 24% higher costs in both the commercial and Medicare cohorts, which translated into $21,607 and $8559 incremental costs, respectively.ConclusionsThe rates of reoperation after BCS have remained high and have contributed to increased healthcare costs. Continuing efforts to reduce reoperation need more attention.

Use of High-Risk Medications Among Older Adults Enrolled in Medicare Advantage Plans vs Traditional Medicare

Limiting the use of high-risk medications (HRMs) among older adults is a national priority to provide a high quality of care for older beneficiaries of both Medicare Advantage and traditional fee-for-service Medicare Part D plans. To evaluate the differences in the rate of HRM prescription fills among beneficiaries of traditional Medicare vs Medicare Advantage Part D plans and to examine the extent to which these differences change over time and the patient-level factors associated with higher rates of HRMs. This cohort study used a 20% sample of Medicare Part D data on filled drug prescriptions from 2013 to 2017 and a 40% sample from 2018. The sample comprised Medicare beneficiaries aged 66 years or older who were enrolled in Medicare Advantage or traditional Medicare Part D plans. Data were analyzed between April 1, 2022, and April 15, 2023. The primary outcome was the number of unique HRMs prescribed to older Medicare beneficiaries per 1000 beneficiaries. Linear regression models were used to model the primary outcome, adjusting for patient characteristics and county characteristics and including hospital referral region fixed effects. The sample included 5 595 361 unique Medicare Advantage beneficiaries who were propensity score-matched on a year-by-year basis to 6 578 126 unique traditional Medicare beneficiaries between 2013 and 2018, resulting in 13 704 348 matched pairs of beneficiary-years. The traditional Medicare vs Medicare Advantage cohorts were similar in age (mean [SD] age, 75.65 [7.53] years vs 75.60 [7.38] years), proportion of males (8 127 261 [59.3%] vs 8 137 834 [59.4%]; standardized mean difference [SMD] = 0.002), and predominant race and ethnicity (77.1% vs 77.4% non-Hispanic White; SMD = 0.05). On average in 2013, Medicare Advantage beneficiaries filled 135.1 (95% CI, 128.4-142.6) unique HRMs per 1000 beneficiaries compared with 165.6 (95% CI, 158.1-172.3) HRMs per 1000 beneficiaries for traditional Medicare. In 2018, the rate of HRMs had decreased to 41.5 (95% CI, 38.2-44.2) HRMs per 1000 beneficiaries in Medicare Advantage and to 56.9 (95% CI, 54.1-60.1) HRMs per 1000 beneficiaries in traditional Medicare. Across the study period, Medicare Advantage beneficiaries received 24.3 (95% CI, 20.2-28.3) fewer HRMs per 1000 beneficiaries per year compared with traditional Medicare beneficiaries. Female, American Indian or Alaska Native, and White populations were more likely to receive HRMs than other groups. Results of this study showed that HRM rates were consistently lower among Medicare Advantage than traditional Medicare beneficiaries. Higher use of HRMs among female, American Indian or Alaska Native, and White populations is a concerning disparity that requires further attention.

Direct health care costs associated with COVID-19 in the United States.

BACKGROUND: Data on the real-world health care burden of COVID-19 in the United States are limited. OBJECTIVE: To compare health care resource use (HRU), direct health care costs, and long-term COVID-19-related complications between patients with vs patients without COVID-19 diagnoses. METHODS: Using IBM MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits administrative claims databases (January 1, 2018, to March 1, 2021), this retrospective, matched cohort study compared patients with a recorded COVID-19 diagnosis to control subjects with no recorded diagnosis for COVID-19, personal history of COVID-19, or pneumonia due to COVID-19. To capture typical health care utilization, the control group was analyzed in 2019 (prepandemic); their index date was assigned as 1 year before the index date (first observed COVID-19 diagnosis) of their matched COVID-19 patient. All patients had continuous health plan coverage for at least 6 months pre-index (baseline) and at least 6 months post-index (allowing censoring during month 6). Separately for commercial and Medicare cohorts, COVID-19 and control patients were matched 1:1 using propensity scores, number of followup months, and indicator of age 18 years or older. During each month of the 6-month follow-up, all-cause HRU, health care costs, and COVID-19-related complications were compared between patients with COVID-19 and controls. RESULTS: After matching COVID-19 and control patients 1:1, a total of 150,731 commercial matched pairs and 1,862 Medicare matched pairs were retained; baseline characteristics were similar between patients with COVID-19 and controls. Patients with COVID-19 and controls had mean ages of 38.9 and 39.7 years in the commercial cohort and 74.3 and 75.3 years in the Medicare cohort, respectively. In month 1 of follow-up, patients with COVID-19 relative to controls were significantly more likely to have at least 1 inpatient admission (commercial: 6.9% vs 0.5%; Medicare: 29.1% vs 1.3%; both P < 0.001) and at least 1 emergency department visit (commercial: 37.3% vs 3.4%; Medicare: 26.2% vs 4.1%; both P < 0.001). Total health care costs in month 1 were significantly higher among patients with COVID-19 than controls (mean differences: $3,706 for commercial; $10,595 for Medicare; both P < 0.001), driven by inpatient costs. Though the incremental HRU and cost burden of COVID-19 decreased over time, patients with COVID-19 continued to have significantly higher total costs through month 5 (all P < 0.001 for both commercial and Medicare). During follow-up, patients with COVID-19 had significantly higher rates of complications than controls (commercial: 52.8% vs 29.0% with any; Medicare: 74.5% vs 47.9% with any; both P < 0.001), most commonly cough, dyspnea, and fatigue. CONCLUSIONS: COVID-19 was associated with significant economic and clinical burden, both in the short-term and over 6 months following diagnosis. DISCLOSURES: Jessica K DeMartino is an employee of Janssen Scientific Affairs, LLC. Elyse Swallow, Debbie Goldschmidt, Karen Yang, Marta Viola, Tyler Radtke, and Noam Kirson are employees of Analysis Group, Inc., which has received consulting fees from Janssen Scientific Affairs, LLC. This study was funded by Janssen Scientific Affairs, LLC. The sponsor was involved in the study design, interpretation of the results, manuscript review, and the decision to publish the article.

