Medicare Enrollees Research Articles

Dental Coverage for Medicare Beneficiaries.

Poor oral health has been associated with various systemic diseases (e.g., endocarditis, pneumonia, cardiovascular disease, and diabetes) and decreased quality of life. When enacted in 1965, Medicare excluded coverage for comprehensive dental services. As of 2023, Medicare has allowed coverage of limited dental services inextricably linked to specific medical conditions. Many Medicare Advantage plans (Medicare Part C) offer dental coverage. Yet in 2019, approximately 24 million Medicare beneficiaries (47% of all Medicare enrollees), lacked dental coverage. Seventy-one percent of traditional Medicare enrollees (those not enrolled in a Medicare Advantage Plan) reported that high cost was the primary reason that they did not obtain dental care. The importance of oral health for the older adults has been the main reason that a national interprofessional consortium, which includes several national nursing organizations, has been advocating for legislation to expand Medicare to include dental coverage. The consortium's efforts have been thwarted by fierce opposition from the American Dental Association and many Republican legislators. Given the vital role that nurses and advanced practice nurses play in caring for the nation's older adults and disabled, nursing's voice needs to be strengthened as leaders in advocating for inclusion of dental benefits in traditional Medicare.

Rates of fall injuries across three claims databases, 2019

IntroductionIn 2021, among all age groups, falls ranked as the third leading cause of unintentional injury death in the USA. Unlike fatal data, which rely on death certificates as the...

Travel burden and bypassing closest site for surgical cancer treatment for urban and rural oncology patients.

We examined the relationship between travel burden for surgical cancer care and rurality, geographic bypass of the nearest surgical facility, cancer type, and mortality outcomes. Using Medicare claims and enrollment data (2016-2018) from beneficiaries with cancer of the colon, rectum, lung, or pancreas, we measured travel times to: the nearest surgical facility and facility used. For those who bypassed the nearest, we examined travel time and rurality in relation to surgical rates. Using multivariable regression modeling, we estimated associations of bypass with 90-day postoperative- and one-year mortality; rurality was examined as an effect modifier. Among 211,025 beneficiaries with cancer, 25.5% resided in non-metropolitan areas. About 66% of metropolitan/micropolitan, and 78% of small town/rural patients bypassed their closest facility. Increasing rurality was significantly associated with increased likelihood of bypass (Referent=metropolitan, OR; 95%CI: micropolitan 1.10; 1.04-1.16, small town/rural 2.08; 1.96-2.20. Bypassing the nearest facility was associated with decreased likelihood of both 90-day postoperative mortality (OR=0.79; 95%CI 0.74-0.85) and 1-year mortality (OR=0.81; 95%CI 0.77-0.86). The greatest decrement in 1-year mortality was for pancreatic cancer across all rural-urban categories (OR; 95%CI: metropolitan 0.63; 0.53-0.76; micropolitan 0.53; 0.29-0.97); small town/rural 0.46; 0.25-0.86). Most Medicare beneficiaries with lung, colon, rectal, or pancreatic cancer bypassed the closest facility providing surgical cancer care, especially rural patients. Bypassing was associated with a lower likelihood of 90-day postoperative, and 1-year mortality. Understanding determinants of bypassing, particularly among rural patients, may reveal potential mechanisms to improve cancer outcomes and reduce rural cancer disparities.

