Abstract W MP97: Trends in Volume and Mortality in CEA after Introduction of CAS in Medicare population

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Hiraku Kumamaru ◽  
Jessica J Jalbert ◽  
Louis L Nguyen ◽  
Jun Liu ◽  
Marie D Gerhard-Herman ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Inverse Relationship ◽  
High Volume ◽  
Patient Characteristics ◽  
Surgeon Volume ◽  
Medicare Beneficiaries ◽  
The Past ◽  
Lower Case ◽  
Medicare Patients ◽  
Procedural Outcomes

Background: Inverse relationship between outcome and physician volume for carotid endarterectomy (CEA) has been previously established. Following the 2005 National Coverage Determination which reimburses carotid artery stenting (CAS) for Medicare beneficiaries, the number of CAS procedures increased and the number of CEA declined. We hypothesized that the reduced number of CEA procedures resulted in lower case volumes for surgeons, adversely affecting patients' peri-procedural outcomes. Methods: We identified inpatient CEA procedures and performing surgeons in the Medicare claims files 2001-2008. We calculated surgeon volume as the number of CEAs performed in the past 365 days and categorized volume as very low (<5), low (5-9), medium (10-29) and high (≥30). Yearly trend of: 1) rate of CEA procedures, 2) proportion of CEAs performed by categories of surgeon volume , 3) patient characteristics , and 4) 30-day mortality overall and by categories of surgeon volume, were analyzed. Results: We identified 450,727 Medicare beneficiaries undergoing CEAs. The rate of CEA procedures per 10,000 beneficiaries declined consistently after 2002, resulting in decrease in the proportion of procedures performed by high volume surgeons (from 46% in 2002 to 33% in 2008). Patients selected for CEA became older and increased in the proportion of patients with atrial fibrillation, COPD, and chronic kidney disease, but decreased in the proportions with prior myocardial infarction and concurrent CABG. Thirty day mortality improved consistently over the years from 1.41% (95% confidence interval: 1.35-1.48) in 2001-2002 to 1.18% (1.12-1.25) in 2007-2008. This trend persisted after adjustment for patient characteristics, and in all volume categories. Conclusion: The rate of CEA procedures decreased substantially between 2001-2008 as have performing surgeon case volumes . Dissemination of CAS has not adversely impacted the peri-procedural mortality of CEA Medicare patients.

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.

scholarly journals Sources of Geographic Variation in Health Care: Evidence From Patient Migration*

2016 ◽  
Vol 131 (4) ◽  
pp. 1681-1726 ◽  
Author(s):  
Amy Finkelstein ◽  
Matthew Gentzkow ◽  
Heidi Williams
Keyword(s):  
Health Care ◽  
Health Care Utilization ◽  
Geographic Variation ◽  
Patient Characteristics ◽  
Care Utilization ◽  
Demand Side ◽  
Medicare Beneficiaries ◽  
Demand And Supply ◽  
Medicare Patients

Abstract We study the drivers of geographic variation in U.S. health care utilization, using an empirical strategy that exploits migration of Medicare patients to separate the role of demand and supply factors. Our approach allows us to account for demand differences driven by both observable and unobservable patient characteristics. Within our sample of over-65 Medicare beneficiaries, we find that 40–50% of geographic variation in utilization is attributable to demand-side factors, including health and preferences, with the remainder due to place-specific supply factors.

scholarly journals Emergency department increased use of observation care for elderly medicare patients

2018 ◽  
Vol 7 (3) ◽  
pp. 9 ◽  
Author(s):  
Gelareh Z. Gabayan ◽  
Li-Jung Liang ◽  
Brian Doyle ◽  
David Yu-Chuang Huang ◽  
Catherine A. Sarkisian
Keyword(s):  
Emergency Department ◽  
Estimating Equation ◽  
Generalized Estimating Equation ◽  
Inpatient Service ◽  
Medicare Beneficiaries ◽  
The Past ◽  
Medicare Patients ◽  
Nationally Representative ◽  
Using Data ◽  
The Relationship