Shoulder MRI lag times after implementation of the Affordable Care Act (ACA): a retrospective review

Background: With the Affordable Care Act (ACA), the challenge of expanding healthcare insurance to Americans without jeopardizing quality of care remains. This study was initiated to evaluate how the timing of magnetic resonance imaging (MRI) completion for shoulder pathology correlates with implementation of the ACA by comparing lag times between the initial visit and the date of MRI completion. In addition, the access to orthopaedic care after ACA implementation was evaluated by comparing shoulder MRI lag times among three cohorts based on insurer status. Methods: All shoulder and proximal upper extremity MRIs between 2009 and 2017 were reviewed, 5 yr before and 3 yr after ACA implementation. Patients were grouped into commercial, Medicare, and Medicaid cohorts. Average lag times for the pre- and post-ACA periods overall and among payor cohorts were calculated. Results: Included were 5900 MRIs, 1997 (33.8%) before and 3903 (66.2%) after ACA implementation. The difference in payor mix before and after ACA implementation was significantly different (P&lt;0.001). Median lag time increased from 23 days pre-ACA to 31 days post-ACA (P&lt;0.001). For commercial insurance, median lag time was 23 days pre-ACA compared with 28 days (P&lt;0.001) post-ACA. Median lag time pre- and post-ACA in the Medicaid cohort was 8 days compared with 30.5 days (P&lt;0.001), respectively. Pre- and post-ACA lag times in the Medicare cohort did not differ significantly (P=0.450). Conclusions: Lag times increased significantly after ACA implementation in patients with commercial and Medicaid insurance. This study provides valuable insight into unintended outcomes associated with the ACA legislation. Level of Evidence: Level III.

An Early Assessment of the Real-World Treatment Patterns of Type 2 Diabetes: A Comparison to the 2018 ADA/EASD Consensus Report Recommendations.

IntroductionUsing the American Diabetes Association (ADA) Hyperglycemic Pharmacotherapy Guidelines for type 2 diabetes, we evaluated the medication use patterns in real-world patients with type 2 diabetes in the USA.MethodsHealth care claims among patients with type 2 diabetes were analyzed (IBM® MarketScan® 2007 to 2019 Commercial and Medicare Databases). Diabetes treatment patterns were evaluated for the total patient sample of 580,741 during the year 2019. Prior years’ claims data were used to construct patient history and determine clinical groups per the 2018 ADA/EASD consensus statement: atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), heart failure (HF), hypoglycemia (hypo), and obesity. The recommended therapy use rates (RTUR) were calculated for clinical groups. Univariate chi-square tests were performed to compare RTUR within and outside clinical groups. Multivariate logistic regression was used to identify variables associated with recommended therapy use.ResultsA large proportion of patients belonged to multiple clinical groups; this was more common in the Medicare cohort. Each clinical group in the Commercial cohort had a substantially higher RTUR than in the Medicare cohort. However, no clinical group achieved > 40% RTUR. The RTUR was the highest in the CKD and obesity groups in the Commercial cohort and in the hypo and obesity groups in the Medicare cohort, but lowest in hypo and HF groups in the Commercial and Medicare cohorts, respectively.ConclusionPrevalence of guideline-aligned treatment use in 2019 was low, particularly since many patients fit into multiple risk groups with established treatment benefits.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13300-022-01289-x.