Medication Changes Among Older Drivers Involved in Motor Vehicle Crashes

Although older adults may use potentially driver-impairing (PDI) medications that can produce psychomotor impairment, little is known about changes to PDI medication use among older adults from the time before to the time after a motor vehicle crash (MVC). To quantify use of and changes in PDI medications among older adults before and after an MVC. This cohort study used linked Medicare claims and police-reported MVC data on 154 096 person-crashes among 121 846 older drivers. Eligible persons were drivers aged 66 years or older, involved in a police-reported MVC in New Jersey from May 1, 2007, through December 31, 2017, and with continuous enrollment in Medicare fee-for-service Parts A and B for at least 12 months and Part D for at least 120 days prior to the MVC. Data were analyzed from January 2022 to May 2024. Use of benzodiazepines, nonbenzodiazepine hypnotics, opioid analgesics, and other PDI medications in the 120 days before and 120 days after the MVC. Because each person could contribute multiple MVCs during the study period if they met eligibility criteria, the unit of analysis was the number of person-crashes. The proportion of person-crashes after which PDI medications were started, discontinued, or continued was quantified as well. Among 154 096 eligible person-crashes, the mean (SD) age of the drivers was 75.2 (6.7) years at the time of the MVC. Of 121 846 unique persons, 51.6% were women. In 80.0% of the person-crashes, drivers used 1 or more PDI medications before the crash, and in 81.0% of the person-crashes, drivers used 1 or more PDI medications after the crash. Use of benzodiazepines (8.1% before the crash and 8.8% after the crash), nonbenzodiazepine hypnotics (5.9% before the crash and 6.0% after the crash), and opioid analgesics (15.4% before the crash and 17.5% after the crash) was slightly higher after the MVC. After the MVC, drivers in 2.1% of person-crashes started benzodiazepines and 1.4% stopped benzodiazepines, drivers in 1.2% of person-crashes started nonbenzodiazepine hypnotics and 1.2% stopped nonbenzodiazepine hypnotics, and drivers in 8.4% of person-crashes started opioid analgesics and 6.3% stopped opioid analgesics. This cohort study suggests that most older drivers involved in MVCs did not use fewer PDI medications after crashes than before crashes. Qualitative research of perceived risks vs benefits of PDI medications is necessary to understand the reasons why MVCs do not appear to motivate clinicians to deprescribe PDI medications as a strategy to avert potential harms, including additional MVCs.

Community-Level Social Vulnerability and Hip and Knee Joint Replacement Surgery Receipt Among Medicare Enrollees With Arthritis.

(1) Explore associations between county minority health social vulnerability index (MH-SVI) and total joint replacement (TJR), and (2) assess associations by individual-level race/ethnicity. An expanded understanding of relevant social determinants of health is essential to inform policies and practices that promote equitable access to hip and knee TJR. Retrospective cohort study of Medicare enrollees. Centers for Medicare and Medicaid Services claims data were linked with MH-SVI. Multivariable logistic regression models were used to evaluate the odds of TJR according to the MH-SVI quartile in which enrollees resided. A total of 10,471,413 traditional Medicare enrollees in 2018 aged 67 years or older with arthritis. The main outcome was enrollee primary TJR during hospitalization. The main exposure was the MH-SVI (composite and 6 themes) for the county of enrollee residence. Results were stratified by enrollee race/ethnicity. Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American (Black), and Hispanic enrollees comparatively had 26%-41% lower odds of receiving TJR than White enrollees. Residing in counties within the highest quartile of composite and socioeconomic status vulnerability measures were associated with lower TJR overall and by race/ethnicity. Residing in counties with increased medical vulnerability for Black and White enrollees, housing type and transportation vulnerability for AANHPI and Hispanic enrollees, minority status and language theme for AANHPI enrollees, and household composition vulnerability for White enrollees were also associated with lower TJR. Higher levels of social vulnerability were associated with lower TJR. However, the association varied by individual race/ethnicity. Implementing multisectoral strategies is crucial for ensuring equitable access to care.

Nationwide Availability of and Enrollment in Medicare and Medicaid Dual-Eligible Special Needs Plans With Exclusively Aligned Enrollment

