Medicare Fee For Service Beneficiaries Research Articles

Comparative effectiveness of denosumab vs alendronate among postmenopausal women with osteoporosis.

Although clinical trials have shown that denosumab significantly increases bone mineral density at key skeletal sites more than oral bisphosphonates, evidence is lacking from head-to-head randomized trials evaluating fracture outcomes. This retrospective cohort study uses administrative claims data from Medicare fee-for service beneficiaries to evaluate the comparative effectiveness of denosumab vs alendronate in reducing fracture risk among women with PMO in the US. Women with PMO ≥ 66yr of age with no prior history of osteoporosis treatment, who initiated denosumab (n = 89 115) or alendronate (n = 389 536) from 2012 to 2018, were followed from treatment initiation until the first of a specific fracture outcome, treatment discontinuation or switch, end of study (December 31, 2019), or other censoring criteria. A doubly robust inverse-probability of treatment and censoring weighted function was used to estimate the risk ratio associated with the use of denosumab compared with alendronate for hip, nonvertebral (NV; includes hip, humerus, pelvis, radius/ulna, other femur), non-hip nonvertebral (NHNV), hospitalized vertebral (HV), and major osteoporotic (MOP; consisting of NV and HV) fractures. Overall, denosumab reduced the risk of MOP by 39%, hip by 36%, NV by 43%, NHNV by 50%, and HV fractures by 30% compared with alendronate. Denosumab reduced the risk of MOP fractures by 9% at year 1, 12% at year 2, 18% at year 3, and 31% at year 5. An increase in the magnitude of fracture risk reduction with increasing duration of exposure was also observed for other NV fracture outcomes. In this cohort of almost half-a-million treatment-naive women with PMO, we observed clinically significant reductions in the risk of MOP, hip, NV, NHNV, and HV fractures for patients on denosumab compared with alendronate. Patients who remained on denosumab for longer periods of time experienced greater reductions in fracture risk.

Idiopathic pulmonary fibrosis in the United States: time to diagnosis and treatment

ObjectiveCreate a timeline of diagnosis and treatment for IPF in the US.Design, setting, and participantsA retrospective analysis was performed in collaboration with the OptumLabs Data Warehouse using an administrative claims database of Medicare Fee for Service beneficiaries. Adults 50 and over with IPF were included (2014 to 2019).ExposureTo focus on IPF, the following diagnoses were excluded: post-inflammatory fibrosis, hypersensitivity pneumonitis, rheumatoid arthritis, sarcoidosis, scleroderma, and connective tissue disease.Main outcomes and measuresData were collected from periods prior, during, and following initial clinical diagnosis of IPF. This included prior respiratory diagnoses, number of respiratory-related hospitalizations, anti-fibrotic and oxygen use, and survival.ResultsA total of 44,891 with IPF were identified. The most common diagnoses prior to diagnosis of IPF were upper respiratory infections (47%), acute bronchitis (13%), other respiratory disease (10%), chronic obstructive pulmonary disease and bronchiectasis (7%), and pneumonia (6%). The average time to a diagnosis of IPF was 2.7 years after initial respiratory diagnosis. Half of patients had two or more respiratory-related hospitalizations prior to IPF diagnosis. Also, 37% of patients were prescribed oxygen prior to diagnosis of IPF. These observations suggest delayed diagnosis. We also observed only 10.4% were treated with anti-fibrotics. Overall survival declined each year after diagnosis with median survival of 2.80 years.Conclusions and relevanceOur retrospective cohort demonstrates that IPF is often diagnosed late, usually preceded by other respiratory diagnoses and hospitalizations. Use of available therapies is low and outcomes remain poor.

Healthcare Resource Utilization and Costs of Medicare Fee for Service Beneficiaries Newly Diagnosed with Moderate to Severe Non-Advanced Systemic Mastocytosis

Healthcare Resource Utilization and Costs of Medicare Fee for Service Beneficiaries Newly Diagnosed with Moderate to Severe Non-Advanced Systemic Mastocytosis

Healthcare Resource Utilization and Costs of Advanced Systemic Mastocytosis Among Medicare Fee for Service Beneficiaries

Healthcare Resource Utilization and Costs of Advanced Systemic Mastocytosis Among Medicare Fee for Service Beneficiaries

ICD-10 anaphylaxis algorithm and the estimate of vaccine-attributable anaphylaxis incidence in Medicare