The Persistent Heart Failure And Mortality Burden Following Anterior STEMI Treated With PCI; The Role Of SSO2 Therapy

<h3>Introduction</h3> Supersaturated oxygen (SSO2) is an FDA approved adjunctive therapy for delivery to the left anterior descending coronary artery immediately following percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). In prior studies SSO2 was associated with reduction in infarct size, which is a key determinant of heart failure (HF) and mortality. Hypothesis: The burden of re-hospitalization (REHOSP) for HF and mortality remains high following anterior STEMI treated with primary PCI and SSO2 can improve these outcomes. <h3>Methods</h3> The 2005-2008 and 2016-2018 Medicare Data rates of mortality and REHOSP for HF were compared using descriptive and regression analysis to control for differences in clinical characteristics over time. From the 2016-2017 Medicare population a group was identified fulfilling the entrance criteria for the IC-HOT single arm study of SSO2 therapy for anterior STEMI conducted during this same time frame. Each of the 100 IC-HOT participants was matched to a Medicare beneficiary based on propensity score to construct a comparison group with similar characteristics also treated with primary PCI. <h3>Results</h3> The eligible Medicare group for comparison with IC-HOT included 10,634 cases and after matching standardized differences were <20, indicating balance in covariates. The IC-HOT treatment group had reduced mortality compared with the matched Medicare group at 1 year (0 vs 4.6%, p <0.02). REHOSP for HF in IC-HOT was also lower than in the Medicare group at 1 year (1.1 vs 9.2%, p <0.05) despite a significant decrease in the 1-year REHOSP for HF from the early to later Medicare cohort. This occurred with no difference in REHOSP for HF at 2 years between the early and later Medicare cohorts suggesting potential discrepancies impacted by changes in payment policy. The risk-adjusted 1-year and 2-year mortality rates increased from the early to later Medicare cohort with anterior STEMI treated with PCI alone. <h3>Conclusion</h3> Mortality and REHOSP for HF has not improved over the last decade for Medicare patients with anterior STEMI treated with PCI alone. The reduction in infarct size with SSO2 therapy is associated with a decrease in these events and thus has the potential to favorably impact this growing clinical burden in an aging population.

Treatment initiation with bone-targeting agents among patients with bone metastasis secondary to solid tumors or patients with multiple myeloma.

309 Background: Recent real-world evidence is lacking regarding the initiation of bone-targeting agents (BTAs), and time to treatment with BTAs after a diagnosis of bone metastasis secondary to solid tumors (BM-ST) or multiple myeloma (MM), in both the commercially insured and Medicare Supplemental populations. Methods: Patients aged &gt;18 and newly diagnosed with BM-ST or MM during 11/1/2016-6/30/2019 (earliest diagnosis = index date) were selected from the IBM MarketScan Commercial and Medicare Databases. Patients were continuously enrolled in the 12 months before and 6 months after the index date and had no prior evidence of BTA use, skeletal-related events (SREs), osteoporosis or Paget’s disease. Initiation of and time to BTA treatment (i.e., denosumab, zoledronic acid, ibandronate or pamidronate) were reported during the variable follow-up period. SREs prior to BTA use were reported and included spinal cord compression, pathological fractures, surgery and radiation to bone. Results were stratified by tumor type (BM-ST and MM) and payer (commercial and Medicare). Results: The analysis included 8,769 commercially insured patients (70% BM-ST and 30% MM [mean age 55 and 54]) and 4,100 Medicare patients (74% BM-ST and 26% MM [mean age 76 and 75]). Across payers, the most common comorbidities were pain and hypertension. BTA initiation for BM-ST and MM patients was 46% and 24% among the commercial cohort, and 33% and 18% among the Medicare cohort. Among BM-ST commercial and Medicare cohorts, respectively, the proportion initiating BTA varied by solid tumor type: 64% and 45% of breast, 43% and 37% of prostate, and 47% and 34% of lung. Mean (SD) time to BTA initiation for BM-ST and MM patients was 3.0 (4.2) and 3.7 (5.2) months for the commercial cohort, and 3.1 (4.7) and 2.9 (3.3) months for the Medicare cohort. Among patients with BTA initiation, the proportion of BM-ST and MM patients with SREs prior to BTA treatment was 33% and 31% for the commercial cohort and 23% and 26% for the Medicare cohort. Across payers, the majority of first SREs were radiation to bone for BM-ST patients and pathological fracture for MM patients. Conclusions: For commercial patients, about one-half of BM-ST patients and a quarter of MM patients initiated BTA treatment; for Medicare patients, these proportions decreased to a third and a fifth, respectively. On average, BTA initiation occurred within about 3 to 4 months from first diagnosis. The proportion of commercial and Medicare patients with SREs prior to BTA initiation was a third and a quarter, respectively. Results generated from this study should be supplemented by the evaluation of the relationship between bone protection treatment patterns and outcomes associated with BM-ST and MM.