In 2021, the Centers for Medicare & Medicaid Services designated a new category of dual-eligible special needs plans (D-SNPs) with exclusively aligned enrollment (receive Medicare and Medicaid benefits through the same plan or affiliated plans within the same organization). To assess the availability of and enrollment in D-SNPs with exclusively aligned enrollment and to compare the characteristics of beneficiaries enrolled in D-SNPs with exclusively aligned enrollment available vs beneficiaries without such enrollment available. Full-benefit beneficiaries enrolled in D-SNPs for 6 months or longer in 2021 or 2022. Availability of and beneficiary enrollment in D-SNPs were assessed by year and county for D-SNPs with exclusively aligned enrollment available vs D-SNPs without exclusively aligned enrollment available. The D-SNP enrollees residing in counties with aligned plans available were compared based on demographic, social, health, and area characteristics vs D-SNP enrollees in counties without such plans available. Comparisons were also made based on beneficiaries who enrolled in the aligned D-SNPs vs those who did not enroll (were enrolled in unaligned D-SNPs). The data analyses were conducted from October 1, 2023, to August 2, 2024. Availability of aligned D-SNPs and beneficiary residence by county; enrollment in exclusively aligned D-SNPs vs unaligned D-SNPs; and beneficiary demographic, social, health, and area characteristics. Of 2 197 732 beneficiaries enrolled in D-SNPs in 2021, 881 736 (40.1%) were living in counties with aligned enrollment available and 251 305 (11.4%) enrolled. Of 2 689 045 beneficiaries enrolled in D-SNPs in 2022, 1 047 223 (38.9%) were living in counties with aligned enrollment available and 318 906 (11.9%) enrolled. Beneficiaries enrolled in D-SNPs residing in counties without aligned enrollment available were more likely to live in rural or micropolitan areas (21.9%) vs beneficiaries in counties with aligned enrollment available (8.1%) (standardized mean difference [SMD], 0.38 [95% CI, 0.38-0.38]), be entitled to disability (44.4% vs 27.3%, respectively; SMD, 0.36 [95% CI, 0.36-0.36]), or be Black individuals (27.4% vs 21.4%; SMD, 0.14 [95% CI, 0.14-0.14]); were less likely to be Hispanic individuals (15.4% vs 33.7%; SMD, 0.45 [95% CI, 0.45-0.45]) or Asian or Pacific Islander individuals (6.1% vs 12.2%; SMD, 0.22 [95% CI, 0.22-0.22]); and lived in zip codes with a higher area deprivation index (mean, 66.8 [SD, 26.4] vs mean, 43.2 [SD, 29.0]; SMD, 0.86 [95% CI, 0.86-0.86]). Beneficiaries enrolled in aligned D-SNPs were more likely to be receiving long-term institutionalized care vs beneficiaries in nonaligned D-SNPs (4.3% vs 1.0%, respectively; SMD, 0.24 [95% CI, 0.24-0.25]) or have dementia or Alzheimer disease (9.2% vs 5.9%; SMD, 0.13 [95% CI, 0.13-0.13]). This study found that availability of and enrollment in D-SNPs with exclusively aligned enrollment are increasing, but the overall proportion enrolled remains low. Further reforms are needed to promote aligned enrollment.

Race/ethnicity and human epidermal growth hormone receptor 2–targeted therapy for breast cancer.

91 Background: Breast cancer is the most common cancer in the US. Up to 25% of breast cancers are classified as human epidermal growth factor receptor 2 (HER2)-positive and associated with an aggressive tumor burden. HER2-targeting monoclonal antibodies improves survival in patients with HER2-positive breast cancer. Prior work has demonstrated disparities in access to oncologic therapies among older women. Our study seeks to examine racial/ethnic disparities in receiving HER2-targeted therapies for patients with HER2-positive breast cancer and trends in use over time. Methods: In the Surveillance, Epidemiology and End Results (SEER) Medicare-linked database we identified women diagnosed with breast cancer from 2010 to 2019. We included those >66 years old who survived 12 months after diagnosis, were enrolled in Medicare Parts A/B for 12 months pre and post-diagnosis, and had local or regional stage HER2-positive cancer. Our primary outcome was receipt of HER2-targeted therapies in the 12 months after diagnosis. Our independent variable was race/ethnicity as measured by the validated Research Triangle Institute race/ethnicity codes in Medicare. Due to small sample sizes, we focus our analysis on White, Black, or Hispanic women. We used multivariable Modified Poisson regression to evaluate changes in the probability of HER2-targeted therapy receipt by race/ethnicity over time, adjusted for sociodemographics, cancer factors, and medical comorbidities. Results: Our cohort comprised 13,887 patients including 8.7% Black, 7.5% Hispanic, and 83.8% White (mean age 74.9). Overall, 7,351 (52.9%) received HER2-targeted therapies in the 12 months post-diagnosis, with use increasing over time in all racial/ethnic groups (Table). Compared with White patients, Black and Hispanic patients had a 19% (adjusted risk ratio [aRR] 0.81, 95% CI:0.69-0.96) and 27% (aRR 0.73, 95% CI 0.61-0.89) lower likelihood, respectively, of receiving HER2-targeted therapies from 2010-2011 (Table). By 2018-2019, no significant differences in receiving HER2-targeted therapies were observed across racial/ethnic groups. Conclusions: In a national cohort of Medicare enrollees with HER2-positive breast cancer, we observed significant racial/ethnic disparities which narrowed over time. Overall utilization rates were low. Future work is needed to understand how improved access to breast cancer treatments impact downstream outcomes. Use of human epidermal growth hormone receptor 2–targeted therapy from 2010-2011 and 2018-2019 by race/ethnicity. Race and Ethnicity Unadjusted Rates Adjusted Risk Ratios (95% CI)* 2010-2011 2018-2019 2010-2011 2018-2019 Black 36% 62% 0.81 (0.69-0.96) 0.97 (0.87-1.08) Hispanic 31% 68% 0.73 (0.61-0.89) 1.01 (0.92-1.12) White 42% 64% Reference Reference *Adjusted for age, marital status, region, breast cancer stage and year of diagnosis, and medical comorbidities.

