Medicare Insurance Status Research Articles

Trends in the Use of Endoscopic Retrograde Cholangiopancreatography for the Management of Acute Pancreatitis in the United States

Introduction: Acute Pancreatitis (AP) is one of the most frequent gastrointestinal causes for hospitalization in US. The incidence of AP has increased over time. Endoscopic retrograde cholangiopancreatography (ERCP) has historically provided a means for both diagnosis and treatment of AP. Methods: We performed a retrospective cohort study using the Nationwide Inpatient Sample from 2002-2014. We identified patients with a primary discharge diagnosis of AP who underwent ERCP via ICD-9 codes. We further categorized acute pancreatitis into two categories i.e biliary and alcoholic AP. We analyzed patient and hospital characteristics, length of stay, and in-hospital mortality, and adjusted for weighted sample schema. Results: From 2002 to 2014, the AP discharges increased from 235589 (81.9 discharges per 100,000 persons) to 279145 (87.5 discharges per 100,000 persons). The percentage of discharges with ERCP declined from 10.84% in 2002 to 6.91% in 2014. For Biliary AP, the ERCP declined from 32.71% in 2002 to 24.04% in 2014. For Alcoholic AP, ERCP declined from 1.36% to 0.77%. Patients undergoing ERCP in biliary AP have decreased mortality than without (0.77% Vs 1.37%, P=0.001). In alcoholic AP, patients undergoing ERCP have increased mortality than without (1.24 Vs 0.64% P=0.002). The odds of getting ERCP was more with age above 70, female gender, Asian race, Medicare insurance status, urban teaching and large hospitals. The odds of having complications like shock, altered mental status, Acute Kidney injury, pleural effusion, acute respiratory failure & pseudocyst formation was more with alcoholic AP undergoing ERCP than with biliary AP. Median length of stay and median total hospital charges were more in hospitalizations with ERCP than without in both biliary and alcoholic pancreatitis. Conclusion: Over the last twelve years ERCP use in US hospitalizations with AP is declining because of newer imaging modalities. ERCP use in biliary AP was associated with having odds of decreased mortality, but in alcoholic AP it was associated with increased mortality. The Alcoholic AP patients undergoing ERCP were having more odds of complications as well. The cohort that underwent ERCP had increased total costs and charges. Further prospective studies are needed to elucidate whether increased mortality in alcoholic AP patients undergoing ERCP is because of procedure itself or these patients are sicker to begin with.801_A Figure 1. Complications and Procedures during Acute Pancreatitis Hospitalizations801_B Figure 2. Trends of In-Hospital Mortality, Median Length of Stay and Median Cost of Care in Acute Pancreatitis patients undergoing ERCP.

Ten-year outcomes of Roux-en-Y gastric bypass are equivalent in patients with Medicare disability and non-Medicare patients

BackgroundBariatric surgery is the most effective intervention for achieving durable weight loss and improvement of comorbidities in patients with obesity. Limited data exist on the impact of Medicare status in patients undergoing Roux-en-Y gastric bypass. We hypothesized that there is no difference in outcomes between Medicare beneficiaries and non-Medicare patients at the 10-year follow-up. MethodsAll patients who underwent Roux-en-Y gastric bypass with 10-year follow-up at a single medical center from 1985 to 2005 were stratified by Medicare insurance status. Outcomes included 10-year percent reduction in excess body mass index and comorbidity resolution. ResultsOf 617 patients who underwent Roux-en-Y gastric bypass with 10-year follow-up, 117 (19%) were insured under Medicare. Medicare patients were older (43 vs 40 years, P = .01) and had a greater preoperative body mass index (53.2 vs 51.0 kg/m2, P = .03) than non-Medicare patients, but there were no differences in preoperative median comorbidity index scores (3 [interquartile range 1–4] vs 2 [interquartile range 1–5], P = .33). At 10 years, weight loss (58.3% vs 57.0 percent reduction in excess body mass index, P = .16) and the decrease in median comorbidity index (1 [interquartile range 0–3] vs 1 [interquartile range 0–3], P = .85) were equivalent between groups. ConclusionsRoux-en-Y gastric bypass is equally beneficial in Medicare Disability and non-Medicare patients at 10 years. These findings support the continued and expanded coverage of bariatric surgery operations by Medicare.