BackgroundAnaphylaxis is a rare, serious allergic reaction. Its identification in large healthcare databases can help better characterize this risk. ObjectiveTo create an ICD-10 anaphylaxis algorithm, estimate its positive predictive values (PPVs) in a post-vaccination risk window, and estimate vaccination-attributable anaphylaxis rates in the Medicare Fee For Service (FFS) population. MethodsAn anaphylaxis algorithm with core and extended portions was constructed analyzing ICD-10 anaphylaxis claims data in Medicare FFS from 2015 to 2017. Cases of post-vaccination anaphylaxis among Medicare FFS beneficiaries were then identified from October 1, 2015 to February 28, 2019 utilizing vaccine relevant anaphylaxis ICD-10 codes. Information from medical records was used to determine true anaphylaxis cases based on the Brighton Collaboration’s anaphylaxis case definition. PPVs were estimated for incident anaphylaxis and the subset of vaccine-attributable anaphylaxis within a 2-day post-vaccination risk window. Vaccine-attributable anaphylaxis rates in Medicare FFS were also estimated. ResultsThe study recorded 66,572,128 vaccinations among 21,685,119 unique Medicare FFS beneficiaries. The algorithm identified a total of 190 suspected anaphylaxis cases within the 2-day post-vaccination window; of these 117 (62%) satisfied the core algorithm, and 73 (38%) additional cases satisfied the extended algorithm. The core algorithm’s PPV was 66% (95% CI [56%, 76%]) for identifying incident anaphylaxis and 44% (95% CI [34%, 56%]) for vaccine-attributable anaphylaxis. The vaccine-attributable anaphylaxis incidence rate after any vaccination was 0.88 per million doses (95% CI [0.67, 1.16]). ConclusionThe ICD-10 claims algorithm for anaphylaxis allows the assessment of anaphylaxis risk in real-world data. The algorithm revealed vaccine-attributable anaphylaxis is rare among vaccinated Medicare FFS beneficiaries.

Primary and Specialty Outpatient Visits for Older Women With Urinary Incontinence: A Comparison of Nurses to the General Population.

We evaluated patterns of outpatient visits seen for urinary incontinence (UI) among women 65 years or older in the Nurses' Health Study and the general Medicare population. We were interested in understanding whether nurses, with high health literacy, may receive more care for UI than the general population. Medicare Fee for Service claims data for women aged 66-91 years were compared for Nurses' Health Study participants (n = 3,213) and a propensity-matched sample from general Medicare Fee for Service beneficiaries (n = 3,213) with 1 or more outpatient evaluation and management visits for UI in 2012. We examined the mean number of outpatient visits for UI and the type of provider seen, using t tests and χ2 tests. Providers were categorized as specialist and nonspecialist providers using taxonomy codes. The percentage of women 65 years or older who had an outpatient visits for UI over 12 months was 6.4% in the Nurses' Health Study cohort and 5.4% in the general population. The mean number of office visits for UI in 2012 was similar between nurses and the matched general population (mean = 1.8 vs 1.8; P = 0.3). A small percentage of women saw both nonspecialists and specialists for UI (9.3% in the Nurses' Health Study and 10.0% in the Center for Medicare Services cohorts). We found that less than 7% of older women had outpatient evaluation of UI symptoms during a 12-month period, despite UI being very common in this age group. This was similar in nurses and the general population, suggesting that even high health care literacy does not increase UI care seeking.

Quantifying the impact of changing the threshold of New York City heat emergency plan in reducing heat-related illnesses

The adverse health impact of high heat is widely documented and can lead to a substantial public health burden. Although heat-related illness in western countries is largely preventable, extreme heat remains the main weather contributor to the burden of disease in the United States. In most US cities, local National Weather Service offices issue heat alerts in advance of forecast periods of high heat. In some locations, additional local heat emergency plans that include additional community-based actions to protect the public from the health impacts of heat are also triggered. In 2008, the NYC Health Department made changes in their local heat emergency plan by lowering the threshold for triggering heat advisories based on evidence from local epidemiological studies. This study aims to quantify the potential benefits associated with the change in the threshold the NYC Heat Emergency Plan in reducing heat-related illnesses for Medicare fee-for service beneficiaries aged 65 years or older. We apply a quasi-experimental study design using the Difference-in-Differences (DID) method coupled with the propensity-score matching and compare the difference in daily rates of heat-related illnesses between eligible and non-eligible days before and after implementing the threshold change (2006–2007 versus 2009–2010). We reveal that the change in threshold for the NYC Heat Emergency Plan is associated with reduced daily number of 0.80 (95%CI: 0.27; 1.33) Heat-related Illnesses during hot days as compared to a counterfactual scenario in which the original threshold did not change. This highlights the benefits of local epidemiological evidence in informing emergency heat action plans, in decreasing the health burden of high ambient heat.