209. Does increased regional discretionary spending correlate with safety in spine surgery among Medicare beneficiaries?

<h3>BACKGROUND CONTEXT</h3> Spine surgery in Medicare patients has increased in recent years and its use is variable across geographic regions. Corresponding wide variation in costs are also well-documented. Provider care intensity, a marker for discretionary care (eg, unnecessary imaging, tests, injections, and visits), is the component of spending variation that is independent of patient severity, age, and regional pricing. It is unknown if greater provider care intensity is associated with improved safety, as we might expect from value-based care. <h3>PURPOSE</h3> To determine if increased provider care intensity was associated with safety among five Medicare cohorts undergoing spinal surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective analysis of Medicare claims, 2013-2017. <h3>PATIENT SAMPLE</h3> We included beneficiaries (age 65+) undergoing inpatient spinal surgery as defined by the Center for Medicare and Medicaid Innovation, including "cervical fusion," "fusion, except cervical," "anterior-posterior combined fusion," "complex fusion," and "back or neck surgery, except fusion." Claims included variables on age, sex and race, as well as codes from the International Classification of Diseases, used to calculate the Charlson Comorbidity Index. Regional 90-day episode costs for the five cohorts ranged from a low of $32,384 for cervical fusion to a high of $123,388 for complex fusion. <h3>OUTCOME MEASURES</h3> Safety was measured as mortality, pulmonary embolism, deep vein thrombosis, and all-cause readmission over the first 90-days following surgery. <h3>METHODS</h3> Patients were classified by the Hospital Referral Region (HRR) where surgery occurred. Regions were grouped into quintiles based on the Dartmouth Atlas End-of-Life Expenditure Index (EOL), reflecting spending variation due to practice care intensity. Multivariable regression examined the association between care intensity and our safety measures, controlling for age, sex, race, and comorbidity. To further mitigate unobserved confounding by indication, we also added year and hospital fixed-effects parameters, and applied EOL as an instrumental variable. <h3>RESULTS</h3> Within each cohort, we observed a 4-fold variation in 90-day episode cost across HRRs. Spine-specific spending was correlated with EOL quintile, confirming that spending variation is due to provider care intensity more than pricing, age, or illness severity. Greater spending across EOL quintile was not associated with improved safety, and in-fact, was associated with significantly worse outcomes in some cohorts. For example, all-cause readmission was greater in the high spending quintile relative to the low spending quintile among the "Fusion, except cervical" cohort (14.2% vs 13.1%; OR 1.10; 95% CI 1.05 – 1.20; p<0.001), the "complex fusion" cohort (28.0% vs 25.4%; OR 1.15; 95% CI 1.01 – 1.30; p=0.033), and the "cervical fusion" cohort (15.0% vs 13.6%; OR 1.12; 95% CI 1.05 – 1.20; p<0.001). Fixed effects and instrumental variable models yielded consistent results. <h3>CONCLUSIONS</h3> Wide variation in regional 90-day episode-of-care spine spending was not explained by differences in patient severity, age, or regional pricing. Hospitals in the highest spending quintile spent between $10,378 (back & neck) to $35,533 (complex fusion) more per patient than those in the lowest quintile, but increased spending did not result in enhanced safety. These findings point to inefficient and potentially wasteful use of health care resources, which should be a focus of payment reforms. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Trends in Coded Indications for Percutaneous Coronary Interventions in Medicare and the Veterans Affairs After Implementation of Hospital-Level Reporting of Appropriate Use Criteria.

In 2009, the American College of Cardiology and American Heart Association published Appropriate Use Criteria for Coronary Revascularization (AUC) to aid patient selection for percutaneous coronary intervention (PCI). The subsequent decline in inappropriate PCIs was interpreted as a success of AUC. However, there are concerns clinicians reclassify nonacute PCIs to acute indications to fulfill AUC. A longitudinal, observational difference-in-differences analysis was performed using administrative claims from US Department of Veterans Affairs (VA) beneficiaries coenrolled in Medicare and from a national random sample of Medicare beneficiaries, undergoing PCI from September 30, 2009, to December 31, 2013. Non-VA hospitals participating in the American College of Cardiology CathPCI registry began receiving AUC reports in 2011, while VA hospitals did not receive reports, serving as quasiexperimental and control cohorts, respectively. We measured the proportion of PCIs coded for acute myocardial infarction, unstable angina, and nonacute coronary syndrome indications by quarter. There were 87 464 and 30 251 PCIs performed in the Medicare and VA cohorts, respectively. In Medicare, proportion of PCIs coded for acute myocardial infarction and unstable angina changed from 31.9% and 12.6% in quarter 4 2009 to 41.0% and 10.5% in quarter 4 2013, an associated 2.00% (95% CI, 1.56%-2.44%; P<0.001) increase per year in PCIs coded for acute coronary syndrome indications. In the VA, proportion of PCIs coded for acute myocardial infarction and unstable angina changed from 26.5% and 15.7% in quarter 4 2009 to 34.3% and 12.3% in quarter 4 2013, an associated 1.20% (95% CI, 0.56%-1.88%; P=0.001) increase per year in PCIs coded for acute coronary syndrome indications. Difference-in-differences modeling found no statistically significant change in PCI coded for acute indications between Medicare and VA, pre- and post-AUC reporting. After introduction of AUC assessments and reporting, we observed comparable increases in coding for acute myocardial infarction and corresponding decreases in coding for unstable angina and nonacute coronary syndrome indications among national cohorts of Medicare and VA enrollees. The provision of appropriate use reporting did not appear to have a substantial impact on the proportion of PCIs coded for acute indications during this study period.

