scholarly journals Retrospective analysis of characteristics associated with higher-value radiotherapy episodes of care for bone metastases in Medicare fee-for-service beneficiaries

BMJ Open ◽  
2021 ◽  
Vol 11 (10) ◽  
pp. e049009
Author(s):  
Deborah Marshall ◽  
Melissa D Aldridge ◽  
Kavita Dharmarajan
Keyword(s):  
Bone Metastases ◽  
Radiation Treatment ◽  
Care Delivery ◽  
Intensity Modulated Radiation Therapy ◽  
Patient Characteristics ◽  
Treatment Setting ◽  
Fee For Service ◽  
Free Standing ◽  
Hospital Outpatient ◽  
Treatment Type

ObjectivesThe Centers for Medicare & Medicaid Services’ newly enacted Radiation Oncology Model (‘RO Model’) was designed to test the cost-saving potential of prospective episode-based payments for radiation treatment for 17 cancer diagnoses by encouraging high-value care and more efficient care delivery. For bone metastases, evidence supports the use of higher-value, shorter courses of radiation (≤10 fractions). Our goal was to determine the prevalence of short radiation courses (≤10 fractions) for bone metastases and the setting, treatment and patient characteristics associated with such courses and their expenditures.DesignUsing the RO Model episode file, we evaluated receipt of ≤10 fractions of radiotherapy for bone metastases and expenditures by treatment setting for Medicare fee-for-service beneficiaries during calendar years 2015–2017.Using unadjusted and adjusted regression models, we determined predictors of receipt of ≤10 fractions and expenditures. Multivariable models adjusted for treatment and patient characteristics.ResultsThere were 48 810 episodes for bone metastases during the period. A majority of episodes for ≤10 fractions occurred in hospital-outpatient settings (62.8% (N=22 715)). After adjusting for treatment and patient factors, hospital-outpatient treatment setting remained a significant predictor of receiving ≤10 fractions (adjusted OR 2.03 (95% CI 1.95, 2.12; p<0.001) vs free-standing). The greatest adjusted contributors to total expenditures were number of fractions (US$−3424 (95% CI US$−3412 to US$−3435) for ≤10 fractions vs >10; p<0.001) and treatment type (including US$7716 (95% CI US$7424 to US$8018) for intensity modulated radiation therapy vs conventional external beam; p<0.001).ConclusionsA measurable performance gap exists for delivery of higher-value bone metastases radiotherapy under an episode-based model, associated with increased expenditures. The RO Model may succeed in improving the value of bone metastases radiation. Increasing the capacity of free-standing centres to implement palliative-focused services may improve the ability of these practices to succeed under the RO Model.

Abstract 16487: Variation in Provider Practice Patterns Across Clinical Settings for Medicare Beneficiaries Undergoing Endovascular Femoropopliteal Artery Revascularization

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Aishwarya Raja ◽  
Eunhee Choi ◽  
Changyu Shen ◽  
tianyi zhao ◽  
Rishi Wadhera ◽  
...  
Keyword(s):  
Average Distance ◽  
Tertiary Care ◽  
Patient Characteristics ◽  
Area Deprivation ◽  
Care Hospital ◽  
Fee For Service ◽  
Free Standing ◽  
Vascular Intervention ◽  
Femoropopliteal Artery ◽  
Outpatient Settings

Introduction: After CMS established bundled payments for outpatient peripheral vascular intervention (PVI) in 2008, a large proportion of PVIs shifted to outpatient settings, including ambulatory surgery centers (ASCs) and office-based laboratories (OBLs). Little is known about these free-standing procedural centers, such as their proximity to tertiary care hospitals and the characteristics of patients being treated. Methods: Medicare fee-for-service beneficiaries ≥66 years undergoing femoropopliteal artery PVI from 4/1/15-12/31/17 in outpatient settings were identified in the CMS Carrier file linked to institutional outpatient files. The exposure was treatment at an ASC/OBL versus an outpatient hospital. An area deprivation index of ≤15th percentile identified those who reside in regions of lower socioeconomic status (SES). The primary business address of each ASC/OBL was identified using the National Provider Identifier. The address of the closest tertiary care hospital was identified in the Medicare Hospital database and distances were calculated using a Google Maps API platform. Results: Of 1,155 providers who performed ≥1 PVI in an ASC/OBL, the average distance to the nearest hospital was 1.5±2.2 miles. There was a weak correlation between the proportion of procedures performed at ASCs/OBLs and the distance to the nearest hospital (Figure). Among 686 providers who performed procedures in both ASCs/OBLs and outpatient hospitals, patients treated in ASCs/OBLs had a higher burden of comorbidities and were more often Black, dually-enrolled in Medicare/Medicaid, and residing in lower SES regions. Conclusions: ASCs/OBLs are geographically close to tertiary care centers, with little correlation between the proportion of procedures performed and the distance to the nearest hospital. The heterogeneity of patient characteristics across outpatient settings underscores the need for better measures of quality and appropriateness of PVI procedures.

scholarly journals Choosing Wisely: Opportunities for Improving Value in Cancer Care Delivery?

2017 ◽  
Vol 13 (1) ◽  
pp. e11-e21 ◽  
Author(s):  
Gabrielle B. Rocque ◽  
Courtney P. Williams ◽  
Bradford E. Jackson ◽  
Audrey S. Wallace ◽  
Karina I. Halilova ◽  
...  
Keyword(s):  
Hierarchical Linear Modeling ◽  
Cancer Care ◽  
Care Delivery ◽  
Patient Characteristics ◽  
Cost Of Care ◽  
Choosing Wisely ◽  
Adherence Rate ◽  
Fee For Service ◽  
Linear Modeling ◽  
Potential Cost

Introduction: Patients, providers, and payers are striving to identify where value in cancer care can be increased. As part of the Choosing Wisely (CW) campaign, ASCO and the American Society for Therapeutic Radiology and Oncology have recommended against specific, yet commonly performed, treatments and procedures. Methods: We conducted a retrospective analysis of Medicare claims data to examine concordance with CW recommendations across 12 cancer centers in the southeastern United States. Variability for each measure was evaluated on the basis of patient characteristics and site of care. Hierarchical linear modeling was used to examine differences in average costs per patient by concordance status. Potential cost savings were estimated on the basis of a potential 95% adherence rate and average cost difference. Results: The analysis included 37,686 patients with cancer with Fee-for-Service Medicare insurance. Concordance varied by CW recommendation from 39% to 94%. Patient characteristics were similar for patients receiving concordant and nonconcordant care. Significant variability was noted across centers for all recommendations, with as much as an 89% difference. Nonconcordance was associated with higher costs for every measure. If concordance were to increase to 95% for all measures, we would estimate a $19 million difference in total cost of care per quarter. Conclusion: These results demonstrate ample room for reduction of low-value care and corresponding costs associated with the CW recommendations. Because variability in concordance was driven primarily by site of care, rather than by patient factors, continued education about these low-value services is needed to improve the value of cancer care.

Abstract 101: Variation in Patient Characteristics and Outcomes Between Clinical Settings for Endovascular Femoropopliteal Artery Revascularization

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Aishwarya Raja ◽  
Eunhee Choi ◽  
Changyu Shen ◽  
Rishi Wadhera ◽  
Jose Figueroa ◽  
...  
Keyword(s):  
Patient Characteristics ◽  
Mortality Rates ◽  
Area Deprivation ◽  
Clinical Settings ◽  
Fee For Service ◽  
Term Survival ◽  
Vascular Intervention ◽  
Femoropopliteal Artery ◽  
Hospital Outpatient

Background: After CMS modified reimbursement rates for outpatient peripheral vascular intervention (PVI) in 2008, clinicians began to increasingly perform PVIs in hospital outpatient centers and ambulatory surgery centers (ASCs)/office-based laboratories (OBLs). Little is known about the characteristics of patients treated in freestanding ASCs/OBLs and their respective long-term outcomes compared to those treated in other settings. Methods: Medicare fee-for-service beneficiaries ≥66 years undergoing femoropopliteal artery PVI between 4/1/15-12/31/17 in ambulatory settings and 10/1/15-12/31/17 in inpatient centers were identified using carrier files linked to institutional outpatient files and MedPAR data. The vital status file was used to determine mortality through 4/30/19. Patients required ≥1 year of data prior to PVI to allow for ascertainment of comorbidities. An area deprivation index of ≤15 th percentile was used to identify those who reside in regions of lower socioeconomic status (SES). Results: Of 147,573 patients undergoing femoropopliteal PVI, 62,673 (42.5%) were treated as inpatients, 82,135 (55.7%) in hospital outpatient centers, and 2,765 (1.9%) in ASCs/OBLs. Patients treated in ASCs/OBLs had a greater burden of comorbidities, and were more likely to be Black (20.5% vs 11.6% outpt vs 14.1% inpt), dually-enrolled in Medicaid-Medicare (32.7% vs 18.5% outpt vs. 24.8% inpt), and reside in lower SES regions (44.8% vs 26.6% oupt vs 34.4% inpt). The unadjusted cumulative incidence of long-term mortality was similar between patients treated at ASCs/OBLs and inpatient centers, whereas hospital outpatients had higher survival (Figure 1). After adjusting for patient characteristics (demographics, comorbidities, and markers of SES), individuals treated in ASCs/OBLs had lower mortality rates than inpatient centers (HR 0.67, 95% CI 0.61-0.73) and attenuated mortality rates compared to outpatient centers (HR 1.10, 95% CI 1.01-1.20). Conclusions: Medicare beneficiaries undergoing femoropopliteal PVI at ASCs/OBLs are more socioeconomically disadvantaged and have a higher burden of comorbidities compared with other clinical settings. These differences in patient characteristics largely explain heterogeneity in long-term survival between facilities.

Toxicity following palliative radiation therapy for painful metastatic bone lesions.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 126-126 ◽  
Author(s):  
Mikayla Jenkins ◽  
Mark Raymond Waddle ◽  
Tasneem Kaleem ◽  
William C Stross ◽  
Timothy D Malouff ◽  
...  
Keyword(s):  
Bone Metastases ◽  
Radiation Treatment ◽  
Performance Status ◽  
Poor Performance ◽  
Patient Characteristics ◽  
Bone Lesions ◽  
Poor Performance Status ◽  
Financial Toxicity ◽  
Palliative Radiation ◽  
Ed Visits

126 Background: Palliative radiation treatment (pRT) is a common and effective treatment for patients with symptomatic bone metastases. However, patients receiving RT for bone metastases often may have a poor performance status and are more likely to experience toxicity during or after treatment. This study aims to investigate the number and type of toxicity event occurring during or after pRT for bone metastases. Methods: Patients treated with RT for bone metastases at Mayo Clinic from 2007 to 2016 were included in this study. Demographic, disease, treatment, and toxicity information were collected. Specifically, toxicity events were identified as emergency department (ED) visits and inpatient hospitalization (IH) within 90 days, breaks in treatment >4 days, and excessive 30 day financial toxicity defined as standardized Medicare costs >1 standard deviation above the mean. RT treatment was compared by dose and fractionation via descriptive statistics. Results: A total of 538 patients treated with pRT were identified, 124 receiving 8Gy x1, 204 receiving 4Gy x5, and 210 receiving 3Gy x10. Patients with breast and prostate cancer were most likely to be treated with 3Gy x10 and patients with GI and Lung cancer were most likely to be treated with 8Gy x1. A description of the patient characteristics and toxicities are shown in Table 1. For 8Gy x1, 4Gy x5, and 3Gy x10 breaks in treatment were rare (0%, 2%, and 3.3%), ED visits (15%, 24%, & 28%), IH (12%, 23%, & 19%), and financial toxicity (13%, 18%, & 21%) were common. A total of 22.6%, 27.5%, and 38.6% of patients were alive two years following pRT from each group. Conclusions: Toxicity during or shortly after pRT of bone metastases is common. This study confirms that additional steps should be taken to monitor and mitigate toxicity in this vulnerable patient group. [Table: see text]

scholarly journals Overlap of Pain and Depression Among Nursing Home Residents With Advanced Alzheimer’s Disease and Related Dementia

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 42-43
Author(s):  
Emmanuelle Belanger ◽  
Richard Jones ◽  
Gary Epstein-Lubow ◽  
Kate Lapane
Keyword(s):  
Alzheimer’S Disease ◽  
Alzheimer's Disease ◽  
Nursing Home ◽  
Depressive Symptoms ◽  
Hospice Care ◽  
Care Delivery ◽  
Nursing Home Residents ◽  
National Sample ◽  
Fee For Service ◽  
Minimum Dataset

Abstract Physical and psychological suffering are interrelated and should be assessed together as part of palliative care delivery. We aimed to describe the overlap of pain and depressive symptoms among long-stay nursing home (NH) residents with advanced Alzheimer’s disease and related dementia (ADRD), and to determine the incidence of pain and depressive symptoms. We conducted a retrospective study of a US national sample of fee-for-Service Medicare beneficiaries who became long-stay NH residents in 2014-2015, had two consecutive quarterly Minimum Dataset assessments (90 and 180 days +/- 30 days), and had a diagnosis of ADRD in the Chronic Condition Warehouse and moderate to severe cognitive impairment (N= 92,682). We used descriptive statistics and Poisson regression models to examine the incidence of each symptom controlling for age, sex, and concurrent hospice care. Sub-groups with self-reported and observer-rated symptoms (pain/PHQ-9) were modelled separately, as were those switching between the two. The prevalence of depressive symptoms was low (5.7%), while pain was more common (18.2%). Across various subgroups, 2% to 4% had both pain and depression, but between 20% and 25% were treated with both antidepressants and scheduled analgesia. Depressed residents at baseline had an incidence rate ratio (IRR) of pain of 1.2 at the second assessment, while the residents with pain at baseline had an IRR of depressive symptoms of 1.3 at the second assessment. Our results support the expected relationship between pain and depressive symptoms in a national sample of long-stay NH residents with advanced ADRD, suggesting the need for simultaneous clinical management.

Direct Primary Care: A Successful Financial Model for the Clinical Practice of Lifestyle Medicine

2021 ◽  
pp. 155982762110066
Author(s):  
Amy R. Mechley
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Care Delivery ◽  
Health Care Systems ◽  
Well Being ◽  
The United States ◽  
Fee For Service ◽  
Financial Model ◽  
Lifestyle Medicine ◽  
Direct Primary

Primary care has been shown to significantly decrease the overall cost of a population’s health care while improving the quality of each person’s well-being. Lifestyle medicine (LM) is ideally positioned to be delivered via primary care and has been shown to improve short- and long-term health outcomes of patients and populations. Direct primary care (DPC) represents a viable alternative to the fee-for-service reimbursement model. It has been shown to be economically and financially sustainable. Furthermore, it has the potential to fulfill the Quadruple Aim of health care in the United States. LM practiced in a DPC model has the potential to transform health care delivery. This article will discuss the need for health care systems change, provide an overview of the DPC model, demonstrate a basic understanding of the benefits, and review the steps needed to de-risk the investment of time, money, and resources for our future DPC providers.

scholarly journals 828. Evaluation of Home Time as a Patient-Centered Metric for Pneumonia Hospitalizations: A Retrospective Cohort Study of Medicare Fee-For-Service Beneficiaries

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S455-S456
Author(s):  
Rajeshwari Nair ◽  
Yubo Gao ◽  
Mary Vaughan-Sarrazin ◽  
Eli N Perencevich ◽  
Saket Girotra ◽  
...  
Keyword(s):  
Performance Metrics ◽  
Care Delivery ◽  
Care Facility ◽  
Hospital Performance ◽  
Policy Implications ◽  
Fee For Service ◽  
Multilevel Regression ◽  
Hospital Level ◽  
Post Discharge ◽  
Patient Centered

Abstract Background The Centers for Medicare & Medicaid Services (CMS) uses hospital readmission to incentivize hospital care delivery for acute conditions including pneumonia. However, current CMS performance metrics do not account for the competing risk of mortality in the post-discharge period or during the hospital stay. Our objective was to assess home time within 30 days after discharge among pneumonia hospitalizations, as a patient-centered metric. Methods A retrospective observational study was conducted in a cohort of Medicare fee-for-service beneficiaries admitted between 01/01/2015 and 11/30/2017. Home time was the number of days spent alive, out of an acute care setting, skilled nursing facility, or a rehabilitation facility within 30 days of discharge. If a patient spends any part of a day in a care facility or died after discharge, then that day was not included in the calculation for home time. Hospital-level rates of risk-adjusted home time were calculated using multilevel regression models. We compared hospital performance on 30-day risk-standardized home time with its performance on 30-day risk standardized readmission rate (RSRR) and mortality rate (RSMR). Characteristics of hospitals with high and low risk-adjusted home-time were compared. Results Among 1.7 million pneumonia admissions admitted to 3,116 hospitals, the median 30-day risk-standardized home time was 20.5 days (interquartile range: 18.9-21.9 days). Hospital-level characteristics such as case volume, bed size, for-profit ownership, rural location of hospital, teaching status, and participation in the bundle payment program were significantly associated with home-time. RSRR (rho: -0.233, p&lt; 0.0001) and RSMR (rho: -0.223, p&lt; 0.0001) had weak, inverse correlations with home time. Using the home time metric, 35.5% of hospitals were reclassified as high performers compared with their average or poor performance on the RSRR or RSMR metric. Conclusion Home time is a novel, patient-centered, hospital-level metric that can be easily calculated using claims data, accounts for differences in post-discharge mortality and can be intuitively interpreted. Utilization of this metric could potentially have policy implications in assessing hospital performance on delivery of healthcare to pneumonia patients. Disclosures Rajeshwari Nair, PhD, Merck and Company, Inc. (Research Grant or Support)

scholarly journals The European TeleCheck-AF project on remote app-based management of atrial fibrillation during the COVID-19 pandemic: centre and patient experiences

EP Europace ◽  
2021 ◽  
Author(s):  
Monika Gawałko ◽  
David Duncker ◽  
Martin Manninger ◽  
Rachel M J van der Velden ◽  
Astrid N L Hermans ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Care Delivery ◽  
Patient Characteristics ◽  
Patient Experiences ◽  
Af Ablation ◽  
District Hospitals ◽  
Inclusion Rate ◽  
Set Up ◽  
Time Required ◽  
Short Time

Abstract Aims TeleCheck-AF is a multicentre international project initiated to maintain care delivery for patients with atrial fibrillation (AF) during COVID-19 through teleconsultations supported by an on-demand photoplethysmography-based heart rate and rhythm monitoring app (FibriCheck®). We describe the characteristics, inclusion rates, and experiences from participating centres according the TeleCheck-AF infrastructure as well as characteristics and experiences from recruited patients. Methods and results Three surveys exploring centre characteristics (n = 25), centre experiences (n = 23), and patient experiences (n = 826) were completed. Self-reported patient characteristics were obtained from the app. Most centres were academic (64%) and specialized public cardiology/district hospitals (36%). Majority of the centres had AF outpatient clinics (64%) and only 36% had AF ablation clinics. The time required to start patient inclusion and total number of included patients in the project was comparable for centres experienced (56%) or inexperienced in mHealth use. Within 28 weeks, 1930 AF patients were recruited, mainly for remote AF control (31% of patients) and AF ablation follow-up (42%). Average inclusion rate was highest during the lockdown restrictions and reached a steady state at a lower level after easing the restrictions (188 vs. 52 weekly recruited patients). Majority (&gt;80%) of the centres reported no problems during the implementation of the TeleCheck-AF approach. Recruited patients [median age 64 (55–71), 62% male] agreed that the FibriCheck® app was easy to use (94%). Conclusion Despite different health care settings and mobile health experiences, the TeleCheck-AF approach could be set up within an extremely short time and easily used in different European centres during COVID-19.

Quality of life outcomes in sarcoma patients receiving care at a tertiary center.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e23557-e23557
Author(s):  
Jonathan R. Day ◽  
Benjamin Miller ◽  
Sarah L. Mott ◽  
Bradley T. Loeffler ◽  
Munir Tanas ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Radiation Treatment ◽  
Soft Tissue Sarcomas ◽  
Well Being ◽  
Self Report ◽  
University Of Iowa ◽  
Treatment Type ◽  
Tertiary Center ◽  
Multiple Domains

e23557 Background: Sarcomas are a diverse group of neoplasms that vary greatly in clinical presentation and responsiveness to treatment. Given the differences in the sites of involvement, rarity, and treatment modality, a multidisciplinary approach is required. Previous literature suggests patients with sarcoma suffer from poorer quality of life (QoL) especially physical and functional well-being. This study aims to understand if there is an association between treatment at a tertiary sarcoma center and a difference in QoL. Methods: De-identified data was obtained from the Sarcoma Tissue Repository at University of Iowa. Mixed effects regression models were utilized to evaluate the association between disease and treatment characteristics and QoL. QoL was assessed using the self-report FACT-G questionnaire at 12-, 24-, and 36-months post-diagnosis; overall scores and the 4 well-being subscales (Physical, Emotional, Social, Functional) were calculated. Results: 443 patients were identified. Soft tissue sarcomas were more prevalent (87.6%) than bone (12.4%). 53% of patients received chemotherapy and 38.6% got radiation therapy. Sarcomas were most frequently located in the lower extremities(ext.) (33.1%), followed by abdomen (20.9%), pelvic (13.6%), upper ext. (13.1%), thorax (11.3%), head & neck (7.8%). For ext. sarcoma; lower ext: 144 (71.3%), Upper ext: 58 (28.7%). Patients with extremity sarcoma; 133 had limb sparing and 48 had amputations. FACT-G Scores did not appreciably vary between 12, 24-, and 36-month for any QoL responses. Overall well-being had a mean score reported of 87.7 (sd = 15.7). Social well-being sores averaged 23.5 (5.0). Emotional well-being (EWB) 19.2 (4.1) and functional well-being (FWB) 21.3 (6.1), and physical well-being (PWB) 23.7 (4.6). There was no association between overall, PWB, EWB, or FWB with the histological subtype, radiation treatment, type of limb surgery, or any location in the same patients over time. Chemotherapy treatments were associated with lower well-being in multiple domains; PWB scores being 2.01 points lower, (p < 0.01), EWB scores being 1.27 points lower (p = 0.01) and FWB scores being 1.72 (p = 0.03), and 4.44 points lower overall (p = 0.03), on average, after adjusting for overall changes across time. Patients with ext. sarcoma only overall FACT-G scores differed 6.72 points higher for upper ext. than lower ext (p = 0.04). Conclusions: Overall QoL areas were similar to normative FACT-G scores both overall and specific areas. Having received chemotherapy was associated with lower well-being scores physically, emotionally, functionally, and overall. There were no clinically relevant differences reported in QoL scores between 12-,24-, and 36-months in the same patients. Further work is needed to describe QoL differences among patients with sarcoma at tertiary centers and examine what protective factors may influence patient well-being.

Abstract 15: Trends in Performance and Outcomes of Carotid Endarterectomy Among Elderly Medicare Beneficiaries, 2003-2010

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Judith H Lichtman ◽  
Michael R Jones ◽  
Alice J Sheffet ◽  
George Howard ◽  
Yun Wang ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Mixed Model ◽  
Patient Characteristics ◽  
Annual Number ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Hospital Level ◽  
Medicare Patients ◽  
Annual Reduction ◽  
Service Data

Background: Carotid endarterectomy (CEA) is the leading procedure for carotid stenosis, yet national data on trends in rates and outcomes are limited. We determined CEA rates among Medicare beneficiaries and evaluated mortality and readmission over 8 years. Methods: We used Medicare fee-for-service data to identify beneficiaries aged ≥65y who had their first CEA (ICD-9 38.12) from 2003-2010 and calculated annual rates per 100,000 person-years (PY). We fit mixed models to assess trends in patient-level outcomes, adjusting for demographics, comorbidities, and symptomatic status. We also evaluated hospital-level trends by calculating risk-standardized mortality (RSMR) and readmission (RSRR) rates. A spatial mixed model adjusted for age, sex, and race was fit to calculate county-specific risk-standardized CEA rates in 2003-2004. Results: There were 505,966 unique CEA hospitalizations. The annual number of CEA discharges decreased from 81,604 in 2003 to 47,597 in 2010 (42% decrease), though the patient characteristics remained largely similar. The national CEA rate was 283 per 100,000 PY in 2003, and there was considerable geographic variability (Figure A). This rate decreased each year to a low of 172 per 100,000 PY in 2010. The rate of stroke or death within 30 days decreased from 3.2 to 2.7%, with a significant adjusted annual reduction of 3% (Figure B). Annual reductions in other short- and long-term outcomes were similar, ranging from 2-3%. The median hospital-level 30-day RSMR decreased over time from 0.99 to 0.57%, while the variation between hospitals increased (interquartile range of 0.7-1.67 percentage points). The 30-day RSRR decreased from 11.0 to 10.1%, but there was more homogeneity across hospitals and years. Conclusions: CEA use among Medicare patients decreased dramatically from 2003-2010, while mortality and readmission outcomes improved. The relative importance of biological and sociological mechanisms for these trends merits further study.

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