The healthcare burden of disease progression in medicare patients with functional mitral regurgitation

Objective: This retrospective database analysis estimated the incremental effect that disease progression from non-clinically significant functional mitral regurgitation (nsFMR) to clinically significant FMR (sFMR) has on clinical outcomes and costs.Methods: Medicare Fee for Service beneficiaries with nsFMR were examined, defined as those with a heart failure diagnosis prior to MR. Patients were classified as ischemic if there was a history of: CAD, AMI, PCI, or CABG. The primary outcome was time to sFMR, defined as pulmonary hypertension, atrial fibrillation, mitral valve surgery, serial echocardiography, or death, using a Cox hazard regression model. Annualized hospitalizations, inpatient hospital days, and healthcare expenditures were also modeled.Results: Patients with IHD had higher risk (Hazard Ratio = 1.22 [1.14–1.30]) for disease progression compared to patients without. The progression cohort had significantly more annual inpatient hospitalizations (non-IHD = 1.32; IHD = 1.40) than the non-progression cohort (non-IHD = 0.36; IHD = 0.34), and significantly more annual inpatient hospital days (non-IHD = 13.07; IHD = 13.52) than the non-progression cohort (non-IHD = 2.29; with IHD = 2.08). The progression cohort had over 3.5-times higher costs vs the non-progression cohort, independent of IHD (non-IHD = $12,798 vs $46,784; IHD = $12,582 vs $49,348).Conclusion: Treating FMR patients earlier in their clinical trajectory may prevent disease progression and reduce high rates of healthcare utilization and expenditures.

Rates of Hospital Readmission Among Medicare Beneficiaries With Gastrointestinal Bleeding Vary Based on Etiology and Comorbidities

Gastrointestinal bleeding results in significant morbidity, mortality, and healthcare costs in the United States. The Center for Medicare and Medicaid Services' payment reform programs assess quality and value based on rates of hospital readmission for patients with gastrointestinal bleeding, but they identify these patients using Medicare Severity Diagnosis Related Groups (MS-DRGs), which include many types of gastrointestinal bleeding and do not account for the clinical heterogeneity among these patients. We aimed to characterize heterogeneity in outcomes of subgroups of patients with gastrointestinal bleeding. We performed was a cross-sectional, claims-based retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding in 2014 (159,000 hospitalizations). The primary outcome was unplanned readmission within 30 days of discharge from the hospital (30-day readmission). Secondary outcomes included length of stay, inpatient mortality, and death within 30 days of admission to the hospital (30-day mortality). Analyses were adjusted for age, sex, race, and Elixhauser comorbidities using logistic and Poisson regression, adjusting for clustering within hospitals. The 30-day readmission rate was 16.0%. Readmission rates varied among patients with different types of gastrointestinal bleeding, ranging from 13.5% for diverticular bleeding to 18.6% for small bowel bleeding. The mean length of stay was 4.2 days and 30-day mortality was 6.9% (ranging from 3.4% for diverticular bleeding to 12.1% for upper gastrointestinal bleeding not otherwise specified). When hospitalizations were stratified by MS-DRGs, the main source of variation in rates of readmission and mortality was MS-DRGs. In a retrospective analysis of Medicare fee for service beneficiaries hospitalized for gastrointestinal bleeding, we found that 16% of these patients are readmitted to the hospital. Rates of hospital readmission, length of stay, and mortality vary with type of gastrointestinal bleeding, but MS-DRGs account for the largest source of variation. Policies focused on quality and value should account for this heterogeneity.

Early death after discharge from emergency departments: analysis of national US insurance claims data

Objective To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.Design Retrospective cohort study.Setting...

Medicare Utilization of CT Angiography from 2001 through 2014: Continued Growth by Radiologists

PurposeTo examine changes in utilization of computed tomography (CT) angiography nationally and changing relative specialty roles in examination interpretation. Materials and MethodsService-specific claims data for region-specific CT angiography examinations were identified using Medicare Physician Supplier Procedure Summary Master Files from 2001 through 2014. Longitudinal national utilization rates were calculated using annual Medicare enrollment data for 2001–2013. Procedure volumes by specialty group and site of service were analyzed. ResultsTotal annual claims for CT angiography for Medicare fee for service beneficiaries increased from 64,846 to 1,709,088 (compound annual growth rate [CAGR] 29%) between 2001 and 2014. Per 1,000 beneficiaries, overall CT angiography utilization increased annually from 2.1 in 2001 to 47.6 in 2013. Overall interpretation market share increased 4% (91%–95%) for radiology. Cardiology increased from 1% in 2001 to 6% in 2007 but decreased annually to 2% in 2014. Vascular surgery market share remained < 1% throughout the study period. Growth of CT angiography in the emergency department (ED) outpaced all other sites of service, increasing from 11% to 28% (CAGR 38%). The chest was the dominant body region imaged with CT angiography, increasing from 36,984 to 914,086 (CAGR 28%). ConclusionsUtilization of CT angiography in the Medicare population increased markedly for 2001–2014, particularly in the ED, with radiologists remaining dominant providers. The chest is the most common body region imaged with CT angiography.

