National Provider Identification Research Articles

Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates.

Cardiovascular disease (CVD) is a leading cause of premature mortality among patients with severe mental illness (SMI). Effective care delivery models are needed to address this mortality gap. This study examines the impact of an enhanced primary care (PC) program that specializes in the treatment of patients with SMI, called Medicine in Psychiatry Service-Primary Care (MIPS-PC). Using multipayer claims data in Western New York from January 1, 2016 to December 31, 2021, patients with SMI and CVD were identified using International Classification of Diseases, Tenth Revision codes. National Provider Identification numbers of MIPS-PC providers were then used to identify those patients who were treated by MIPS-PC during the period. These MIPS-PC-treated patients were compared against a cohort of one-to-one propensity score matched contemporaneous comparison group (ie, patients receiving PC from providers unaffiliated with MIPS-PC). A difference-in-difference approach was used to identify the treatment effects of MIPS-PC on all-cause emergency department (ED) visits and hospitalization rates. The MIPS-PC group was associated with a downtrend in the acute care utilization rates over a 3-year period following the index date (ie, date of first MIPS-PC or other PC provider encounter), specifically a lower hospitalization rate in the first year since the index date (25%; P < 0.001). ED visit rate reduction was significant in the third-year period (18%; P = 0.021). In summary, MIPS-PC treatment is associated with a decreasing trend in acute care utilization. Prospective studies are needed to validate this effect of enhanced PC in patients with SMI and CVD.

Insider Threats to the Military Health System: A Systematic Background Check of TRICARE West Providers.

To address the pandemic, the Defense Health Agency (DHA) expanded its TRICARE civilian provider network by 30.1%. In 2022, the DHA Annual Report stated that TRICARE's provider directories were only 80% accurate. Unlike Medicare, the DHA does not publicly reveal National Provider Identification (NPI) numbers. As a result, TRICARE's 9.6 million beneficiaries lack the means to verify their doctor's credentials. Since 2013, the Department of Health and Human Services' (HHS) Office of Inspector General (OIG) has excluded 17,706 physicians and other providers from federal health programs due to billing fraud, neglect, drug-related convictions, and other offenses. These providers and their NPIs are included on the OIG's List of Excluded Individuals and Entities (LEIE). Patients who receive care from excluded providers face higher risks of hospitalization and mortality. We sought to assess the extent to which TRICARE screens health care provider names on their referral website against criminal databases. Between January 1-31, 2023, we used TRICARE West's provider directory to search for all providers within a 5-mile radius of 798 zip codes (38 per state, ≥10,000 residents each, randomly entered). We then copied and pasted all directory results' first and last names, business names, addresses, phone numbers, fax numbers, degree types, practice specialties, and active or closed statuses into a CSV file. We cross-referenced the search results against US and state databases for medical and criminal misconduct, including the OIG-LEIE and General Services Administration's (GSA) SAM.gov exclusion lists, the HHS Office of Civil Rights Health Insurance Portability and Accountability Act (HIPAA) breach reports, 15 available state Medicaid exclusion lists (state), the International Trade Administration's Consolidated Screening List (CSL), 3 Food and Drug Administration (FDA) debarment lists, the Federal Bureau of Investigation's (FBI) list of January 6 federal defendants, and the OIG-HHS list of fugitives (FUG). Our provider search yielded 111,619 raw results; 54 zip codes contained no data. After removing 72,156 (64.65%) duplicate entries, closed offices, and non-TRICARE West locations, we identified 39,463 active provider names. Within this baseline sample group, there were 2398 (6.08%) total matches against all exclusion and sanction databases, including 2197 on the OIG-LEIE, 2311 on the GSA-SAM.gov list, 2 on the HIPAA list, 54 on the state Medicaid exclusion lists, 69 on the CSL, 3 on the FDA lists, 53 on the FBI list, and 10 on the FUG. TRICARE's civilian provider roster merits further scrutiny by law enforcement. Following the National Institute of Standards and Technology 800, the DHA can mitigate privacy, safety, and security clearance threats by implementing an insider threat management model, robust enforcement of the False Claims Act, and mandatory security risk assessments. These are the views of the author, not the Department of Defense or the US government.

Nurse-Led Models of Care: Practice and Policy to Support Aging in Place.

