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Importance: Lack of a US dementia surveillance system hinders efforts to support and address disparities among persons living with Alzheimer disease and related dementias (ADRD). Objective: To review diagnosis and prescription drug code ADRD identification algorithms to develop and implement case definitions for national surveillance. Design, Setting, and Participants: In this cross-sectional study, a systematic literature review was conducted to identify unique International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and prescription drug codes used by researchers to identify ADRD in administrative records. Code frequency of use, characteristics of beneficiaries identified by codes, and expert and author consensus around code definitions informed code placement into categories indicating highly likely, likely, and possible ADRD. These definitions were applied cross-sectionally to 2017 to 2019 Medicare fee-for-service (FFS) claims and Medicare Advantage (MA) encounter data to classify January 2019 Medicare enrollees. Data analysis was conducted from September 2022 to March 2024. Exposures: ICD-10-CM and national drug codes in FFS claims or MA encounters. Main Outcomes and Measures: The primary outcome was counts and rates of beneficiaries meeting each case definition. Category-specific age, sex, race and ethnicity, MA enrollment, dual-eligibility, long-term care utilization, mortality, and rural residence distributions, as well as frailty scores and FFS monthly expenditures were also analyzed. Beneficiary characteristics were compared across categories, and age-standardized to minimize confounding by age. Results: Of the 60â¯000â¯869 beneficiaries included (50â¯853â¯806 aged 65 years or older [84.8%]; 32â¯567â¯891 female [54.3%]; 5â¯555â¯571 Hispanic [9.3%]; 6â¯318â¯194 non-Hispanic Black [10.5%]; 44â¯384â¯980 non-Hispanic White [74.0%]), there were 4â¯312â¯496 (7.2%) with highly likely ADRD, 1â¯124â¯080 (1.9%) with likely ADRD, and 2â¯572â¯176 (4.3%) with possible ADRD, totaling more than 8.0 million with diagnostic evidence of at least possible ADRD. These beneficiaries were older, more frail, more likely to be female, more likely to be dual-eligible, more likely to use long-term care, and more likely to die in 2019 compared with beneficiaries with no evidence of ADRD. These differences became larger when moving from the possible ADRD group to the highly likely ADRD group. Mean (SD) FFS monthly spending was $2966 ($4921) among beneficiaries with highly likely ADRD compared with $936 ($2952) for beneficiaries with no evidence of ADRD. Differences persisted after age standardization. Conclusions and Relevance: This cross-sectional study of 2019 Medicare beneficiaries identified more than 5.4 million Medicare beneficiaries with evidence of at least likely ADRD in 2019 using the diagnostic case definition. Pending validation against clinical and other methods of ascertainment, this approach can be adopted provisionally for national surveillance.
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Enfermedad de Alzheimer , Demencia , Medicare , Humanos , Estados Unidos/epidemiología , Enfermedad de Alzheimer/diagnóstico , Enfermedad de Alzheimer/epidemiología , Estudios Transversales , Anciano , Femenino , Masculino , Medicare/estadística & datos numéricos , Demencia/epidemiología , Demencia/diagnóstico , Clasificación Internacional de Enfermedades , Anciano de 80 o más Años , Planes de Aranceles por Servicios/estadística & datos numéricosRESUMEN
Importance: Positive airway pressure (PAP) is the first-line treatment for obstructive sleep apnea (OSA), but evidence on its beneficial effect on major adverse cardiovascular events (MACE) and mortality prevention is limited. Objective: To determine whether PAP initiation and utilization are associated with lower mortality and incidence of MACE among older adults with OSA living in the central US. Design, Setting, and Participants: This retrospective clinical cohort study included Medicare beneficiaries with 2 or more distinct OSA claims identified from multistate, statewide, multiyear (2011-2020) Medicare fee-for-service claims data. Individuals were followed up until death or censoring on December 31, 2020. Analyses were performed between December 2021 and December 2023. Exposures: Evidence of PAP initiation and utilization based on PAP claims after OSA diagnosis. Main Outcomes and Measures: All-cause mortality and MACE, defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights were used to estimate treatment effect sizes controlling for sociodemographic and clinical factors. Results: Among 888â¯835 beneficiaries with OSA included in the analyses (median [IQR] age, 73 [69-78] years; 390â¯598 women [43.9%]; 8115 Asian [0.9%], 47â¯122 Black [5.3%], and 760â¯324 White [85.5%] participants; median [IQR] follow-up, 3.1 [1.5-5.1] years), those with evidence of PAP initiation (290â¯015 [32.6%]) had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% CI, 0.52-0.54) and MACE incidence risk (HR, 0.90; 95% CI, 0.89-0.91). Higher quartiles (Q) of annual PAP claims were progressively associated with lower mortality (Q2 HR, 0.84; 95% CI, 0.81-0.87; Q3 HR, 0.76; 95% CI, 0.74-0.79; Q4 HR, 0.74; 95% CI, 0.72-0.77) and MACE incidence risk (Q2 HR, 0.92; 95% CI, 0.89-0.95; Q3 HR, 0.89; 95% CI, 0.86-0.91; Q4 HR, 0.87; 95% CI, 0.85-0.90). Conclusions and Relevance: In this cohort study of Medicare beneficiaries with OSA, PAP utilization was associated with lower all-cause mortality and MACE incidence. Results might inform trials assessing the importance of OSA therapy toward minimizing cardiovascular risk and mortality in older adults.