Adverse respiratory events during treatment with gabapentin and opioids among older adults with spine-related conditions: a propensity-matched cohort study in the US Medicare population.

Recent work indicates no increased mortality risk with concurrent gabapentin and opioid use when using an active comparator control design. However, concurrent gabapentin and opioid prescriptions have been associated with greater risk of respiratory depression in some studies. To compare the risk of respiratory events among Medicare enrollees with spine-related diagnoses treated with gabapentin + opioids vs those treated with tricyclic antidepressants (TCA) or duloxetine + opioids. We hypothesized that enrollees treated with gabapentin + opioids would have increased risk of adverse respiratory events compared to those treated with an active control + opioids. Propensity score-matched cohort study with an incident user, active comparator (TCA/duloxetine) control design. The primary analysis included those who concurrently (within 30 days) filled ≥1 incident gabapentin + ≥1 opioid or ≥1 incident TCA/duloxetine + ≥1 opioid prescription. U.S. Medicare beneficiaries with spine-related diagnoses 2017-2019. People treated with gabapentin + opioids (n=66,580) were matched on demographic and clinical factors to people treated with TCAs/duloxetine + opioids (n=66,580). Time to a composite respiratory outcome consisting of mechanical ventilation, intubation, respiratory failure, pneumonia, or acute respiratory distress syndrome. Cox proportional hazard regression was used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (95% CIs). Among 133,160 Medicare enrollees (median age 73.3 years; 66.7% female), 6089 (4.6%) experienced respiratory events before the end of follow-up. A total of 3297 (5.0%) of people who were treated with gabapentin + opioids (median initial dose/day of gabapentin was 338 mg) had respiratory events compared to 2792 (4.2%) of those treated with an active control + opioids. The increased risk in those treated with gabapentin + opioids was statistically significant after adjustment (HR 1.14; 95% CI 1.09, 1.20; p<0.0001). The most common respiratory events were pneumonia (3.5% of people in the gabapentin + opioids group versus 3.0% of people in the TCA/duloxetine + opioids group) and respiratory failure (2.2% in the gabapentin + opioids group versus 1.8% in the TCA/duloxetine + opioids group). Results were similar in analyses (a) restricted to ≤30-day follow-up and (b) that required ≥2 fills of each prescription. While recent work has indicated no increased mortality risk with concurrent gabapentin and opioid use, the current findings suggest clinicians should exercise caution in prescribing gabapentin to people experiencing pain who are also being treated with opioids, due to the potentially increased risk of respiratory events.

Save A Leg – Exploring Disparities in Community Characteristics Between Regions of High and Low Leg Amputation Rates

ObjectiveTo explore the disparities in community characteristics between the regions with the highest and lowest leg amputation rates. ApproachThis study used an exploratory method to describe the disparities between community characteristics of these two regions. The study team used several data sources: 1) We used the Dartmouth Atlas Healthcare Map to identify the highest and lowest leg amputation areas. This data was based on leg amputations per 1,000 Medicare enrollees by Hospital referral regions (HRRs) in 2015. 2) We used population estimates and income data from The Census Bureau. 3) We gathered climate, crime index, walk score, bike lanes, and park data from numerous websites. ResultsFlorence, SC has the highest leg amputation rate and Bridgeport, CT has the lowest across the nation. Florence also shows higher cardiovascular disease and diabetes discharge rates. Florence’s population has a slightly higher percentage of persons 65 years and over, a higher percentage of bachelor’s degrees, a higher per capita income, and a lower poverty rate. Florence also has fewer parks, is less walkable or bikeable, and has worse crime. It is worth noting that Bridgeport is close to Yale New Haven Hospital, which has a Limb Preservation Program that could contribute to the region’s extremely low leg amputation rate. ConclusionsThere are disparities in community characteristics between the regions with the highest and lowest leg amputation rates. ImplicationsFuture work needs to investigate the association between community characteristics and leg amputation rates and assess the impact of the Limb Preservation Program.

