Primary Care Provider Cultural Competence and Racial Disparities in HIV Care and Outcomes

BACKGROUND

Health professional organizations have advocated for increasing the “cultural competence” (CC) of healthcare providers, to reduce racial and ethnic disparities in patient care. It is unclear whether provider CC is associated with more equitable care.

OBJECTIVE

To evaluate whether provider CC is associated with quality of care and outcomes for patients with HIV/AIDS.

DESIGN AND PARTICIPANTS

Survey of 45 providers and 437 patients at four urban HIV clinics in the U.S.

MAIN MEASURES

Providers’ self-rated CC was measured using a novel, 20-item instrument. Outcome measures included patients’ receipt of antiretroviral (ARV) therapy, self-efficacy in managing medication regimens, complete 3-day ARV adherence, and viral suppression.

KEY RESULTS

Providers’ mean age was 44 years; 56 % were women, and 64 % were white. Patients’ mean age was 45; 67 % were men, and 77 % were nonwhite. Minority patients whose providers scored in the middle or highest third on self-rated CC were more likely than those with providers in the lowest third to be on ARVs, have high self-efficacy, and report complete ARV adherence. Racial disparities were observed in receipt of ARVs (adjusted OR, 95 % CI for white vs. nonwhite: 6.21, 1.50–25.7), self-efficacy (3.77, 1.24–11.4), and viral suppression (13.0, 3.43–49.0) among patients of low CC providers, but not among patients of moderate and high CC providers (receipt of ARVs: 0.71, 0.32–1.61; self-efficacy: 1.14, 0.59–2.22; viral suppression: 1.20, 0.60–2.42).

CONCLUSIONS

Provider CC was associated with the quality and equity of HIV care. These findings suggest that enhancing provider CC may reduce racial disparities in healthcare quality and outcomes.     

Do Changes in Post-acute Care Use at Hospitals Participating in an Accountable Care Organization Spillover to All Medicare Beneficiaries?

Background

While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown.

Objective

The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare Shared Savings Program (MSSP).

Design

Observational study using a difference-in-differences design comparing changes in PAC utilization and spending among beneficiaries admitted to ACO-participating hospitals before and after the start of the ACO contracts, compared to those admitted to non-ACO hospitals.

Setting

A total of 233 hospitals participate in MSSP ACOs and 3103 non-ACO hospitals.

Participants

A national sample of 11,683,573 Medicare beneficiaries experiencing 26,503,086 hospital admissions from 2010 to 2013.

Exposure

Admission to a hospital participating in an MSSP ACO.

Main Measures

The probability of discharge and Medicare payments to inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and home health agencies (HHA).

Key Results

For beneficiaries admitted to hospitals that joined an ACO, the likelihood of being discharged to PAC did not change after the hospital joined the ACO compared with non-ACO hospitals over the same period (differential change in probability of discharge to any PAC was 0.000 (P?=?0.89), SNF was 0.000 (P?=?0.73), IRF was 0.000 (P?=?0.96), and HHA was 0.001 (P?=?0.57)). Payments reduced significantly for PAC overall (??$130.41, P?=?0.03), but not for any individual PAC type alone. These results were consistent in samples that were conditional on discharge to any PAC, across conditions with high PAC use nationally, and among ACO-participating hospitals that also had a PAC participant.

Conclusions

Hospital participation in an ACO did not result in spillovers in PAC utilization or payments to all beneficiaries, even when considering high PAC-use conditions and ACO hospitals that also have an ACO-participating PAC.

     

A Systematic Review of the Extent and Measurement of Healthcare Provider Racism

BACKGROUND

Although considered a key driver of racial disparities in healthcare, relatively little is known about the extent of interpersonal racism perpetrated by healthcare providers, nor is there a good understanding of how best to measure such racism.

OBJECTIVES

This paper reviews worldwide evidence (from 1995 onwards) for racism among healthcare providers; as well as comparing existing measurement approaches to emerging best practice, it focuses on the assessment of interpersonal racism, rather than internalized or systemic/institutional racism.

METHODS

The following databases and electronic journal collections were searched for articles published between 1995 and 2012: Medline, CINAHL, PsycInfo, Sociological Abstracts. Included studies were published empirical studies of any design measuring and/or reporting on healthcare provider racism in the English language. Data on study design and objectives; method of measurement, constructs measured, type of tool; study population and healthcare setting; country and language of study; and study outcomes were extracted from each study.

