Medicare Provider Analysis Research Articles

Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections*

To determine whether the absence or presence of clinical pharmacists in intensive care units (ICUs) results in differences in mortality rates, length of ICU stay, and ICU charges for Medicare patients with nosocomial-acquired infections, community-acquired infections, and sepsis. The type and level of pharmacy services provided to ICUs were obtained from a 2004 national survey. Clinical pharmacy services were defined as having at least a partial pharmacist full-time equivalent specifically devoted to the ICU for the purpose of direct involvement in patient care. Infections were defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. ICU outcome data were drawn from the 2004 modified Medicare provider analysis and review. Depending on the infection studied, the involvement of clinical pharmacists was evaluated in 8,927-54,042 patients from 265 to 276 hospitals. None. Mortality rates, length of ICU stay, Medicare charges, drug charges, and laboratory charges for each of the infections categorized according to the absence or presence of clinical pharmacists. Compared to ICUs with clinical pharmacists, mortality rates in ICUs that did not have clinical pharmacists were higher by 23.6% (p < 0.001, 386 extra deaths), 16.2% (p = 0.008, 74 extra deaths), and 4.8% (p = 0.008, 211 extra deaths) for nosocomial-acquired infections, community-acquired infections, and sepsis, respectively. Similarly, ICU length of stay was longer by 7.9% (p < 0.001, 14,248 extra days), 5.9% (p = 0.03, 2855 extra days), and 8.1% (p < 0.001, 19,215 extra days) for nosocomial-acquired infections, community-acquired infections, and sepsis, respectively. ICUs that did not have clinical pharmacists had greater total Medicare billings of 12% (p < 0.001, $132,978,807 extra billing charges), 11.9% (p < 0.001, $32,240,378 extra billing charges), and 12.9% (p < 0.001, $224,694,784 extra billing charges) for nosocomial-acquired infections, community-acquired infections, and sepsis, respectively. Similar findings were observed for Medicare drug charges and laboratory charges. The involvement of clinical pharmacists in the care of critically ill Medicare patients with infections is associated with improved clinical and economic outcomes. Hospitals should consider employing clinical ICU pharmacists.

Sex Differences in Hospital Risk-Adjusted Mortality Rates for Medicare Beneficiaries Undergoing CABG Surgery

The primary purpose of this study was to rank US hospitals performing coronary artery bypass graft (CABG) surgery on Medicare beneficiaries into 4 performance tiers and determine if there were overall and sex-specific differences in the risk-adjusted mortality rates across performance tiers. A retrospective analysis was done using a Medicare Provider Analysis and Review (MEDPAR) file of all Medicare beneficiaries who underwent CABG surgery without valve repair or replacement during fiscal years 2003 and 2004. Logistic regression models controlling for demographic characteristics, comorbidities, and cardiac risk factors were used to predict the probability of in-hospital mortality. Hospitals performing at least 52 CABG surgeries during a fiscal year (at least 17 female patients) were ranked into 4 tiers. Rankings were based on the number of lives saved, calculated as the expected number of risk-adjusted deaths minus the actual number of deaths in the hospital during each fiscal year. Average risk-adjusted mortality rate was stable and declining over the 2 years: 3.68% in 2003 and 3.61% in 2004. In 2004, the average risk-adjusted mortality rate ranged from 1.39% in tier 1 hospitals to 6.40% in tier 4 hospitals. The sex-specific mortality rate was consistently higher for women in all tiers, with the differential smallest (0.68%) in tier 1 hospitals and greatest (2.67%) in tier 4 hospitals. The sex differential increases from top- to bottom-tier hospitals, suggesting female beneficiaries could benefit from having CABG performed at tier 1 hospitals.

