Medicare Provider Analysis And Review Research Articles

Abstract 4145877: Association of heat exposure with cardiovascular and all-cause hospitalizations among elderly adults in the United States

Background: Heat exposure is associated with an increase in cardiovascular mortality, particularly among older adults. Climate change has led to an increase in days with hot temperatures. The burden of hospitalizations associated with heat exposure is not well known. Methods: Data on all hospitalizations among Medicare beneficiaries 65 years of age and older in summer months (May through September) for 2016 to 2019 were obtained from Medicare Provider Analysis and Review (MEDPAR) files. Total daily cardiovascular and all-cause hospitalizations in each US county in the contiguous United States (US) were determined and daily county-level maximum heat index levels were obtained from the gridMET dataset. Counties with <100 elderly residents were excluded. The association between daily heat index and hospitalizations was quantified using the distributive lag non-linear framework, with a generalized linear regression model – assuming a quasi-Poisson distribution. The model accounted for the lagged association, for up to 10 days, for daily heat index as well as covariates (ozone, particulate matter, and precipitation levels). Estimates from this model were used to determine the number and fraction of hospitalizations attributable to high temperatures on hot days. Hot days were defined as those with a heat index level in the 90 th percentile based on a county-specific historical period (1979-2015). Results: A total of 2085 counties (out of 3108) were included. The median threshold for hot days was 90.2°F (IQR 84.8°F to 95.5°F) [32.3°C (IQR 29.3°C to 35.3°C)]. Between 2016 and 2019, hot days were associated with 3044.0 (95% CI 2641.5 to 3380.9) or 0.067% (95% CI 0.058% to 0.074%) of all cardiovascular hospitalizations. Hot days were associated with 42132.2 (95% CI 41159.9 to 43082.1) or 0.22% (95% 0.21% to 0.225%) of all hospitalizations among Medicare beneficiaries. Conclusions: Between 2016 and 2019 days with high heat index levels were associated with higher levels of cardiovascular and all-cause hospitalizations among elderly Medicare beneficiaries across the contiguous US. As the number of hot days continues to increase due to climate change, the burden of heat related hospitalizations is likely to continue to increase.

Benzodiazepine Initiation Effect on Mortality Among Medicare Beneficiaries Post Acute Ischemic Stroke.

Despite guideline warnings, older acute ischemic stroke (AIS) survivors still receive benzodiazepines (BZD) for agitation, insomnia, and anxiety despite being linked to severe adverse effects, such as excessive somnolence and respiratory depression. Due to polypharmacy, drug metabolism, comorbidities, and complications during the sub-acute post-stroke period, older adults are more susceptible to these adverse effects. We examined the impact of receiving BZDs within 30 days post-discharge on survival among older Medicare beneficiaries after an AIS. Using the Medicare Provider Analysis and Review (MedPAR) dataset, Traditional fee-for-service Medicare (TM) claims, and Part D Prescription Drug Event data, we analyzed a random 20% sample of TM beneficiaries aged 66 years or older who were hospitalized for AIS between July 1, 2016, and December 31, 2019. Eligible beneficiaries were enrolled in Traditional Medicare Parts A, B, and D for at least 12 months before admission. We excluded beneficiaries who were prescribed a BZD within 90 days before hospitalization, passed away during their hospital stay, left against medical advice, or were discharged to institutional post-acute care. Our primary exposure was BZD initiation within 30 days post-discharge, and the primary outcome was 90-day mortality risk differences (RD) from discharge. We followed a trial emulation process involving cloning, weighting, and censoring, plus we used inverse-probability-of-censoring weighting to address confounding. In a sample of 47,421 beneficiaries, 826 (1.74%) initiated BZD within 30 days after discharge from stroke admission or before readmission, whichever occurred first, and 6,392 (13.48%) died within 90 days. Our study sample had a median age of 79, with an inter-quartile range (IQR) of 12, 55.3% female, 82.9% White, 10.1% Black, 1.7% Hispanic, 2.2% Asian, 0.4% American Native, 1.5% Other and 1.1% Unknown. After standardization based on age, sex, race/ethnicity, length of stay in inpatient, and baseline dementia, the estimated 90-day mortality risk was 159 events per 1,000 (95% CI: 155, 166) for the BZD initiation strategy and 133 events per 1,000 (95% CI: 132, 135) for the non-initiation strategy, with an RD of 26 events per 1,000 (95% CI: 22, 33). Subgroup analyses showed RDs of 0 events per 1,000 (95% CI: -4, 11) for patients aged 66-70, 3 events per 1,000 (95% CI: -1, 13) for patients aged 71-75, 10 events per 1,000 (95% CI: 3, 23) for patients aged 76-80, 27 events per 1,000 (95% CI: 21, 46) for patients aged 81-85, and 84 events per 1,000 (95% CI: 73, 106) for patients aged 86 years or older. RDs were 34 events per 1,000 (95% CI: 26, 48) and 20 events per 1,000 (95% CI: 11, 33) for males and females, respectively. RDs were 87 events per 1,000 (95% CI: 63, 112) for patients with baseline dementia and 18 events per 1,000 (95% CI: 13, 21) for patients without baseline dementia. Initiating BZDs within 30 days post-AIS discharge significantly increased the 90-day mortality risk among Medicare beneficiaries aged 76 and older and for those with baseline dementia. These findings underscore the heightened vulnerability of older adults, especially those with cognitive impairment, to the adverse effects of BZDs.