A Bayesian Multi-Layered Record Linkage Procedure to Analyze Functional Status of Medicare Patients with Traumatic Brain Injury

Understanding associations between injury severity and post-acute care recovery for older adults with traumatic brain injury (TBI) is crucial to improving care. Estimating these associations requires information on patients’ injury, demographics, and long-term health outcomes. This data is despersed across two different datasets: Medicare claims data and the National Trauma Data Bank (NTDB). Because of privacy regulations, unique identifiers are not available to link records across these two data sets. Record linkage methods identify records that represent the same patient across data sets in the absence of unique identifiers. With a large number of records, these methods may result in many false links. Health providers are a natural grouping scheme for patients, because only records that receive care from the same provider can represent the same patient. In some cases, providers are defined within each data set, but they are not uniquely identified across data sets. We propose a Bayesian record linkage procedure that simultaneously links providers and patients. The procedure improves the accuracy of the estimated links compared to current methods. We implement the proposed method to examine the associations between functional status assessments and TBI patients' ability to be independent following their injury by linking records from Medicare enrollment records and the NTDB.

Medicare Advantage Enrollment Following the 21st Century Cures Act in Adults With End-Stage Renal Disease

In January 2021, under the 21st Century Cures Act, Medicare beneficiaries with end-stage renal disease (ESRD) were permitted to enroll in private Medicare Advantage (MA) plans for the first time. In the first year of the Cures Act, there was a 51% increase in MA enrollment among beneficiaries with ESRD. To examine changes in MA enrollment among Medicare beneficiaries with ESRD in the first 2 years of the Cures Act and, among beneficiaries newly enrolled in MA in 2021, to assess the proportion of beneficiaries who switched MA contracts and how the characteristics of contracts changed. This cross-sectional, population-based time-trend study was conducted from January 2020 to December 2022. Eligible participants included Medicare beneficiaries with ESRD. Data analysis was conducted from August 2023 to March 2024. Enrollment in Medicare during the first 2 years of the 21st Century Cures Act. The primary outcomes were enrollment in MA, switching between traditional Medicare (TM) and MA, and switching between MA contracts from 2021 to 2022. There were 718 252 unique Medicare beneficiaries with ESRD between 2020 and 2022 (1 659 652 beneficiary-years). In 2022, there were 583 203 beneficiaries with ESRD (mean [SD] age, 64.9 [14.1] years, 245 153 female (42.0%); 197 988 Black [34.0%]; 47 912 Hispanic [8.2%]). The proportion of beneficiaries with ESRD who were enrolled in MA increased from 25.1% (118 601 of 472 234 beneficiaries) in January 2020 to 43.1% (211 896 of 491 611 beneficiaries) in December 2022. Increases in MA enrollment were larger in the first year of the Cures Act (12.6 percentage points [pp]; 95% CI 12.3-12.8 pp) compared with the second year (5.7 pp; 95% CI, 5.5-5.9 pp). Changes between December 2020 and December 2022 ranged between 49.3% for Asian or Pacific Islander beneficiaries (difference = 13.0 pp; 95% CI, 12.2-13.8 pp) and 207.2% for American Indian or Alaska Native beneficiaries (difference = 17.0 pp; 95% CI, 15.3-18.7 pp). Changes were high among partial dual-eligible (difference = 35.5 pp; 95% CI, 34.9-36.1 pp; 134.7% increase) and fully dual-eligible beneficiaries (difference = 22.8 pp, 95% CI, 22.5-23.1 pp; 98.0% increase). Among 53 366 beneficiaries enrolled in MA in 2021, 37 439 (70.2%) remained in their contract, 11 730 (22.0%) switched contracts, and 4197 (7.9%) switched to TM in 2022. Compared with the characteristics of MA enrollees with ESRD in 2021, those in 2022 were more likely to be in contracts with lower premiums and with a rating of 4.5 stars or higher. In this cross-sectional time-trend study of Medicare beneficiaries with ESRD, MA enrollment continued to increase in the second year of the Cures Act, particularly among racially or ethnically minoritized individuals and dual eligible populations. These findings suggest need to monitor the equity of care for beneficiaries with ESRD as they enroll in managed care plans.

Case Definition for Diagnosed Alzheimer Disease and Related Dementias in Medicare