Research demonstrates that aging in place is the goal of most adults aged >50 years. Unfortunately, multiple barriers to aging in place continue to exist, especially for vulnerable populations. Achieving this goal will require innovative nurse-led models of care and new policies for RN reimbursement. The current article describes a nurse-led clinic implemented in one community. Using an evidence-based nurse-led model of care, a team of university faculty, students, and a family nurse practitioner designed and implemented a nurse-led clinic for a religious community in the Pacific Northwest. Today, the nurse-led clinic offers care coordination and primary care to support aging in place and is one example of a nurse-led model well-positioned to address the aging in place needs of vulnerable populations. Replication and sustainability of this nurse-led model requires sweeping policy change, including consideration of requiring all nurses to attain a National Provider Identification number to expand RN reimbursement and ultimately increase access to care. [Journal of Gerontological Nursing, 50(3), 13-17.].

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.

An EMR-Based Approach to Determine Frequency, Prescribing Pattern, and Characteristics of Patients Receiving Drugs with Pharmacogenomic Guidelines.

(1) Background: This retrospective analysis utilizing electronic medical record (EMR) data from a tertiary integrated health system sought to identify patients and prescribers who would benefit from pharmacogenomic (PGx) testing based on Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. (2) Methods: EMR data from a clinical research data warehouse were analyzed from 845,518 patients that had an encounter between 2015 and 2019 at an academic medical center. Data were collected for 42 commercially available drugs with 52 evidence-based PGx guidelines from CPIC. Provider data were obtained through the EMR linked by specialty via national provider identification (NPI) number. (3) Results: A total of 845,518 patients had an encounter in the extraction period with 590,526 medication orders processed. A total of 335,849 (56.9%) patients had medication orders represented by CPIC drugs prescribed by 2803 providers, representing 239 distinct medications. (4) Conclusions: The results from this study show that over half of patients were prescribed a CPIC actionable medication from a variety of prescriber specialties. Understanding the magnitude of patients that may benefit from PGx testing, will enable the development of preemptive testing processes, physician support strategies, and pharmacist workflows to optimize outcomes should a PGx service be implemented.

High-volume Arthroplasty Centers Are Associated With Lower Hospital Costs When Performing Primary THA and TKA: A Database Study of 288,909 Medicare Claims for Procedures Performed in 2019.

With bundled payments and alternative reimbursement models expanding in scope and scale, reimbursements to hospitals are declining in value. As a result, cost reduction at the hospital level is paramount for the sustainability of profitable inpatient arthroplasty practices. Although multiple prior studies have investigated cost variation in arthroplasty surgery, it is unknown whether contemporary inpatient arthroplasty practices benefit from economies of scale after accounting for hospital characteristics and patient selection factors. Quantifying the independent effects of volume-based cost variation may be important for guiding future value-based health reform. We performed this study to (1) determine whether the cost incurred by hospitals for performing primary inpatient THA and TKA is independently associated with hospital volume and (2) establish whether length of stay and discharge to home are associated with hospital volume. The primary data source for this study was the Medicare Provider Analysis and Review Limited Data Set, which includes claims data for 100% of inpatient Medicare hospitalizations. We included patients undergoing primary elective inpatient THA and TKA in 2019. Exclusion criteria included non-Inpatient Prospective Payment System hospitalizations, nonelective admissions, bilateral procedures, and patients with cancer of the pelvis or lower extremities. A total of 500,658 arthroplasties were performed across 2762 hospitals for 492,262 Medicare beneficiaries during the study period; 59% (288,909 of 492,262) of procedures were analyzed after the exclusion criteria were applied. Most exclusions (37% [182,733 of 492,262]) were because of non-Inpatient Prospective Payment System hospitalizations. Among the study group, 87% (251,996 of 288,909) of procedures were in patients who were 65 to 84 years old, 88% (255,415 of 288,909) were performed in patients who were White, and 63% (180,688 of 288,909) were in patients who were women. Elixhauser comorbidities and van Walraven indices were calculated as measures of patient health status. Hospital costs were estimated by multiplying cost-to-charge ratios obtained from the 2019 Impact File by total hospital charges. This methodology enabled us to use the large Medicare Provider Analysis and Review database, which helped decrease the influence of random cost variation through the law of large numbers. Hospital volumes were calculated by stratifying claims by national provider identification number and counting the number of claims per national provider identification number. The data were then grouped into bins of increasing hospital volume to more easily compare larger-volume and smaller-volume centers. The relationship between hospital costs and volume was analyzed using univariable and multivariable generalized linear models. Results are reported as exponential coefficients, which can be interpreted as relative differences in cost. The impact of surgical volume on length of stay and discharge to home was assessed using binary logistic regression, considering the nested structure of the data, and results are reported as odds ratios (OR). Hospital cost and mean length of stay decreased, while rates of discharge to home increased with increasing hospital volume. After controlling for potential confounding variables such as patient demographics, health status, and geographic location, we found that inpatient arthroplasty costs at hospitals with 10 or fewer, 11 to 100, and 101 to 200 procedures annually were 1.32 (95% confidence interval [CI] 1.30 to 1.34; p < 0.001), 1.17 (95% CI 1.17 to 1.17; p < 0.001), and 1.10 (95% CI 1.10 to 1.10; p < 0.001) times greater than those of hospitals with 201 or more inpatient procedures annually. In addition, patients treated at smaller-volume hospitals had increased odds of experiencing a length of stay longer than 2 days (OR 1.25 to 3.44 [95% CI 1.10 to 4.03]; p < 0.001) and decreased odds of being discharged to home (OR 0.34 to 0.78 [95% CI 0.29 to 0.86]; p < 0.001). Higher-volume hospitals incur lower costs, shorter lengths of stay, and higher rates of discharge to home than lower-volume hospitals when performing inpatient THA and TKA. These findings suggest that small and medium-sized regional hospitals are disproportionately impacted by declining reimbursement and may necessitate special treatment to remain viable as bundled payment models continue to erode hospital payments. Further research is also warranted to identify the key drivers of this volume-based cost variation, which may facilitate quality improvement initiatives at the hospital and policy levels.