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Enfermedades Cardiovasculares , Presión de las Vías Aéreas Positiva Contínua , Medicare , Apnea Obstructiva del Sueño , Humanos , Femenino , Masculino , Anciano , Estudios Retrospectivos , Estados Unidos/epidemiología , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/epidemiología , Apnea Obstructiva del Sueño/mortalidad , Apnea Obstructiva del Sueño/terapia , Apnea Obstructiva del Sueño/complicaciones , Medicare/estadística & datos numéricos , Anciano de 80 o más Años , Incidencia , Factores de Riesgo de Enfermedad CardiacaRESUMEN
OBJECTIVE: To determine the rate of Medicare opt-out among optometrists and ophthalmologists and to contrast the differences in the characteristics and geographic distribution of these populations. DESIGN: A retrospective cross-sectional study. SETTING: Using a publicly available Centers for Medicare & Medicaid Services (CMS) data set, we collated data for ophthalmologists and optometrists who opted out in each year between 2005 and 2023. We calculated the rate of opt-out annually in each year window and cumulatively from 2005 to 2023. Comparative analysis was used to identify clinician characteristics associated with opt-out. MAIN OUTCOMES AND MEASURES: Both annual and cumulative rate of ophthalmologist and optometrist opt-out from Medicare. RESULTS: The estimated prevalence of Medicare opt-outs was 0.52% (77/14,807) for ophthalmologists and 0.38% (154/40,526) for optometrists. Ophthalmologists opting out were predominantly male (67.5%), had a longer practice duration (average 31.8 years), and were more often located in urban areas (83.1%), compared to optometrists (53.2% male, average 19.6 years in practice, 59.1% in urban areas, p = 0.04, p<0.001, p<0.001 respectively). Approximately 83% of ophthalmologists were either anterior segment or oculoplastics specialties, while the majority (52.1%) of optometrists were in optometry-only practices; >75% of identified clinicians were in private practice. Geographical distribution across the US showed variable opt-out rates, with the top 3 states including Oklahoma (3.4%), Arizona (2.1%), and Kansas (1.6%) for ophthalmology and Idaho (4.3%), Montana (3.1%), and Wyoming (1.4%) for optometry. CONCLUSIONS AND RELEVANCE: Few ophthalmologists and optometrists opt-out of Medicare but this trend has significantly increased since 2012. Of those who disenrolled from Medicare, 83% of ophthalmologists were in urbanized areas while 41% of optometrists were in non-urbanized areas. Because reasons for Medicare opt-out cannot be solely determined by administrative data, further investigation is warranted given the potential impact on healthcare accessibility.
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Medicare , Oftalmólogos , Optometristas , Humanos , Oftalmólogos/estadística & datos numéricos , Estados Unidos , Optometristas/estadística & datos numéricos , Masculino , Femenino , Medicare/estadística & datos numéricos , Estudios Retrospectivos , Estudios Transversales , Optometría/estadística & datos numéricosRESUMEN
OBJECTIVE: To determine whether mandatory participation by hospitals in bundled payments for lower extremity joint replacement (LEJR) was associated with changes in outcome disparities for patients dually eligible for Medicare and Medicaid. DATA SOURCES AND STUDY SETTING: We used Medicare claims data for beneficiaries undergoing LEJR in the United States between 2011 and 2017. STUDY DESIGN: We conducted a retrospective observational study using a differences-in-differences method to compare changes in outcome disparities between dual-eligible and non-dual eligible beneficiaries after hospital participation in the Comprehensive Care for Joint Replacement (CJR) program. The primary outcome was LEJR complications. Secondary outcomes included 90-day readmissions and mortality. DATA EXTRACTION METHODS: We identified hospitals in the US market areas eligible for CJR. We included beneficiaries in the intervention group who received joint replacement at hospitals in markets randomized to participate in CJR. The comparison group included patients who received joint replacement at hospitals in markets who were eligible for CJR but randomized to control. PRINCIPAL FINDINGS: The study included 1,603,555 Medicare beneficiaries (mean age, 74.6 years, 64.3% women, 11.0% dual-eligible). Among participant hospitals, complications decreased between baseline and intervention periods from 11.0% to 10.1% for dual-eligible and 7.0% to 6.4% for non-dual-eligible beneficiaries. Among nonparticipant hospitals, complications decreased from 10.3% to 9.8% for dual-eligible and 6.7% to 6.0% for non-dual-eligible beneficiaries. In adjusted analysis, CJR participation was associated with a reduced difference in complications between dual-eligible and non-dual-eligible beneficiaries (-0.9 percentage points, 95% CI -1.6 to -0.1). The reduction in disparities was observed among hospitals without prior experience in a voluntary LEJR bundled payment model. There were no differential changes in 90-day readmissions or mortality. CONCLUSIONS: Mandatory participation in a bundled payment program was associated with reduced disparities in joint replacement complications for Medicare beneficiaries with low income. To our knowledge, this is the first evidence of reduced socioeconomic disparities in outcomes under value-based payments.
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Medicare , Factores Socioeconómicos , Humanos , Estados Unidos , Femenino , Masculino , Anciano , Estudios Retrospectivos , Medicare/estadística & datos numéricos , Medicare/economía , Disparidades en Atención de Salud/estadística & datos numéricos , Paquetes de Atención al Paciente/economía , Artroplastia de Reemplazo/economía , Artroplastia de Reemplazo/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Anciano de 80 o más Años , Medicaid/estadística & datos numéricos , Medicaid/economía , Artroplastia de Reemplazo de Rodilla/economía , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Artroplastia de Reemplazo de Cadera/economía , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Disparidades Socioeconómicas en SaludRESUMEN
Purpose: Inflammatory and infectious eye diseases are an important cause of visual impairment in patients older than 65 years of age. Health care disparities for eye care are present for general eye care. However, there is lack of national data on health disparities regarding eye care use for inflammatory and infectious eye diseases. Our study examines the effect of gender and race on eye care in patients with inflammatory and infectious eye diseases who are equal or greater than 65 years of age. Methods: We have used Medicare data to examine the effect gender and race on use of eye care services in patients with inflammatory and infectious eye diseases for 2014 to 2018. Medicare is a national insurance program administered by the government of United States to insure people age 65 years or older. Owing to its high enrollment, those in Medicare are representative of the U.S. population aged 65 and older. Results: We found that females have higher use for Medicare for inflammatory and infectious eye diseases across all races from 2014 to 2018. On examining the effect of race, African Americans have lower use as compared with Whites. People of Asian descent have the highest use, followed by Hispanic people. Conclusions: Health care disparities exist for eye care use for inflammatory and infectious eye diseases for patients 65 years of age and older. Future studies are required to address these disparities to provide equitable eye care. Translational Relevance: Identification of eye care disparities is the first step to addressing these disparities.