Isolated decompression for degenerative spondylolisthesis is less costly than fusion even with high revision rates

BACKGROUND CONTEXTIsolated decompression and decompression with instrumented fusion are accepted surgical treatments for lumbar spondylolisthesis. Although isolated decompression is a less costly solution with similar patient-reported outcomes, it is associated with higher rates of reoperation than primary fusion. PURPOSETo determine the costs associated with primary decompression, primary fusion, and decompression and fusion for degenerative spondylolisthesis. We further sought to establish at what revision rate is primary decompression still a less costly surgical treatment for degenerative lumbar spondylolisthesis. STUDY DESIGN/SETTINGA retrospective database study of the Medicare Provider Analysis and Review (MEDPAR) limited data set. PATIENT SAMPLEPatients who underwent single-level fusion or decompression for degenerative spondylolisthesis. OUTCOME MEASURESCost of surgical care. METHODSAll inpatient stays that underwent surgery for single-level lumbar/lumbosacral degenerative spondylolisthesis in the 2019 calendar year (n=6,653) were queried from the MEDPAR limited data set. Patients were stratified into three cohorts: primary decompression (n=300), primary fusion (n=5,757), and revision fusion (n=566). Univariate analysis was conducted to determine cost differences between these groups and results were confirmed with multivariable regression. An economic analysis was then done to determine at what revision rate would primary decompression still be a less costly treatment choice. resultson univariate analysis, the cost of primary single-level decompression for spondylolisthesis was $14,690±9,484, the cost of primary single-level fusion was $26,376±11,967, and revision fusion was $26,686±11,309 (p<0.001). on multivariate analysis, primary fusion was associated with an increased cost of $3,751, and revision fusion was associated with increased cost of $7,502 (95%ci: 2,990-4,512, p<0.001). economic analysis found that a revision rate less than or equal to 43.8% would still result in primary decompression being less costly for a practice than primary fusion for all patients. CONCLUSIONSIsolated decompression for degenerative lumbar spondylolisthesis is a less costly treatment choice even with rates of revision fusion as high as 43.8%. This was true even with an assumed revision rate of 0% after primary fusion. This study solely looks at cost data, however, and many patients may still benefit from primary fusion when appropriately indicated.

Elective Single-Level Primary Anterior Cervical Decompression and Fusion for Degenerative Spondylotic Cervical Myelopathy Is Associated With Decreased Resource Utilization Versus Posterior Cervical Decompression and Fusion.

Retrospective cohort study. To compare elective single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for degenerative cervical myelopathy (DCM) in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination in Medicare patients. A sub-analysis of potential cost drivers was also performed. In the era of value-based medicine, there is substantial interest in reducing the cost of care. Both ACDF and PCDF are used to treat DCM but carry different morbidity and risk profiles that can impact hospital resource utilization. However, this has not been assessed on a national level. Patients undergoing single-level elective ACDF and PCDF surgery were identified using the 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File. Multivariate models of hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. A univariate sub-analysis of 9 revenue centers was performed. In all, 3942 patients met the inclusion criteria. The mean cost of elective single-level cervical fusion for myelopathy was $18,084±10,783, and the mean length of stay was 2.45±2.95d. On multivariate analysis, ACDF was independently associated with decreased cost of $5,814 ( P <0.001), shorter length of stay by 1.1 days ( P <0.001), and decreased risk of nonhome discharge destination by 58% (adjusted odds ratio: 0.422, P <0.001).On sub-analysis of 9 revenue centers, medical/surgical supply ($10,497, 44%), operating room charges ($5401, 23%), and accommodations ($3999, 17%) were the largest drivers of charge differences. Single-level elective primary ACDF for DCM was independently associated with decreased cost, decreased hospital length of stay, and a lower rate of nonhome discharge compared with PCDF. Medical and surgical supply, operating room, and accommodation differences between ACDF and PCDF are potential areas for intervention. Increased granularity in reimbursement structures is warranted to prevent the creation of disincentives to the treatment of patients with DCM with pathology that is better addressed with PCDF. Level-III Retrospective Cohort Study.

An assessment of completeness and medical coding of Medicare Advantage hospitalizations in two national data sets.