The Importance of Accurately Defining Gender and Sex in Pathology.

The recent publication by Arvisais-Anhalt et al1 effectively highlights the persistent remuneration inequities between women and men in pathology. Given this key finding, we were disappointed that the terminology used throughout the investigation to identify pathologists based on their “gender” or “sex” was not addressed or defined. We also believe that since the authors broached this important topic, it would have been prudent to discuss the inherent limitations of the data sources regarding gender mischaracterization. “Provider sex” was methodologically assessed; however, the Centers for Medicare and Medicaid Services and National Provider Identification data sets specify “gender” as the identification category, despite reporting “M” and “F” as each provider’s gender. Sex refers to a label assigned at birth—usually female or male. However, sex can also encompass nonbinary characterizations, including intersex when reproductive anatomy does not fit either option. In contrast, gender is self-defined and associated with the emotional,...

The AMA Graduate Profile: Tracking Medical School Graduates Into Practice.

Purpose: Medical schools aim to train competent physicians that meet the health care needs of society. Yet beyond the results of the residency match, medical schools often do not know what kind of workforce they are creating or how their graduates perform in practice. 1 Here, we describe the creation of a personalized Graduate Profile for 32 medical schools in the American Medical Association (AMA) Accelerating Change in Medical Education grant consortium. The Graduate Profile addressed 3 core questions: (1) Workforce: Where do graduates practice and to which communities do they contribute?, (2) Clinical Exposure: What prescriptions are graduates ordering for various patient types?, and (3) Quality of Care: What are graduates’ standardized quality measures? Approach: The Graduate Profile links the AMA Physician Masterfile—a nationwide database of physicians in training and practice—to multiple public data sources spanning undergraduate medical education, graduate medical education (GME), and post-GME practice using individuals’ unique national provider identification numbers. Medical students graduating from 32 institutions between 1981 and 2012 were included (n = 120,426 graduates). Graduates’ demographics, self-designated practice specialty, practice location, and practice setting in the year 2019 were tabulated. Specialties were coded as primary care or not primary care. Practice locations were geocoded to identify practice in underserved or rural areas. Additionally, Centers for Medicare and Medicaid Services (CMS) utilization data and Merit-based Incentive Payment System (MIPS) standardized quality scores from the year 2017—representing over 140 million Medicare beneficiary interactions—were tabulated. Outcomes: Graduate Profiles were delivered to 32 medical schools in November 2020. A webinar and 2 office hours were held to support rollout of the profiles. The profiles compared each institution’s graduates from 1981 to 2012 with an average across all medical schools in a series of tables and figures. Trends in graduate gender distribution, in-state retention, practice specialty, primary care practice, office-based practice, and underserved practice were visualized and benchmarked against all 32 medical schools. For example, practice in primary care specialties peaked in the late 1990s and has since declined. Practice in medically underserved communities remained largely constant across 3 decades of graduate cohorts, suggesting that programmatic and policy efforts have not dramatically increased underserved practice. Average MIPS scores were delineated by specialty and over time. Overall, more recent graduates were associated with higher MIPS scores. Finally, graduates’ most prescribed medications to Medicare beneficiaries were tabulated. Across these 32 medical schools, the most prescribed medications were hydrocodone–acetaminophen, lisinopril, atorvastatin, omeprazole, and levothyroxine; as expected, substantial prescribing differences were observed by specialty. Each institution’s personalized profile differed, with substantial interinstitutional differences in most assessed areas. Discussion: Harnessing the AMA Physician Masterfile and multiple open data sources, this project provided medical schools with detailed profiles of their graduates—some of whom had been in practice for nearly 40 years. The project relied on data science and informatics approaches, using a centralized process that had “economy of scale.” Early feedback from medical schools indicates that the profiles are hypothesis generating and may highlight alignment (or misalignment) with their stated educational mission. We envision a future state where the constituent institutions generate questions to be answered via the Graduate Profile, which then drives medical education innovation at the medical school level. 2 Significance: The AMA Graduate Profile uses informatics approaches to link multiple data sources for 3 decades of graduates, providing medical schools a tool to understand if their graduates’ practice patterns align with their stated mission and workforce needs. The Graduate Profile is unique as it incorporates actual practice specialties, practice locations, prescribing behaviors, and standardized quality scores of over 120,000 graduates—a proof of concept for future work exploring additional domains of graduates in practice.