Hospitalization for Psychiatric Illness Among Community-Dwelling Elderly Persons in 1992 and 2002

The authors evaluated the evolution of inpatient care for psychiatric illness in 1992 and 2002 for senior community-dwelling Medicare beneficiaries.National Medicare Provider Analysis and Review files for 1992 and 2002 were analyzed.From 1992 to 2002, rates of inpatient hospital use for treatment of psychiatric illness declined 28%, from 429 to 311 stays per 100,000 eligible beneficiaries, mostly because of reduced hospitalization for depression, and next, for substance use disorder. Inpatient care patterns for patients with schizophrenia and bipolar disorder changed little. Although stays were shorter in 2002 in general, rehospitalization rates remained the same in 2002 as they were in 1992.Trends in hospitalizations differed by diagnoses, which may be representative of general changes in treatment philosophy during the 1990s.

Growth of intensive care unit resource use and its estimated cost in Medicare*

The past 10-15 yrs brought significant changes in the United States healthcare system. Effects on Medicare intensive care unit use and costs are unknown. Intensive care unit costs are estimated using the Russell equation with a ratio of intensive care unit to floor cost per day, or "R value," of 3, which may no longer be valid. We sought to determine contemporary Medicare intensive care unit resource use, costs, and R values; whether these vary by patient and hospital characteristics; and the impact of updated values on estimated intensive care unit costs. Retrospective analysis of Medicare Inpatient Prospective Payment System hospitalizations from 1994 to 2004 using Medicare Provider Analysis and Review files. All nonfederal acute care US hospitals paid through the Inpatient Prospective Payment System. Inpatient prospective payment system hospitalizations from 1994 to 2004 (n = 121,747, 260). None. We examined resource use and costs (adjusted to y2004$), calculating intensive care unit and floor costs directly and using these to generate year-specific R values. By 2004, 33% of Medicare hospitalizations had intensive care unit or coronary care unit care, with more than half of the increase in total hospitalizations because of additional intensive care unit hospitalizations. Adjusted intensive care unit cost per day remained stable ($2,616 vs. $2,575; 1994 vs 2004), yet adjusted floor cost per day rose substantially ($1,027 vs. $1,488) driven by decreased floor length of stay. Annual adjusted Medicare intensive care unit costs increased 36% to $32.3B, largely because of increased utilization. R values decreased progressively from 2.55 to 1.73, were lower for surgical vs. medical admissions and survivors vs. nonsurvivors, but varied little by hospital characteristics. An R value of 3 overestimated Medicare intensive care unit costs by 17.6% ($5.7 billion) in 2004. Medicare intensive care unit use is rising rapidly and will likely continue to do so. Despite significant healthcare system changes, adjusted daily critical care costs remained stable, yet care outside the intensive care unit became more expensive. To track intensive care unit cost over time, year-specific R values should be used.

Hospitalization for Psychiatric Illness Among Community-Dwelling Elderly Persons in 1992 and 2002

The authors evaluated the evolution of inpatient care for psychiatric illness in 1992 and 2002 for senior community-dwelling Medicare beneficiaries. National Medicare Provider Analysis and Review files for 1992 and 2002 were analyzed. From 1992 to 2002, rates of inpatient hospital use for treatment of psychiatric illness declined 28%, from 429 to 311 stays per 100,000 eligible beneficiaries, mostly because of reduced hospitalization for depression, and next, for substance use disorder. Inpatient care patterns for patients with schizophrenia and bipolar disorder changed little. Although stays were shorter in 2002 in general, rehospitalization rates remained the same in 2002 as they were in 1992. Trends in hospitalizations differed by diagnoses, which may be representative of general changes in treatment philosophy during the 1990s.

Short‐ and Long‐Term Mortality after an Acute Illness for Elderly Whites and Blacks

To estimate racial differences in mortality at 30 days and up to 2 years following a hospital admission for the elderly with common medical conditions. The Medicare Provider Analysis and Review File and the VA Patient Treatment File from 1998 to 2002 were used to extract patients 65 or older admitted with a principal diagnosis of acute myocardial infarction, stroke, hip fracture, gastrointestinal bleeding, congestive heart failure, or pneumonia. A retrospective analysis of risk-adjusted mortality after hospital admission for blacks and whites by medical condition and in different hospital settings. Black Medicare patients had consistently lower adjusted 30-day mortality than white Medicare patients, but the initial survival advantage observed among blacks dissipated beyond 30 days and reversed by 2 years. For VA hospitalizations similar patterns were observed, but the initial survival advantage for blacks dissipated at a slower rate. Racial disparities in health are more likely to be generated in the posthospital phase of the process of care delivery rather than during the hospital stay. The slower rate of increase in relative mortality among black VA patients suggests an integrated health care delivery system like the VA may attenuate racial disparities in health.