RESULTS

The 37 studies included in this review were almost solely conducted in the U.S. and with physicians. Statistically significant evidence of racist beliefs, emotions or practices among healthcare providers in relation to minority groups was evident in 26 of these studies. Although a number of measurement approaches were utilized, a limited range of constructs was assessed.

CONCLUSION

Despite burgeoning interest in racism as a contributor to racial disparities in healthcare, we still know little about the extent of healthcare provider racism or how best to measure it. Studies using more sophisticated approaches to assess healthcare provider racism are required to inform interventions aimed at reducing racial disparities in health.     

Variation in the Risk of Readmission Among Hospitals: The Relative Contribution of Patient,Hospital and Inpatient Provider Characteristics

BACKGROUND

The risk of readmission varies among hospitals. This variation has led the Centers of Medicare and Medicaid services to reduce payments to hospitals with excess readmissions. The contribution of patient characteristics, hospital characteristics and provider type to the variation in risk of readmission among hospitals has not been determined.

OBJECTIVE

To describe the variation in risk of readmission among hospitals and partition it by patient characteristics, hospital characteristics and provider type.

DESIGN

Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models.

SUBJECTS

A total of 514,064 admissions of Medicare beneficiaries to 272 hospitals in Texas for medical diagnoses during the years 2008 and 2009.

MAIN MEASURES

Using hierarchical generalized linear models, we describe the hospital-specific variation in risk of readmission that is attributable to patients characteristics, hospital characteristics and provider type by measuring the variance and intraclass correlation coefficients.

KEY RESULTS

Of the total variation in risk of readmission, only a small amount (0.84 %) is attributed to hospitals. In further analyses modeling the components of this variation among hospitals, differences in patient characteristics in the hospitals explained 56.2 % of the variation. Hospital characteristics and the type of provider explained 9.3 % of the variation among hospitals and 0.08 % of the total variation in risk of readmission.

CONCLUSIONS

Patient characteristics are the largest contributor to variation in risk of readmission among hospitals. Measurable hospital characteristics and the type of inpatient provider contribute little to variation in risk of readmission among hospitals.     

Higher Practice Intensity Is Associated with Higher Quality of Care but More Avoidable Admissions for Medicare Beneficiaries

BACKGROUND

The relationship between practice intensity and the quality and outcomes of care has not been studied.

OBJECTIVE

To examine the relationship between primary care physicians’ costliness both for defined episodes of care and for defined patients and the quality and outcomes of care delivered to Medicare beneficiaries.

STUDY DESIGN

Cross sectional analysis of physician survey data linked to Medicare claims. Physician costliness measures were calculated by comparing the episode specific and overall costs of care for their patients with the care delivered by other physicians.

PARTICIPANTS

We studied physicians participating in the 2004–2005 Community Tracking Study Physician Survey linked with administrative claims from the Medicare program for the years 2004–2006.

MAIN MEASURES

Proportion of eligible beneficiaries receiving each of seven preventive services and rates of preventable admissions for acute and chronic conditions.

KEY RESULTS

The 2,211 primary care physician respondents included 937 internists and 1,274 family or general physicians who were linked to more than 250,000 Medicare enrollees. Patients treated by more costly physicians (whether measured by the overall costliness index or the episode-level index) were more likely to receive recommended preventive services, but were also more likely to experience preventable admissions. For instance, physicians in the lowest quartile of costliness performed appropriate monitoring for hemoglobin A1C for diabetics 72.8 % of the time, as compared with 81.9 % for physicians in the highest quartile of costliness (p?<?0.01). In contrast, patients treated by the physicians in the lowest quartile of episode costliness were admitted at a rate of 1.8/100 for both acute and chronic Prevention Quality Indicators (PQIs), as compared with 2.9/100 for both acute and chronic PQIs for those treated by physicians in the highest quartile of costliness (p?<?0.001).

CONCLUSIONS

Physician practice patterns are associated with the quality of preventive services delivered to Medicare patients. Ongoing efforts to influence physician practice patterns may have differential effects on different aspects of quality.     

Early Hospital Readmission is a Predictor of One-Year Mortality in Community-Dwelling Older Medicare Beneficiaries

BACKGROUND

Hospital readmission within thirty days is common among Medicare beneficiaries, but the relationship between rehospitalization and subsequent mortality in older adults is not known.