Association of Adults With Congenital Heart Disease-Specific Care With Clinical Characteristics and Healthcare Use.

BackgroundMany adults with congenital heart disease (ACHD) are cared for by non‐ACHD specialists, if they receive care at all. Little is known about the differences between those who access care at an ACHD center and those who do not access ACHD‐specific care.Methods and ResultsThe Oregon All Payer All Claims database was queried to identify subjects aged 18 to 65 years with an International Classification of Diseases, Ninth Revision (ICD‐9) code consistent with ACHD from 2010 to 2015. ACHD center providers were identified using National Provider Identification numbers. Usage rates and percentages were calculated with person‐years in the denominator, and rate ratios and odds ratios (ORs) were estimated using negative binomial and logistic regression. Only 11.7% of identified individuals (N=10 199) were seen at the ACHD center. These individuals were younger (median 36 versus 47 years; P<0.0001) and had higher rates of Medicaid insurance (47.8% versus 28.4%; P<0.0001), heart failure (31.4% versus 15.3%; P<0.0001), and arrhythmia (75.5 versus 49.2%; P<0.0001). They had more visits of all types (outpatient: 79% per year versus 64% per year [age‐adjusted OR, 2.54; 99% CI, 2.24–2.88]; emergency department: 29% versus 22% per year [adjusted OR, 1.34; 99% CI, 1.18–1.52]; inpatient: 17% versus 12.0% per year [adjusted OR, 1.92; 99% CI, 1.67–2.20]). Rates of guideline‐indicated annual echocardiography were low (7.7% overall, 13.4% in patients at the ACHD center).ConclusionsPatients at an ACHD center comprise a distinct and complex group with a high rate of healthcare use and a relatively higher compliance with guideline‐indicated annual follow‐up. These findings underscore the importance of building and supporting robust systems for ACHD care in the United States.

Adventures in getting paid

Adventures in getting paid

Academyhealth annual Research Meeting (ARM): A Selection of Abstracts accepted for Oral Presentation, 2020.