Social and Medical Determinants of Cardiometabolic Health: The Big Picture.

Cardiometabolic diseases, including diabetes and heart disease, account for >12 million years of life lost annually among Black adults in the United States. Health disparities are geographically localized, with ~80% of health disparities occurring within ~6000 (16%) of all 38,000 US ZIP codes. Socio-economic status (SES), behavioral and environmental factors (social determinants) account for ~80% of variance in health outcomes and cluster geographically. Neighborhood SES is inversely associated with prevalent diabetes and hypertension, and Blacks are four times more likely than Whites to live in lowest SES neighborhoods. In ZIP code 48235 (Detroit, 97% Black, 16.2% unemployed, income/capita $18,343, 23.6% poverty), 1082 Medicare fee-for service (FFS) beneficiaries received care for type 2 diabetes (T2D) and coronary artery disease (CAD) in 2012. Collectively, these beneficiaries had 1082 inpatient admissions and 839 emergency department visits, mean cost $27,759/beneficiary and mortality 2.7%. Nationally in 2011, 236,222 Black Medicare FFS beneficiaries had 213,715 inpatient admissions, 191,346 emergency department visits, mean cost $25,580/beneficiary and 2.4% mortality. In addition to more prevalent hypertension and T2D, Blacks appear more susceptible to clinical complications of risk factors than Whites, including hypertension as a contributor to stroke. Cardiometabolic health equity in African Americans requires interventions on social determinants to reduce excess risk prevalence of risk factors. Social-medical interventions to promote timely access to, delivery of and adherence with evidence-based medicine are needed to counterbalance greater disease susceptibility. Place-based interventions on social and medical determinants of health could reduce the burden of life lost to cardiometabolic diseases in Blacks.

Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study

Objective To characterize the absolute risks for older patients of readmission to hospital and death in the year after hospitalization for heart failure, acute myocardial infarction, or pneumonia.Design Retrospective cohort...

The cost implications of prostate cancer screening in the Medicare population.

6549 Background: Recent debate about prostate specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost associated with screening. Methods: We assembled a population-based cohort of male Medicare beneficiaries aged 66-99 years who had never been diagnosed with prostate cancer at the end of 2005 (n = 84,699) and followed them for two years to assess the cost of PSA screening and downstream procedures (biopsy, pathology, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level. The relation of screening cost to stage of prostate cancer at diagnosis at the HRR level was analyzed using multivariate Poisson models. We also evaluated the initial treatment cost of Medicare fee for service beneficiaries diagnosed with prostate cancer during 2006-2007 (n = 31,653). Results: Approximately 42.8% of the 84,699 men received PSA screening tests during the two-year study period, with 2.4% undergoing biopsy. The annual expenditures by the national fee for service Medicare program were $454 million for screening and $1.79 billion for initial treatment (in 2009 US dollars). The mean annual screening cost at the regional (HRR) level ranged from $16 to $65 per beneficiary. Downstream biopsy-related procedures (biopsy, pathology, and hospitalization due to biopsy complications) accounted for 73% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage [incidence rate ratio (IRR) = 1.23, 95% confidence interval (CI): 1.07-1.42] and localized cancer (IRR = 1.31, 95% CI: 1.13-1.53). Conclusions: Medicare prostate cancer screening-related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis.

Use of Preventive Services by Medicare Fee-For-Service Beneficiaries

Health care delivery varies with the level of managed care activity (MCA) in an area, potentially affecting health care for those not participating in managed care programs. However, the extent to which MCA is associated with the use of cancer screening by fee-for-service beneficiaries (FFS) is unclear. We sought to study colorectal cancer screening among Medicare FFS beneficiaries in relation to levels of Medicare MCA. This study linked 1999 Medicare denominator and Part B claims data with the 1998 Area Resource File. After categorizing MCA as low (<10%), moderate (10-29.99%), or high (> or =30%), we assessed the association between colorectal cancer screening among FFS beneficiaries and MCA, controlling for individual demographic variables and county-level attributes of socioeconomic status and physician resources. We included Medicare FFS beneficiaries 65 years of age or older with both Part A and Part B coverage for the entire calendar year from large counties in the study. We measured the likelihood of undergoing fecal occult blood testing (FOBT), flexible sigmoidoscopy (FLEX), or colonoscopy (COL). Compared with Medicare FFS beneficiaries residing in counties with low MCA, those in high MCA counties were significantly more likely to undergo FOBT (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] 1.04-1.16), FLEX (AOR 1.11, 95% CI 1.04-1.18), or colonoscopy, after receiving FOBT/FLEX (AOR 1.07, 95% CI 1.02-1.13). From a public health perspective, an association between higher levels of MCA and colorectal cancer screening among those not enrolled in managed care may translate into modest increases in use of colorectal cancer screening and possibly earlier detection.