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Disparidades en Atención de Salud , Medicare , Humanos , Estados Unidos/epidemiología , Medicare/estadística & datos numéricos , Anciano , Femenino , Masculino , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/etnología , Anciano de 80 o más Años , Infecciones del Ojo/terapia , Oftalmopatías/etnología , Oftalmopatías/terapia , Oftalmopatías/epidemiología , Inflamación/epidemiologíaRESUMEN
INTRODUCTION: In the last decade, melanoma treatment has improved significantly. However, data on population-level treatment utilization and survival trends among older patients is limited. This study aimed to analyze trends in systemic anticancer therapy (Rx), including the uptake of immune checkpoint inhibitors (ICIs), in conjunction with trends in cause-specific survival among older patients (66+) diagnosed with advanced melanoma (2008-2019). METHODS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare Condensed Resource to assess any Rx utilization among patients first diagnosed with advanced melanoma in 2008-2010, 2011-2014, and 2015-2019, stratified by stage, and type of first-line Rx among patients receiving Rx. The SEER dataset was used to evaluate trends in cause-specific survival by year of diagnosis. RESULTS: Rx utilization (any type) almost doubled, from 28.6% (2008-2010) to 55.4% (2015-2019) for stage 3 melanoma, and from 35.5% to 68.0% for stage 4 melanoma. In 2008-2010, the standard first-line treatment was cytokines/cytotoxic chemotherapy/other. By 2015-2019, only 5.1% (stage 3) and <3.6% (stage 4) of patients receiving Rx received these agents, as ICIs emerged as the dominant treatment. Both 1-year and 5-year cause-specific survival significantly improved since 2010 for stage 4 and since 2013 for stage 3. CONCLUSIONS: This study shows a significant rise in Rx utilization and a rapid transition from cytokines/cytotoxic chemotherapy to ICIs, reflecting a rapid uptake of highly effective treatment in a previously challenging disease with limited options before 2011. The documented survival improvement aligns with the adoption of these novel treatments, underscoring their significant impact on real-world patient outcomes.
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Inhibidores de Puntos de Control Inmunológico , Melanoma , Estadificación de Neoplasias , Programa de VERF , Neoplasias Cutáneas , Humanos , Melanoma/mortalidad , Melanoma/tratamiento farmacológico , Melanoma/patología , Neoplasias Cutáneas/mortalidad , Neoplasias Cutáneas/tratamiento farmacológico , Neoplasias Cutáneas/patología , Anciano , Masculino , Femenino , Anciano de 80 o más Años , Inhibidores de Puntos de Control Inmunológico/uso terapéutico , Estados Unidos/epidemiología , Melanoma Cutáneo Maligno , Medicare/estadística & datos numéricos , Antineoplásicos/uso terapéuticoRESUMEN
Background: Lewy body dementia (LBD) is the second most common neurodegenerative dementia in the US, presenting unique end-of-life challenges. Objective: This study examined healthcare utilization and care continuity in the last year of life in LBD. Methods: Medicare claims for enrollees with LBD, continuously enrolled in the year preceding death, were examined from 2011-2018. We assessed hospital stays, emergency department (ED) visits, intensive care unit (ICU) admissions, life-extending procedures, medications, and care continuity. Results: We identified 45,762 LBD decedents, predominantly female (51.8%), White (85.9%), with average age of 84.1 years (SD 7.5). There was a median of 2 ED visits (IQR 1-5) and 1 inpatient stay (IQR 0-2). Higher age was inversely associated with ICU stays (Odds Ratio [OR] 0.96; 95% Confidence Interval [CI] 0.96-0.97) and life-extending procedures (OR 0.96; 95% CI 0.95-0.96). Black and Hispanic patients experienced higher rates of ED visits, inpatient hospitalizations, ICU admissions, life-extending procedures, and in-hospital deaths relative to White patients. On average, 15 (7.5) medications were prescribed in the last year. Enhanced care continuity correlated with reduced hospital (OR 0.72; 95% CI 0.70-0.74) and ED visits (OR 0.71; 95% CI 0.69-0.87) and fewer life-extending procedures (OR 0.71; 95% CI 0.64-0.79). Conclusions: This study underscored the complex healthcare needs of people with LBD during their final year, which was influenced by age and race. Care continuity may reduce hospital and ED visits and life-extending procedures.