Use of VA and Medicare Services By Dually Eligible Veterans with Psychiatric Problems

To examine how service accessibility measured by geographic distance affects service sector choices for veterans who are dually eligible for veterans affairs (VA) and Medicare services and who are diagnosed with mental health and/or substance abuse (MH/SA) disorders. Primary VA data sources were the Patient Treatment (acute care), Extended Care (long-term care), and Outpatient Clinic files. VA cost data were obtained from (1) inpatient and outpatient cost files developed by the VA Health Economics and Resource Center and (2) outpatient VA Decision Support System files. Medicare data sources were the denominator, Medicare Provider Analysis Review (MEDPAR), Provider-of-Service, Outpatient Standard Analytic and Physician/Supplier Standard Analytic files. Additional sources included the Area Resource File and Census Bureau data. We identified dually eligible veterans who had either an inpatient or outpatient MH/SA diagnosis in the VA system during fiscal year (FY)'99. We then estimated one- and two-part regression models to explain the effects of geographic distance on both VA and Medicare total and MH/SA costs. Results provide evidence for substitution between the VA and Medicare, demonstrating that poorer geographic access to VA inpatient and outpatient clinics decreased VA expenditures but increased Medicare expenditures, while poorer access to Medicare-certified general and psychiatric hospitals decreased Medicare expenditures but increased VA expenditures. As geographic distance to VA medical facility increases, Medicare plays an increasingly important role in providing mental health services to veterans.

The economic impact of aspergillosis: analysis of hospital expenditures across patient subgroups

To measure the impact of invasive aspergillosis infection on US hospital costs and financial performance across different patient populations. Hospital discharge data for patients with a primary or secondary diagnosis of aspergillosis were extracted from the 2003 Nationwide Inpatient Sample (NIS) and the fiscal year 2003 (FYO3) Medicare Provider Analysis and Review (MedPAR) file. The data on patient demographics, length of stay (LOS), hospital charges, estimated costs, and reimbursement levels were reported. After controlling for comorbidities, operative procedures, and diagnosis-related group (DRG) assignment, the clinical and economic outcomes were compared for patients with and without aspergillosis. The NIS contains a total of over 38 million projected hospital discharges. From these, 10400 aspergillosis cases were identified across 171 DRGs, resulting in a US incidence rate of 36 per million per year. The mean age of aspergillosis patients was 55.6 years, with 53.4% male and 67.9% Caucasian. The median (mean) LOS per aspergillosis patient was 10 (17.7) days, with a median (mean) total hospital charge (THC) of $44,845 ($96,731). Among the patient subgroups analyzed, the median (mean) THC per patient ranged from $47,252 ($82,946) for HIV to $413,200 ($442,233) for bone marrow transplant (BMT). When compared to the non-aspergillosis patient population, the data showed a significant increase in LOS, THC, and hospital costs. Furthermore, the higher hospital costs associated with aspergillosis patients were not matched by similar increases in reimbursements, resulting in a greater financial loss for hospitals. The mean reimbursement-to-cost ratio for aspergillosis cases across the DRGs analyzed was 0.80. Aspergillosis affects a wide range of patient groups and has a negative economic impact across many DRGs. Improved prevention, diagnosis, and patient management strategies can help mitigate these effects on hospital financial performance.