Utilization of initial chemotherapy for newly diagnosed acute myeloid leukemia in the United States

AbstractThe use of chemotherapy in patients with acute myeloid leukemia (AML) is associated with survival benefits and alleviation of symptoms related to AML. Prior studies have demonstrated a lower receipt of chemotherapy with increasing age and comorbidities. We hypothesized that socioeconomic and health system factors also determine the use of chemotherapy. We included 61 775 adults with AML diagnosed between 2003 and 2011 from the National Cancer Database, and performed a multivariable logistic regression model to determine the association between receipt of chemotherapy and several factors. A total of 15 608 patients (25.3%) did not receive chemotherapy. In a multivariable analysis, the likelihood of getting chemotherapy declined with increasing age and comorbidities and among patients with therapy-related and intermediate-/high-risk AML. Other factors associated with a lower likelihood of receiving chemotherapy included receipt of care in nonacademic centers, African American race, lower income status, uninsured or Medicare insurance status, and female sex. Compared with the previous studies, our study is novel because it provides data from a large, unselected cohort of patients diagnosed in the United States in recent years, and simultaneously examines the effect of various biological, socioeconomic, and health system factors. The results of our study raise a possibility of leukemia care disparity based on socioeconomic and health system factors. Better understanding of ways such factors may influence receipt of chemotherapy may allow an increase in the use of chemotherapy.

Sex, race, and insurance status differences in hospital treatment and outcomes following out-of-hospital cardiac arrest

BackgroundSex, race, and insurance status are associated with treatment and outcomes in several cardiovascular diseases. These disparities, however, have not been well-studied in out-of-hospital cardiac arrest (OHCA). ObjectiveOur objective was to evaluate the association of patient sex, race, and insurance status with hospital treatments and outcomes following OHCA. MethodsWe studied adult patients in the 2011–2015 California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database with a “present on admission” diagnosis of cardiac arrest (ICD-9-CM 427.5). Insurance status was classified as private, Medicare, and Medi-Cal/government/self-pay. Our primary outcome was good neurologic recovery at hospital discharge, which was determined by discharge disposition. Secondary outcomes were survival to hospital discharge, treatment at a 24/7 percutaneous coronary intervention (PCI) center, “do not resuscitate” orders within 24 h of admission, and cardiac catheterization during hospitalization. Data were analyzed with hierarchical multiple logistic regression models. ResultsWe studied 38,163 patients in the OSHPD database. Female sex, non-white race, and Medicare insurance status were independently associated with worse neurologic recovery [OR 0.94 (0.89–0.98), 0.93 (0.88–0.98), and 0.85 (0.79–0.91), respectively], lower rates of treatment at a 24/7 PCI center [OR 0.89 (0.85–0.93), 0.88 (0.85–0.93), and 0.87 (0.82–0.94), respectively], and lower rates of cardiac catheterization [OR 0.61 (0.57–0.65), 0.90 (0.84–0.97), and 0.44 (0.40–0.48), respectively]. Female sex, white race, and Medicare insurance were associated with DNR orders within 24 h of admission [OR 1.16 (1.10–1.23), 1.14 (1.07–1.21), and 1.25 (1.15–1.36), respectively]. ConclusionsSex, race, and insurance status were independently associated with post-arrest care interventions, patient outcomes and treatment at a 24/7 PCI center. More studies are needed to fully understand the causes and implications of these disparities.

Aortic Dissection after Percutaneous Coronary Intervention for Acute Coronary Syndrome: An Outcomes-Based Study from the Nationwide Inpatient Sample Database

Introduction: Aortic dissection is a rare complication of Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome (ACS), but is associated with mortality rates of up to 20%. This study assessed the demographic and clinical profile of a large cohort of patients undergoing PCI for ACS to assess patient and clinical risk factors that may predispose to the development of aortic dissection. Methods: The Nationwide Inpatient Sample (NIS) database (2001-2011) was used to abstract admission data on patients undergoing PCI for ACS. Results: 777,595 patients underwent PCI and 380 (0.05%) developed aortic dissection. Patients who developed aortic dissection were more often older (68 vs. 64 years), female (47.4% vs. 33.8%), insured through Medicare (56.2% vs. 50.7%), Medicaid (7.9% vs. 5.3%) or uninsured/self-pay (6.3% vs. 4.7%), p < 0.05. Patients with aortic dissection had a higher rate of ventricular fibrillation (6.3% vs. 1.8%), cerebrovascular accident (2.4% vs. 0.4%), longer lengths of hospitalization (9 days vs. 3 days), as well as higher mortality (13.2% vs. 1.4%), p < 0.001. Multivariate analysis identified female gender, Hispanic race, uninsured/self-pay, fluid and electrolyte disorders, and peripheral vascular disease (PVD) as independent risk factors for aortic dissection after PCI. Conclusion: Aortic dissection is a rare complication of PCI, which occurs more often in older patients with Medicare insurance status. Hispanics, females, uninsured patients and those with PVD are at the highest risk of aortic dissection. Clinicians should be more cognizant of patients at increased risk of developing PCI in order to institute earlier screening in high-risk patients.