OBJECTIVE

To compare one-year mortality rates among community-dwelling elderly hospitalized Medicare beneficiaries who did and did not experience early hospital readmission (within 30?days), and to estimate the odds of one-year mortality associated with early hospital readmission and with other patient characteristics.

DESIGN AND PARTICIPANTS

A cohort study of 2133 hospitalized community-dwelling Medicare beneficiaries older than 64?years, who participated in the nationally representative Cost and Use Medicare Current Beneficiary Survey between 2001 and 2004, with follow-up through 2006.

MAIN MEASURE

One-year mortality after index hospitalization discharge.

KEY RESULTS

Three hundred and four (13.7?%) hospitalized beneficiaries had an early hospital readmission. Those with early readmission had higher one-year mortality (38.7?%) than patients who were not readmitted (12.1?%; p?<?0.001). Early readmission remained independently associated with mortality after adjustment for sociodemographic factors, health and functional status, medical comorbidity, and index hospitalization-related characteristics [HR (95?% CI) 2.97 (2.24-3.92)]. Other patient characteristics independently associated with mortality included age [1.03 (1.02-1.05) per year], low income [1.39 (1.04-1.86)], limited self-rated health [1.60 (1.20-2.14)], two or more recent hospitalizations [1.47 (1.01-2.15)], mobility difficulty [1.51 (1.03-2.20)], being underweight [1.62 (1.14-2.31)], and several comorbid conditions, including chronic lung disease, cancer, renal failure, and weight loss. Hospitalization-related factors independently associated with mortality included longer length of stay, discharge to a skilled nursing facility for post-acute care, and primary diagnoses of infections, cancer, acute myocardial infarction, and heart failure.

CONCLUSIONS

Among community-dwelling older adults, early hospital readmission is a marker for notably increased risk of one-year mortality. Providers, patients, and families all might respond profitably to an early readmission by reviewing treatment plans and goals of care.     

Potential Savings Associated with Drug Substitution in Medicare Part D: The Translating Research into Action for Diabetes (TRIAD) Study

BACKGROUND

Drug substitution is a promising approach to reducing medication costs.

OBJECTIVE

To calculate the potential savings in a Medicare Part D plan from generic or therapeutic substitution for commonly prescribed drugs.

DESIGN

Cross-sectional, simulation analysis.

PARTICIPANTS

Low-income subsidy (LIS) beneficiaries (n?=?145,056) and non low-income subsidy (non-LIS) beneficiaries (n?=?1,040,030) enrolled in a large, national Part D health insurer in 2007 and eligible for a possible substitution.

MEASUREMENTS

Using administrative data from 2007, we identified claims filled for brand-name drugs for which a direct generic substitute was available. We also identified the 50 highest cost drugs separately for LIS and non-LIS beneficiaries, and reached consensus on which drugs had possible therapeutic substitutes (27 for LIS, 30 for non-LIS). For each possible substitution, we used average daily costs of the original and substitute drugs to calculate the potential out-of-pocket savings, health plan savings, and when applicable, savings for the government/LIS subsidy.

RESULTS

Overall, 39 % of LIS beneficiaries and 51 % of non-LIS beneficiaries were eligible for a generic and/or therapeutic substitution. Generic substitutions resulted in an average annual savings of $160 in the case of LIS beneficiaries and $127 in the case of non-LIS beneficiaries. Therapeutic substitutions resulted in an average annual savings of $452 in the case of LIS beneficiaries and $389 in the case of non-LIS beneficiaries.

CONCLUSIONS

Our findings indicate that drug substitution, particularly therapeutic substitution, could result in significant cost savings. There is a need for additional studies evaluating the acceptability of therapeutic substitution interventions within Medicare Part D.     

Association Between Quality of Care and the Sociodemographic Composition of Physicians�� Patient Panels: A Repeat Cross-Sectional Analysis

BACKGROUND

Pay-for-performance programs could worsen health disparities if providers who care for disadvantaged patients face systematic barriers to providing high-quality care. Risk adjustment that includes sociodemographic factors could mitigate the financial incentive to avoid disadvantaged patients.

OBJECTIVE

To test for associations between quality of care and the composition of a physician??s patient panel.