The Frequency and Cost of Complications Associated With Coronary Artery Bypass Grafting Surgery: Results from the United States Medicare Program

We estimate the incremental hospital resource consumption associated with treating selected complications experienced by Medicare beneficiaries undergoing coronary artery bypass grafting (CABG). This retrospective study, using the Medicare Provider Analysis and Review file, identified 114,233 Medicare beneficiaries who survived CABG without concomitant valve repair during a hospitalization for fiscal year 2005. The frequencies of seven complications were determined: hemorrhage or postoperative shock, reoperation, postoperative adult respiratory distress syndrome, new-onset hemodialysis, postoperative stroke, postoperative infection and septicemia. The observed and adjusted incremental hospital resources consumed (cost and length-of-stay) in treating beneficiaries experiencing each of the selected complications were estimated. The mean cost of a hospitalization associated with a CABG procedure among Medicare beneficiaries was $32,201 +/- $23,059, and the mean length of stay was 9.9 +/- 7.8 days. After adjusting for patient demographics and comorbid conditions, the 13.64% of Medicare beneficiaries experiencing any of the study complications consumed significantly more hospital resources (incremental cost, $15,468) and had a longer length of stay (incremental stay, 5.3 days). Despite ongoing improvements in outcomes, major complications remain common after bypass grafting and add substantially to hospital costs for these procedures. These findings suggest that the potential cost savings of redirecting resources currently spent on treating complications will help make the "business case" for investing in patient safety initiatives and best practices guidelines shown to reduce selected complications.

The impact of esophageal candidiasis on hospital charges and costs across patient subgroups

ABSTRACTObjective: Assess the impact of esophageal candidiasis on US hospital inpatient charges, length of stay (LOS), and costs across clinically relevant subgroups.Methods: Total hospital charge (THC) and LOS data extracted from the 2005 National Inpatient Sample (NIS) were compared for patients with and without esophageal candidiasis within the top 20 most commonly assigned Diagnosis Related Groups (DRGs) for the disease. Total hospital costs were estimated using hospital charges in the 2005 Medicare Provider Analysis and Review (MEDPAR) file and hospital cost-to-charge ratios published in the Center for Medicare and Medicaid Service's (CMS) 2005 Inpatient Prospective Payment System Standardization File.Results: Across 274 DRGs, 45 727 esophageal candidiasis patients were identified. Mean age was 50.8 years; 52.5% were female, 59.3% Caucasian. Median LOS was 7 days; median THC was $25 649.Of all esophageal candidiasis cases identified, 65% fell into the top 20 most commonly assigned DRGs. Within this subset, HIV-related DRGs accounted for 22% of the esophageal candidiasis cases. The difference in mean THC and LOS for esophageal candidiasis patients in HIV-related DRGs was not significant. However, total hospital costs were higher for esophageal candidiasis patients in this subset ($11 886 vs. $10 534, p < 0.01). The remaining 78% of esophageal candidiasis cases were assigned to 19 non-HIV-related DRGs. Mean LOS, THC, and total hospital costs were significantly higher for esophageal candidiasis patients within these 19 non-HIV-related DRGs, (8.4 vs. 6.1; $35 704 vs. $23 874, and $10 917 vs. $7474, p < 0.01 in all cases).Conclusions: Esophageal candidiasis affects a wide range of patient groups; it increases LOS and total charges within non-HIV-related hospitalizations. Although the costs presented in this study are estimates, they do suggest a significant increase in cost among esophageal candidiasis cases. Future studies on treatment and preventive care strategies for esophageal candidiasis should not be limited to HIV patients, but instead performed across a wider range of disease settings.

Comparison of Cardiac Surgery Volumes and Mortality Rates Between The Society of Thoracic Surgeons and Medicare Databases From 1993 Through 2001

This study compares surgical volumes and mortality rates in the Society of Thoracic Surgeons voluntary clinical National Cardiac Database (NCD) with those from an administrative claims database (Medicare Provider Analysis and Review [MedPAR]) to assess the suitability of the NCD for tracking national cardiac surgery outcomes. Hospitals common to both databases were matched. In each database, patients aged 65 years and older who underwent coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement in United States hospitals from 1993 to 2001 were identified. Annual volumes for all procedures were consistently higher in the NCD. This may be attributed to Medicare managed care; a Medicare group not collected into MedPAR. In-hospital mortality rates trended lower over time and were comparable between the databases. Surgical volumes were generally higher and mortality rates lower for hospitals that submitted data to the NCD than for those that did not. The close match between NCD and MedPAR in-hospital mortality rates combined with the larger volumes in the NCD suggest that under-reporting in the NCD is not a significant issue. Further investigations into the accuracy of both the NCD and MedPAR are necessary because both are being used for evaluation of provider quality.

Invited commentary

Invited commentary

The cost of pneumonia after acute stroke

To determine the incremental costs of pneumonia occurring during hospitalization for stroke. We reviewed hospital records of all Medicare patients admitted for ischemic or hemorrhagic stroke to 29 hospitals in a large metropolitan area, 1991 through 1997, excluding those who died or had do not resuscitate orders written within 3 days of admission. Hospital costs of patients with stroke were determined using Medicare Provider Analysis and Review data after adjustment for baseline factors affecting cost and propensity for pneumonia. Secondary analyses examined the risk-adjusted relationship of pneumonia to discharge disposition. Pneumonia occurred in 5.6% (635/11,286) of patients with stroke, and was more common among patients admitted from nursing homes and those with greater severity of illness (p < 0.001). Mean adjusted costs of hospitalization for patients with stroke with pneumonia were $21,043 (95% CI $19,698 to 22,387) and were $6,206 (95% CI $6,150 to 6,262) for patients without pneumonia, resulting in an incremental cost of $14,836 (95% CI $14,436 to 15,236). Patients with pneumonia were over 70% more likely to be discharged with requirements for extended care (adjusted OR 1.73, 95% CI 1.32 to 2.26). Extrapolated to the over 500,000 similar patients hospitalized for stroke in the United States, the annual cost of pneumonia as a complication after acute stroke is approximately $459 million.

SF-36 PCS Benefit-Cost Ratio of Lumbar Fusion Comparison to Other Surgical Interventions

A retrospective review of prospectively collected data. To review systematically the SF-36 PCS outcomes of a large data set, including several randomized clinical trials for lumbar spine fusion at 1 and 2 years after surgery. We also present for comparison a review of typical changes in SF-36 PCS in other surgical interventions (total knee replacement, total hip replacement, and coronary artery bypass surgery) to define the average reimbursement costs per PCS improvement with each of these interventions. Data from 11 prospective multicenter studies (9 Food and Drug Administration Investigational Device Exemption, Randomized Prospective Clinical Trials, class 1 data) accounted for the lumbar spine fusion group (n = 1826). Data for total knee replacement, total hip replacement, and coronary artery bypass surgery were obtained from a comprehensive review of the literature. Comparisons of SF-36 PCS improvements were made at defined postoperative time points and with published study findings of other medical conditions. Reimbursement estimates (not including estimated physician and rehabilitation fees) for each surgical intervention were based on Centers for Medicare and Medicaid Services Medicare Provider Analysis and Review and All Payer Data (2002). Cost estimates were calculated for a minimal clinical important improvement (reimbursement dollars/mean PCS change *5.42 point PCS improvement). SF-36 PCS significantly improved at both 1 and 2 years following lumbar spine fusion surgery (P < 0.0001), and was comparable to the control surgical outcomes. With the use of data from Centers for Medicare and Medicaid Services Medicare Provider Analysis and Review and All Payer Data, hospital reimbursement averaged $15.2-18.2K for lumbar spine fusion, $9.8-11.3K for total knee replacement, $9.6-11.3K for total hip replacement, and $9.8-11.3K for coronary artery bypass surgery. Calculations of reimbursement dollars to elicit minimum clinically important change in PCS of 5.42 points following surgery ranged from $6.1 to $7.3K for lumbar spine fusion, $5.7 to $6.6K for total knee arthroplasty, $3.9 to $4.5K for total hip replacement, and $18.2 to $22.5K for coronary artery bypass surgery. While the exact numbers may vary for each treatment based on the population studied and the cost estimates used, lumbar fusion cost per benefit achieved was very comparable to other well-accepted medical interventions (total hip replacement, total knee replacement, and coronary artery bypass surgery).

Critical care medicine use and cost among Medicare beneficiaries 1995–2000: Major discrepancies between two United States federal Medicare databases*

A comparison of federal Medicare databases to identify critical care medicine (CCM) use, cost discrepancies, and their possible causes. A 6-yr (1995-2000) retrospective analysis of Medicare hospital and CCM use and cost, comparing the Hospital Cost Report Information System (HCRIS) with Medicare Provider Analysis and Review File (MedPAR) supplemented when necessary by Health Care Information System (HCIS) (identified herein as MedPAR/HCIS). All nonfederal U.S. hospitals. None. None. Data are presented as days (M = million) and costs ($; B = Billion) for both hospitals and CCM. Between 1995 and 2000, the number of hospital days decreased in both databases: HCRIS (-13.2%; 78M to 67.7M) and MedPAR/HCIS (-14.1%; 82.8M to 71.1M). CCM days decreased in HCRIS (-4.6%; 8.3M to 7.9M). In contrast, CCM days increased in MedPAR/HCIS (7.2%; 13.9M to 14.9M). The discrepancy in CCM days between HCRIS and MedPAR/HCIS increased from 40% (5.6M days) in 1995 to 47% (7M days) in 2000. Two CCM billing codes (intensive care unit and coronary care unit "post/intermediate") used in MedPAR/HCIS were responsible for 73% on average per year, over the study period, for this CCM discrepancy. The use of these two codes progressively increased (44%; 3.9M to 5.6M days) by the end of the study. The cumulative 6-yr discrepancy in CCM days between HCRIS and MedPAR/HCIS (37.3M days) had a calculated cost of $92.3B. We have identified major, and progressively increasing, discrepancies between two U.S. federal databases tabulating hospital and CCM use and cost for Medicare beneficiaries. Two CCM "post/intermediate" billing codes in MedPAR/HCIS were predominantly responsible for the CCM discrepancy. To accurately assess Medicare CCM use and cost, either HCRIS, or MedPAR/HCIS without the "post/intermediate" codes, should be used.

Blood use by inpatient elderly population in the United States

Our objective was to characterize inpatient blood use by the US elderly population during 2001. As the US population ages the demand for blood is expected to grow. There have been no comprehensive studies, however, detailing blood use by the elderly in the United States. A descriptive cross-sectional study of blood utilization was conducted with the 5 percent Medicare Provider Analysis and Review (MedPAR) data file obtained from the Centers for Medicare and Medicaid Services (CMS). Each record of the file represented a billing record of an inpatient stay. Blood use was identified by either a nonzero blood pints furnished quantity or a procedure code for transfusion of whole blood or red blood cells (RBCs). Among 635,700 stays, 43,220 (6.8%) recorded transfusion of whole blood or RBCs. Blood use prevalence was approximately 4.5 times higher for stays with at least one medical procedure compared to stays without procedures. Of 15,579 stays with number of blood pints furnished recorded, the top 20 principal procedures with the largest quantities of blood accounted for about 56 percent of total blood pints furnished; however, these procedures represented only about 19 percent of all stays. Our study shows a strong association between medical procedures and blood use among inpatient stays for the elderly. Some of the highest blood utilization occurred with surgical procedures. More precise information on blood utilization may serve as the basis for estimating risks associated with blood transfusion and may inform decisions that maintain an adequate supply of blood.

Impact of the Medicare Short Stay Transfer Policy on patients undergoing major orthopedic surgery.

To examine the impact of the Short Stay Transfer Policy (SSTP) on practice patterns. This study uses data from the Centers for Medicare and Medicaid Services Medicare Provider Analysis and Review (MEDPAR) file, Home Health Standard Analytical File, 1999 Provider of Service file, and data from the 2000 United States Census. An interrupted time-series analysis was used to examine the length of stay (LOS) and probability of "early" discharge to post acute care (PAC). Separate 100 percent samples of all fee-for-service Medicare recipients undergoing either elective joint replacement (JR) surgery or surgical management of hip fracture (FX) between January 1, 1996 and December 31, 2000 were selected. Prior to implementation of the SSTP. LOS had been falling by 0.37 and 0.30 days per year for JR and FX patients respectively. After implementation of the SSTP, there was an immediate increase in LOS by 0.20 and 0.17 days, respectively. Thereafter, LOS remained flat. The proportion of patients discharged "early" to PAC had been rising by 4.4 and 2.6 percentage points per year for JR and FX patients respectively, to a peak of 28.8 percent and 20.4 percent early PAC utilization in September 1998. Immediately after implementation of the SSTP, there was a 4.3 and 3.0 percentage point drop in utilization of "early" PAC. Thereafter utilization of early PAC increased at a much slower rate (for JR) or remained flat (for FX). There was significant regional variation in the magnitude of response to the policy. Implementation of the SSTP reduced the financial incentive to discharge patients early to PAC. This was accomplished primarily through longer LOS without meaningful change in PAC utilization. With the recent expansion of the SSTP to 29 DRGs (representing 34 percent of all discharges), these findings have important implications regarding patient care.

Rural–Urban Differences in Medical Care for Nursing Home Residents with Severe Dementia at the End of Life

To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes. Retrospective cohort study using Centers for Medicare and Medicaid Services administrative data for 1998 through 2002. Minnesota and Texas nursing homes. Nursing home residents aged 65 and older with severe cognitive impairment who subsequently died during 2000/01. Minimum Data Set and Medicare Provider Analysis and Review, Hospice, and Denominator files were used to identify subjects and to assess medical service use. U.S. Department of Agriculture metro-nonmetro continuum county codes defined rural (codes 6-9) and urban (codes 0-2) nursing homes. Nursing home residents with hospice or health maintenance organization benefits were excluded. Use of hospital services at the end of life was adjusted for use of corresponding services before the last year of life. Outcome variables were feeding tube use, any hospitalization, more than 10 days of hospitalization, and intensive care unit (ICU) admission. The population included 3,710 subjects (1,886 rural, 1,824 urban). In multivariable logistic regression analyses (all P<.05), feeding tube use was more common in urban nursing home residents, whereas rural nursing home residents were at greater risk for hospitalization. Rural residence was also associated with lower risk of more than 10 days of hospitalization and ICU admission. Nonwhite race and stroke were associated with higher use of all services. Rural nursing home residence is associated with lower likelihood of use of the most-intensive medical services at the end of life.

The Frequency and Incremental Cost of Major Complications Among Medicare Beneficiaries Receiving Implantable Cardioverter-Defibrillators

We aimed to quantify the frequency and nature of early complications after implantable cardioverter-defibrillator (ICD) implantation in general practice, and estimate the incremental costs of those complications to the health care system. Cardioverter-defibrillator implantation rates are rising quickly. Little has been published regarding the outcomes and costs of these procedures in unselected populations. Using Medicare Provider Analysis and Review (MedPAR) files, we identified 30,984 admissions containing procedure codes for new ICD or cardiac resynchronization therapy defibrillator implantation in fiscal year 2003. The frequencies of eight complicating diagnoses during these admissions were determined. Length of stay (LOS) and total hospital costs, derived using whole-hospital cost to charge ratios, were calculated for each admission. The incremental effects of any and each complication on LOS and hospital cost were estimated in multivariable models, adjusting for demographic factors and comorbid conditions. The mean cost for all admissions was 42,184 dollars (median 37,902 dollars) with mean LOS of 4.7 days (median 2.0 days). One or more complications were coded in 10.8% of admissions, most commonly "mechanical complication of the ICD" and hemorrhage/hematoma. The occurrence of any complication increased adjusted LOS by 3.4 days and costs by 7,251 dollars. Each of the individual complications was associated with highly significant increases in both LOS (1 to 10 days) and hospital cost (5,000 dollars to 20,000 dollars). In fiscal 2003, 10.8% of Medicare patients undergoing cardioverter-defibrillator implantation experienced one or more early complications, associated with significant increases in LOS and costs. Efforts to reduce these complications could have significant clinical and financial benefits.

Research Note: Standard Scores Based on the Median and Inter-quartile Range

Recently when asked to help with statistical analyses of the Medicare Provider Analysis and Review (MEDPar) Data, I encountered a common statistical and analytical problem with this national database, which is also common to many national and health databases. This problem was the problem of extremely skewed distributions (g1 and/or g2 typically exceeding 20), which creates numerous difficulties in comparing and interpreting values and results both between and within variables, never mind statistically testing them.