Presenting Symptoms and Dysphagia Screen Predict Outcome in Mild and Rapidly Improving Acute Ischemic Stroke Patients

There are limited data on which patients not treated with intravenous (IV) tissue-type plasminogen activator (tPA) due to mild and rapidly improving stroke symptoms (MaRISS) have unfavorable outcomes. Acute ischemic stroke (AIS) patients not treated with IV tPA due to MaRISS from January 1, 2009 to December 31, 2013 were identified as part of the Georgia Coverdell Acute Stroke Registry. Multivariable regression analysis was used to identify factors associated with a lower likelihood of favorable outcome, defined as discharge to home. There were 1614 AIS patients who did not receive IV tPA due to MaRISS (median National Institutes of Health stroke scale [NIHSS] 1], of which 305 (19%) did not have a favorable outcome. Factors associated with lower likelihood of favorable outcome included Medicare insurance status (odds ratio [OR]: .53, 95% confidence interval [CI]: .34-.84), arrival by emergency medical services (OR: .46, 95% CI: .29-.73), increasing NIHSS score (per unit OR: .89, 95% CI: .84-.93), weakness as the presenting symptom (OR: .50, 95% CI: .30-.84), and a failed dysphagia screen (OR: .43, 95% CI: .23-.80). During the study period, <1% of patients presenting to participating hospitals with MaRISS within the eligible time window received IV tPA. Baseline characteristics, presenting symptoms, and response to dysphagia screen identify a subgroup of patients who are more likely to have an unfavorable outcome. Whether IV tPA treatment can improve the outcome in this subgroup of patients needs to be evaluated in a randomized placebo-controlled trial.

Trends of acute kidney injury after radical or partial nephrectomy for renal cell carcinoma

ObjectivesTo investigate the prevalence, temporal trends, and predictors of postoperative acute kidney injury (AKI) in a large cohort of patients with renal cell carcinoma treated with radical or partial nephrectomy. MethodsBetween January 1998 and December 2010, patients who underwent radical or partial tumor nephrectomy were identified within the Nationwide Inpatient Sample. First, prevalence and temporal trends of AKI were analyzed. Second, predictors of AKI were identified using multivariable regression analyses. Third, associations between AKI and in-hospital complications, length of stay, hospital costs, and in-hospital mortality were evaluated using logistic regression models adjusted for clustering. ResultsOf total 253,046 patients, 5.5% (14,303 in radical and 3,525 in partial nephrectomy) experienced AKI. Rates of AKI significantly increased from 2.0% in 1998 to 10.4% in 2010 (P<0.001). Predictors of AKI included male sex, radical nephrectomy, more contemporary years (2004–2010), older age, black race, higher comorbidities, higher preoperative chronic kidney disease stage, Medicare insurance status, and nephrectomy at urban hospitals (all P<0.01). Postoperative AKI during hospitalization was associated with an increased rate of in-hospital mortality, any complications, transfusion, prolonged length of stay, and higher hospital costs (all P<0.001). ConclusionsRising rates of in-hospital AKI after radical and partial nephrectomy were observed. Increasing awareness of AKI, identification of patients at risk before surgery, early postoperative AKI diagnosis, collaboration with nephrologists, implementation of renoprotective strategies, long-term renal functional follow-up, and a well-designed prospective study, may be warranted.

Abstract P3-07-17: Rates of adherence and persistence to adjuvant endocrine therapy among women enrolled in Medicare Part D in a four-state region of Appalachia

Abstract Background: Disparities exist in breast cancer outcomes by age, geographic location, and socioeconomic status, but there is little data regarding contributing factors to disparities within Appalachia. Underuse of adjuvant endocrine therapy for breast cancer can contribute to disparities. We studied older women within four states of Appalachia and explored adherence and persistence rates for adjuvant endocrine therapy. Methods: The study group consisted of women with stage I-III breast cancer diagnosed 2008-2009 in North Carolina, Pennsylvania, Kentucky, and Georgia, who were continuously enrolled in Part D Medicare and filled a prescription for tamoxifen, anastrozole, letrozole, or exemestane. Adherence rate is defined by medication possession ratio (MPR=sum of days supply for all claims during the calendar year after first prescription). Persistence rate was defined as absence of a 90 day or greater gap in prescription coverage since the first prescription fill. Univariate analyses by Kruskall-Wallis nonparametric test were performed. Variables included age, year of diagnosis, Charlson comorbidity score, Medicaid/Medicare versus Medicare insurance status, rural versus urban residence, county-level economic status (Appalachia Regional Commission: Distressed, At risk, Transitional, or Competitive), state, stage (1, 2A, 2B, or 3), and breast conserving surgery (BCS) versus mastectomy. Results: We identified 726 eligible cases. Mean age was 75.1 years (range 41-98); 97.9% were white; 47.9% had rural residence, 9.5% lived in distressed counties, 29.1% were dual-Medicaid/Medicare insured, mean Charlson comorbidity score was 1.66, and tumor was stage 1 in 56.6%, 2 in 33.6%, and 3 in 9.8%. Mean MPR was 57% (SD 0.27). Persistence rate at 6-months was 79% (SD 0.41) and at 12-months was 36% (SD 0.48). MPR varied significantly within age groups (p=0.01), county-level economic status levels (p=0.01), and Singh Index Area Deprivation tertiles (p=0.01). Mean MPR increased with increasing age: 48% for age 40--65, 55% for age 66-75, 59% for age 76-85, and 63% for age 86 and older. MPR was highest among those in the Competitive ARC class at median levels of 64%, versus 53% in Distressed, 58% in At Risk, and 58% in Transitional. Greatest area deprivation tertile also coincided with lower mean and median MPR adherence. Persistence at 12 months varied significantly among age groups (p=0.01), and type of surgery (p=0.04). Persistence rates were lower in younger cases: 23% for age 40-65, 34% for age 66-75, 37% for age 76-85, and 49% for age 86 and older. Persistence rates were 32% in those who had BCS and 42% in mastectomy. Persistence rates varied significantly among comorbidity levels (p=0.0260); but, after adjusting for age and using logistic regression, this association was only marginally significant (p=0.05). Adjusted expected persistence increased as comorbidity score increased: 28% for 0; 35% for 1; and 39% for 2 or more. Conclusions: Among this group of women within four states in Appalachia with Medicare Part D who filled a prescription for endocrine therapy, overall adherence and persistence rates were low. Higher adherence and persistence rates were seen in older age groups. Citation Format: Gretchen G Kimmick, Fabian Camacho, Roger T Anderson. Rates of adherence and persistence to adjuvant endocrine therapy among women enrolled in Medicare Part D in a four-state region of Appalachia [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-17.

