Sample Of Medicare Data Research Articles

Abstract 17485: Risk of Heart Failure Hospitalizations With Exposure to Colder Temperature and Regional Variations Among Older Adults in the United States

Introduction: Extreme cold was associated with excess heart failure (HF) deaths in ecological studies. The relationship between colder temperatures and HF hospitalizations is not well understood. Hypothesis: Lower minimum temperatures (T min ) increase the risk of HF hospitalization among older adults and the impact varies by climate regions. Methods: A time-stratified case-crossover study among adults aged ≥66 hospitalized for HF was conducted using a 20% sample of Medicare data (2008-2019, Nov-Feb). Daily T min from the Parameter-elevation Relationships on Independent Slopes model were linked to Medicare data by zip code of residence. We used bidirectional sampling to select up to 5 controls. We used conditional logistic regression with a restricted cubic spline to model non-linear effects between T min and HF hospitalization in all patients and regional subgroups. Results: Among 529,879 cases (mean age 79, 61% female, 86% white), the risk of HF hospitalization peaked at 4 °F (OR 1.29 [CI 1.28-1.30]) and plateaued over colder T min relative to the median T min (31.5°F). Above 31.5 °F, the risk was reduced by 18% for every 10 °F (Figure 1). This inverse relationship between T min and HF hospitalizations during the winter were most prominent in colder regions (Figure 2). Conclusions: T min ≤4 °F increased the risk of HF hospitalizations by upwards of 29% compared to the national median T min . The plateau at more extreme T min may be due to avoidance of outdoor exposure. A similar behavioral response may occur in warmer regions, whereas some degree of cold exposure is inevitable in colder regions. HF patients should be aware of the risks from exposure to colder temperatures during winter months.

Racial Disparities Exist in Outcomes After Major Fragility Fractures.

Fractures associated with postmenopausal osteoporosis (PMO) are associated with pain, disability, and increased mortality. A recent, nationwide evaluation of racial difference in outcomes after fracture has not been performed. To determine if 1-year death, debility, and destitution rates differ by race. Observational cohort study. US Medicare data from 2010 to 2016. Non-Hispanic black and white women with PMO who have sustained a fragility fracture of interest: hip, pelvis, femur, radius, ulna, humerus, and clinical vertebral. Outcomes included 1-year: (1) mortality, identified by date of death in Medicare vital status information, (2) debility, identified as new placement in long-term nursing facilities, and (3) destitution, identified as becoming newly eligible for Medicaid. Among black and white women with PMO (n = 4,523,112), we identified 399,000 (8.8%) women who sustained a major fragility fracture. Black women had a higher prevalence of femur (9.0% vs 3.9%; P < .001) and hip (30.7% vs 28.0%; P < .001) fractures and lower prevalence of radius/ulna (14.7% vs 17.0%; P < .001) and clinical vertebral fractures (28.8% vs 33.5%; P < .001) compared with white women. We observed racial differences in the incidence of 1-year outcomes after fracture. After adjusting for age, black women had significantly higher risk of mortality 1 year after femur, hip, humerus, and radius/ulna fractures; significantly higher risk of debility 1 year after femur and hip fractures; and significantly higher risk of destitution for all fractures types. In a sample of Medicare data from 2010 to 2016, black women with PMO had significantly higher rates of mortality, debility, and destitution after fracture than white women. These findings are a first step toward understanding and reducing disparities in PMO management, fracture prevention, and clinical outcomes after fracture. J Am Geriatr Soc 68:1803-1810, 2020.

Extrahepatic manifestations and healthcare expenditures of non-alcoholic fatty liver disease in the Medicare population.

Non-alcoholic fatty liver disease (NAFLD) is a very common liver disease which has been associated with a number of the extrahepatic manifestations (EHMs) and healthcare expenditures. Our aim was to assess the presence and impact of these EHMs of NAFLD on mortality and healthcare expenditures. Medicare beneficiaries (2005-2016) were included. ICD-9 and ICD-10 codes were used to identify patients with NAFLD and EHMs which included cardiovascular disease (CVD), hypertension (HTN), diabetes (DM), hyperlipidemia (HL), non-hepatocellular carcinoma (HCC) cancers, and others. Temporal trends among different groups were analyzed by join point regression model. Independent predictors of outcomes were evaluated in multiple generalized linear or logistic regression models. Among 30,908,679 Medicare beneficiaries (5% sample of Medicare data from 2005-2016), 1,980,950 (6.4%) had NAFLD diagnosis. From 2005 to 2016, the prevalence of NAFLD in the Medicare population increased at an average annual increase of 3.1%. The most common diseases associated with NAFLD were DM (86.3%), followed by HTN (85.2%), HL (79.8%), and CVD (35.8%). One-year mortality rate in NAFLD patients increased from 3.55 to 6.33 per 1000 from 2005 to 2016. One-year mortality was independently associated with diagnosis of HCC, cirrhosis, DM (outpatient), depression, dementia, lung disease, renal failure, thyroid disorder (inpatient), neurological disorder as well as non-HCC cancers. NAFLD is associated with a number of EHMs that increases its mortality and increased healthcare expenditure.