DESIGN

Repeat cross-sectional analysis

PARTICIPANTS

Nationally representative sample of US primary care physicians responding to a panel telephone survey in 2000?C2001 and 2004?C2005

MAIN MEASURES

Quality of primary care as measured by provision of eight recommended preventive services (diabetic monitoring [hemoglobin A1c testing, eye examinations, cholesterol testing and urine protein analysis], cancer screening [screening colonoscopy/sigmoidoscopy and mammography], and vaccinations against influenza and pneumococcus) documented in Medicare claims data and the association between quality and the sociodemographic composition of physicians?? patient panels.

KEY RESULTS

Across eight quality measures, physicians?? quality of care was not consistently associated with the composition of their patient panel either in a single year or between time periods. For example, a substantial number (seven) of the eighteen significant associations seen between sociodemographic characteristics and the delivery of preventive services in the first time period were no longer seen in the second time period. Among sociodemographic characteristics, panel Medicaid eligibility was most consistently associated with differences in the delivery of preventive services between time points; among preventive services, the delivery of influenza vaccine was most likely to demonstrate disparities in both time points.

CONCLUSIONS

In a Medicare pay-for-performance program, a better understanding of the effect of effect of patient panel composition on physicians?? quality of care may be necessary before implementing routine statistical adjustment, since the association of quality and sociodemographic composition is small and inconsistent. In addition, we observed improvements between time periods among physicians with varying panel composition.     

Depression and Risk of Hospitalizations for Ambulatory Care-Sensitive Conditions in Patients with Diabetes

BACKGROUND

Hospitalizations for ambulatory care-sensitive conditions (ACSCs), conditions that should not require inpatient treatment if timely and appropriate ambulatory care is provided, may be an important contributor to rising healthcare costs and public health burden.

OBJECTIVE

To examine if probable major depression is independently associated with hospitalization for an ACSC in patients with diabetes.

DESIGN

Secondary analysis of data from a prospective cohort study.

PARTICIPANTS

Population-based cohort of 4,128 patients with diabetes ≥ 18 years old seen in primary care, who were enrolled between 2000 and 2002 and followed for 5 years (through 2007).

MAIN MEASURES

Depressive symptoms were assessed with the Patient Health Questionnaire-9. Outcomes of interest included time to initial hospitalization for an ACSC and total number of ACSC-related hospitalizations. We used Cox proportional hazards regression models to ascertain an association between probable major depression and time to ACSC-related hospitalization, as well as Poisson regression for models examining probable major depression and number of ACSC-related hospitalizations.

KEY RESULTS

Patients’ mean age at study enrollment was 63.4 years (Standard Deviation: 13.4 years). Over the 5-year follow-up period, 981 patients in the study were hospitalized a total of 1,721 times for an ACSC, comprising 45.1 % of all hospitalizations. After adjusting for baseline demographic, clinical and health-risk behavioral factors, probable major depression was associated with initial ACSC-related hospitalization (Hazard Ratio: 1.41, 95 % Confidence Interval [95 % CI]: 1.15, 1.72) and number of ACSC-related hospitalizations (Relative Risk: 1.37, 95 % CI: 1.12, 1.68).

CONCLUSIONS

Probable major depression in patients with diabetes is independently associated with hospitalization for an ACSC. Additional research is warranted to ascertain if effective interventions for depression in patients with diabetes could reduce the risk of hospitalizations for ACSCs and their associated adverse outcomes.     

Predictors of CT Colonography Utilization Among Asymptomatic Medicare Beneficiaries

BACKGROUND

Although the Centers for Medicare and Medicaid Services (CMS) denied coverage for screening computed tomography colonography (CTC) in March 2009, little is understood about whether CTC was targeted to the appropriate patient population prior to this decision.

OBJECTIVE

Evaluate patient characteristics and known relative clinical indications for screening CTC among patients who received CTC compared to optical colonoscopy (OC).

DESIGN/PARTICIPANTS

Cross-sectional study of all 10,538 asymptomatic Medicare beneficiaries who underwent CTC between January 2007 and December 2008, compared to a cohort of 160,113 asymptomatic beneficiaries who underwent OC, matched on county of residence and year of examination.

MAIN MEASURES

Patient characteristics and known relative appropriate and inappropriate clinical indications for screening CTC.