Lack of a US dementia surveillance system hinders efforts to support and address disparities among persons living with Alzheimer disease and related dementias (ADRD). To review diagnosis and prescription drug code ADRD identification algorithms to develop and implement case definitions for national surveillance. In this cross-sectional study, a systematic literature review was conducted to identify unique International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and prescription drug codes used by researchers to identify ADRD in administrative records. Code frequency of use, characteristics of beneficiaries identified by codes, and expert and author consensus around code definitions informed code placement into categories indicating highly likely, likely, and possible ADRD. These definitions were applied cross-sectionally to 2017 to 2019 Medicare fee-for-service (FFS) claims and Medicare Advantage (MA) encounter data to classify January 2019 Medicare enrollees. Data analysis was conducted from September 2022 to March 2024. ICD-10-CM and national drug codes in FFS claims or MA encounters. The primary outcome was counts and rates of beneficiaries meeting each case definition. Category-specific age, sex, race and ethnicity, MA enrollment, dual-eligibility, long-term care utilization, mortality, and rural residence distributions, as well as frailty scores and FFS monthly expenditures were also analyzed. Beneficiary characteristics were compared across categories, and age-standardized to minimize confounding by age. Of the 60 000 869 beneficiaries included (50 853 806 aged 65 years or older [84.8%]; 32 567 891 female [54.3%]; 5 555 571 Hispanic [9.3%]; 6 318 194 non-Hispanic Black [10.5%]; 44 384 980 non-Hispanic White [74.0%]), there were 4 312 496 (7.2%) with highly likely ADRD, 1 124 080 (1.9%) with likely ADRD, and 2 572 176 (4.3%) with possible ADRD, totaling more than 8.0 million with diagnostic evidence of at least possible ADRD. These beneficiaries were older, more frail, more likely to be female, more likely to be dual-eligible, more likely to use long-term care, and more likely to die in 2019 compared with beneficiaries with no evidence of ADRD. These differences became larger when moving from the possible ADRD group to the highly likely ADRD group. Mean (SD) FFS monthly spending was $2966 ($4921) among beneficiaries with highly likely ADRD compared with $936 ($2952) for beneficiaries with no evidence of ADRD. Differences persisted after age standardization. This cross-sectional study of 2019 Medicare beneficiaries identified more than 5.4 million Medicare beneficiaries with evidence of at least likely ADRD in 2019 using the diagnostic case definition. Pending validation against clinical and other methods of ascertainment, this approach can be adopted provisionally for national surveillance.

Physical and Cognitive Function Trends in Post-acute Care after Total Joint Arthroplasty in Medicare Beneficiaries: 2013-2018

ObjectivesPhysical and cognitive conditions of patients discharged to skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home with home health agencies (HHAs) following total joint arthroplasty (TJA) have not been evaluated. The purpose of this study is to examine the physical and cognitive function trends of Medicare beneficiaries discharged to SNFs, HHAs, and IRFs following TJA from 2013 to 2018. DesignObservational study using Medicare enrollment, claims, and assessment data from 2013–2018. Setting and Participants1,278,939 Medicare beneficiaries discharged to SNFs, HHAs, or IRFs for post-acute care following TJA from 2013 to 2018. MethodsMedicare data were used to examine the association between the endpoints of interest [discharge destination (SNF, HHA, or IRF) and the physical (measured using activities of daily living) and cognitive (measured using a range of setting-specific metrics) status of patients in each setting] and the year of TJA (2013–2018) by estimating multivariable models that controlled for patient- and hospital-level covariates. ResultsMultivariable analysis of 1,278,939 TJAs revealed that SNF discharge decreased [44.15% (2013)–21.57% (2018), P < .001], HHA increased (46.72%–72.47%, P < .001), and IRF decreased (9.13%–5.69%, P < .001). For SNF, the mean physical function scores [14.61 (2013)–14.23 (2018), P < .001] and cognitive impairment (13.25%–12.33%, P = .01) decreased, indicating less dependence. Physical function scores (3.09–3.94, P < .001) and cognitive impairment (13.95%–16.52%, P < .001) increased for HHA patients, indicating greater dependence. For IRF, motor functional independence measure decreased (38.81–37.78, P < .001) and cognitive dependence increased (39.08%–46.36%, P < .001), indicating greater dependence. Conclusions and ImplicationsFrom 2013 to 2018, patients were increasingly discharged to HHA. Although SNF patients were less dependent over time, HHA and IRF patients were physically and cognitively more dependent. Each setting is likely to benefit from policy and fiscal supports that help them manage changes in the volume and clinical intensity of patients requiring their services.

