Geographic variation of epilepsy for older Americans: How close to the geographic variation of stroke?

Purpose: Given the strong association of stroke and epilepsy in older persons, and the existence of a Stroke Belt in the United States, we hypothesized that geographic variation in epilepsy prevalence would follow geographic patterns similar to stroke. Methods: We used a 2005 5% random sample of Medicare beneficiaries 65 and older in 48 U.S. contiguous states. Epilepsy was identified from claims for physician visits, hospitalizations, and outpatient procedures. Prevalence was obtained by state and county. Logistic regressions determined the independent association of the likelihood of epilepsy (prevalent or new case) and residence in Stroke Belt states, controlling for residence in highest epilepsy prevalence states, demographics (race, age, gender), comorbid conditions, cerebrovascular disease, dementia, and county characteristics. Key Findings: Of 1,212,015 beneficiaries, 11.9 per 1,000 had prevalent and 2.9 new cases of epilepsy. Nine of 11 Stroke Belt states were among the 20 states with the highest epilepsy prevalence. Counties in the 10 highest epilepsy prevalence states were more likely to be large urban counties with a higher number of neurologists or neurosurgeons per capita. The higher likelihood of prevalent epilepsy cases associated with Stroke Belt residence was explained by beneficiaries’ race; that associated with residence in high epilepsy prevalence states was not. The likelihood of new epilepsy cases was negatively associated with Stroke Belt residence when controlling for covariates. Significance: The geographic variation in epilepsy prevalence is not explained by variations in known risk factors. Further research should investigate why eastern U.S. states have higher frequency of epilepsy.     

Issues with implementing a high‐quality lung cancer screening program

Answer questions and earn CME/CNE After a comprehensive review of the evidence, the United States Preventive Services Task Force recently endorsed screening with low‐dose computed tomography as an early detection approach that has the potential to significantly reduce deaths due to lung cancer. Prudent implementation of lung cancer screening as a high‐quality preventive health service is a complex challenge. The clinical evaluation and management of high‐risk cohorts in the absence of symptoms mandates an approach that differs significantly from that of symptom‐detected lung cancer. As with other cancer screenings, it is essential to provide to informed at‐risk individuals a safe, high‐quality, cost‐effective, and accessible service. In this review, the components of a successful screening program are discussed as we begin to disseminate lung cancer screening as a national resource to improve outcomes with this lethal cancer. This information about lung cancer screening will assist clinicians with communications about the potential benefits and harms of this service for high‐risk individuals considering participation in the screening process. CA Cancer J Clin 2014;64:351–363. © 2014 American Cancer Society.     

Volume and Coverage of Secondary Imaging Interpretation Under Medicare, 2003 to 2016

PurposeThe aim of this study was to assess changing Medicare volumes of, and coverage for, secondary interpretations of diagnostic imaging examinations stratified by modality and body region service families.MethodsMedicare Physician/Supplier Procedure Summary Master Files for 2003 to 2016 were obtained. Aggregate Part B fee-for-service claims frequency and payment data were isolated for noninvasive diagnostic imaging and stratified by service family. Using published Medicare payment rules, secondary interpretations were identified as studies billed using both modifiers 26 and 77. Billed and denied services volumes were calculated and compared across modality and body region service families.ResultsSeven service families showed a compound annual growth rate from 2003 to 2016 of >20% (an additional 12 service families, >10% growth). For select high-volume service families (chest radiography and fluoroscopy [R&F], brain MRI, and abdominal and pelvic CT), relative growth in billed secondary interpretation services exceeded that for primary interpretations. In 2016, body region and modality service families with the most billed secondary interpretations were chest R&F (674,124), abdominal and pelvic R&F (65,566), brain CT (45,642), extremity R&F (34,560), abdominal and pelvic CT (14,269), and chest CT (10,914). All service families had secondary interpretation denial rates <25% in 2016 (15 service families, <10%).ConclusionsAmong Medicare beneficiaries, the frequency of billed secondary interpretation services for diagnostic imaging services increased from 2003 to 2016 across a broad range of modalities and body regions, often dramatically. Payment denial rates were consistently low across service families. As CMS continues to seek input on appropriate coverage for these services, these findings suggest increasing clinical demand for and payer acceptance of these value-added radiologist services.     

Is 30-Day Mortality after Admission for Heart Failure an Appropriate Metric for Quality?

Background

The Centers for Medicare and Medicaid Services (CMS) model for publicly reporting national 30-day-risk-adjusted mortality rates for patients admitted with heart failure fails to include clinical variables known to impact total mortality or take into consideration the culture of end-of-life care. We sought to determine if those variables were related to the 30-day mortality of heart failure patients at Geisinger Medical Center.

Annual Medicare Wellness Visit: Advanced Nurse Practitioner Perceptions and Practices

Advanced Practice Nurses (APNs) can contribute to health prevention efforts with older adults by utilizing a health risk appraisal (HRA) during the Medicare Annual Wellness Visit. This study examined APN perceptions and practices concerning use of HRAs during Annual Wellness Visits (N = 51). Results indicate that respondents agree it is important to collaboratively identify risks and develop a personalized prevention plan, but only a small percentage (7.8%) use HRA data to do so. Reported concerns include reimbursement and time; further work on how to best integrate HRAs into APN practice to enhance prevention efforts with older adults is critical.     

Effect of Medicare Dialysis Payment Reform on Use of Erythropoiesis Stimulating Agents

ObjectiveIn 2011, the Centers for Medicare and Medicaid Services (CMS) replaced fee-for-service reimbursement for erythropoiesis stimulating agents (ESAs) with a fixed-sum bundled payment for all dialysis-related care and pay-for-performance incentives to discourage maintaining patients'' hematocrits above 36 percent. We examined the impact of the new payment policy on the use of ESAs.ConclusionsCMS''s payment reform for dialysis care reduced the use of ESAs in patients who may not benefit from these agents.     

Medicare's use of cost-effectiveness analysis for prevention (but not for treatment)

ContextMedicare currently pays for 23 preventive services in its benefits package, the majority of which were added since 2005. In the past decade, the program has transformed from one essentially administering treatment claims, to one increasingly focused on health promotion and maintenance. What is largely unappreciated is the role cost-effectiveness analysis has played in the coverage of preventive services.MethodsWe review the role of cost-effectiveness analysis in Medicare coverage of preventive services and contrast it to the lack of such consideration in the coverage of treatments.FindingsWhile not considered for coverage of treatment, cost-effectiveness analysis played a role in the coverage of nine preventive services, and was evaluated in a number of instances when the service was not added. Pneumococcal vaccine, the first preventive service added to the benefit (1981), followed a Congressionally requested cost-effectiveness analysis, which showed it to be cost-saving. More recently, the Centers for Medicare and Medicaid Services (CMS) reviewed cost-effectiveness evidence when covering preventive services such as HIV screening (2010) and screening and behavioral counseling for alcohol misuse (2011) (studies reported cost-effectiveness ratios of $55,440 per QALY, and $1755 per QALY, respectively).ConclusionsCost-effectiveness analysis has played a longstanding role in informing the addition of preventive services to Medicare. It offers Medicare officials information they can use to help ensure health gains are achieved at reasonable cost. However, limiting cost-effectiveness evidence to prevention and not treatment is inconsistent and potentially inefficient.     

Limited Osteoporosis Screening Effectiveness Due to Low Treatment Rates in a National Sample of Older Men

Objective

To determine the association between dual-energy x-ray absorptiometry (DXA) testing for osteoporosis and subsequent fractures in US male veterans without a previous fracture.