A Multi-institutional Analysis of Insurance Status as a Predictor of Morbidity Following Breast Reconstruction.

Background:Although recent literature suggests that patients with Medicaid and Medicare are more likely than those with private insurance to experience complications following a variety of procedures, there has been limited evaluation of insurance-based disparities in reconstructive surgery outcomes. Using a large, multi-institutional database, we sought to evaluate the potential impact of insurance status on complications following breast reconstruction.Methods:We identified all breast reconstructive cases in the 2008 to 2011 Tracking Operations and Outcomes for Plastic Surgeons clinical registry. Propensity scores were calculated for each case, and insurance cohorts were matched with regard to demographic and clinical characteristics. Outcomes of interest included 15 medical and 13 surgical complications.Results:Propensity-score matching yielded 493 matched patients for evaluation of Medicaid and 670 matched patients for evaluation of Medicare. Overall complication rates did not significantly differ between patients with Medicaid or Medicare and those with private insurance (P = 0.167 and P = 0.861, respectively). Risk-adjusted multivariate regressions corroborated this finding, demonstrating that Medicaid and Medicare insurance status does not independently predict surgical site infection, seroma, hematoma, explantation, or wound dehiscence (all P > 0.05). Medicaid insurance status significantly predicted flap failure (odds ratio = 3.315, P = 0.027).Conclusions:This study is the first to investigate the differential effects of payer status on outcomes following breast reconstruction. Our results suggest that Medicaid and Medicare insurance status does not independently predict increased overall complication rates following breast reconstruction. This finding underscores the commitment of the plastic surgery community to providing consistent care for patients, irrespective of insurance status.

Medicare's Increasing Focus on Prevention and Wellness Services Should Garner Greater Attention by Health Care Practitioners and Communities

Since 2011, the Affordable Care Act (ACA) requires the provision of certain recommended clinical preventive services without cost-sharing for individuals in Medicare. We re-visited the effects of the ACA on preventive services utilization under Medicare, using data from the Medical Expenditure Panel Survey (MEPS) and examined the ACA's longer-term effects on preventive services utilization among Medicare beneficiaries. We analyzed nationally representative data on non-institutionalized Medicare beneficiaries (n = 27,124) from the 2006–2010 and 2012–2016 Medical Expenditure Panel Survey. Preventive services of interest were cholesterol test, blood pressure test, flu shot, endoscopy, blood stool test, clinical breast exam, mammography and prostate exam. We estimated propensity score weighted difference-in-difference (DID) models to test for differences in preventive services utilization based on Medicare insurance status. Nationwide, among beneficiaries with traditional Medicare only, who stood to gain the most from eliminating cost-sharing for preventive services, the percentage of women receiving clinical breast exams rose post-reform (Δ = 8.1%; p < 0.015) as compared to Medicare beneficiaries with supplemental private coverage, while at the same time the percentage receiving other preventive services did not change post-reform (all p > 0.05). Based on this analysis of MEPS data spanning 2006–2016, the ACA's enhancement of Medicare coverage had only modest effects on the percentage of beneficiaries receiving a range of preventive services. Medicare beneficiaries should be better informed of the availability of these services and encouraged by their physicians to avail the no cost-sharing incentive of these reforms.