Minimally invasive colorectal cancer surgery: an observational study of medicare advantage and fee-for-service beneficiaries

BackgroundEnrollment of Medicare beneficiaries in medicare advantage (MA) plans has been steadily increasing. Prior research has shown differences in healthcare access and outcomes based on Medicare enrollment status. This study sought to compare utilization of minimally invasive colorectal cancer (CRC) surgery and postoperative outcomes between MA and Fee-for-Service (FFS) beneficiaries.MethodsA retrospective cohort study of beneficiaries ≥ 65.5 years of age enrolled in FFS and MA plans was performed of patients undergoing a CRC resection from 2016 to 2019. The primary outcome was operative approach, defined as minimally invasive (laparoscopic) or open. Secondary outcomes included robotic assistance, hospital length-of-stay, mortality, discharge disposition, and hospital readmission. Using balancing weights, we performed a tapered analysis to examine outcomes with adjustment for potential confounders.ResultsMA beneficiaries were less likely to have lymph node (12.9 vs 14.4%, p < 0.001) or distant metastases (15.5% vs 17.0%, p < 0.001), and less likely to receive chemotherapy (6.2% vs 6.7%, p < 0.001), compared to FFS beneficiaries. MA beneficiaries had a higher risk-adjusted likelihood of undergoing laparoscopic CRC resection (OR 1.12 (1.10–1.15), p < 0.001), and similar rates of robotic assistance (OR 1.00 (0.97–1.03), p = 0.912), compared to FFS beneficiaries. There were no differences in risk-adjusted length-of-stay (β coefficient 0.03 (− 0.05–0.10), p = 0.461) or mortality at 30-60-and 90-days (OR 0.99 (0.95–1.04), p = 0.787; OR 1.00 (0.96–1.04), p = 0.815; OR 0.98 (0.95–1.02), p = 0.380). MA beneficiaries had a lower likelihood of non-routine disposition (OR 0.77 (0.75–0.78), p < 0.001) and readmission at 30-60-and 90-days (OR 0.76 (0.73–0.80), p < 0.001; OR 0.78 (0.75–0.81), p < 0.001; OR 0.79 (0.76–0.81), p < 0.001).ConclusionsMA beneficiaries had less advanced disease at the time of CRC resection and a greater likelihood of undergoing a laparoscopic procedure. MA enrollment is associated with improved health outcomes for elderly beneficiaries undergoing operative treatment for CRC.

Examining the effects of power outages on cardiovascular hospitalizations among Medicare enrollees in New York State, 2007-2008

Examining the effects of power outages on cardiovascular hospitalizations among Medicare enrollees in New York State, 2007-2008

PM2.5 components mixture and atherosclerotic cardiovascular disease mortality: a national analysis of Medicare enrollees

PM2.5 components mixture and atherosclerotic cardiovascular disease mortality: a national analysis of Medicare enrollees

Behind the Curtain: Comparing Predictive Models Performance in 2 Publicly Insured Populations.

Predictive models have proliferated in the health system in recent years and have been used to predict both health services utilization and medical outcomes. Less is known, however, on how these models function and how they might adapt to different contexts. The purpose of the current study is to shed light on the inner workings of a large-scale predictive model deployed in 2 distinct populations, with a particular emphasis on adaptability issues. We compared the performance and functioning of a predictive model of avoidable hospitalization in 2 very different populations: Medicaid and Medicare enrollees in Maryland. Specifically, we assessed characteristics of the risk scores from March 2022 for the 2 populations, the predictive ability of the scores, and the driving risk factors behind the scores. In addition, we created and assessed the performance of an "unadapted" model by applying coefficients from the Medicare model to the Medicaid population. The model adapted to, and performed well in, both populations, despite demographic differences in these 2 groups. However, the most salient risk factors and their relative weightings differed, sometimes dramatically, across the 2 populations. The unadapted Medicaid model displayed poor performance relative to the adapted model. Our findings speak to the need to "peek behind the curtain" of predictive models that may be applied to different populations, and we caution that risk prediction is not "one size fits all": for optimal performance, models should be adapted to, and trained on, the target population.

Vaccine patterns among older adults with Guillain-Barré syndrome and matched comparators, 2006-2019.

Some vaccines have a small risk of triggering Guillain-Barré syndrome (GBS), an autoimmune disorder where nerve damage leads to paralysis. There is a CDC precaution for patients whose GBS was associated with an influenza or tetanus toxoid-containing vaccine (GBS occurring within 42 days following vaccination). We described vaccine patterns before and after a GBS diagnosis with a matched cohort design in a 20% random sample of fee-for-service Medicare enrollees. We defined the index date as an ICD-9-CM or ICD-10-CM GBS diagnosis code in the primary position of an inpatient claim. We matched each GBS patient to five non-GBS comparators on sex, exact age, racial and ethnic category, state of residence and the month of preventive health visits during baseline; used weighting to balance covariates; and measured frequency of vaccines received per 100 people during year before and after the index date using the weighted mean cumulative count (wMCC). We identified 1567 patients with a GBS diagnosis with at least 1 year of prior continuous enrollment in Medicare A and B that matched to five comparators each. The wMCCs in the 1 year before the index date were similar for both groups, with a wMCC of 74 vaccines/100 people in the GBS group (95% CI 71, 77). Within 1 year after the index date, patients with GBS had received 26 vaccines/100 people (95% CI 23, 28), which was 41 fewer vaccines than matched non-GBS comparators (95% CI -44, -38). Among GBS patients, 11% were diagnosed with GBS within 42 days after a vaccine. GBS diagnosis has a strong impact on reducing subsequent vaccination even though there is no warning or precaution about future vaccines for most patients diagnosed with GBS. These data suggest discordance between clinical practice and current vaccine recommendations.