Rates of genetic testing in patients prescribed drugs with pharmacogenomic information in FDA-approved labeling.

This study examined rates of genetic testing in two cohorts of publicly insured individuals who have newly prescribed medication with FDA pharmacogenomic labeling guidance. Genetic testing was rare (4.4% and 10.5% in Medicaid and Medicare cohorts, respectively) despite the fact that all participants selected were taking medications that contained pharmacogenomic labeling information. When testing was conducted it was typically done before the initial use of a target medication. Factors that emerged as predictors of the likelihood of undergoing genetic testing included White ethnicity (vs. Black), female gender, and age. Cost analyses indicated higher expenditures in groups receiving genetic testing vs. matched comparators with no genetic testing, as well as disparities between proactively and reactively tested groups (albeit in opposite directions across cohorts). Results are discussed in terms of the possible reasons for the low base rate of testing, mechanisms of increased cost, and barriers to dissemination and implementation of these tests.

Outcomes of Same-Day Discharge After Total Hip Arthroplasty in the Medicare Population

BackgroundThere is an increasing utilization of same-day discharge total hip arthroplasty (SDD THA). As the Center for Medicare and Medicaid Services considers removing THA from the inpatient-only list, there is likely to be a significant increase in the number of Medicare patients undergoing SDD THA. Thus, there is a need to report on outcomes of SDD THA in this population. MethodsA retrospective review was performed on 850 consecutive SDD THA patients including 161 Medicare patients. We compared failure to launch, complication, emergency department visit, and 90-day readmission rates between the Medicare and non-Medicare cohorts. ResultsThe Medicare group was older and had less variability in their admission diagnosis. There was no significant difference in failure to launch, complication, emergency department visit, or 90-day readmission rates between Medicare and non-Medicare groups. ConclusionThe benefits of SDD THA can be safely extended to the carefully indicated and motivated Medicare patient.

Impact of Centers for Medicare and Medicaid Services Non-Reimbursement on Hospital-Acquired Conditions Following Spine Procedures

Abstract INTRODUCTION In an effort to reduce inpatient complications, the Centers for Medicare and Medicaid Services (CMS) discontinued reimbursements for certain complications beginning in October 2008. These were termed hospital-acquired conditions (HACs), and include surgical site infection, deep venous thrombosis, catheter-associated urinary tract infections, and falls, among others. The effect of this policy has not been extensively studied in the spine surgery population. METHODS A retrospective administrative insurance claims database containing data on Medicare and commercially insured patients was used to extract information on admissions associated with 1- and 2-level anterior discectomy and fusion (ACDF), lumbar laminectomy (LL), lumbar discectomy (LD), and 2- and 3-level posterior lumbar fusion (PLF). Relevant HACs were selected using International Classification of Diseases-9 codes, and a present-on-admission indicator was estimated using prior records. Difference-in-difference (DID) regressions were used to estimate the effect of the CMS nonreimbursement policy on Medicare insured patients compared to a similarly aged nonMedicare patient populations. RESULTS A total of 23 120 and 38 290 commercially insured patients met criteria. Of those, 20 265 (33%) underwent ACDF, 24 918 (41%) underwent LL or LD, and 16 227 (26%) underwent PLF. From 2007 to 2014, 2.4% (95% CI: 2.2-2.6%) and 2.2% (2.1-2.4%) of admissions were associated with at least 1 HAC in the Medicare and commercial cohorts, respectively (P = .08). A DID regression on the occurrence of any HAC, which included patients from 2007 to 2010, explained 0.8% of the total variance (adjusted multiple R2 = 0.008). Medicare insurance, postpolicy admissions, and their interaction term were not significant (all P &gt; .29). CONCLUSION In this study, we found no effect of the CMS policy on rates of HAC in spinal surgery patients. This suggests that this policy, implemented in 2008, has not reduced HAC occurrence in this spine surgery population compared to our control population.

Unicondylar Knee Arthroplasty Has Fewer Complications but Higher Revision Rates Than Total Knee Arthroplasty in a Study of Large United States Databases

BackgroundUnicondylar knee arthroplasty (UKA) has superior functional outcomes compared to total knee arthroplasty (TKA) with good mid-term and long-term survival data from high-volume institutions. We sought to quantify the risk of complications, re-operation/revision, hospital re-admission for any reason, and mortality of knee arthroplasty patients in the US patient population using 2 large databases. MethodsUKA and TKA patients who were identified in the 2002-2011, 5% sample of Medicare data and 2004-2012 (June) MarketScan Commercial and Medicare Supplemental Databases were followed to evaluate the risk of complications, hospital re-admission for any reason, and mortality within 90 days of surgery. Survival probability defined by re-operation was calculated using the Kaplan-Meier method at 0.5, 2, 5, 7, and up to 10 years post-operatively. ResultsCompared to UKA, complication rates for TKA patients were significantly higher, including wound complication, pulmonary embolism, stiffness, peri-prosthetic joint infection, myocardial infarction, re-admission, and death. Age was found to be a significant risk factor (P < .05) for all complications in the Medicare cohort, except stiffness (P = .839), and all complications in the MarketScan cohort, except re-admission (P = .418), whereas gender had a variable effect on complications based on age. Survivorship of UKA was lower than TKA at all time points. Additionally, younger age adversely affected implant survival. By 7 years post-surgery, UKA survivorship in the Medicare and MarketScan cohorts was 80.9% and 74.4%, respectively. In contrast, TKA survivorship for the same cohorts was 95.7% and 91.9% by the same time point. ConclusionPatients undergoing UKA have fewer post-operative complications and re-admissions than those undergoing TKA. However, patients undergoing UKA have a higher rate of re-operation and revision at up to 10 years of follow-up. It appears that age, as well as surgeon and hospital volume significantly impacts implant survivorship while gender does not have a relation. Level of EvidenceLevel III.