KEY RESULTS

CTC utilization was higher among women, patients > 65 years of age, white patients, and those with household income > 75 % (p?=?0.001). Patients with relatively appropriate clinical indications for screening CTC were more likely to undergo CTC than OC including presumed incomplete OC (OR 80.7, 95 % CI 76.01–85.63); sedation risk (OR 1.11, 95 % CI 1.05–1.17); and chronic anticoagulation risk (OR 1.46, 95 % CI 1.38–1.54), after adjusting for patient characteristics and known clinical indications. Conversely, patients undergoing high-risk screening, an inappropriate indication, were less likely to receive CTC (OR 0.4, 95 % CI 0.37–0.42). Overall, 83 % of asymptomatic patients referred to CTC had at least one clinical indication relatively appropriate for CTC (8,772/10,538).

CONCLUSION

During the 2 years preceding CMS denial for screening, CTC was targeted to asymptomatic patients with relatively appropriate clinical indications for CTC/not receiving OC. However, CTC utilization was lower among certain demographic groups, including minority patients. These findings raise the possibility that future coverage of screening CTC might exacerbate disparities in colorectal cancer screening while increasing overall screening rates.     

Reducing Racial/Ethnic Disparities in Diabetes: The Coached Care (R2D2C2) Project

BACKGROUND

Despite numerous efforts to change healthcare delivery, the profile of disparities in diabetes care and outcomes has not changed substantially over the past decade.

OBJECTIVE

To understand potential contributors to disparities in diabetes care and glycemic control.

DESIGN

Cross sectional analysis.

SSETTING

Seven outpatient clinics affiliated with an academic medical center.

PATIENTS

Adult patients with type 2 diabetes who were Mexican American, Vietnamese American or non-Hispanic white (n?=?1,484).

MEASUREMENTS

Glycemic control was measured as hemoglobin A1c (HbA1c) level. Patient, provider and system characteristics included demographic characteristics; access to care; quality of process of care including clinical inertia; quality of interpersonal care; illness burden; mastery (diabetes management confidence, passivity); and adherence to treatment.

RESULTS

Unadjusted HbA1c values were significantly higher for Mexican American patients (n?=?782) (mean?=?8.3 % [SD:2.1]) compared with non-Hispanic whites (n?=?389) (mean?=?7.1 % [SD:1.4]). There were no significant differences in HbA1c values between Vietnamese American and non-Hispanic white patients. There were no statistically significant group differences in glycemic control after adjustment for multiple measures of access, and quality of process and interpersonal care. Disease management mastery and adherence to treatment were related to glycemic control for all patients, independent of race/ethnicity.

LIMITATIONS

Generalizability to other minorities or to patients with poorer access to care may be limited.

CONCLUSIONS

The complex interplay among patient, physician and system characteristics contributed to disparities in HbA1c between Mexican American and non-Hispanic white patients. In contrast, Vietnamese American patients achieved HbA1c levels comparable to non-Hispanic whites and adjustment for numerous characteristics failed to identify confounders that could have masked disparities in this subgroup. Disease management mastery appeared to be an important contributor to glycemic control for all patient subgroups.     

Provider Visit Frequency and Vascular Access Interventions in Hemodialysis

Background and objectives

Medicare reimbursement policy encourages frequent provider visits to patients with ESRD undergoing hemodialysis. This study sought to determine whether more frequent face-to-face provider (physician and advanced practitioner) visits lead to more procedures and therapeutic interventions aimed at preserving arteriovenous fistulas and grafts, improved vascular access outcomes, and fewer related hospitalizations.

Design, setting, participants, & measurements

Multivariable regression was used to evaluate the association between provider (physician and advanced practitioner) visit frequency and interventions aimed at preserving vascular access, vascular access survival, hospitalization for vascular access infection, and outpatient antibiotic use in a cohort of 63,488 Medicare beneficiaries receiving hemodialysis in the United States. Medicare claims were used to identify the type of vascular access used, access-related events, and vascular access failure.

Results

One additional provider (physician and advanced practitioner) visit per month was associated with a 13% higher odds of receiving an intervention to preserve vascular access (95% confidence interval [95% CI], 12% to 14%) but was not associated with vascular access survival (hazard ratio, 1.01; 95% CI, 0.99 to 1.03). One additional provider visit was associated with a 9% (95% CI, 5% to 14%) lower odds of hospitalization for vascular access infection and a corresponding 9% (95% CI, 5% to 14%) higher odds of outpatient intravenous antibiotic administration. However, the associated changes in absolute probabilities of hospitalization and antibiotic administration were small.