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Enfermedad por Cuerpos de Lewy , Medicare , Aceptación de la Atención de Salud , Cuidado Terminal , Humanos , Enfermedad por Cuerpos de Lewy/terapia , Enfermedad por Cuerpos de Lewy/epidemiología , Femenino , Masculino , Cuidado Terminal/estadística & datos numéricos , Anciano de 80 o más Años , Anciano , Estados Unidos/epidemiología , Medicare/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Continuidad de la Atención al Paciente/estadística & datos numéricosRESUMEN
INTRODUCTION: Research efforts to characterize and evaluate care delivery and outcomes for older adults with cancer and comorbid dementia are limited by varied methods used to classify Alzheimer's disease and related dementias (ADRD). The purpose of this study is to evaluate differences in demographic, clinical, and cancer characteristics of people newly diagnosed with cancer and concomitant dementia comparing two common methods to identify ADRD using administrative claims data. MATERIALS AND METHODS: We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Our sample included adults aged 66 years and older with a first primary diagnosis of lung or colorectal cancer between 2011 and 2017. For each cancer diagnosis, we constructed analytical cohorts using the Center for Medicare and Medicaid Services' Chronic Condition Warehouse (CCW) flag and the Bynum-Standard one- and three-year algorithms to capture diagnosed ADRD. We estimated ADRD prevalence using the algorithms and compared Bynum and CCW cohorts on demographic, clinical, and cancer characteristics at cancer diagnosis and survival for lung and colorectal cancer separately. RESULTS: Among older adults with lung cancer, ADRD prevalence was 4.7% with the one-year Bynum, 6.5% with the three-year Bynum, and 12.5% using the CCW flag. In the colorectal cohort, ADRD prevalence was 5.6% with the one-year Bynum, 7.6% with the three-year Bynum, and 14.1% with the CCW flag. Demographic characteristics were similar across ADRD cohorts. The Bynum cohorts identified higher proportions of individuals with moderate to severe dementia (13.8% and 11.2% versus 7.1% CCW in lung cancer; 13.1% and 10.6% versus 6.8% CCW in colorectal cancer), higher frailty rates (27.4% and 22.7% versus 15.0% CCW in lung cancer; 26.4% and 22.3% versus 14.8% CCW in colorectal cancer). Median survival was lower for the Bynum cohorts compared to the CCW, regardless of cancer type. DISCUSSION: Findings demonstrate that ADRD prevalence and certain clinical characteristics vary based on dementia ascertainment method and observation period used to classify individuals with ADRD. Considering differences in the cohorts of registry cases generated by the identification method used is essential when interpreting findings related to treatment, utilization, and outcomes within and across cancer cohorts.
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Enfermedad de Alzheimer , Neoplasias Colorrectales , Demencia , Neoplasias Pulmonares , Medicare , Programa de VERF , Humanos , Anciano , Masculino , Femenino , Estudios Retrospectivos , Enfermedad de Alzheimer/epidemiología , Enfermedad de Alzheimer/diagnóstico , Anciano de 80 o más Años , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/diagnóstico , Estados Unidos/epidemiología , Medicare/estadística & datos numéricos , Demencia/epidemiología , Demencia/diagnóstico , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/mortalidad , Prevalencia , Comorbilidad , Algoritmos , Neoplasias/epidemiologíaRESUMEN
Patients' experience accessing dermatologic care is understudied. The purpose of this cross-sectional study was to examine current wait times for new patients to receive dermatological care in NYC. Websites at 58 accredited private and public hospitals in the five boroughs of NYC were reviewed to identify dermatology practices. Office telephone numbers listed on each website were called to collect information pertaining to whether the physician was accepting new patients, type of insurance accepted (public, private, both, or none), and the number of days until a new patient could be seen for an appointment. Data pertaining to the time kept on hold and availability of web-based booking were also collected. Mean waiting time for an appointment was 50 days [standard deviation, SD 66] - nearly 2 months, but the distribution was considerably skewed. The median waiting time was 19.5 days [Interquartile range, IQR 4-60]. The time kept on hold to make the appointment was negligible at about 1 min (63 s, SD = 77) but could take up to ~ 7 min. Two-thirds of dermatologists accepted private, Medicare, and Medicaid insurance (n = 228, 66%); a small number accepted only private insurance (n = 12, 4%) or no insurance at all (n = 16, 5%). The median waiting time for an appointment for the 228 providers that accepted Medicaid was 30.5 days (IQR = 5.0-73.25) while for providers who did not accept Medicaid (n = 116) the median wait time for an appointment was 13.0 days (IQR = 3.0-38.0). Just over half (56%) of the dermatologists allowed for appointments to be booked on their website (n = 193). This research highlights the necessity of incorporating new strategies into routine dermatology appointments in order to increase treatment availability and decrease healthcare inequality.
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Citas y Horarios , Dermatólogos , Listas de Espera , Humanos , Estudios Transversales , Ciudad de Nueva York , Dermatólogos/estadística & datos numéricos , Factores de Tiempo , Dermatología/estadística & datos numéricos , Estados Unidos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Medicare/estadística & datos numéricosRESUMEN
OBJECTIVE: We described patterns and trends in ED use among adults with epilepsy in the United States. METHODS: Utilizing inpatient and ED discharge data from seven states, we conducted a cross-sectional analysis to identify adult ED visits diagnosed with epilepsy or seizures from 2010 to 2019. Using ED visit counts and estimates of state-level epilepsy prevalence, we calculated ED visit rates overall and by payer, condition, and year. RESULTS: Our data captured 304,935 ED visits with epilepsy as a primary or secondary diagnosis in 2019. Across the seven states, visit rates ranged between 366 and 726 per 1000 and were higher than rates for adults without epilepsy in all states but one. ED visit rates were highest among Medicare and Medicaid beneficiaries (vs commercial or self-pay). Adults with epilepsy were more likely to be admitted as inpatients. Visits for nervous system disorders were 6.3-8.2â¯times higher among people with epilepsy, and visits for mental health conditions were 1.2-2.6â¯times higher. Increases in ED visit rates from 2010 to 2019 among people with epilepsy exceeded increases among adults without by 6.0-27.3 percentage points. CONCLUSION: Adults with epilepsy visit the ED frequently and visit rates have been increasing over time. These results underscore the importance of identifying factors contributing to ED use and designing tailored interventions to improve ambulatory care quality.