Research ObjectiveIn 2016, the 1% of Medicare beneficiaries with end‐stage renal disease (ESRD) constituted &gt; 7% of total Medicare spending ($35 billion). To improve the value of care for the ESRD population, the Centers for Medicare and Medicaid Services (CMS) implemented an alternative payment model (APM) for ESRD care, the ESRD Seamless Care Organization (ESCO). This model shares savings with organizations that reduce spending for their ESRD patients below a defined benchmark. This study evaluated the relationship between key organizational, provider, community characteristics, and ESCO performance.Study DesignWe constructed a novel, linked ESCO‐level data set capturing key information for all 37 Wave 2 (2017) ESCOs. After describing the organizational diversity of 2017 ESCOs, we performed bivariate comparisons of high‐ and low‐performing (eg, above versus below median) ESCOs based on three key outcomes: gross savings/losses, composite quality score, and standardized mortality ratio. Subsequently, we estimated generalized logistic regression models of ESCO performance as a function of organizational (number and type of participating facilities, and beneficiary‐to‐provider ratio), ESCO‐participating provider (credential and specialty), and community (percent Hispanic, non‐Hispanic black, percent Medicaid eligible, and median household income) characteristics.Population StudiedThe 37 ESCOs of 2017 were characterized using information from CMS reports, the National Plan and Provider Enumeration System National Provider Identification registry, and the Area Health Resource File. Combined, these ESCOs represented 40 162 Medicare beneficiaries.Principal FindingsESCO performance on the three outcomes was highly varied (ranges: savings/losses, −3.9% to 10.2%; quality, 76.4% to 100.0%; standardized mortality, 0.75 to 1.14), as were the ESCOs’ characteristics. Bivariate analysis showed that ESCOs with above (vs below) median savings had more aligned physicians (57.8 vs 28.6, P = .06), fewer dialysis facilities (8.66 vs 17.2, P = .07), a smaller non‐Hispanic black population (14.1% vs 21.9%, P = .06), and higher median household income ($55 532 vs $48 952, P &lt; .001). Facilities reporting a composite quality score of 100% (vs &lt;100%) had fewer aligned practices (22.3 vs 42.6, P = .05) and smaller non‐Hispanic black (16.3% vs 21.3%, P = .06) and Medicaid‐eligible (6.47% vs 8.9%, P = .14) populations. Low standardized mortality ratio (vs above median) was associated with higher median household income ($58 162 vs $45 810, P &lt; .001). Logistic regression model results were broadly consistent with these findings, though small sample size prevented finding statistically significant estimates.ConclusionsESCOs are highly diverse with respect to organizational composition and community characteristics; this variation partially explained the observed variation in ESCO performance. Among 2017 ESCOs, larger ESCOs (eg, with more affiliated physicians) and those in higher SES communities performed better with respect to savings and mortality. Quality measure performance was greater among smaller ESCOs, perhaps because of the difficulty of managing quality measure reporting efforts among larger physician groups.Implications for Policy or PracticeDrawing on data from the only ESRD‐specific APM effective to date, we offer the first evidence of the impact of organizational composition and social disparities on ESCO performance. This study provides crucial evidence that will inform policy deliberations about the design and implementation of APMs in specialty care, and the organizational decisions of provider groups considering whether to participate.

Practice Patterns of Vascular Surgery's “1%”

Public focus on health care spending has increased attention on variation in practice patterns and overutilization of high-cost services. Mainstream news reports have revealed that a small number of providers account for a disproportionate amount of total Medicare payments. Here, we explore variation in Medicare payments among vascular surgeons and compare practice patterns of the most highly reimbursed surgeons to the rest of the workforce. 2016 Medicare Provider Utilization Data were queried to identify procedure, charge, and payment data to vascular surgeons, identified by National Provider Identification taxonomy. Commonly performed services (>10/year) were stratified into categories (endovascular, open surgery, varicose vein, evaluation and management, etc.). Practice patterns of vascular surgeons comprising the top 1% Medicare payments (n=31) were compared with the remainder of the workforce (n=3,104). In 2016, Medicare payments to vascular surgeons totaled $589 M. 31 vascular surgeons-1% of the workforce-received $91 million (15% of total payments). Practice patterns of the 1% differed significantly from the remainder of vascular surgeons (P<0.05), with endovascular procedures accounting for 85% of their reimbursement. Specifically, the 1% received 49% of total Medicare payments for atherectomy ($121 M), 98% of which were performed in the office setting. One percentage of vascular surgeons receive an inordinate amount of total Medicare payments to the specialty. This discrepancy is due to variations in volume, utilization, and site of service. Disproportionate use of outpatient atherectomy in a small number of providers, for example, raises concerns regarding appropriateness and overutilization. Given current scrutiny over health care spending, these findings should prompt serious discussion regarding the utility of personal and societal self-regulation.

Concurrent Use of Opioids with Other Central Nervous System-Active Medications Among Older Adults.

The primary objective was to determine the prevalence and characteristics of older adults concurrently using opioids and other central nervous system (CNS)-active medications, and the specialties of providers who ordered the medications. A secondary objective was to document medication-related adverse effects associated with such concurrent drug use. Study populations were identified as older adults aged ≥65 years with 1 year continuous medical and drug plan enrollment during 2017 and opioid use of ≥2 prescriptions for ≥15 days' supply. CNS-active medications included benzodiazepines, non-benzodiazepine hypnotics, muscle relaxants, antipsychotics, and gabapentinoids. Provider specialties were identified from the National Provider Identification database. Characteristics associated with opioids only, opioids plus 1, and opioids plus ≥2 additional CNS-active medications were determined using multinomial logistic regression. Outcome measures during 2017 included injurious falls/fractures and ≥3 emergency room (ER) visits. Among eligible insureds (N = 209,947), 57% used opioids only, 28% used opioids plus 1 additional CNS medication, and 15% used ≥2 additional medications. About 60% of opioids and other concurrent CNS medications were prescribed by the same provider, generally a primary care provider. Benzodiazepines and gabapentinoids were most often used concurrently with opioids. Health status, insomnia, anxiety, depression, and low back pain had the strongest associations with concurrent medication use. Overall, concurrent use with ≥2 CNS medications increased the likelihood of injurious falls/fractures or ≥3 ER visits in this population by about 18% and 21%, respectively. Both patients and providers may benefit from an awareness of adverse outcomes associated with concurrent opioid and other CNS-active medication use.