To compare the Encounter Data System (EDS) and Medicare Provider Analysis and Review (MedPAR) completeness and medical coding of Medicare Advantage hospitalizations. FY 2016-FY 2019 data limited to hospitals paid under Medicare's Inpatient Prospective Payment System. Secondary data analysis. Completeness of EDS and MedPAR data was estimated using the total number of unique hospitalizations in both data sources as denominator. Deriving this denominator involved matching cases in the EDS and MedPAR by MA enrollee, discharge date, and hospital. The higher the match rate, the more informative the comparison of EDS and MedPAR medical coding of the same hospitalization. EDS and MedPAR codes were assessed for similarity on six measures of Medicare Severity Diagnosis-Related Group (MS-DRG) assignment and identical diagnosis and procedure codes. EDS hospitalizations' completeness increased steadily each year from 90% to 93%, driven by the 23 largest Medicare Advantage Organizations, which account for 83% of total cases. MedPAR completeness was relatively stable (89%) and benefited from 91% completeness among the largest hospitals, which are often teaching hospitals and account for 63% of MedPAR cases. By 2019, 97% of medical cases were assigned the same MS-DRG, indicating the high consistency of the severity level coding, since 98% were assigned the same base MS-DRGs, which include all severity levels for the same condition. Without chart reviews, medical cases with identical diagnosis codes increased from 87% to 92%. The EDS has a completeness advantage over MedPAR for studies of non-teaching disproportionate share (DSH) hospitals and individual hospitals generally. MedPAR is only slightly less complete for hospitalizations of teaching DSH hospitals and large hospitals in general. A highly consistent EDS and MedPAR medical coding of matched cases is an important finding since the matched cases are 88% of EDS and 90% of MedPAR cases.

Assessing the validity of race and ethnicity coding in administrative Medicare data for reporting outcomes among Medicare advantage beneficiaries from 2015 to 2017.

To assess the validity of race/ethnicity coding in Medicare data and whether misclassification errors lead to biased outcome reporting by race/ethnicity among Medicare Advantage beneficiaries. In this national study of Medicare Advantage beneficiaries, we analyzed individual-level data from the Health Outcomes Survey (HOS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS), race/ethnicity codes from the Medicare Master Beneficiary Summary File (MBSF), and outcomes from the Medicare Provider Analysis and Review (MedPAR) files from 2015 to 2017. We used self-reported beneficiary race/ethnicity to validate the Medicare Enrollment Database (EDB) and Research Triangle Institute (RTI) race/ethnicity codes. We measured the sensitivity, specificity, and positive and negative predictive values of the Medicare EDB and RTI codes compared to self-report. For outcomes, we compared annualized hospital admission, 30-day, and 90-day readmission rates. Data for Medicare Advantage beneficiaries who completed either the HOS or CAHPS survey were linked to MBSF and MedPAR files. Validity was assessed for both self-reported multiracial and single-race beneficiaries. For beneficiaries enrolled in Medicare Advantage, the EDB and RTI race/ethnicity codes have high validity for identifying non-Hispanic White or Black beneficiaries, but lower sensitivity for beneficiaries self-reported Hispanic any race (EDB: 28.3%, RTI: 85.9%) or non-Hispanic Asian American or Native Hawaiian Pacific Islander (EDB: 56.1%, RTI: 72.1%). Only 8.7% of beneficiaries self-reported non-Hispanic American Indian Alaska Native are correctly identified by either Medicare code, resulting in underreported annualized hospitalization rates (EDB: 31.5%, RTI: 31.6% vs. self-report: 34.6%). We find variation in 30-day readmission rates for Hispanic beneficiaries across race categories, which is not measured by Medicare race/ethnicity coding. Current Medicare race/ethnicity codes misclassify and bias outcomes for non-Hispanic AIAN beneficiaries, who are more likely to select multiple racial identities. Revisions to race/ethnicity categories are needed to better represent multiracial/ethnic identities among Medicare Advantage beneficiaries.

DISCHARGE LOCATIONS AFTER HOSPITALIZATIONS INVOLVING OPIOID USE DISORDER AMONG MEDICARE ENROLLEES

Abstract Hospitalizations involving opioid use disorder (OUD) are increasing in the Medicare population. Rising OUD-related acute care use emphasizes the need to understand where post-acute care is provided and opportunities to facilitate OUD treatment in those settings. We conducted a retrospective cohort study using 2016-2018 Medicare Provider Analysis and Review (MedPAR) files linked to enrollment data and the Residential History File (RHF) for 100% of Medicare fee-for-service beneficiaries aged ≥18 years. We used diagnostic codes for opioid dependence or “abuse” to identify OUD from MedPAR data. The RHF identified hospital discharge locations. Our analysis included 459,763 OUD-related hospitalizations. Overall, individuals &amp;lt; 65 years (60.3%), female (53.7%), or Medicare-Medicaid dually enrolled (59.1%) were the majority. The mean (standard deviation) length of stay was 5.5 (6.6) days and 31.3% of OUD-related hospitalizations required intensive care use. Seventy percent of patients with OUD-related hospitalizations were discharged home, 15.8% to skilled nursing facilities (SNFs), 9.6% to non-SNF institutional facilities, 2.5% home with home health services, and 1.8% died in-hospital. Within 30 days of hospital discharge, the range for 30-day all-cause readmissions was 27.7% (home) to 47.5% (non-SNF institutional setting). The 30-day all-cause mortality ranged from 3.1% (home without health) to 6.4% (non-SNF institutional settings). Given that over one-quarter of OUD-related hospitalizations resulted in discharge to locations other than home and that many institutional post-acute care settings cannot obtain OUD medications, modifying Drug Enforcement Administration regulations and expanding access to OUD medications for aging adults in post-acute and long-term care settings must be a near-term policy focus.