Background: Over the past decade, a growing number of older Medicare beneficiaries visit the emergency department (ED) and have been placed in observation care. We investigated and compared the prevalence and factors associated with patients age ≥ 65 years with Medicare insurance who are placed in the hospital, observation care, or discharged following an ED visit.Methods: We conducted a retrospective cohort study using data from a nationally representative 5% sample of Medicare patients age ≥ 65 years during the year 2013. We performed multiple generalized estimating equation (GEE) logistic regression analyses to assess the relationship between placement in a hospital vs. discharge, observation care vs. discharge, and observation care vs. admission.Results: Of 537,455 Medicare beneficiaries age ≥ 65 years who visited an ED in 2013, 48.0% (N = 258,083) were discharged, 10.5% (N = 56,184) placed in observation care, and 41.5% (N = 223,188) were admitted to the inpatient service following the ED visit. The top 2 diagnoses associated with placement in the hospital vs. discharge were ischemic heart disease and renal disease. Patients with symptomatic diagnoses such as chest pain and dizziness were more likely to be placed in observation care following an ED visit as compared to admission to the hospital.Conclusions: Compared to prior studies, we found a greater number of older Medicare ED patients placed in observation care and a lower number admitted to the hospital. Most common diagnoses of placement in observation care were symptom-based as compared to being admitted to the hospital which were disease-based.

scholarly journals Changes in ST segment elevation myocardial infarzzction hospitalisations in China from 2011 to 2015

Open Heart ◽  
2021 ◽  
Vol 8 (2) ◽  
pp. e001666
Author(s):  
Tianna Zhou ◽  
Xi Li ◽  
Yuan Lu ◽  
Karthik Murugiah ◽  
Xueke Bai ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Patient Characteristics ◽  
Hospital Death ◽  
St Segment Elevation ◽  
Prehospital Delay ◽  
The Past ◽  
Representative Study ◽  
St Segment ◽  
Nationally Representative ◽  
Cardiovascular Care

ObjectiveAccess to acute cardiovascular care has improved and health services capacity has increased over the past decades. We assessed national changes in (1) patient characteristics, (2) in-hospital management and (3) patient outcomes among patients presenting with ST segment elevation myocardial infarction (STEMI) in 2011–2015 in China.MethodsIn a nationally representative sample of hospitals in China, we created two random cohorts of patients in 2011 and 2015 separately. We weighted our findings to estimate nationally representative numbers and assessed changes from 2011 to 2015. Data were abstracted from medical charts centrally using standardised definitions.ResultsWhile the proportion of patients with STEMI among all patients with acute myocardial infarction decreased over time from 82.5% (95% CI 81.7 to 83.3) in 2011 to 68.5% (95% CI 67.7 to 69.3) in 2015 (p<0.0001), the weighted national estimate of patients with STEMI increased from 210 000 to 380 000. The rate of reperfusion eligibility among patients with STEMI decreased from 49.3% (95% CI 48.1 to 50.5) to 42.2% (95% CI 41.1 to 43.4) in 2015 (p<0.0001); ineligibility was principally driven by larger proportions with prehospital delay exceeding 12 hours (67.4%–76.7%, p<0.0001). Among eligible patients, the proportion receiving reperfusion therapies increased from 54% (95% CI 52.3 to 55.7) to 59.7% (95% CI 57.9 to 61.4) (p<0.0001). Crude and risk-adjusted rates of in-hospital death did not differ significantly between 2011 and 2015.ConclusionsIn this most recent nationally representative study of STEMI in China, the use of acute reperfusion increased, but no significant improvement occurred in outcomes. There is a need to continue efforts to prevent cardiovascular diseases, to monitor changes in in-hospital treatments and outcomes, and to reduce prehospital delay.

scholarly journals Phantom Prescribing: Examining the Frequency of Antimicrobial Prescriptions Without a Patient Visit