Individual Surgeon Report Cards for Rate of Carotid Endarterectomies in Asymptomatic Patients: An Improving Wisely Performance Metric for Carotid Disease

Introduction - Prior randomized trials have demonstrated that carotid endarterectomy (CEA) can reduce stroke risk in asymptomatic patients. However, subsequent improvements in medical management have challenged this notion. The aim of our study was to describe surgeon-specific CEA rates for asymptomatic versus symptomatic patients in the United States, and to identify factors associated with potential overuse of asymptomatic CEA. Methods - We studied all patients undergoing an initial CEA in the Medicare Claims database between 01/2014 – 12/2016. The database includes National Provider Identification (NPI) numbers for surgeons. Patients with any prior CEA and surgeons who performed ≤ 10 CEAs during the study period were excluded. For each individual surgeon, we calculated the proportion of patients undergoing CEA for asymptomatic vs. symptomatic carotid disease. Multivariable logistic regression was performed to identify surgeon covariates associated with performing a very high proportion (100%) of CEA in asymptomatic patients. Results - Overall, 108,391 patients (median age 75 years, 62% male) underwent CEA by 2,983 surgeons during the study period, of whom 89.5% (N=97,007) were asymptomatic. The majority of surgeons performing CEA were vascular surgeons (64.1%, N=1,912), followed by general surgeons (24.0%, N=716) and cardiac surgeons (11.9%, N=355). The median number of CEA cases performed by a single surgeon over the 2-year study period was 28 (range 11-331), of which the median proportion of asymptomatic CEA procedures was 93.8% (IQR 87.6-100%). More than half (56.3%, N=1,679) of surgeons performed CEA for asymptomatic disease in ≥90% of their cases. 17.6% (N=514) of surgeons performed CEA for asymptomatic disease in 100% of their cases, including 12.9% of vascular surgeons and 25.0% of non-vascular surgeons (Figure 1). Individual surgeon factors that were independently associated with operating exclusively on asymptomatic patients included low-volume vs. high-volume CEA practice [OR 6.4 (95%CI 4.3-9.5)] and non-vascular surgical specialty [OR 2.1 (95%CI 1.7-2.6)]. Conclusion - Carotid endarterectomy is performed primarily for asymptomatic carotid disease by the majority of surgeons in the US. One quarter of non-vascular surgeons perform carotid endarterectomy only in asymptomatic patients, suggesting that vascular surgeons user stricter criteria for the operation than non-vascular surgeons. These findings underscore the potential broad implications of the results of the CREST-2 trial, which seeks to better inform our understanding of the benefits of CEA versus modern medical management for asymptomatic carotid disease.

Association of Practitioner Interfacility Triage Performance With Outcomes for Severely Injured Patients With Fee-for-Service Medicare Insurance