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Servicio de Urgencia en Hospital , Epilepsia , Medicaid , Humanos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Estudios Transversales , Epilepsia/epidemiología , Epilepsia/terapia , Masculino , Adulto , Femenino , Estados Unidos/epidemiología , Persona de Mediana Edad , Anciano , Medicaid/estadística & datos numéricos , Adulto Joven , Medicare/estadística & datos numéricos , Adolescente , Aceptación de la Atención de Salud/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Hospitalización/tendenciasRESUMEN
BACKGROUND: Understanding the relationship between neighborhood environment and cardiovascular outcomes is important to achieve health equity and implement effective quality strategies. We conducted a population-based cohort study to determine the association of neighborhood socioeconomic deprivation and 30-day mortality and readmission rate for patients admitted with common cardiovascular conditions. METHODS AND RESULTS: We examined claims data from fee-for-service Medicare beneficiaries aged ≥65 years between 2017 and 2019 admitted for heart failure, valvular heart disease, ischemic heart disease, or cardiac arrhythmias. The primary exposure was the Area Deprivation Index; outcomes were 30-day all-cause death and unplanned readmission. More than 2 million admissions were included. After sequential adjustment for patient characteristics (demographics, dual eligibility, comorbidities), area health care resources (primary care clinicians, specialists, and hospital beds per capita), and admitting hospital characteristics (ownership, size, teaching status), there was a dose-dependent association between neighborhood socioeconomic deprivation and 30-day mortality rate for all conditions. In the fully adjusted model for death, estimated effect sizes of residence in the most disadvantaged versus least disadvantaged neighborhoods ranged from adjusted odds ratio 1.29 (95% CI, 1.22-1.36) for the heart failure group to adjusted odds ratio 1.63 (95% CI, 1.36-1.95) for the valvular heart disease group. Neighborhood deprivation was associated with increased adjusted 30-day readmission rates, with estimated effect sizes from adjusted odds ratio 1.09 (95% CI, 1.05-1.14) for heart failure to adjusted odds ratio 1.19 (95% CI, 1.13-1.26) for arrhythmia. CONCLUSIONS: Neighborhood socioeconomic disadvantage was associated with 30-day mortality rate and readmission for patients admitted with common cardiovascular conditions independent of individual demographics, socioeconomic status, medical risk, care access, or admitting hospital characteristics.
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Enfermedades Cardiovasculares , Medicare , Readmisión del Paciente , Disparidades Socioeconómicas en Salud , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/terapia , Medicare/estadística & datos numéricos , Características del Vecindario , Readmisión del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Determinantes Sociales de la Salud , Factores Socioeconómicos , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
PURPOSE: To study the effects of benign prostatic hyperplasia treatments, namely: alpha-adrenergic receptor blockers, 5-alpha-reductase inhibitors and phosphodiesterase-5 inhibitors on the risk of Parkinson's disease, Alzheimer's disease and mortality. MATERIALS AND METHODS: All male Medicare enrollees aged 65 or above who were diagnosed with benign prostatic hyperplasia and received one of the study drugs between 2007-2020 were followed-up for the three outcomes. We used Cox regression analysis to assess the relative risk of each of the outcomes for each study drug compared to the most prescribed drug, tamsulosin, while controlling for demographic, socioeconomic and comorbidity factors. RESULTS AND CONCLUSIONS: The study analyzed 1.1 million patients for a mean follow-up period of 3.1 years from being prescribed one of the study drugs. For all outcomes, patients on tamsulosin were used as the reference for comparison. For mortality, alfuzosin was associated with 27% risk reduction (HR 0.73, 95%CI 0.68-0.78), and doxazosin with 6% risk reduction (HR 0.94, 95%CI 0.91-0.97). For Parkinson's disease, terazosin was associated with 26% risk reduction (HR 0.74, 95%CI 0.66-0.83), and doxazosin with 21% risk reduction (HR 0.79, 95%CI 0.72-0.88). For Alzheimer's disease, terazosin was associated with 27% risk reduction (HR 0.73, 95%CI 0.65-0.82), and doxazosin with 16% risk reduction (HR 0.84, 95%CI 0.76-0.92). Tadalafil was associated with risk reduction (27-40%) in all 3 outcomes. More research is needed to elucidate the underlying mechanisms of these observations. Given the availability of safer alternatives for treating benign prostatic hyperplasia, caution should be exercised when using tamsulosin in elderly patients, especially those with an increased risk of developing neurodegenerative diseases.
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Enfermedad de Alzheimer , Medicare , Enfermedad de Parkinson , Hiperplasia Prostática , Tamsulosina , Humanos , Masculino , Tamsulosina/uso terapéutico , Tamsulosina/efectos adversos , Anciano , Hiperplasia Prostática/tratamiento farmacológico , Hiperplasia Prostática/mortalidad , Hiperplasia Prostática/epidemiología , Enfermedad de Alzheimer/tratamiento farmacológico , Enfermedad de Alzheimer/mortalidad , Enfermedad de Alzheimer/epidemiología , Medicare/estadística & datos numéricos , Estados Unidos/epidemiología , Enfermedad de Parkinson/tratamiento farmacológico , Enfermedad de Parkinson/mortalidad , Enfermedad de Parkinson/epidemiología , Anciano de 80 o más Años , Estudios de Cohortes , Antagonistas de Receptores Adrenérgicos alfa 1/uso terapéutico , Antagonistas de Receptores Adrenérgicos alfa 1/efectos adversos , Inhibidores de 5-alfa-Reductasa/uso terapéutico , Inhibidores de 5-alfa-Reductasa/efectos adversos , Inhibidores de Fosfodiesterasa 5/uso terapéutico , Inhibidores de Fosfodiesterasa 5/efectos adversosRESUMEN
INTRODUCTION: Statins and testosterone replacement therapy (TTh) have been inconsistently associated with a reduced risk of hormone-related cancers (HRCs, prostate [PCa], colorectal [CRC], and male breast cancers [BrCa]). Yet, the joint association of statins and TTh with the incidence of these cancers, and whether these associations vary by race, remains poorly understood. The objective of this retrospective cohort study is to examine the independent and joint effects of pre-diagnostic use of statins and TTh on the risk of HRCs, including PCa, CRC, and male BrCa. MATERIALS: and Methods: In 105,690 men (≥65â¯yrs) identified using the SEER-Medicare 2007-2015 data, we identified 82,578 White and 10,256 Black men. Pre-diagnostic prescription of statins and TTh was ascertained for this analysis and categorized into four groups (Neither users, statins alone, TTh alone and Dual users). Multivariable Time-varying Cox proportional hazards and Accelerated Failure Time (AFT) models were performed. RESULTS: We found inverse joint associations of statins and TTh with incident HRCs before (aHR: 0.39; 95â¯% CI: 0.35-0.44) and after 3 years of follow-up (aHR: 0.74; 95â¯% CI: 0.67-0.82). This included a lower risk for advanced stage HRC (only <3 years follow-up). Similar joint associations were identified with incident PCa, aggressive PCa, incident CRC, and its specific right- and left-sided CRC (only <3 years follow-up). In general, the inverse associations persisted among White (mainly <3 years follow-up) and Black men (high-grade HRC and <3 years follow-up). Findings from the AFT analysis were similar. DISCUSSION: Pre-diagnostic use of statins and TTh were, independently and jointly, associated with reduced risks of HRC and specific cancer sites at three years of follow-up overall, and among White and Black men. Greatest associations of HRCs risk reduction were observed among dual users (statins plus TTh). Further studies are needed to validate these findings, including larger samples of Black men, and male BrCa sites.