Unicondylar Knee Arthroplasty Has Fewer Complications but Higher Revision Rates Than Total Knee Arthroplasty in a Study of Large United States Databases

BackgroundUnicondylar knee arthroplasty (UKA) has superior functional outcomes compared to total knee arthroplasty (TKA) with good mid-term and long-term survival data from high-volume institutions. We sought to quantify the risk of complications, re-operation/revision, hospital re-admission for any reason, and mortality of knee arthroplasty patients in the US patient population using 2 large databases. MethodsUKA and TKA patients who were identified in the 2002-2011, 5% sample of Medicare data and 2004-2012 (June) MarketScan Commercial and Medicare Supplemental Databases were followed to evaluate the risk of complications, hospital re-admission for any reason, and mortality within 90 days of surgery. Survival probability defined by re-operation was calculated using the Kaplan-Meier method at 0.5, 2, 5, 7, and up to 10 years post-operatively. ResultsCompared to UKA, complication rates for TKA patients were significantly higher, including wound complication, pulmonary embolism, stiffness, peri-prosthetic joint infection, myocardial infarction, re-admission, and death. Age was found to be a significant risk factor (P < .05) for all complications in the Medicare cohort, except stiffness (P = .839), and all complications in the MarketScan cohort, except re-admission (P = .418), whereas gender had a variable effect on complications based on age. Survivorship of UKA was lower than TKA at all time points. Additionally, younger age adversely affected implant survival. By 7 years post-surgery, UKA survivorship in the Medicare and MarketScan cohorts was 80.9% and 74.4%, respectively. In contrast, TKA survivorship for the same cohorts was 95.7% and 91.9% by the same time point. ConclusionPatients undergoing UKA have fewer post-operative complications and re-admissions than those undergoing TKA. However, patients undergoing UKA have a higher rate of re-operation and revision at up to 10 years of follow-up. It appears that age, as well as surgeon and hospital volume significantly impacts implant survivorship while gender does not have a relation. Level of EvidenceLevel III.

Poor Nutrition Status and Lumbar Spine Fusion Surgery in the Elderly: Readmissions, Complications, and Mortality.

Retrospective database review. To quantify the medical and surgical risks associated with elective lumbar spine fusion surgery in patients with poor preoperative nutritional status and to assess how nutritional status alters length of stay and readmission rates. There has been recent interest in quantifying the increased risk of complications caused by frailty, an important consideration in elderly patients that is directly related to comorbidity burden. Preoperative nutritional status is an important contributor to both sarcopenia and frailty and is poorly studied in the elderly spine surgery population. The full 100% sample of Medicare data from 2005 to 2012 were utilized to select all patients 65 to 84 years old who underwent elective 1 to 2 level posterior lumbar fusion for degenerative pathology. Patients with diagnoses of poor nutritional status within the 3 months preceding surgery were selected and compared with a control cohort. Outcomes that were assessed included major medical complications, infection, wound dehiscence, and mortality. In addition, readmission rates and length of stay were evaluated. When adjusting for demographics and comorbidities, malnutrition was determined to result in significantly increased odds of both 90-day major medical complications (adjusted odds ratio, OR: 4.24) and 1-year mortality (adjusted OR: 6.16). Multivariate analysis also demonstrated that malnutrition was a significant predictor of increased infection (adjusted OR: 2.27) and wound dehiscence (adjusted OR: 2.52) risk. Length of stay was higher in malnourished patients, though 30-day readmission rates were similar to controls. Malnutrition significantly increases complication and mortality rates, whereas also significantly increasing length of stay. Nutritional supplementation before surgery should be considered to optimize postoperative outcomes in malnourished individuals. 3.

Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis.