Despite evidence that treatment of severely injured patients at trauma centers is associated with reduced mortality, nearly half of all such patients are treated at nontrauma centers (undertriaged). Little is known about whether interfacility undertriage occurs because of practitioner decision-making or institutional and regional factors. To assess the associations between variation in triage practitioners at nontrauma centers and between practitioner-level variation and patient outcomes after injury. This retrospective cohort study used Medicare claims data from severely injured patients presenting to nontrauma centers and the practitioners who evaluated them in the emergency department from January 1, 2010, to October 15, 2015. Data analysis was performed from January 15, 2018, to March 21, 2019. Proportion of variation in undertriage associated with practitioners, practitioner rates of undertriage, practitioner characteristics associated with undertriage, and 30-day case-fatality rate. A total of 124 008 severely injured patients (mean [SD] age, 81 [8.4] years; 67 253 [54.2%] female) and the 25 376 practitioners (5564 [21.9%] female) who evaluated the patients in the emergency department of nontrauma centers were included in the study. Undertriage occurred among 85 403 patients (68.9%), with 40.6% of total variation associated with practitioners, 37.8% with hospitals, and 6.7% with regions. Compared with physicians with National Provider Identification (NPI) enumeration before 2007, those with an NPI enumerated between 2007 and 2010 had an undertriage risk ratio (RR) of 0.98 (95% CI, 0.97-0.99), and those with an NPI enumerated after 2010 had an undertriage RR of 0.96 (95% CI, 0.94-0.99). Hospitals with neurosurgeons had an undertriage RR of 1.51 (95% CI, 1.45-1.57) compared with those that did not; hospitals with spine surgeons had an undertriage RR of 1.10 (95% CI, 1.06-1.13); hospitals with general surgeons had an undertriage RR of 1.13 (95% CI, 1.09-1.17). Compared with practitioners who undertriaged 25% or less of patients, a statistically significant increase was found in the odds of death for patients treated by practitioners with a triage rate of less than 25% to 50% (odds ratio [OR], 1.08; 95% CI, 1.05-1.20) and less than 50% to 75% undertriage (OR, 1.12; 95% CI, 1.09-1.26) but not undertriage at greater than 75% (OR, 1.03, 95% CI, 1.00-1.18). In sensitivity analyses to adjust for unmeasured confounding, the association between triage practices and the case fatality rate became monotonic; compared with patients treated by practitioners with an undertriage rate of 25% or less, the odds of case fatality were 1.13 (95% CI, 1.05-1.21; P = .001) among patients treated by practitioners with undertriage rates less than 25% to 50%, 1.22 (95% CI, 1.13-1.32; P < .001) for patients treated by practitioners with undertriage rates less than 50% to 75%, and 1.20 (95% CI, 1.10-1.30; P < .001) for patients treated by practitioners with undertriage rates greater than 75%. The findings suggest that individual practitioner practices are an important source of variation in triage and represent a potential locus of intervention to reduce preventable deaths after injury.

Proposed 2020 Medicare Outpatient Rule Calls for Slight Increase in Fees

Proposed 2020 Medicare Outpatient Rule Calls for Slight Increase in Fees

Industry Payments to Obstetricians and Gynecologists Under the Sunshine Act.

To evaluate financial relationships between obstetrician-gynecologists (ob-gyns) and industry, including the prevalence, magnitude, and the nature of payments. We conducted a cross-sectional study in which we obtained a list of industry contributions to U.S. obstetricians and gynecologists through the Centers for Medicare and Medicaid Services Open Payments Database from August 1, 2013, to December 31, 2015. These data were cross-referenced with the entire cohort of practicing obstetricians and gynecologists, who were identified using the National Provider Identification database, because not all practicing ob-gyns received payments. These payments were analyzed with respect to 1) types of payments, 2) demographic attributes of health care providers receiving payments, and 3) comparisons between obstetrician and gynecologist subspecialties. Continuous data were compared using the Mann-Whitney test for variables that were not normally distributed and with the t test for variables that are normally distributed. A total of 517,077 nonresearch payments, totaling $79,965,244, were made to 23,292 ob-gyns. Physicians receiving payments were predominantly female, younger than 65 years old, allopathic physicians who graduated from U.S. medical schools in the late 1990s, and were board-certified subspecialists (P<.001 for all). Half of all ob-gyns received payments of varying amounts from drug manufacturers, device manufacturers, or both, with most of the payments for honoraria, faculty compensation, or consulting. Female pelvic medicine and reconstructive surgery physicians received the largest median dollar amount; maternal-fetal medicine physicians received the smallest. Obstetricians and gynecologists receive a substantial amount of payments from industry. Most of these payments were for honoraria, faculty compensation, or consulting and totaled less than $400 per health care provider. Although this total amount is less than typically received by surgical providers, including orthopedic surgeons who account for the highest compensated group in total and mean industry payments, the median payment value for obstetrics and gynecology subspecialists surpasses the median payment to orthopedic surgeons. These financial relationships warrant further exploration with future research.