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Neoplasias de la Mama Masculina , Neoplasias Colorrectales , Terapia de Reemplazo de Hormonas , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Medicare , Neoplasias de la Próstata , Programa de VERF , Testosterona , Humanos , Masculino , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Anciano , Incidencia , Programa de VERF/estadística & datos numéricos , Estados Unidos/epidemiología , Estudios Retrospectivos , Neoplasias de la Próstata/epidemiología , Neoplasias de la Próstata/tratamiento farmacológico , Terapia de Reemplazo de Hormonas/estadística & datos numéricos , Terapia de Reemplazo de Hormonas/métodos , Medicare/estadística & datos numéricos , Neoplasias Colorrectales/epidemiología , Neoplasias de la Mama Masculina/epidemiología , Neoplasias de la Mama Masculina/tratamiento farmacológico , Anciano de 80 o más AñosRESUMEN
BACKGROUND: We aimed to identify combinations of long-term services and supports (LTSS) Veterans use, describe transitions between groups, and identify factors influencing transition. METHODS: We explored LTSS across a continuum from home to institutional care. Analyses included 104,837 Veterans Health Administration (VHA) patients 66 years and older at high-risk of long-term institutional care (LTIC). We conduct latent class and latent transition analyses using VHA and Medicare data from fiscal years 2014 to 2017. We used logistic regression to identify variables associated with transition. RESULTS: We identified 5 latent classes: (1) No Services (11% of sample in 2015); (2) Medicare Services (31%), characterized by using LTSS only in Medicare; (3) VHA-Medicare Care Continuum (19%), including LTSS use in various settings across VHA and Medicare; (4) Personal Care Services (21%), characterized by high probabilities of using VHA homemaker/home health aide or self-directed care; and (5) Home-Centered Interdisciplinary Care (18%), characterized by a high probability of using home-based primary care. Veterans frequently stayed in the same class over the three years (30% to 46% in each class). Having a hip fracture, self-care impairment, or severe ambulatory limitation increased the odds of leaving No Services, and incontinence and dementia increased the odds of entering VHA-Medicare Care Continuum. Results were similar when restricted to Veterans who survived during all 3 years of the study period. CONCLUSIONS: Veterans at high risk of LTIC use a combination of services from across the care continuum and a mix of VHA and Medicare services. Service patterns are relatively stable for 3 years.
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Cuidados a Largo Plazo , Medicare , United States Department of Veterans Affairs , Veteranos , Humanos , Anciano , Estados Unidos , Femenino , Masculino , Veteranos/estadística & datos numéricos , Cuidados a Largo Plazo/estadística & datos numéricos , Medicare/estadística & datos numéricos , Anciano de 80 o más Años , Continuidad de la Atención al Paciente/estadística & datos numéricos , Servicios de Atención de Salud a Domicilio/estadística & datos numéricosRESUMEN
Importance: A growing proportion of the population is enrolling in Medicare Advantage (MA), which typically offers additional benefits compared with traditional Medicare (TM). Objective: To determine whether frailty and frailty trajectories differ between MA enrollees and TM enrollees. Design, Setting, and Participants: This retrospective cohort study used data from the National Health and Aging Trends Study (2015-2016). Analyses were conducted from August 2023 to March 2024. Participants were community-dwelling Medicare beneficiaries aged 65 years and older. Exposure: Enrollment in MA vs TM. Main Outcomes and Measures: Frailty was calculated by a frailty index (FI) (range, 0-1, with higher values indicating greater frailty) and the Fried Frailty Phenotype (FFP) score (range, 0-5, with higher values indicating greater frailty). Physical performance, including Short Physical Performance Battery (SPPB) score (range, 0-12, with higher values indicating better performance), and gait speed (meters per second) were measured. The primary outcome was the difference in FI and FFP scores from the 2015 baseline assessment to the 2016 follow-up assessment. Secondary outcomes include the 1-year changes in SPPB and gait speed. Results: The final cohort consisted of 7063 participants (2775 [23.1%] aged >80 years; 4040 [54.7%] female), representing a sample of the 38.8 million beneficiaries. There were 2583 (35.0%) MA enrollees (13.6 million) and 4480 (65.0%) TM enrollees (25.2 million). At baseline, the FI score was similar between MA and TM enrollees (mean [SD], 0.22 [0.15] vs 0.21 [0.14]), although MA enrollees had worse phenotypic frailty (496 participants [15.2%] vs 811 participants [13.7%] considered frail by FFP score), SPPB scores (mean [SD], 6.91 [3.34] vs 7.21 [3.27]), and gait speed (0.79 [0.24] m/s vs 0.82 [0.23] m/s) than TM enrollees. One year later, there were no differences between MA and TM enrollees in the 1-year change in FI score (mean [SD], 0.016 [0.071] vs 0.014 [0.066]; adjusted mean difference, 0.001 [95% CI, -0.004 to 0.005]), FFP score (mean [SD], 0.017 [1.004] vs 0.007 [0.958]; adjusted mean difference, -0.009 [95% CI, -0.067 to 0.049]), SPPB score (mean [SD], -0.144 [2.064] vs -0.211 [1.968]; adjusted mean difference, 0.068 [95% CI, -0.076 to 0.212]), and gait speed (mean [SD], -0.0160 [0.148] m/s vs -0.007 [0.148] m/s; adjusted mean difference, -0.010 m/s [95% CI, -0.067 to 0.049 m/s]). Conclusions and Relevance: In this cohort study of Medicare beneficiaries from 2015, MA enrollees experienced similar declines in frailty over 1 year compared with TM enrollees. Future work should examine whether the specific types of services covered by health insurance can impact frailty and health trajectories for older adults.