2314. Hospitalizations and Antibiotic Use in the Year Prior to an Incident C. difficile Infection for Medicare Beneficiaries in Four States, 2016–2018

Abstract Background Studies describing risk factors for Clostridioides difficile infection (CDI) are often limited in their ability to identify potentially important exposures occurring long before diagnosis. We describe hospitalizations and antibiotic use (AU) occurring up to one year prior to CDI diagnosis among Medicare beneficiaries. Methods We studied incident CDI cases (positive C. difficile test in a person ≥65 years without a positive test in the prior 8 weeks) identified during 2016–2018 through population-based CDI surveillance from four states participating in the Centers for Disease Control and Prevention’s Emerging Infections Program. The analysis included specimens collected in all settings and was limited to case patients who were identified as having fee-for-service Medicare and Part D drug coverage for the year preceding specimen collection. Inpatient hospitalization data was extracted from Medicare Provider Analysis and Review (MEDPAR) files and outpatient AU (prescriptions filled) was determined using Part D drug event files. Timing of hospitalizations and antibiotic prescriptions were described as recent (0–3 months prior to specimen collection) or remote (4–12 months prior). Results Of 1,953 CDI cases, 1,594 (82%) filled ≥1 course of outpatient antibiotics in the prior year; 805 (41%) filled an antibiotic both recently and remotely, 497 (25%) only remotely, and 292 (15%) only recently. Cases with outpatient AU received a median of 23.5 (IQR 12–46) total days supplied, and a median of 2 different antibiotic classes (IQR 1 – 3). The most frequent antibiotic classes filled include fluoroquinolones (17% of all antibiotics filled), 1st generation cephalosporins (10%), and folate pathway inhibitors (10%). Overall, 1,314 (67%) cases were hospitalized in the prior year; 569 (29%) were hospitalized both recently and remotely, 446 (23%) only recently, and 299 (15%) only remotely. Median length of stay was 13 days (IQR 6–28). A total of 142 cases (7%) did not have hospitalization or outpatient AU in the prior year, and 1,097 (56%) had both. Conclusion Incident CDI cases have substantial exposure to recent and remote hospitalization and outpatient AU. Understanding cumulative effects of multiple risk factors can guide prevention strategies, including antibiotic stewardship efforts. Disclosures Scott Fridkin, MD, Pfizer: Grant/Research Support Ghinwa Dumyati, MD, Pfizer: Grant/Research Support.

18. The impact of race/ethnicity on length of stay, discharge destination and cost of care after anterior cervical decompression and fusion

18. The impact of race/ethnicity on length of stay, discharge destination and cost of care after anterior cervical decompression and fusion

135. Elective primary anterior cervical decompression and fusion for degenerative spondylotic cervical myelopathy is associated with decreased resource utilization vs posterior cervical decompression and fusion

135. Elective primary anterior cervical decompression and fusion for degenerative spondylotic cervical myelopathy is associated with decreased resource utilization vs posterior cervical decompression and fusion

P84. Day of admission is associated with hospital length of stay following elective posterior cervical decompression and fusion for cervical myelopathy