Racial and Ethnic Disparities in Outcomes After the Development of Ascites: A National Cohort Study.

Ascites, a severe complication of cirrhosis, significantly impacts patient morbidity and mortality especially in Black patients. Access to disease optimizing care has been proposed as a potential driver of this disparity. In this study, we evaluate TIPS utilization across racial and ethnic groups. We examined data from a 20% random sample of US Medicare enrollees with continuous Part Dcoverage. We required 180 days of continuous outpatient enrollment prior to cirrhosis diagnosis and all patients had ≥1 paracentesis within 180 days of their cirrhosis diagnosis. Time zero was the date of the first paracentesis. We assessed the likelihood of TIPS placement. Analyses were conducted to determine the independent associations between each outcome and race/ethnicity. 5915 patients (average age 68.2, 64.4% male) were included in the analysis. 439 (7.4%) patients were identified as Black, 223 (3.8%) as Hispanic, and 4942 (83.6%) as white. When compared to white patients in a multivariable analysis, Black patients were less likely to receive a TIPS procedure (hazard ratio 0.4; 95% confidence interval (CI) 0.2-0.8) and had less days alive outside of the hospital (-100.5; 95% CI -189.4 - -11.6). There were no significant differences in transplant-free survival or number of paracenteses per year between ethnic and racial groups. Black patients are less likely to receive a TIPS procedure when controlling for common patient- and disease-specific variables. Access to optimal specialized services may be a significant driver for disparities in outcomes of patients with cirrhosis between racial and ethnic groups.

Burden of illness and mortality in men with Adrenomyeloneuropathy: a retrospective cohort study

BackgroundAdrenomyeloneuropathy (AMN) is a neurodegenerative disease phenotype of X-linked adrenoleukodystrophy (ALD), resulting in progressive myeloneuropathy causing spastic paraparesis, sensory ataxia, and bowel/bladder symptoms. We conducted a retrospective cohort study using two large administrative databases to characterize mortality and the burden of illness in adult men with AMN in the US.ResultsHealthcare resource use was assessed using a national commercial insurance claims database (2006–2021). Males with AMN ages 18–64 years and no evidence of cerebral ALD or other peroxisomal disorders were included and 1:4 matched on demographic characteristics to individuals without AMN. All study participants were followed for as long as observable. Patients with AMN were also identified in the Medicare Limited Dataset (2017–2022); mortality and age at death were compared with all Medicare enrollees. We identified 303 commercially insured men with AMN. Compared with non-AMN, individuals with AMN had significantly more inpatient hospital admissions (0.44 vs. 0.04 admissions/patient/year), outpatient clinic (8.88 vs. 4.1 visits/patient/year), outpatient hospital (5.33 vs. 0.99 visits/patient/year), and home healthcare visits (4.66 vs. 0.2 visits/patient/year), durable medical equipment claims (0.7 vs. 0.1 claims/patient/year), and prescription medication fills (18.1 vs. 5.4 fills/patient/year) (all p < 0.001). Average length-of-stay per hospitalization was also longer in AMN (8.88 vs. 4.3 days; p < 0.001). Rates of comorbidities were significantly more common in AMN compared to controls, including peripheral vascular disease (4.6% vs. 0.99%), chronic pulmonary disease (6.3% vs. 2.6%), and liver disease (5.6% vs. 0.88%), all p < 0.001. Among individuals age < 65 with Medicare disability coverage, mortality rates were 5.3x higher for adult AMN males (39.3% vs. 7.4%) and the age at death significantly younger (47.0 ± 11.3 vs. 56.5 ± 7.8 years), both p < 0.001. Among Medicare beneficiaries ages ≥ 65 mortality rates were 2.2x higher for men with AMN vs. those without AMN (48.6% vs. 22.4%), p < 0.001.ConclusionAMN imposes a substantial and underrecognized health burden on men, with higher healthcare utilization, greater medical comorbidity, higher mortality rates, and younger age at death.