Conclusions

More frequent face-to-face provider (physician and advanced practitioner) visits were associated with more procedures and therapeutic interventions aimed at preserving vascular accesses, but not with prolonged vascular access survival and only a small decrease in hospitalization for vascular access.     

Abdominal Aortic Aneurysm Screening: How Many Life Years Lost from Underuse of the Medicare Screening Benefit?

BACKGROUND

Since 2007, Medicare has provided one-time abdominal aortic aneurysm (AAA) screening for men with smoking history, and men and women with a family history of AAA as part of its Welcome to Medicare visit.

OBJECTIVE

We examined utilization of the new AAA screening benefit and estimated how increased utilization could influence population health as measured by life years gained. Additionally, we explored the impact of expanding screening to women with smoking history.

DESIGN

Analysis of Medicare claims and a simulation model to estimate the effects of screening, using published data for parameter estimates.

SETTING

AAA screening in the primary care setting.

PATIENTS

Newly-enrolled Medicare beneficiaries aged 65 years, with smoking history or family history of AAA.

MAIN MEASURES

Life expectancy, 10-year survival rates.

KEY RESULTS

Medicare data revealed low utilization of AAA screening, under 1 % among those eligible. We estimate that screening could increase life expectancy per individual invited to screening for men with smoking history (0.11 years), with family history of AAA (0.17 years), and women with family history (0.08 years), and smoking history (0.09 years). Average gains of 131 life years per 1,000 persons screened for AAA compare favorably with the grade B United States Preventive Services Task Force (USPSTF) recommendation for breast cancer screening, which yields 95–128 life years per 1,000 women screened. These findings were robust over a range of scenarios.

LIMITATIONS

The simulation results reflect assumptions regarding AAA prevalence, treatment, and outcomes in specific populations based on published research and US survey data. Published data on women were limited.

CONCLUSIONS

The Welcome to Medicare and AAA screening benefits have been underutilized. Increasing utilization of AAA screening would yield substantial gains in life expectancy. Expanding screening to women with smoking history also has the potential for substantial health benefits.     

Use of Chronic Care Management Codes for Medicare Beneficiaries: a Missed Opportunity?

Background

Physicians spend significant time outside of regular office visits caring for complex patients, and this work is often uncompensated. In 2015, the Centers for Medicare & Medicaid Services (CMS) introduced a billing code for care coordination between office visits for beneficiaries with multiple chronic conditions.

Objective

Characterize use of the Chronic Care Management (CCM) code in New England in 2015.

Design

Retrospective observational analysis.

Participants

All Medicare fee-for-service beneficiaries in New England continuously enrolled in Parts A and B in 2015.

Intervention

None.

Main measures

The primary outcome was the number of beneficiaries with a CCM claim per 1000 eligible beneficiaries. Secondary outcomes included the total number of CCM claims, total reimbursement, mean number of claims per beneficiary, and beneficiary characteristics independently associated with receiving CCM services.

Key results

Of the more than two million Medicare fee-for-service beneficiaries in New England, almost 1.7 million were potentially eligible for CCM services. Among eligible beneficiaries, 10,951 (0.65%) had a CCM claim in 2015. Massachusetts had the highest penetration of CCM use (9.40 claims per 1000 eligible beneficiaries); Vermont had the lowest (0.54 claims per 1000 eligible beneficiaries). Mean reimbursement per physician was $1745.98. Age, race/ethnicity, dual-eligible status, income, number of chronic conditions, and state of residence were associated with receiving CCM services in an adjusted model.

Conclusions

The CCM code is likely underutilized in New England; the program may therefore not be achieving its intended goal of encouraging consistent, team-based chronic care management for Medicare’s most complex beneficiaries. Or practices may be foregoing reimbursement for care coordination that they are already providing. Recently implemented revisions may improve uptake of CCM services; it will be important to compare our results with future utilization.

     

Association of Living Alone and Hospitalization Among Community-Dwelling Elders With and Without Dementia

BACKGROUND

Older persons account for the majority of hospitalizations in the United States.1 Identifying risk factors for hospitalization among elders, especially potentially preventable hospitalization, may suggest opportunities to improve primary care. Certain factors—for example, living alone—may increase the risk for hospitalization, and their effect may be greater among persons with dementia and the old-old (aged 85+).

OBJECTIVES

To determine the association of living alone and risk for hospitalization, and see if the observed effect is greater among persons with dementia or the old-old.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

2,636 participants in the Adult Changes in Thought (ACT) study, a longitudinal cohort study of dementia incidence. Participants were adults aged 65+ enrolled in an integrated health care system who completed biennial follow-up visits to assess for dementia and living situation.