The Timing of Corticosteroid Injections After Arthroscopic Shoulder Procedures Affects Postoperative Infection Risk

Background: Corticosteroid injections are sometimes used in the postoperative period after shoulder arthroscopy; however, a well-defined safety profile has not been established. Purpose: To examine the association between the timing of postoperative corticosteroid injections and rates of infection after shoulder arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: Private payer and Medicare national insurance databases were queried for patients who underwent arthroscopic rotator cuff repair, debridement, or subacromial decompression. Patients who underwent corticosteroid injections within 1, 2, 3, or 4 months postoperatively were identified and compared with a matched control group that underwent the same procedures without a postoperative steroid injection. International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes were used to identify rates of postoperative infection within 90 days after injection for the study groups and controls. Multivariate binomial logistic regression analysis was used to compare groups, and adjusted odds ratios (ORs) and 95% CIs were calculated, with P < .05 considered significant. Results: A total of 3946 patients were identified, including 264 patients who received an injection within 1 month after surgery, 471 within 2 months, 1037 within 3 months, 1874 within 4 months, and 2640 matched controls. When compared with controls, patients who underwent a corticosteroid injection within 1 month postoperatively had a significantly higher rate of infection (private payer: OR, 2.63; P = .014; Medicare: OR, 11.2; P < .0001). There were no differences in infection rates at all other time points (P = .264-.835). Conclusion: This study adds to the evidence suggesting caution when administering injections in the immediate postoperative period after shoulder arthroscopy. Although causality cannot be determined on the basis of this database review, the authors found a significant association between intra-articular corticosteroid injections administered 1 month postoperatively and an increased rate of postoperative infection in Medicare and private payer patient cohorts as compared with a control group.

Payer type does not impact patient-reported outcomes after primary total knee arthroplasty.

BackgroundThere is a paucity of literature assessing whether payer type has an impact on postoperative patient-reported outcomes (PROs) after total knee arthroplasty (TKA). The aim of this study was to comparatively evaluate TKA PROs among patients with commercial and Medicare insurance.MethodsWe conducted a single-center, retrospective review of patients operated between January 2017 and March 2018. Knee Disability and Osteoarthritis Outcome Score Junior (KOOS-Jr) and Veterans RAND 12 Health Survey (VR-12) Physical Component (VR-12 PCS) and Mental Component (VR-12 MCS) PRO scores were collected prospectively at baseline and 12 weeks postoperatively via an electronic patient rehabilitation application. Univariable and multivariable linear regressions were utilized to assess the effects of patient insurance type on PRO.ResultsIn total, 193 TKA candidates had commercial (n = 91) or Medicare (n = 102) as their primary payer type. Demographic variables including age, gender, body mass index, and race varied significantly between the cohorts (P < .05). Length of stay and discharge disposition also varied significantly (P < .05). When compared with commercial payers, Medicare beneficiaries demonstrated a 4.13 ± 2.06 increase in Knee Disability and Osteoarthritis Outcome Score JR. scores at baseline (P < .05). However, after adjusting for patient-specific demographic and perioperative variables, all PROs recorded in this study were similar between the 2 payer groups at baseline and 12 weeks postoperatively (P > .05). Furthermore, ΔPRO scores from baseline to 12 weeks were also similar (P > .05).ConclusionsAfter adjusting for patient-specific variables, PROs are similar at baseline and 12 weeks postoperatively between commercial and Medicare cohorts. For TKA candidates with similar baseline demographics, surgeons can expect similar perioperative PROs regardless of insurance type.

Representativeness of Medicare Participants in the Jackson Heart Study for African American Medicare Beneficiaries.