BACKGROUND CONTEXTThe COVID-19 pandemic has caused significant strain on the US health care system, with many hospitals struggling to provide resources for perioperative care and even necessitating the cessation of elective surgery for periods of time. Therefore, it is imperative to understand the hospital resource demands of elective surgery and identify ways to optimize them. With the traditional hospital staffing structure, there is minimal coverage on weekends, which can lead to delays in discharge for surgeries performed later in the week.PURPOSETo identify 1) length of hospital stay 2) cost of hospital episode and 3) discharge destination following treatment of cervical spondylotic myelopathy (CSM) with posterior cervical decompression and fusion (PCDF) based on day of hospital admission.STUDY DESIGN/SETTINGRetrospective case-control analysis.PATIENT SAMPLEThe 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File were utilized. Patients undergoing elective PCDF for CSM were included. Nonelective surgery, combined anterior and posterior cervical fusions, revision cases, thoracic extension, disc replacements, fractures, traumatic spinal cord injury and epidural abscesses were excluded.OUTCOME MEASURESLength of stay, cost, and discharge destination.METHODSPotential demographic, comorbidity, surgical, perioperative and hospital confounders were evaluated. Multivariate models for hospital length of stay, cost of care and discharge destination were performed including surgical approach and potential confounders.RESULTSThere were 7,212 cases that met inclusion criteria. There were 4,026 males (55.8%) and 3,186 females (44.2%). The majority of patients were aged 65-74 (n=3,609, 50.0%) and 75-84 (n=2,009, 27.9%). The mean length of stay was 3.89±3.171 days and cost of hospital episode was $28,854.066±15,649.294 for elective surgical treatment of CSM with PCDF. The majority of patients were discharged home (n=4,605, 63.9%). There were 1,507 cases admitted on Tuesday (20.9%), 1,601 cases admitted on Wednesday (22.2%),623 cases admitted on Thursday (22.5%), 373 cases admitted on Friday (19.0%) and 1,108 cases admitted on Saturday (15.4%). On univariate analysis, there were significant differences in length of stay based on day of admission (Tuesday: 3.59±2.58 days, Wednesday: 3.74±2.919 days, Thursday: 3.89±2.92 days, Friday: 4.13±3.76 days and Saturday: 4.23±3.71 days, p=0.006). However, there were no differences in cost (p=0.340) or incidence of discharge home (p=0.389). On multivariate analysis, day of admission was associated with length of stay, with each later day in the week associated with a 0.155 days increased length of hospital stay (95% confidence interval: 0.101-0.208, p<0.001). Day of admission was not associated with cost of hospital episode (p=0.591) or discharge destination (p=0.813).CONCLUSIONSElective PCDF for CSM involves significant hospital resource utilization with almost 4 day mean length of stay and 40% of patients discharged to non-home destinations. Cost of care reached almost $30,000 for the acute hospital episode. Surgery performed later in the week was independently associated with increased length of stay. Interestingly, cost of care and discharge destination were not associated with day of surgery. These findings may aid surgeons and hospitals organize weekly surgery schedules to optimize hospital resources.FDA DEVICE/DRUG STATUSThis abstract does not discuss or include any applicable devices or drugs.

Use of Post-Acute Care by Medicare Beneficiaries With a Diagnosis of Dementia.

Hospitalized patients with dementia transitioning to post-acute care may be particularly vulnerable to changes in post-acute care utilization driven by payment reforms; however, use of post-acute care in this population is incompletely understood. We sought to describe post-acute care utilization in skilled nursing facilities (SNFs) and from home health (HH) agencies among Medicare beneficiaries with a diagnosis of dementia. Retrospective, observational study using 100% sample of Medicare beneficiaries from 2013 to2016. We identified hospitalizations and diagnoses using Medicare Provider Analysis and Review (MedPAR), SNF stays using the Minimum Data Set, HH episodes using the Outcome and Assessment Information Set, and dementia diagnoses using the Medicare Beneficiary Summary File Chronic Conditions segment. We calculated overall utilization and trends in post-acute care use over time, stratified by dementia diagnosis, type of post-acute care (SNF vs HH), and payer (fee-for-service vs Medicare Advantage). Of the 9,762,208 Medicare fee-for-service beneficiaries who received post-acute care from 2013 to 2016, 3,155,560 (32.3%) carried a diagnosis of dementia. Rates of post-acute care use were similar over time. More beneficiaries with a diagnosis of dementia received post-acute care (44.2% vs 27.7%) and proportionally more SNF care (71.7% vs 49.6%). Overall use and trends were similar in the Medicare Advantage population. One-third of all fee-for-service Medicare beneficiaries receiving post-acute care have a diagnosis of dementia, and more than 7 in 10 receive this care in an SNF. These findings serve as a foundation for needed evaluations of how best to meet the post-hospital needs of older adults with dementia.

Implementation of resource use measures in Medicare Advantage.

To complement the previously illustrated method to measure resource use in Medicare Advantage (MA) using Encounter data and provide technical details and SAS code to validate Encounter data and implement resource use measures in MA. 2015-2018 MA Encounter, Medicare Provider Analysis and Review (MedPAR), Healthcare Effectiveness Data and Information System (HEDIS), and Traditional Medicare (TM) claims data. Secondary data analysis. We select MA contracts with high data completeness (≤10% missing hospital stays in Encounter data and ≤±10% difference in ambulatory and emergency department visits between Encounter and HEDIS data). We randomly sample TM beneficiaries with a similar geographic distribution as MA enrollees in the selected contracts. We develop standardized prices of services using TM payments, and we measure MA resource use for inpatient, outpatient, Part D, and hospice services. We report identifiers/names of contracts with high data completeness. We provide SAS code to manage Encounter data, develop standardized prices, and measure MA resource use. Greater use and validation of Encounter data can help improve data quality. Our results can be used to inform studies using Encounter data to learn about MA performance.

Stroke thrombectomy volume, rather than stroke center accreditation status of hospitals, is associated with mortality and discharge disposition

BackgroundFew studies have explored the association between stroke thrombectomy (ST) volume and hospital accreditation with clinical outcomes.ObjectiveTo assess the association of ST case volume and accreditation status with in-hospital mortality...