MAIN MEASURES

Hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs) were identified using automated data.

KEY RESULTS

At baseline, the mean age of participants was 75.5 years, 59 % were female and 36 % lived alone. Follow-up time averaged 8.4 years (SD 3.5), yielding 10,431 approximately 2-year periods for analysis. Living alone was positively associated with being aged 85+, female, and having lower reported social support and better physical function, and negatively associated with having dementia. In a regression model adjusted for age, sex, comorbidity burden, physical function and length of follow-up, living alone was not associated with all-cause (OR?=?0.93; 95 % CI 0.84, 1.03) or ambulatory care sensitive condition (ACSC) hospitalization (OR?=?0.88; 95 % CI 0.73, 1.07). Among participants aged 85+, living alone was associated with a lower risk for all-cause (OR?=?0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. Dementia did not modify any observed associations.

CONCLUSION

Living alone in later life did not increase hospitalization risk, and in this population may be a marker of healthy aging in the old-old.     

Disparities in 30-day readmission rates among Medicare enrollees with dementia

Background

Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses.

Methods

This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds.

Results

Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35–1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31–1.34), social factors (OR 1.25, CI 1.23–1.27), hospital characteristics (OR 1.24, CI 1.23–1.26), stay-level factors (OR 1.22, CI 1.21–1.24), demographics (OR 1.21, CI 1.19–1.23), and comorbidities (OR 1.16, CI 1.14–1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts.

Conclusions

There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations.     

Quality of care in for-profit and not-for-profit health plans enrolling Medicare beneficiaries

Background

For-profit health plans now enroll the majority of Medicare beneficiaries who select managed care. Prior research has produced conflicting results about whether for-profit health plans provide lower quality of care.

Objective

The objective was to compare the quality of care delivered by for-profit and not-for-profit health plans using Medicare Health Plan Employer Data and Information Set (HEDIS) clinical measures.

Research design

This was an observational study comparing HEDIS scores in for-profit and not-for-profit health plans that enrolled Medicare beneficiaries in the United States during 1997.

Outcome measures

Outcome measures included health plan quality scores on each of 4 clinical services assessed by HEDIS: breast cancer screening, diabetic eye examination, beta-blocker medication after myocardial infarction, and follow-up after hospitalization for mental illness.

Results

The quality of care was lower in for-profit health plans than not-for-profit health plans on all 4 of the HEDIS measures we studied (67.5% vs 74.8% for breast cancer screening, 43.7% vs 57.7% for diabetic eye examination, 63.1% vs 75.2% for beta-blocker medication after myocardial infarction, and 42.1% vs 60.4% for follow-up after hospitalization for mental illness). Adjustment for sociodemographic case-mix and health plan characteristics reduced but did not eliminate the differences, which remained statistically significant for 3 of the 4 measures (not beta-blocker medication after myocardial infarction). Different geographic locations of for-profit and not-for-profit health plans did not explain these differences.

Conclusion

By using standardized performance measures applied in a mandatory measurement program, we found that for-profit health plans provide lower quality of care than not-for-profit health plans. Special efforts to monitor and improve the quality of for-profit health plans may be warranted.     

Dual Medicare and Veteran Health Administration Use and Ambulatory Care Sensitive Hospitalizations

OBJECTIVE

The objective of the study is to examine the association between ambulatory care sensitive hospitalizations (ACSH) and dual Medicare/Veteran Health Administration use.

PARTICIPANTS

A nationally representative sample of Medicare beneficiaries, who participated in the Medicare Current Beneficiary Survey (MCBS).

DESIGN/MEASUREMENTS

Cross-sectional analyses (

RESULTS

Among inpatient users, 10.1% had ACSH events for acute conditions and 15.8% for chronic conditions. Among all survey respondents, 5% had any ACSH event. Among predominant-VHA users the rate was 4.9% and among veterans with some VHA use it was 3.7%. In bivariate and multivariate analyses, dual Medicare/VHA use was not significantly associated with any ACSH.

CONCLUSION

In a representative sample of Medicare beneficiaries, despite low income and health status, veterans with dual Medicare/VHA use were as likely as veterans without dual use to have any ACSH, perhaps due to expanded healthcare access and emphasis on primary care in the VHA system.