The Jackson Heart Study (JHS) assesses cardiovascular disease risk factors among African Americans in Jackson, Mississippi. Whether characteristics of JHS participants differ from those of a broader African American population are unknown. In a retrospective observational analysis, we compared characteristics and outcomes of JHS participants 65 years old and older and enrolled in Medicare (n = 1,105) to regional (n = 57,489) and national (n = 95,494) cohorts of African American Medicare beneficiaries. We weighted the regional and national cohorts to match the age and sex distributions of the JHS-Medicare cohort for pairwise baseline comparisons. Outcomes of interest included mortality and Medicare costs. We used Cox proportional hazards models to test associations between cohorts and outcomes. The JHS-Medicare cohort was younger, included more women, and had fewer beneficiaries with dual Medicare-Medicaid eligibility, compared with regional and national Medicare cohorts. The cohort also had lower risks of stroke, lung disease, heart failure, diabetes, and renal disease. Mean Medicare costs were lower ($5,066 [SD = $11,932]) than in the regional ($7,419 [SD = $17,574]) and national ($8,013 [SD = $19,378]) cohorts. The regional and national cohorts had higher mortality (adjusted hazard ratios = 1.52; 95% confidence interval [CI] = 1.31, 1.76; and 1.49; 95% CI = 1.29, 1.73, respectively). Subgroup analysis for dual Medicare-Medicaid eligibility attenuated mortality differences. JHS-Medicare participants had fewer comorbid conditions, better survival, and lower Medicare costs compared with regional and national cohorts. Observed differences may reflect healthy volunteer bias and higher socioeconomic status.See video abstract at, http://links.lww.com/EDE/B235.

Impact of Insurance Provider on Overall Costs in Failed Back Surgery Syndrome: A Cost Study of 122,827 Patients

Failed back surgery syndrome (FBSS) affects 40% of patients following spine surgery with estimated costs of $20 billion to the US health care system. The aim of this study was to assess the cost differences across the different insurance providers for FBSS patients. A retrospective longitudinal study was performed using the Truven MarketScan® database to identify FBSS patients from 2001 to 2012. Patients were grouped into Commercial, Medicaid, or Medicare cohorts. We collected one-year prior to FBSS diagnosis (baseline), then at year of spinal cord stimulation (SCS)-implantation and nine-year post-SCS implantation cost outcomes. We identified 122,827 FBSS patients, with 117,499 patients who did not undergo an SCS-implantation (Commercial: n = 49,075, Medicaid: n = 23,180, Medicare: n = 45,244) and 5328 who did undergo an SCS implantation (Commercial: n = 2279, Medicaid: n = 1003, Medicare: n = 2046). Baseline characteristics were similar between the cohorts, with the Medicare-cohort being significantly older. Over the study period, there were significant differences in overall cost metrics between the cohorts who did not undergo SCS implantation with the Medicaid-cohort had the lowest annual median (interquartile range) total cost (Medicaid: $4530.4 [$1440.6, $11,973.5], Medicare: $7292.0 [$3371.4, $13,989.4], Commercial: $4944.3 [$363.8, $13,294.0], p < 0.0001). However, when comparing the patients who underwent SCS implantation, the commercial-cohort had the lowest annual median (interquartile range) total costs (Medicaid: $4045.6 [$1146.9, $11,533.9], Medicare: $7158.1 [$3160.4, $13,916.6], Commercial: $2098.1 [$0.0, $8919.6], p < 0.0001). Our study demonstrates a significant difference in overall costs between various insurance providers in the management of FBSS, with Medicaid-insured patients having lower overall costs compared to Commercial- and Medicare-patients. SCS is cost-effective across all insurance groups (Commercial > Medicaid > Medicare) beginning at two years and continuing through nine-year follow-up. Further studies are necessary to understand the cost differences between these insurance providers, in hopes of reducing unnecessary health care expenditures for patients with FBSS.

The Effect of Payer Type, Disposition, and Day of Surgery on Resource Consumption following Hip Fracture Care

AbstractAs we shift from a fee-for-service to value-based reimbursement system, it is critical that orthopaedic surgeons assess all characteristics of the patient prior to surgical intervention. The purpose of this study was to evaluate the relationship of payer type and disposition on direct and indirect measures of resource consumption (length-of-stay [LOS], hospital cost, and 30-day readmission). Patients equal to or more than 55 years of age with radiographic evidence of hip fracture necessitating surgical intervention were included. Initially, baseline characteristics, including age, body mass index (BMI), American Society of Anesthesiologist (ASA) score, fracture type, and instrumentation, were reported by payer type (private versus Medicare) and disposition (skilled nursing facility [SNF], home, and home health). In the second phase, the independent effects of payer type and disposition on resource consumption were evaluated. Lastly, the impact of payer type and day of admission on disposition were assessed. A total of 478 patients met the inclusion criteria. Evaluation of baseline characteristics demonstrated that age and ASA scores were significantly higher within the Medicare and SNF cohorts, when compared with private payers and home/home health, respectively. Medicare as a payer type resulted in an increased LOS (5.6 versus 4.5 days) and greater hospital cost (12.1%) than private payers. Moreover, payer type was not predictive of 30-day readmission. Disposition following operative fixation resulted in an average LOS of 5.8, 4.4, and 4 days for patients discharged to SNF, home, and home health, respectively. No significant difference in hospital stay was noted between home and home health patients. Compared with patients discharged home, in-hospital cost was 33.9 and 12.3% greater for the SNF and home heath cohorts, respectively. Finally, 21.6% of patients discharged to a SNF were readmitted within 30 days. Our results indicate Medicare patients and those discharged to a SNF are more likely to have longer LOS and incur greater costs. Additionally, 30-day readmission is significantly higher in patients discharged to SNF. Thus, patients with hip fracture should be rigorously optimized within the preoperative setting to enhance clinical outcomes. Moreover, additional resources should be allocated to the higher risk patients.