Post-acute care transitions and outcomes among medicare beneficiaries in assisted living communities.

Despite the rapid growth of assisted living (AL) and frequent hospitalizations among AL residents, little is known about their patterns of post-acute care transitions and outcomes. This study examined the post-acute care transitions among AL residents and their association with outcomes in the first 30 and 60 days after hospital discharge. This study used data from 2018 national Medicare enrollment and claims datasets, the Minimum Data Set (MDS), and Medicare Provider Analysis and Review (MedPAR) of 104,497 unique Medicare beneficiaries residing in ALs in the U.S. Post-acute care referrals, based on hospital discharge status, to skilled nursing facilities (SNF), home with home health care (HHC), home without HHC, and other settings. Outcomes included 30-day and 60-day hospital readmissions, emergency department (ED) visits, long-stay care nursing home placement, and mortality. Multinomial logistic regression analysis and logistic regression analysis were conducted. The most common post-acute care referral was to SNF (40%), followed by home without HHC (28%), home with HHC (17%), and others (15%). Compared to discharge home without HHC, discharge to SNF was associated with a lower likelihood of ED visits (Odds Ratio=0.597, p < 0.01) and hospital readmissions (OR=0.856, p < 0.001), and higher likelihood of long-stay nursing home placement (OR=11.224, p < 0.01) and mortality (OR=2.025, p < 0.01). Discharge home with HHC was associated with a higher likelihood of hospital readmissions (OR=1.148, p < 0.01) and a lower likelihood of long-stay nursing home placement (OR=0.737, p < 0.05) than discharge home without HHC. The results were similar within the first 30 days as well as 60 days after hospital discharge. AL residents who are discharged to different post-acute care settings tend to differ in 30-day and 60-day outcomes. At hospital discharge, clinicians and discharge planners should be provided information about the exact type and availability of services at AL to make the most appropriate discharge referrals for AL residents.

Discharge locations after hospitalizations involving opioid use disorder among medicare beneficiaries

BackgroundHospitalizations involving opioid use disorder (OUD) have been increasing among Medicare beneficiaries of all ages. With rising OUD-related acute care use comes the need to understand where post-acute care is provided and the capacities for OUD treatment in those settings. Our objective was to describe hospitalized Medicare beneficiaries with OUD, their post-acute care locations, and all-cause mortality and readmissions stratified by post-acute care location.MethodsWe conducted a retrospective cohort study of acute hospitalizations using 2016–2018 Medicare Provider Analysis and Review (MedPAR) files linked to Medicare enrollment data and the Residential History File (RHF) for 100% of Medicare fee-for-service beneficiaries. The RHF which provides a person-level chronological history of health service utilization and locations of care was used to identify hospital discharge locations. We used ICD-10 codes for opioid dependence or “abuse” to identify OUD diagnoses from the MedPAR file. We conducted logistic regression to identify factors associated with discharge to an institutional setting versus home adjusting for demographics, comorbidities, and hospital stay characteristics.ResultsOur analysis included 459,763 hospitalized patients with OUD. Of these, patients aged < 65 years and those dually enrolled in Medicaid comprised the majority (59.1%). OUD and opioid overdose were primary diagnoses in 14.3% and 6.2% of analyzed hospitalizations, respectively. We found that 70.3% of hospitalized patients with OUD were discharged home, 15.8% to a skilled nursing facility (SNF), 9.6% to a non-SNF institutional facility, 2.5% home with home health services, and 1.8% died in-hospital. Within 30 days of hospital discharge, rates of readmissions and mortality were 29.7% and 3.9%; respectively, with wide variation across post-acute locations. Factors associated with greater odds of discharge to institutional settings were older age, female sex, non-Hispanic White race and ethnicity, dual enrollment, longer hospital stay, more comorbidities, intensive care use, surgery, and primary diagnoses including opioid or other drug overdoses, fractures, and septicemia.ConclusionsMore than one-quarter (25.8%) of hospitalized Medicare beneficiaries with OUD received post-acute care in a setting other than home. High rates and wide variation in all-cause readmissions and mortality within 30 days post-discharge emphasize the need for improved post-acute care for people with OUD.

Measuring resource use in Medicare Advantage using Encounter data.