Objective To determine the demographics and seasonal and geographic variation of epistaxis in the United States. Study Design Retrospective cohort analysis based on data from Medicare claims. Setting Emergency department visits. Subjects and Methods We used a 5% sample of Medicare data from January 2012 to December 2012. Our cohort included patients with an incident diagnosis of epistaxis during a visit to the emergency department, excluding those with a diagnosis in the prior 12 months. Demographics included age, sex, race, and ethnicity. We compared the rate of emergency department visits for epistaxis by geographic division and individual states. Results In the 5% sample of Medicare data, 4120 emergency department visits for incident epistaxis were identified in 2012. Our results showed an increase in the emergency department visits for epistaxis with age. Compared with patients <65 years old, patients who were 66 to 76, 76 to 85, and >85 years old were 1.36 (95% confidence interval [95% CI], 1.23-1.50), 2.37 (95% CI, 2.14-2.62), and 3.24 (95% CI, 2.91-3.62) more likely to present with epistaxis, respectively. Men were 1.24 (95% CI, 1.17-1.32) times more likely to present with epistaxis than women. Blacks were 1.23 (95% CI, 1.10-1.36) times more likely to present with epistaxis when compared with non-Hispanic whites. Epistaxis emergency department visits were 40% lower in the summer months versus winter. The seasonal variation was more pronounced in the northern versus southern United States. Conclusion Emergency department visits for epistaxis increase with age and appear to be seasonal, with a more pronounced variation in the northern versus southern United States.

Abstract 371: Proportion of Readmissions to Non-Index Hospitals is Associated with All-Cause Risk-Adjusted Readmission Rate for Medicare Patients with AMI and CHF

Background: The Affordable Care Act introduced the Hospital Readmissions Reduction Program (HRRP), implementing financial penalties for hospitals with excess risk-standardized readmission rates (RSRRs) for specific diagnoses including congestive heart failure (CHF) and acute myocardial infarction (AMI). Hospitals may have more ability to reduce readmission rates for readmissions at their own hospitals as opposed to other hospitals. We hypothesize that hospitals with higher proportions of patients re-admitted to a different (“non index”) hospital also have higher all-cause 30-day RSRRs. Methods: We used a national sample of Medicare data to identify hospitalizations for CHF and AMI and subsequent all-cause 30-day readmissions using data from 5,291 hospitals for the period 1999 to 2010. For each hospital we calculated the proportion of readmissions at a different (“non-index”) hospital and the all-cause 30-day risk-adjusted readmission rate (RSRR). We then fitted a regression model to estimate the relationship between the proportion of admissions to the non-index hospital and all-cause RSRRs across hospitals. Results: We identified 2,863,696 discharges for AMI and 6,981,895 discharged for CHF for the period 1999 to 2010. On average across hospitals, the percentage of readmissions to non-index hospitals was 28.0% (SD 25.4%) for AMI and 22.7% (SD 17.8%) for CHF. Hospitals with higher RSRRs had higher percentages of their readmissions occurring at a different hospital for both AMI and CHF (p &lt; 0.001 for both conditions). Due to this association, hospitals in the highest decile for 30-day RSRR had 29.1% and 20.7% of readmissions occur at non-index hospitals for AMI and CHF, respectively, while the corresponding proportions for hospitals in the lowest decile were 19.1% and 18.4%. Conclusions: Compared to high performing hospitals, hospitals with the worst 30-day readmission rates for AMI and CHF also have the highest percentage of those readmissions occurring at hospitals other than their own. The relationship was particularly strong for AMI. These results suggest that the proportion of readmissions to other hospitals might be a structural disadvantage associated with higher readmission rates.

Older Patients Benefited Most From EVAR

Older Patients Benefited Most From EVAR

Trends in the United States in the Treatment of Distal Radial Fractures in the Elderly

Traditionally, distal radial fractures in the elderly have been treated nonoperatively with casting. However, since the introduction of the volar locking plating system in 2000, there has been an interest in the use of more aggressive treatment methods. The purpose of the present study was to assess changing trends in the treatment of distal radial fractures in elderly patients in the United States. We evaluated a 5% sample of Medicare data from 1996 to 1997 and a 20% sample from 1998 to 2005. Information on four treatment methods (closed treatment, percutaneous pin fixation, internal fixation, and external fixation) was extracted from the dataset. Other available data were diagnosis, physician specialty, and patient age, sex, and race. We calculated frequencies and rates to compare the utilization of different treatments over time. Over the ten-year time period examined, the rate of internal fixation of distal radial fractures in the elderly increased fivefold, from 3% in 1996 to 16% in 2005. Closed treatment, however, remained the predominant method (used for 82% of the fractures in 1996 and 70% in 2005). Fractures in patients with an age of eighty-five years or more were significantly more likely to be treated in a closed fashion (p < 0.0001). There was a large variation among physician specialties with regard to the fixation methods that were used. Orthopaedic surgeons were significantly more likely to use closed treatment than hand surgeons were, whereas hand surgeons were significantly more likely to use internal fixation than orthopaedic surgeons were. Since 2000, although the majority of distal radial fractures are still treated nonoperatively, there has been an increase in the use of internal fixation and a concurrent decrease in the rate of closed treatment of distal radial fractures in the elderly in the United States.