PHS5 - Contextual analysis of determinants of late Diagnosis of Hepatitis C Virus infection in medicare patients

Patient- and county-level characteristics associated with advanced liver disease (ALD) at hepatitis C virus (HCV) diagnosis were examined in three Medicare cohorts: (1) elderly born before 1945; (2) disabled born 1945-1965; and (3) disabled born after 1965. We used Medicare claims (2006-2009) linked to the Area Health Resource Files. ALD was measured over the period of 6 months before to 3 months after diagnosis. Using weighted multivariate modified Poisson regression to address generalizability of findings to all Medicare patients, we modeled the association between contextual characteristics and presence of ALD at HCV diagnosis. We identified 1,746, 3,351, and 592 patients with ALD prevalence of 28.0%, 23.0%, and 15.0% for birth cohorts 1, 2, and 3. Prevalence of drug abuse increased among younger birth cohorts (4.2%, 22.6%, and 35.6%, respectively). Human immunodeficiency virus coinfection (prevalence ratio [PR] = 0.63; 95% confidence interval [CI]: 0.50-0.80; P = 0.001), dual Medicare/Medicaid eligibility (PR = 0.89; 95% CI: 0.80-0.98; P = 0.017), residence in counties with higher median household income (PR = 0.82; 95% CI: 0.71-0.95; P = 0.008), higher density of primary care providers (PR = 0.84; 95% CI: 0.73-0.98; P = 0.022), and more rural health clinics (PR = 0.90; 0.81-1.01; P = 0.081) were associated with lower ALD risk. End-stage renal disease (PR = 1.41; 95% CI: 1.21-1.63; P = 0.001), alcohol abuse (PR = 2.57; 95% CI: 2.33-2.84; P = 0.001), hepatitis B virus (PR = 1.32; 95% CI: 1.09-1.59; P = 0.004), and Midwest residence (PR = 1.22; 95% CI: 1.05-1.41; P = 0.010) were associated with higher ALD risk. Living in rural counties with high screening capacity was protective in the elderly, but associated with higher ALD risk among the disabled born 1945-1965. Conclusions: ALD prevalence patterns were complex and were modified by race, elderly/disability status, and the extent of health care access and screening capacity in the county of residence. These study results help inform treatment strategies for HCV in the context of coordinated models of care. (Hepatology 2015;62:68-78)

Contextual analysis of determinants of late diagnosis of hepatitis C virus infection in medicare patients.

Patient- and county-level characteristics associated with advanced liver disease (ALD) at hepatitis C virus (HCV) diagnosis were examined in three Medicare cohorts: (1) elderly born before 1945; (2) disabled born 1945-1965; and (3) disabled born after 1965. We used Medicare claims (2006-2009) linked to the Area Health Resource Files. ALD was measured over the period of 6 months before to 3 months after diagnosis. Using weighted multivariate modified Poisson regression to address generalizability of findings to all Medicare patients, we modeled the association between contextual characteristics and presence of ALD at HCV diagnosis. We identified 1,746, 3,351, and 592 patients with ALD prevalence of 28.0%, 23.0%, and 15.0% for birth cohorts 1, 2, and 3. Prevalence of drug abuse increased among younger birth cohorts (4.2%, 22.6%, and 35.6%, respectively). Human immunodeficiency virus coinfection (prevalence ratio [PR] = 0.63; 95% confidence interval [CI]: 0.50-0.80; P = 0.001), dual Medicare/Medicaid eligibility (PR = 0.89; 95% CI: 0.80-0.98; P = 0.017), residence in counties with higher median household income (PR = 0.82; 95% CI: 0.71-0.95; P = 0.008), higher density of primary care providers (PR = 0.84; 95% CI: 0.73-0.98; P = 0.022), and more rural health clinics (PR = 0.90; 0.81-1.01; P = 0.081) were associated with lower ALD risk. End-stage renal disease (PR = 1.41; 95% CI: 1.21-1.63; P = 0.001), alcohol abuse (PR = 2.57; 95% CI: 2.33-2.84; P = 0.001), hepatitis B virus (PR = 1.32; 95% CI: 1.09-1.59; P = 0.004), and Midwest residence (PR = 1.22; 95% CI: 1.05-1.41; P = 0.010) were associated with higher ALD risk. Living in rural counties with high screening capacity was protective in the elderly, but associated with higher ALD risk among the disabled born 1945-1965. ALD prevalence patterns were complex and were modified by race, elderly/disability status, and the extent of health care access and screening capacity in the county of residence. These study results help inform treatment strategies for HCV in the context of coordinated models of care.