To check the completeness of Medicare Advantage (MA) Encounter data and to illustrate a process to measure resource use among MA enrollees using Encounter data. 2015 Preliminary MA Encounter, Medicare Provider Analysis and Review (MedPAR), Healthcare Effectiveness Data and Information System (HEDIS), and 2013 Traditional Medicare (TM) claims data. Secondary data analysis. We calculated the percentage of each contract's total hospitalizations in Encounter data after identifying total inpatient stays from Encounter and MedPAR data. We constructed each contract's ambulatory visits and emergency department (ED) visits per 1000 enrollees using Encounter data and compared those visit counts with the counts from HEDIS. We defined high data completeness as having less than 10% missing hospital stays and less than ±10% difference in ambulatory and ED visits between Encounter and HEDIS data. We used TM payments as standardized prices of services to examine resource use among MA enrollees with cancer in the contracts with high data completeness. We identified 83 of 380 MA contracts with high data completeness. Total resource use per enrollee with cancer in the 83 contracts was $14,715 in 2015. Service-specific resource use was $5342 for inpatient care, $5932 for professional services and $3441 for outpatient facility services. These represent what an MA enrollee with cancer would have cost on average if MA plans paid providers at TM payment rates, holding the observed utilization constant. Checking the completeness of Encounter data is an important step to ensure the validity of research on MA resource use. Using Encounter data to measure MA resource use is feasible. It can compensate for the lack of payment information in Encounter data. It will be important to identify and refine ways to best use Encounter data to learn about care provision to MA enrollees.

Admissions to High‐Quality Nursing Homes from Community: Racial Differences and Medicaid Policy Effects

Research ObjectiveTo examine racial differences in admissions to high‐quality nursing homes (NHs) among residents with Alzheimer's disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia‐related state Medicaid add‐on policies.Study DesignMultiple CY2011‐2017 national data were linked: The Minimum Data Set (MDS) 3.0, Medicare Beneficiary Summary File (MBSF), Medicare Provider Analysis and Review (MedPAR), and nursing home compare (NHC). We also collected information on state dementia‐related Medicaid add‐on policies and the 2015 national Area Deprivation Index (ADI).For each identified resident, we constructed a choice set of NHs, defined as a set of NHs within a certain driving distance radius from home (15 miles in urban areas and 20 miles in rural areas), based on the 5‐digit zip‐code of a NH and individuals' community residence. We excluded individuals who did not choose a NH within their choice set and individuals with only one NH within their choice set.The dependent variable was whether a NH is “chosen” or not (binary). Key independent variables included the interaction of NH quality (measured by 5‐star rating) and race (i.e. black versus white), and interaction of NH quality, race, and state Medicaid dementia‐related add‐on policies. Individual‐ and facility‐level covariates (e.g. distance from residence to NHs) were identified. A set of McFadden's choice (conditional logit) models were estimated.Population StudiedWe identified Medicare enrolled NH residents with ADRD who were newly admitted from community (i.e. no NH episodes or hospitalizations in the prior 30 days) between 01/01/2011 and 12/31/2017. In total, 874,526 individuals in 15,755 NHs were identified.Principal FindingsIn the study sample, 89% were whites and 11% were blacks. Overall, 50% of whites and 35% of blacks were admitted to high‐quality NHs (4‐ or 5‐star). Blacks were less likely to have aggressive behaviors (14.7% vs. 16.6%, P &lt; 0.01) but more likely to have severe cognitive impairment (9.6% vs. 6.8%, P &lt; 0.01) than whites. Blacks were more likely to live in social‐economically disadvantaged neighborhoods and be Medicare‐Medicaid dually eligible. Results from the McFadden's model suggested that blacks were less likely to be admitted to a high‐quality NH than whites (OR = 0.7, P &lt; 0.01). Although residents with low socio‐economic status, cognitive impairment and behavioral problems were less likely to enter high‐quality NHs, these characteristics did not fully explain the observed racial differences in entering high‐quality NHs. However, the racial difference was reduced in states with dementia‐related add‐on policies, compared to states without these policies (OR = 1.2, P &lt; 0.01).ConclusionsBlacks with ADRD were less likely to be admitted to high‐quality NHs than whites. Individuals' health conditions and social‐economic status could not fully explain this racial difference. State Medicaid policies that provided additional subsidies to ADRD residents may reduce this racial difference.Implications for Policy or PracticeIt is important to deliver high quality NH care for individuals with ADRD. Racial minorities still face barriers in accessing high‐quality NHs. Medicaid add‐on policies appear to reduce the racial difference in entering high‐quality NHs.Primary Funding SourceNational Institutes of Health.