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Anciano Frágil , Fragilidad , Medicare Part C , Medicare , Humanos , Estados Unidos , Femenino , Masculino , Anciano , Anciano de 80 o más Años , Estudios Retrospectivos , Fragilidad/epidemiología , Medicare Part C/estadística & datos numéricos , Medicare/estadística & datos numéricos , Anciano Frágil/estadística & datos numéricos , Evaluación Geriátrica/métodos , Evaluación Geriátrica/estadística & datos numéricos , Vida Independiente/estadística & datos numéricosRESUMEN
Importance: Cancer treatment delay is a recognized marker of worse outcomes. Timely treatment may be associated with physician patient-sharing network characteristics, yet this remains understudied. Objective: To examine the associations of surgeon and care team patient-sharing network measures with breast cancer treatment delay. Design, Setting, and Participants: This cross-sectional study of Medicare claims in a US population-based setting was conducted from 2017 to 2020. Eligible participants included patients with breast cancer who received surgery and the subset who went on to receive adjuvant therapy. Patient-sharing networks were constructed for treating physicians. Data were analyzed from September 2023 to February 2024. Exposures: Surgeon linchpin score (a measure of local uniqueness or scarcity) and care density (a measure of physician team familiarity) were assessed. Surgeons were considered linchpins if their linchpin score was in the top 15%. The care density of a patient's physician team was calculated on preoperative teams for surgically-treated patients and postoperative teams for adjuvant therapy-receiving patients. Main Outcomes and Measures: The primary outcomes were surgical and adjuvant delay, which were defined as greater than 60 days between biopsy and surgery and greater than 60 days between surgery and adjuvant therapy, respectively. Results: The study cohort included 56â¯433 patients (18â¯004 aged 70-74 years [31.9%]) who were mostly from urban areas (44â¯931 patients [79.6%]). Among these patients, 8009 (14.2%) experienced surgical delay. Linchpin surgeon status (locally unique surgeon) was not statistically associated with surgical delay; however, patients with high preoperative care density (ie, high team familiarity) had lower odds of surgical delay compared with those with low preoperative care density (odds ratio [OR], 0.58; 95% CI, 0.53-0.63). Of the 29â¯458 patients who received adjuvant therapy after surgery, 5700 (19.3%) experienced adjuvant delay. Patients with a linchpin surgeon had greater odds of adjuvant delay compared with those with a nonlinchpin surgeon (OR, 1.30; 95% CI, 1.13-1.49). Compared with those with low postoperative care density, there were lower odds of adjuvant delay for patients with high postoperative care density (OR, 0.77; 95% CI, 0.69-0.87) and medium postoperative care density (OR, 0.85; 95% CI, 0.77-0.94). Conclusions and Relevance: In this cross-sectional study of Medicare claims, network measures capturing physician scarcity and team familiarity were associated with timely treatment. These results may help guide system-level interventions to reduce cancer treatment delays.
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Neoplasias de la Mama , Medicare , Grupo de Atención al Paciente , Cirujanos , Tiempo de Tratamiento , Humanos , Neoplasias de la Mama/terapia , Femenino , Estudios Transversales , Anciano , Estados Unidos , Cirujanos/estadística & datos numéricos , Medicare/estadística & datos numéricos , Tiempo de Tratamiento/estadística & datos numéricos , Anciano de 80 o más AñosRESUMEN
Background: Alzheimer's disease and related dementias (ADRD) prevalence varies geographically in the United States. Objective: To assess whether the geographic variation of ADRD in Central Appalachia is explained by county-level sociodemographics or access to care. Methods: Centers for Medicare and Medicaid Services Public Use Files from 2015- 2018 were used to estimate county-level ADRD prevalence among all fee-for-service (FFS) beneficiaries with≥1 inpatient, skilled nursing facility, home health agency, hospital outpatient or Carrier claim with a valid ADRD ICD-9/10 code over three-years in Central Appalachia (Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia). Negative binomial regression was used to estimate prevalence overall, by Appalachian/non-Appalachian designation, and by rural/urban classification. Models were then adjusted for county-level: 1) FFS demographics (age, gender, and Medicaid eligibility), comorbidities; 2) population sociodemographics (race/ethnicity, education, aging population distribution, and renter-occupied housing); and 3) diagnostic access (PCP visits, neurology visits, and imaging scans). Results: Across the 591 counties in the Central Appalachian region, the average prevalence of ADRD from 2015- 2018 was 11.8%. ADRD prevalence was modestly higher for Appalachian counties both overall (PR: 1.03; 95% CI: 1.02, 1.04) and after adjustment (PR: 1.02; 95% CI: 1.00, 1.03) compared to non-Appalachian counties. This difference was similar among rural and urban counties (pâ=â0.326) but varied by state (pâ=â0.004). Conclusions: The relative variation in ADRD prevalence in the Appalachian region was smaller than hypothesized. The case mixture of the dual eligible population, accuracy of the outcome measurement, and impact of educational attainment in this region may contribute to this observation.