Impact of Provider Characteristics on Outcomes of Carotid Endarterectomy for Asymptomatic Carotid Stenosis in New York State

The purpose of this study is to explore the impact of surgeon characteristics (including annual volume, specialty, and years in practice) on outcomes of carotid endarterectomy (CEA) for asymptomatic carotid atherosclerosis in New York State. The New York Statewide Planning and Cooperation System database was utilized to identify patients undergoing CEA from 2004 to 2011. Provider characteristics were determined by linkage to the New York Office of Professions and National Provider Identification databases. Provider-level factors were characterized by defining 5 quintiles of equal size for each factor. Hierarchical logistic regression models were created to evaluate the impact of provider characteristics on outcome. In total, 36,495 patients underwent CEA for asymptomatic disease performed by vascular (75.7%), general (16.1%), cardiac (6%), and neuro (2.1%) surgeons. Outcomes of interest included in-hospital mortality (0.26%), stroke (0.45%), and the composite end point of mortality, stroke, or cardiac complication (2.2%). Unadjusted outcomes improved with increasing surgeon annual CEA volume. Mid-career surgeons had lower mortality and stroke rates than early or late-career surgeons. Odds of mortality were increased when surgery was performed by the lowest volume providers (quintile 1; 0-11 CEA/year) (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.3-5.28) or a nonspecialty trained (general) surgeon (OR 1.64, 95% 1.01-2.67). After adjustment for all patient-level factors, provider volume remained an independent predictor of outcome, with significantly increased odds of mortality for volume quintile 1 (OR 2.57, 95% CI 1.27-5.23) and quintile 2 (12-22 CEA/year) (0.30%; OR 2.07, 95% CI 1-4.27) surgeons. Adverse events after CEA for asymptomatic disease are comparatively rare. However, surgeon characteristics impact outcome, with the best results offered by high-volume, mid-career, specialty-trained surgeons. Efforts to define the optimal treatment of asymptomatic carotid atherosclerosis must account for the impact of surgeon characteristics on patient outcomes.

Impact of surgeon and hospital experience on outcomes of abdominal aortic aneurysm repair in New York State

ObjectiveThis study aimed to assess the impact of the surgeon's and hospital's experience on the outcomes of open surgical repair (OSR) and endovascular aneurysm repair (EVAR) of intact and ruptured abdominal aortic aneurysms (AAAs) in New York State. MethodsNew York Statewide Planning and Research Cooperative System data were used to identify patients undergoing AAA repair from 2000 to 2011. Characteristics of the provider and hospital were determined by linkage to the New York Office of Professions and National Provider Identification databases. Distinct hierarchical logistic regression models for EVAR and OSR for intact and ruptured AAAs were created to adjust for the patient's comorbidities and to evaluate the impact of the surgeon's and hospital's experience on outcomes. The provider's years since medical school graduation as well as annual volume of the facility and provider are examined in tertiles. Adjusted odds ratios and 95% confidence intervals are presented. ResultsA total of 18,842 patients underwent AAA repair by a vascular surgeon. For intact AAAs (n = 17,118), 26.2% of patients underwent OSR and 73.8% underwent EVAR. For ruptured AAAs (n = 1724), 63.9% underwent OSR and 36.1% underwent EVAR. After intact AAA repair, OSR adjusted outcomes were significantly influenced by the surgeon's annual volume but not by the facility's volume or the surgeon's age. The lowest volume providers (1-4 OSRs) had higher in-hospital mortality rates than high-volume (>11 OSRs) surgeons (adjusted odds ratio, 1.87 [95% confidence interval, 1.1-3.17]). Low-volume providers also had higher odds of major complications (1.23 [1-1.51]). For patients with intact AAA undergoing EVAR, mortality was higher at low-volume facilities (2.6 [1.3-5.3] and 2.7 [1.5-4.8] for <33 EVARs and 34-81 EVARs, respectively). After OSR for ruptured AAA, treatment at a low-volume facility (<9 OSRs for ruptured AAA) was associated with greater mortality than at high-volume (>27 OSRs for ruptured AAA) centers (1.56 [1.02-2.39]), whereas low-volume physicians (<4 OSRs for ruptured AAA) had higher odds of major complications (1.58 [1.04-2.41]). In the case of EVAR for rupture, there were no characteristics of the hospital or surgeon significantly associated with poorer outcomes. ConclusionsFor intact AAA, the surgeon's volume was an important factor for OSR outcomes, whereas low facility volume was associated with worse outcomes after EVAR. For ruptured AAA, low-volume surgeons and low-volume facilities had worse outcomes after OSR but not after EVAR. The interaction between the surgeon's volume and the hospital's volume is complex and varies on the basis of the acuity of presentation and treatment modality.

Oregon pharmacists begin prescribing hormonal contraceptives

O pharmacists now have prescribing authority for oral and patch contraceptives after a woman completes a self-screening risk assessment questionnaire and receives a blood pressure screening. The new statute, which was signed into law in July 2015, became effective in January. Since November 2015, many pharmacists throughout the state have completed the 5-hour online certification course, developed by Oregon State University College of Pharmacy with guidance from the Oregon Board of Pharmacy.