Racial/Ethnic Disparities in Post‐Acute Care Discharge Patterns

Research ObjectiveAmericans who belong to racial/ethnic minorities, particularly those who are Black and/or Hispanic, face substantial inequities in access to care. To better understand the drivers of these inequities, it's important to quantify how care patterns differ between groups. There is limited research that describes patterns of post‐acute care (PAC) use of racial/ethnic minorities following hospitalizations. We used a national sample of hospitalized Medicare enrollees to compare first discharge location across racial/ethnic minority groups.Study DesignWe conducted a cohort study of Medicare enrollees admitted to the hospital for five conditions that often require post‐acute care (PAC): congestive heart failure (CHF), stroke, hip fracture, lower extremity joint replacement (LEJR), and chronic obstructive pulmonary disorder (COPD). We identified all traditional Medicare beneficiaries hospitalized for these conditions from 2007 through 2017 using the Medicare Provider Analysis and Review (MedPAR) file. We then used MDS, OASIS, and IRF‐PAI assessments and claims to identify which PAC locations patients were discharged to. Our multinomial outcome of interest was discharge to home without home health, home with home health (HH), skilled nursing facility (SNF), inpatient rehabilitation (IRF), other locations (long term care hospitals or other acute care), or death during hospitalization. Our primary explanatory variable was patient race/ethnicity.We first compared discharge locations by disease cohort and race ethnicity. We then used multinomial logit models to adjust for age, gender, Medicare disability entitlement, dual Medicare‐Medicaid eligibility, and zipcode and hospital fixed effects. We purposefully did not include chronic disease indicators as chronic disease coding may be endogenous with race/ethnicity, however in sensitivity analyses that included chronic disease flags, the results did not differ substantially. From these models, we calculated the adjusted percent discharged to each location and compared by race/ethnicity.Population Studied2,782,117 Medicare beneficiaries who were admitted to a hospital for our target conditions from 2007 through 2017.Principal FindingsThe study included 313,735 patients admitted for CHF, 387,792 for stroke, 289,027 for hip fracture, 591,677 for LEJR and 1,199,886 for COPD. After adjustment, among patients with COPD, 26.9% of white patients were discharged to home without PAC, and 35.8% were discharged to SNF compared to 34.6% and 28.7% of Black and 33.9% and 27.5% of Hispanic patients. Among patients with CHF, 50.1% of white patients were discharged to home without PAC, and 19% were discharged to SNF compared to 57.1% and 11.4% of Asian and 55.3% and 11.9% of Hispanic patients. Among patients with stroke, 43.4% of white patients were discharged to home without PAC, and 19% were discharged to SNF compared to 31.3% and 19.0% of Black patients. Discharge patterns were similar for hip fracture and lower extremity joint replacement.ConclusionsEven after accounting for a patient's discharging hospital and residential zipcode, there are important conditions with substantial differences in PAC utilization patterns across racial/ethnic minorities for stroke, CHF, and COPD, but not for hip fracture or LEJR.Implications for Policy or PracticeAs the proportion of patients requiring PAC continues to diversify over time, it will be imperative to understand the drivers of differences in PAC use and whether they lead to differential health outcomes.Primary Funding SourceNational Institutes of Health.

Infection Hospitalization Trends Among US Home Healthcare Patients, 2013–2018

Background: Infections are a frequent cause of hospital (re)admissions for older adults receiving home health care (HHC) in the United States. However, previous investigators have likely underestimated the prevalence of infections leading to hospitalization due to limitations of identifying infections using Outcome and Assessment Information Set (OASIS), the standardized assessment tool mandated for all Medicare-certified HHC agencies. By linking OASIS data with inpatient data from the Medicare Provider Analysis and Review (MedPAR) file, we were able to better quantify infection hospitalization trends and subsequent mortality among HHC patients. Method: After stratification (by census region, ownership, and urban or rural location) and random sampling, our data set consisted of 2,258,113 Medicare beneficiaries who received HHC services between January 1, 2013, and December 31, 2018, from 1,481 Medicare-certified HHC agencies. The 60-day HHC episodes were identified in OASIS. Hospital transfers reported in OASIS were linked with corresponding MedPAR records. Our outcomes of interest were (1) hospitalization with infection present on admission (POA); (2) hospitalization with infection as the primary cause; and (3) 30-day mortality following hospitalization with infection as the primary cause. We identified bacterial (including suspected) infections based on International Classification of Disease, Ninth Revision (ICD-9) and ICD-10 codes in MedPAR. We classified infections by site: respiratory, urinary tract, skin/soft tissue, intravenous catheter-related, and all (including other or unspecified infection site). We also identified sepsis diagnoses. Result: From 2013 through 2018, the percentage of 60-day HHC episodes with 1 or more hospital transfers ranged from 15% to 16%. Approximately half of all HHC patients hospitalized had an infection POA. Over the 6 years studied, infection (any type) was the primary cause of hospitalization in more than a quarter of all transfers (25.86%–27.57%). The percentage of hospitalizations due to sepsis increased from 7.51% in 2013 to 11.49% in 2018, whereas the percentage of hospitalizations due to respiratory, urinary tract, or skin/soft-tissue infections decreased (p &lt;0.001). Thirty-day mortality following a transfer due to infection ranged from 14.14% in 2013 to 14.98% in 2018; mortality rates were highest following transfers caused by sepsis (23.14%-26.51%) and respiratory infections (13.07%-14.27%). Conclusion: HHC is an important source of post-acute care for those aging in place. Our findings demonstrate that infections are a persistent problem in HHC and are associated with substantial 30-day mortality, particularly following hospitalizations caused by sepsis, emphasizing the importance of infection prevention in HHC. Effective policies to promote best practices for infection prevention and control in the home environment are needed to mitigate infection risk.Funding: NoDisclosures: None