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Enfermedad de Alzheimer , Humanos , Femenino , Enfermedad de Alzheimer/epidemiología , Masculino , Prevalencia , Anciano , Región de los Apalaches/epidemiología , Anciano de 80 o más Años , Demencia/epidemiología , Estados Unidos/epidemiología , Población Rural/estadística & datos numéricos , Medicare/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricosRESUMEN
Importance: Despite advances in treatment and care quality for patients hospitalized with heart failure (HF), minimal improvement in mortality has been observed after HF hospitalization since 2010. Objective: To evaluate trends in mortality rates across specific intervals after hospitalization. Design, Setting, and Participants: This cohort study evaluated a random sample of Medicare fee-for-service beneficiaries with incident HF hospitalization from January 1, 2008, to December 31, 2018. Data were analyzed from February 2023 to May 2024. Main Outcomes and Measures: Unadjusted mortality rates were calculated by dividing the number of all-cause deaths by the number of patients with incident HF hospitalization for the following periods: in-hospital, 30 days (0-30 days after hospital discharge), short term (31 days to 1 year after discharge), intermediate term (1-2 years after discharge), and long term (2-3 years after discharge). Each period was considered separately (ie, patients who died during one period were not counted in subsequent periods). Annual unadjusted and risk-adjusted mortality ratios were calculated (using logistic regression to account for differences in patient characteristics), defined as observed mortality divided by expected mortality based on 2008 rates. Results: A total of 1â¯256â¯041 patients (mean [SD] age, 83.0 [7.6] years; 56.0% female; 86.0% White) were hospitalized with incident HF. There was a substantial decrease in the mortality ratio for the in-hospital period (unadjusted ratio, 0.77; 95% CI, 0.67-0.77; risk-adjusted ratio, 0.74; 95% CI, 0.71-0.76). For subsequent periods, mortality ratios increased through 2013 and then decreased through 2018, resulting in no reductions in unadjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.94; 95% CI, 0.82-1.06; short-term mortality ratio, 1.02; 95% CI, 0.87-1.17; intermediate-term mortality ratio, 0.99; 95% CI, 0.79-1.19; and long-term mortality ratio, 0.96; 95% CI, 0.76-1.16) and small reductions in risk-adjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.88; 95% CI, 0.86-0.90; short-term mortality ratio, 0.94; 95% CI, 0.94-0.95; intermediate-term mortality ratio, 0.94; 95% CI, 0.92-0.95; and long-term mortality ratio, 0.95; 95% CI, 0.93-0.96). Conclusions and Relevance: In this study of Medicare fee-for-service beneficiaries, there was a substantial decrease in in-hospital mortality for patients hospitalized with incident HF from 2008 to 2018, but little to no reduction in mortality for subsequent periods up to 3 years after hospitalization. These results suggest opportunities to improve longitudinal outpatient care for patients with HF after hospital discharge.
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Insuficiencia Cardíaca , Hospitalización , Medicare , Humanos , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Estados Unidos/epidemiología , Femenino , Masculino , Medicare/estadística & datos numéricos , Anciano , Hospitalización/estadística & datos numéricos , Hospitalización/tendencias , Anciano de 80 o más Años , Estudios de Cohortes , Mortalidad Hospitalaria/tendenciasAsunto(s)
Dermatología , Medicare , Población Rural , Humanos , Estados Unidos , Medicare/economía , Medicare/estadística & datos numéricos , Dermatología/economía , Dermatología/estadística & datos numéricos , Población Rural/estadística & datos numéricos , Población Urbana/estadística & datos numéricos , Disparidades en Atención de Salud/economía , Disparidades en Atención de Salud/estadística & datos numéricos , Atención Ambulatoria/economía , Atención Ambulatoria/estadística & datos numéricos , Anciano , Femenino , Masculino , Pacientes Ambulatorios/estadística & datos numéricos , Costos de la Atención en Salud/estadística & datos numéricos , Enfermedades de la Piel/economía , Enfermedades de la Piel/terapia , Enfermedades de la Piel/epidemiologíaRESUMEN
BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) introduced chronic care management (CCM) services in 2015 for patients with multiple chronic diseases. Few studies examine the utilization of CCM services by geographic region, sociodemographic, and clinical characteristics. METHODS: We used 2014-2019 Medicare claims data from a 5% random sample of fee-for-service beneficiaries aged 65 years or over. We included beneficiaries potentially eligible for CCM services because they had multiple chronic conditions (1,073,729 in 2015 and 1,130,523 in 2019). We calculated the proportion of potentially eligible beneficiaries receiving CCM service each year for the total population and by geographic region, sociodemographic, and clinical characteristics. RESULTS: The proportion of beneficiaries with two or more chronic conditions receiving CCM services increased from 1.1% in 2015 to 3.4% in 2019. The increase in CCM use was higher in the southern region, among dually eligible beneficiaries and beneficiaries with a greater burden of chronic conditions (2-5 conditions vs ≥10 conditions: 0.7% vs 2.0% in 2015; 2.1% vs 7.0% in 2019) and frailty (robust vs severely frail: 0.6% vs 3.3% in 2015; 1.9% vs 9.4% in 2019). Nearly one out of five recipients did not continue CCM service after the initial service. CONCLUSION: We found that CCM service is being used by a very small fraction of eligible patients. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit.