Medicare Services Research Articles

Hospital use of common Z-codes for Medicare fee-for-service beneficiaries, 2017-2021.

Recognizing the impact of the social determinants of health (SDOH) on health outcomes, in 2016, the Centers for Medicare and Medicaid Services recommended the use of International Classification of Diseases, 10th Revision (ICD-10), Z-codes to capture patients' health-related social needs. We examined changes in Z-code utilization to document health-related social needs for Medicare fee-for-service recipients among US hospitals between 2017 and 2021 across 5 common SDOH domains. We found that, while 56.9% of hospitals had at least 1 Z-code recorded in at least 1 patient per year, apart from those referring to housing needs, rates of Z-code adoption were low. Additionally, hospitals that were general medical, part of a teaching institution, affiliated with larger health systems, and of medium to large size had greater odds of utilizing Z-codes. Findings from this study highlight the need for continued efforts in promoting the consistent use of standardized SDOH capturing methods like Z-code documentation, such as provider training.

Patients, practice, and price transparency: The impact of disclosing healthcare costs on consumer decision-making

The introduction of price transparency mandates by the Center for Medicare and Medicaid Services (CMS) aimed to reduce healthcare spending by promoting price comparison and the selection of lower-cost providers. In this brief communication, we will discuss how consumer interests in price comparison are influenced and how price transparency is expected to impact consumer decision-making with specific examples for imaging as a shoppable service.

Making Sense of Vagus Nerve Stimulation for Stroke.

Implantable vagus nerve stimulation, paired with high-dose occupational therapy, has been shown to be effective in improving upper limb function among patients with stroke and received regulatory approval from the US Food and Drug Administration and the Centers for Medicare & Medicaid Services. Combining nonsurgical and surgical approaches of vagus nerve stimulation in recent meta-analyses has resulted in misleading reports on the efficacy of each type of stimulation among patients with stroke. This article aims to clarify the confusion surrounding implantable vagus nerve stimulation as a poststroke treatment option, highlighting the importance of distinguishing between transcutaneous auricular vagus nerve stimulation and implantable vagus nerve stimulation. Recent meta-analyses on vagus nerve stimulation have inappropriately combined studies of fundamentally different interventions, outcome measures, and participant selection, which do not conform to methodological best practices and, hence, cannot be used to deduce the relative efficacy of the different types of vagus nerve stimulation for stroke rehabilitation. Health care providers, patients, and insurers should rely on appropriately designed research to guide well-informed decisions.

Evidence inventory: A patient-centered framework for Centers for Medicare & Medicaid Services to assess the clinical benefit of drugs to inform its maximum fair price negotiation.

The Inflation Reduction Act passed in August 2022 empowers the Centers for Medicare & Medicaid Services (CMS) to negotiate maximum fair prices for certain expensive drugs. In the process of determining maximum fair prices, CMS gathers evidence on the clinical benefits of these drugs as compared with their therapeutic alternative(s) from various sources. As patients are the primary beneficiaries of the treatment, we recommend that CMS should embrace an approach that prioritizes patient experience when evaluating such diverse sources of evidence in the assessment of the clinical benefit. Thus, we propose to draw on several existing frameworks to support the concept of "evidence inventory," a patient-centered approach to systematically evaluate benefits of drugs under consideration. This 4-step process to develop an evidence inventory includes the following: (1) Formulate the research question-in a PICO(T) (P = population, I = Intervention or exposure, C = comparator, O = outcome, and T = time frame) format, (2) Synthesize evidence, (3) Evaluate the evidence-using evidence inventory, and (4) Reevaluate evidence as new information become available. Patients and other relevant stakeholders play a critical role in each of these 4 steps. The proposed evidence inventory holds the potential to provide a structured and transparent patient-centered framework for evaluating the clinical benefits of drugs as compared with their therapeutic alternative(s) informing CMS maximum fair price negotiation.

Concomitant Treatment of Atrial Fibrillation in Isolated Coronary Artery Bypass Grafting

BackgroundSocietal guidelines support concomitant management of atrial fibrillation (AF) in patients undergoing cardiac surgery. To assess real-world adoption and outcomes, this study evaluated Medicare beneficiaries with AF who underwent isolated coronary artery bypass grafting (CABG) with surgical ablation (SA) or left atrial appendage obliteration (LAAO) or both procedures in combination (SA + LAAO). MethodsThe US Centers for Medicare & Medicaid Services inpatient claims database identified all patients with AF who underwent isolated CABG from 2018 to 2020. Diagnosis-related group and International Classification of Diseases-10th revision procedure codes defined covariates for doubly robust risk adjustment. ResultsA total of 19,524 patients with preoperative AF who underwent isolated CABG were stratified by SA + LAAO (3475 patients; 17.8%), LAAO only (4541 patients; 23.3%), or no AF treatment (11,508 patients; 58.9%). After doubly robust risk adjustment, longitudinal analysis highlighted that concomitant AF treatment with SA + LAAO (hazard ratio [HR], 0.74; P = .049) or LAAO alone (HR, 0.75; P = . 031) was associated with a significant reduction in readmission for stroke at 3 years compared with no AF treatment. Furthermore, SA + LAAO (HR, 0.86; P = .016) but not LAAO alone (HR, 0.97; P = .573) was associated with improved survival compared with no AF treatment. Finally, SA + LAAO was associated with a superior composite outcome of freedom from stroke or death at 3 years compared with LAAO alone (HR, 0.86;, P = .033) or no AF treatment (HR, 0.81; P = .001). ConclusionsIn Medicare beneficiaries with AF who underwent isolated CABG, concomitant AF treatment was associated with reduced 3-year readmission for stroke. SA + LAAO was associated with superior reduction in stroke or death at 3 years compared with LAAO alone or no AF treatment.

Medicare drug price negotiation: The complexities of selecting therapeutic alternatives for estimating comparative effectiveness.

Under the 2022 Inflation Reduction Act, the Centers for Medicare and Medicaid Services (CMS) are able to negotiate prices for topselling drugs in the Medicare Part B and D programs. In determining initial price offers, CMS will compare the prices and clinical benefits of the drugs subject to negotiation to the prices and clinical benefits of therapeutic alternatives. Despite the central role that the selection of therapeutic alternatives will play in the price negotiations, the available guidance published by CMS provides few details about how the organization will undertake this process, which will be particularly complex for drugs approved for more than one indication. To better inform the selection process, we identified all US Food and Drug Administration-approved indications for the first 10 drugs subject to negotiation. Using 2020-2021 Medicare claims data, we identified Medicare Part D beneficiaries using each of the 10 drugs. We extracted medical claims with diagnosis codes for each of the approved indications to report the relative treated prevalence of use by indication for each drug. We reviewed published clinical guidelines to identify relevant therapeutic alternatives for each of the indications. We integrated the evidence on the relative treated prevalence of indications and clinical guidelines to propose therapeutic alternatives for each of the 10 drugs. We describe challenges that CMS may face in selecting therapeutic alternatives.

Introduction to School Medicaid for School Nurses.

School nurses are important participants in School Medicaid (SM) programs nationally. Yet, the complexity of SM programs and required documentation are major barriers to implementing this program for nurses. School nurses are often required to participate in the SM program without having a clear understanding of the purpose and components of the overall program. With the expansion of SM programs due to the Centers for Medicare and Medicaid Services "free care" guidance change, nursing services and documentation are receiving more attention and scrutiny as more nursing services become eligible for reimbursement in states across the country. This article presents a clear overview of SM, its history, different components of state SM programs, school nursing documentation and challenges, and resources for school nurses who are interested in more information.

Identifying therapeutic alternatives in Medicare drug price negotiation: The case of etanercept.

As the Centers for Medicare & Medicaid Services (CMS) navigates the process of negotiating drug prices, it plans to compare the cost, safety, and effectiveness of each drug with its therapeutic alternatives. How CMS selects therapeutic alternatives is a consequential decision, and there remains uncertainty about their methodology. To understand the challenges CMS will face in selecting therapeutic alternatives, we developed a methodology that leverages clinical guidelines by US medical professional associations to identify potential therapeutic alternatives for etanercept, one of the first 10 drugs selected for Medicare price negotiation. For each of etanercept's 5 US Food and Drug Administration-approved indications, we identified all drugs with the same mechanism of action as etanercept and considered drugs with different mechanisms if they were recommended in place of etanercept at the same treatment stage, or if there was no strong comparative safety or effectiveness evidence that the drug differed from etanercept. We identified 22 potential therapeutic alternatives to etanercept, including 4 drugs with the same mechanism, 10 biologics with different mechanisms, and 8 small-molecule drugs. We faced several challenges in selecting therapeutic alternatives using clinical guidelines, such as how to reconcile strong recommendations that were based on weak evidence and how to consider combination therapies. This exercise demonstrates the complex considerations that CMS will face as it negotiates drug prices based on therapies' cost, safety, and effectiveness relative to therapeutic alternatives.

Uptake and outcomes of supervised exercise therapy for peripheral artery disease: The importance of vascular medicine specialists at a large midwestern health care system during the first 5 years of CMS reimbursement.

Supervised exercise therapy (SET) is the cornerstone of medical therapy for symptomatic peripheral artery disease (PAD). Despite the efficacy of SET, initial reports following the 2017 Centers for Medicare and Medicaid Services (CMS) reimbursement decision indicate low SET uptake, referral, and completion. Vascular medicine specialists are key to the success of such programs. We examined rates of SET referral, completion, and outcomes in a health system with a robust SET program during the first 5 years of CMS reimbursement. A retrospective chart review of patients with PAD referred to SET between October 1, 2017 and December 31, 2022 was conducted. Patient demographic and medical characteristics, SET indication, referring provider specialty, SET participation (e.g., exercise modality, number of sessions, treadmill prescription), and outcomes were abstracted. Descriptive statistics, t-tests, and multiple linear regression were used to examine the sample, evaluate outcomes, and explore outcomes by relevant covariates (i.e., age, sex, referring provider specialty). Of 5320 patients with PAD, N = 773 were referred to SET; N = 415 enrolled and were included in the present study. Vascular medicine and vascular surgery specialists were the two primary sources of referrals (30.6% and 51.6%, respectively). A total of 207 patients (49.9%) completed SET. Statistically significant and clinically meaningful improvements were observed in all outcomes. SET referral and completion rates are low in the 5 years following CMS reimbursement, despite the advocacy of vascular medicine specialists. SET is effective in improving patient functional capacity and quality of life. Additional efforts are needed to increase both SET availability and referrals as part of comprehensive treatment of PAD.

Patient-Reported Outcomes Measurement Information System Physical Function and Global Physical Health Subscale Strongly Correlate and Perform Similarly to the Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form

BackgroundArthroplasty surgeons use a variety of patient-reported outcome measures (PROMs) to assess functional well-being, including the Knee Injury and Osteoarthritis Outcome Score (KOOS) Physical Function short form (KOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PROMIS PF SF 10a), and PROMIS Global-10 Physical Health subscale. However, there is a paucity of literature assessing their concurrent validity and performance. MethodsBetween June 2016 and December 2020, patient visits at an arthroplasty clinic for knee concerns were identified. Patients who completed KOOS-PS, PROMIS PF SF 10a, and PROMIS Global-10, including its physical and mental health subscales, at the same visit were identified. Spearman rho (ρ) correlations were calculated and ceiling and floor effects identified. Overall, 5,303 patient encounters were included. ResultsAmong physical function domains, strong correlation existed between the KOOS-PS and PROMIS PF SF 10a (ρ = 0.76, P < .001), KOOS-PS and PROMIS Global Physical Health (ρ = 0.71, P < .001), and PROMIS PF SF 10a and PROMIS Global Physical Health (ρ = 0.78, P < .001). No physical function–focused PROM had an appreciable floor effect (ie, at or more than 1%). The KOOS-PS had a small but measurable ceiling effect (n = 105 [2.0%]). ConclusionsAll of the examined PROMs are acceptable to measure the functional status of patients with knee pathology, with the PROMIS Global-10 also being able to capture elements of mental health too. The PROMIS Global-10 may be of most value of the PROMs assessed, as the United States Centers for Medicare and Medicaid Services already incorporate the mental health component into new alternative payment models.

The ethics of hypopnea scoring.

In February of 2023, the American Academy of Sleep Medicine issued a "recommended" way to score hypopneas using 1A criteria (scoring of hypopneas using a ≥ 3% oxygen desaturation from pre-event baseline) that is at odds with the Centers for Medicare & Medicaid Services mandate of scoring hypopneas using a ≥ 4% oxygen desaturation from pre-event baseline. This dichotomy will present an ethical dilemma for sleep medicine providers. We use the principles of medical ethics to discuss the challenges this discrepancy poses for sleep medicine providers. Disparate hypopnea scoring undermines beneficent patient care and impairs providers' duty to deliver just, equitable care, hence violating the principles of justice and beneficence. This primarily affects older adults, the disabled, the "medically needy," and those living at the federal poverty line dependent on public insurance. This discrepancy creates a situation that falls below acceptable levels of health care justice. It is recommended that the American Academy of Sleep Medicine work with the Centers for Medicare & Medicaid Services to develop a scoring policy that consistently promotes individual sleep health regardless of payor. Skolnik C, Attarian H. The ethics of hypopnea scoring. J Clin Sleep Med. 2024;20(4):615-617.

Trends in Utilization and Medicare Spending on Short-Course Radiation Therapy for Breast and Prostate Cancer: An Episode-Based Analysis From 2015 to 2019

Evidence supports the value of shorter, similarly efficacious, and potentially more cost-effective hypofractionated radiation therapy (RT) regimens in many clinical scenarios for breast cancer (BC) and prostate cancer (PC). However, practice patterns vary considerably. We used the most recent Centers for Medicare and Medicaid Services data to assess trends in RT cost and practice patterns among episodes of BC and PC. We performed a retrospective cohort analysis of all external beam RT episodes for BC and PC from 2015 to 2019 to assess predictors of short-course RT (SCRT) use and calculated spending differences. Multivariable logistic regression defined adjusted odds ratios of receipt of SCRT over longer-course RT (LCRT) by treatment modality, age, year of diagnosis, type of practice, and the interaction between year and treatment setting. Medicare spending was evaluated using multivariable linear regression controlling for duration of RT regimen (SCRT vs LCRT) in addition to the above covariables. Of 143,729 BC episodes and 114,214 PC episodes, 63,623 (44.27%) and 25,955 (22.72%) were SCRT regimens, respectively. Median total spending for SCRT regimens among BC episodes was $9418 (interquartile range [IQR], $7966-$10,983) versus $13,602 (IQR, $11,814-$15,499) for LCRT. Among PC episodes, median total spending was $6924 (IQR, $4,509-$12,905) for stereotactic body RT, $18,768 (IQR, $15,421-$20,740) for moderate hypofractionation, and $27,319 (IQR, $25,446-$29,421) for LCRT. On logistic regression, receipt of SCRT was associated with older age among both BC and PC episodes as well as treatment at hospital-affiliated over freestanding sites (P < .001 for all). In this evaluation of BC and PC RT episodes from 2015 to 2019, we found that shorter-course RT resulted in lower costs than longer-course RT. SCRT was also more common in hospital-affiliated sites. Future research focusing on potential payment incentives encouraging SCRT when clinically appropriate in the 2 most common cancers treated with RT will be valuable as the field continues to prospectively evaluate cost-effective hypofractionation in other disease sites.

Characteristics and Outcomes of Patients With Pregnancy-Related End-Stage Kidney Disease

The incidence of pregnancy-related acute kidney injury is increasing and is associated with significant maternal morbidity including progression to end-stage kidney disease (ESKD). Little is known about characteristics and long-term outcomes of patients who develop pregnancy-related ESKD. To examine the characteristics and clinical outcomes of patients with pregnancy-related ESKD and to investigate associations between pre-ESKD nephrology care and outcomes. This was a cohort study of 183 640 reproductive-aged women with incident ESKD between January 1, 2000, and November 20, 2020, from the US Renal Data System and maternal data from births captured in the US Centers for Disease Control and Prevention publicly available natality data. Data were analyzed from December 2022 to June 2023. Pregnancy-related primary cause of ESKD, per International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes reported at ESKD onset by the primary nephrologist on Centers for Medicare and Medicaid Services form 2728. Multivariable Cox proportional hazards and competing risk models were constructed to examine time to (1) mortality, (2) access to kidney transplant (joining the waiting list or receiving a live donor transplant), and (3) receipt of transplant after joining the waitlist. A total of 341 patients with a pregnancy-related primary cause of ESKD were identified (mean [SD] age 30.2 [7.3]). Compared with the general US birthing population, Black patients were overrepresented among those with pregnancy-related ESKD (109 patients [31.9%] vs 585 268 patients [16.2%]). In adjusted analyses, patients with pregnancy-related ESKD had similar or lower hazards of mortality compared with those with glomerulonephritis or cystic kidney disease (adjusted hazard ratio [aHR], 0.96; 95% CI, 0.76-1.19), diabetes or hypertension (aHR, 0.49; 95% CI, 0.39-0.61), or other or unknown primary causes of ESKD (aHR, 0.60; 95% CI, 0.48-0.75). Despite this, patients with pregnancy-related ESKD had significantly lower access to kidney transplant compared with those with other causes of ESKD, including (1) glomerulonephritis or cystic kidney disease (adjusted subhazard ratio [aSHR], 0.51; 95% CI, 0.43-0.66), (2) diabetes or hypertension (aSHR, 0.81; 95% CI, 0.67-0.98), and (3) other or unkown cause (aSHR, 0.82; 95% CI, 0.67-0.99). Those with pregnancy-related ESKD were less likely to have nephrology care or have a graft or arteriovenous fistula placed before ESKD onset (nephrology care: adjusted relative risk [aRR], 0.47; 95% CI, 0.40-0.56; graft or arteriovenous fistula placed: aRR, 0.31; 95% CI, 0.17-0.57). In this study, those with pregnancy-related ESKD had reduced access to transplant and nephrology care, which could exacerbate existing disparities in a disproportionately Black population. Increased access to care could improve quality of life and health outcomes among these young adults with high potential for long-term survival.

Characterizing Opioid Prescribing Trends of Medical Oncologists From 2013 to 2019: Analysis From the Centers for Medicare & Medicaid Services Medicare Part D Prescribers Database.

Opioid prescribing trends in medical oncology are poorly defined past 2017, the year after the CDC updated opioid prescription guidelines in noncancer settings. We aim to characterize pain management by medical oncologists by analyzing opioid and gabapentin prescribing trends from 2013 to 2019, identify physician-related factors associated with prescribing patterns, and assess whether CDC guidelines for nononcologic settings changed prescribing patterns. The Centers for Medicare & Medicaid Services (CMS) Medicare Part D Prescribers-by Provider, CMS Medicare Part D Prescribers-by Provider and Drug, and CMS Medicare Physician National Downloadable files from 2013 to 2019 were merged by National Provider Identification. The database included physicians' sex, years of practice, regions, and practice settings. Multivariable binary logistic regression identified significant predictors of total opioid, long-acting opioid, and gabapentin prescriptions. Binary logistic regression modeling revealed no significant difference in mean daily total opioid prescriptions from 2013 to 2017. Daily opioid prescriptions by medical oncologists decreased significantly after 2017 (P < .001). Increased opioid prescribing was associated with physician male sex (P < .001), practicing over 10 years (P < .001), and practice in nonurban areas (P < .001). Opioid prescribing was greatest in the South and Midwest United States (P < .001). The same patterns were observed with total long-acting opioid prescriptions, whereas gabapentin prescribing increased from 2013 to 2019 (P < .001). Opioid prescriptions by medical oncologists decreased significantly from 2013 to 2019, but this decrease was most substantial from 2017 to 2019. These results may imply that the 2016 CDC guidelines influenced medical oncologists, particularly more junior physicians in urban settings, to manage chronic cancer pain with alternative therapies.

MMS hotspots: a cross-sectional comparison of U.S. counties with and without Mohs micrographic surgery

Healthcare access greatly impacts skin cancer diagnosis and mortality rates. Recognition of current disparities in Mohs micrographic surgery (MMS) access can assist future policy and clinical decisions to correct them. For the years 2014–2018, the CPT codes for MMS (17,311 and 17,313) were counted on a per county level across the United States per the Medicare Centers for Medicare & Medicaid Services (CMS) Medicare Prescriber Database. Any county with 0 MMS CPT codes recorded were classified as “without MMS cases.” MMS “hotspots” were identified as counties that possessed a high average number of MMS cases compared to the national average, while also being surrounded by counties that possessed a low average number of MMS cases compared to the national average. Three thousand eighty-four counties in the United States were analyzed; 785 (25%) counties were designated as “with MMS cases” and 2301 (75%) “without MMS cases.” There were no significant differences in age, ethnicity distribution, or cost per enrollee between the two designations. 74% of counties with MMS cases were considered urban, while only 25% of those without cases were urban (p < 0.01). The median household income was markedly higher in counties with MMS cases ($71,428 vs. $58,913, p < 0.01). With respect to education, more individuals in counties with MMS cases possessed their General Education Development (GED) (89% vs. 86%, p < 0.01) or a college degree (30% vs. 19%, p < 0.01). Forty-nine counties were considered MMS “hotspots.” The density of MMS procedures varies greatly based on geography, maintaining the urban–rural disparity matched by the distribution of MMS surgeons. Additionally, there remains a wide income and educational gap between counties with and without MMS. Identifying MMS hotspots may facilitate further investigation into potential surgical access disparities.

Health-Related Social Needs Screening: Promising Practices From the Accountable Health Communities Model.

Health-related social needs (HRSNs), such as food insecurity and housing instability, drive health and well-being. The socioeconomic impacts of the COVID-19 pandemic increased the prevalence of HRSNs and highlighted the critical need for strategies to address those needs, particularly in communities experiencing health disparities. Implementing HRSN screening requires adopting effective strategies to overcome common challenges. This report synthesizes promising implementation approaches and lessons learned from the Accountable Health Communities Model, a national effort funded by the Centers for Medicare & Medicaid Services Innovation Center to systematically screen for and address HRSNs in clinical settings. Key strategies include increasing patient engagement and building trust through culturally tailored language and outreach; using and sharing data for monitoring and improvement; using technology to expand access to screening and referrals; dedicating staff to screening roles; integrating screening into existing workflows; and building buy-in among staff by communicating the impact of screening and encouraging peer connections.

Effectiveness of Transitional Care Program among High-Risk Discharged Patients: A Quasi-Experimental Study on Saving Costs, Post-Discharge Readmissions and Emergency Department Visits

Transitional care programs (TCPs), where hospital care team members repeatedly follow up with discharged patients, aim to reduce post-discharge hospital or emergency department (ED) utilization and healthcare costs. We examined the effectiveness of TCPs at reducing healthcare costs, hospital readmissions, and ED visits. Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) program adjudicated claims files and electronic health records from Greenville Memorial Hospital, Greenville, SC, were accessed. Data on post-discharge 30- and 90-day ED visits and readmissions, total costs, and episodes with costs over BPCI target prices were extracted from November 2017 to July 2020 and compared between the “TCP-Graduates” (N = 85) and “Did Not Graduate” (DNG) (N = 1310) groups. As compared to the DNG group, the TCP-Graduates group had significantly fewer 30-day (7.1% vs. 14.9%, p = 0.046) and 90-day (15.5% vs. 26.3%, p = 0.025) readmissions, episodes with total costs over target prices (25.9% vs. 36.6%, p = 0.031), and lower total cost/episode (USD 22,439 vs. USD 28,633, p = 0.018), but differences in 30-day (9.4% vs. 11.2%, p = 0.607) and 90-day (20.0% vs. 21.9%, p = 0.680) ED visits were not significant. TCP was associated with reduced post-discharge hospital readmissions, total care costs, and episodes exceeding target prices. Further studies with rigorous designs and individual-level data should test these findings.

Look to the past to improve our future: Improving quality, safety and equity through community and patient engagement

Healthcare administrators must ensure delivery of care that is high quality, safe and produces equitable outcomes while balancing business, workforce and community needs. To meet these challenges while guiding their organisations through COVID-19 recovery, administrators can look to a strategy with a strong track record for success: engaging patients, families and communities. This paper focuses on evidence, experience and best practices for improving quality, safety and equity by engaging people, patients, families and communities. Effective patient and family engagement (PFE) and community engagement strategies draw on research and experience across a wide variety of efforts, from nationwide federal programmes such as the Centers for Medicare and Medicaid Services Partnership for Patients initiative to health system- and neighbourhood-level programmes. Research demonstrates that commitment to PFE leads to measurable improvements in quality and safety. Experience shows that engagement, when practiced with attention to diversity, equity and inclusion, can reduce health disparities. Engagement best practices include: making engagement a strategic priority, embedding patients and families with diverse perspectives into improvement efforts, supporting continuous learning by adapting engagement efforts over time, benchmarking progress and measuring disparities. To continue the advances begun before the pandemic, healthcare administrators and leaders must redouble engagement efforts and implement best practices. Administrators can meet the many challenges of the moment by returning to the proven strategy of engaging patients, families and communities to drive integrated quality, safety and equity efforts.

Incidence of Alzheimer’s disease (AD) dementia and mild cognitive impairment (MCI) in the United States Medicare population

AbstractBackgroundAlzheimer’s disease (AD) is a chronic, neurodegenerative condition. Mild cognitive impairment (MCI) is characterized by cognitive decline, without dementia. We aimed to estimate the incidence of AD and MCI among Medicare beneficiaries.MethodPatients were identified from the US Center for Medicare and Medicaid Services (CMS) database using International Classification of Diseases (ICD) codes for AD (331.0, G30.9, G30.8, or G30.1,) and MCI (331.83 or G31.84). Both AD and MCI were identified using the search rule of 2 ICD codes ≥30 days apart ≤365 days from both Medicare fee‐for‐service (FFS: 2008‐2018) and Medicare Advantage (MA: 2015‐2018). US regions were derived using zip codes and categorized by National Center for Chronic Disease Prevention/Health Promotion regions. Yearly incidence was defined as the number of new cases of AD or MCI in each year divided by the population at risk in the year. Confidence intervals were not reported due to small intervals.ResultThe incidence of AD and MCI per 10,000 person‐years was 82.9 and 4.9, 80.3 and 7.4, 74.5 and 9.3, 69.8 and 10.9, 65.3 and 13.4, 62.8 and 15.8, 60.7 and 17.4, 65.5 and 20.7, 61.4 and 22.4, 56.0 and 22.9, and 52.2 and 23.2 spanning from 2008 through 2018, respectively. In 2018, the incidence of AD and MCI per 10,000 person‐years by demographic subgroups was: 43 and 21 for men and 59 and 25 for women; 16 and 10 among those aged 65‐69 years, 30 and 18 for ages 70‐74 years, 58 and 30 for ages 75‐79, 102 and 44 for ages 80‐84, 176 and 57 for age ≥85 years old; 56 and 26 for Whites, 38 and 13 for Blacks, and 43 and 15 for Asians. The incidence of AD and MCI per 10,000 person‐years in 2018 was highest in the US Northeast, especially in New Hampshire (77 and 39), Vermont (74 and 47), and New Jersey (73 and 33).ConclusionAmong Medicare beneficiaries from 2008 to 2018, AD incidence generally decreased while MCI increased. Women, older age, White race, and Northeast region were associated with higher incidence of AD and MCI in 2018.

The Variation of Chargemaster Price Listings for Urogynecologic Procedures.

A 2018 Executive Order calling for price transparency required hospitals to publicly provide chargemasters, which are detailed lists of standard price listings for billable medical procedures. The objective of this study was to evaluate price listing variations in common urogynecology procedures. This was a cross-sectional study of chargemasters obtained between February and April 2020 from hospitals across 5 states chosen to reflect the diversity of health systems in the United States. Hospital characteristic and quality metric data were obtained from the Homeland Infrastructure Foundation, U.S. Department of Agriculture, and U.S. Centers for Medicare & Medicaid Services websites. Current Procedural Terminology codes and procedure names for 9 urogynecologic procedures were used to search each chargemaster and extract price listings. Price listings were compared with data on quality, population demographics, and hospital characteristics to determine if any significant relationships existed. Eight hundred thirty-four chargemasters were identified. Price listings for most procedures differed significantly across the 5 states, including colpocleisis, cystoscopy with chemodenervation, diagnostic cystoscopy, diverticulectomy, sacral neuromodulation, midurethral sling, and sacrospinous ligament fixation. Price listings were significantly higher in urban hospitals than rural hospitals for 6 procedures. No significant association was seen with price listing and quality measures for most procedures. Listed prices varied for several urogynecologic procedures. Some of this variation is associated with hospital characteristics such as urban setting. However, notably, price listing was not associated with quality. Further investigation of chargemaster price listings with hospital characteristics and quality metrics and with what is actually paid by patients is imperative for patients to navigate charges.