2016 ◽  
Vol 38 (3) ◽  
pp. 273-280 ◽  
Author(s):  
Benjamin N. Riedle ◽  
Linnea A. Polgreen ◽  
Joseph E. Cavanaugh ◽  
Mary C. Schroeder ◽  
Philip M. Polgreen
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Chronic Conditions ◽  
Retrospective Cohort ◽  
Patient Characteristics ◽  
Patient Visit ◽  
Cardiac Events ◽  
Antimicrobial Prescribing ◽  
Medicare Patients ◽  
Antimicrobial Prescription

OBJECTIVETo investigate the scale of antimicrobial prescribing without a corresponding visit, and to compare the attributes of patients who received antimicrobials with a corresponding visit with those who did not have a visit.DESIGNRetrospective cohort.METHODSWe followed up 185,010 Medicare patients for 1 year after an acute myocardial infarction. For each antimicrobial prescribed, we determined whether the patient had an inpatient, outpatient, or provider claim in the 7 days prior to the antimicrobial prescription being filled. We compared the proportions of patient characteristics for those prescriptions associated with a visit and without a visit (ie, phantom prescriptions). We also compared the rates at which different antimicrobials were prescribed without a visit.RESULTSWe found that of 356,545 antimicrobial prescriptions, 14.75% had no evidence of a visit in the week prior to the prescription being filled. A higher percentage of patients without a visit were identified as white (P<.001) and female (P<.001). Patients without a visit had a higher likelihood of survival and fewer additional cardiac events (acute myocardial infarction, cardiac arrest, stroke, all P<.001). Among the antimicrobials considered, amoxicillin, penicillin, and agents containing trimethoprim and methenamine were much more likely to be prescribed without a visit. In contrast, levofloxacin, metronidazole, moxifloxacin, vancomycin, and cefdinir were much less likely to be prescribed without a visit.CONCLUSIONSAmong this cohort of patients with chronic conditions, phantom prescriptions of antimicrobials are relatively common and occurred more frequently among those patients who were relatively healthy.Infect Control Hosp Epidemiol 2017;38:273–280

scholarly journals Association of Region and Hospital and Patient Characteristics With Use of High-Intensity Statins After Myocardial Infarction Among Medicare Beneficiaries

2019 ◽  
Vol 4 (9) ◽  
pp. 865 ◽  
Author(s):  
Vera Bittner ◽  
Lisandro D. Colantonio ◽  
Yuling Dai ◽  
Mark Woodward ◽  
Matthew T. Mefford ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
High Intensity ◽  
Patient Characteristics ◽  
Medicare Beneficiaries

Aspirin in the Treatment of Acute Myocardial Infarction in Elderly Medicare Beneficiaries

Circulation ◽  
1995 ◽  
Vol 92 (10) ◽  
pp. 2841-2847 ◽  
Author(s):  
Harlan M. Krumholz ◽  
Martha J. Radford ◽  
Edward F. Ellerbeck ◽  
John Hennen ◽  
Thomas P. Meehan ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Medicare Beneficiaries

High-Volume Hospitals with High-Volume and Low-Volume Surgeons: Is There a “Field Effect” for Pancreaticoduodenectomy?

2016 ◽  
Vol 82 (5) ◽  
pp. 407-411 ◽  
Author(s):  
Thomas W. Wood ◽  
Sharona B. Ross ◽  
Ty A. Bowman ◽  
Amanda Smart ◽  
Carrie E. Ryan ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Field Effect ◽  
Hospital Volume ◽  
Patient Discharge ◽  
High Volume ◽  
Surgeon Volume ◽  
Hospital Charges ◽  
Leapfrog Group ◽  
Discharge Status ◽  
Low Volume

Since the Leapfrog Group established hospital volume criteria for pancreaticoduodenectomy (PD), the importance of surgeon volume versus hospital volume in obtaining superior outcomes has been debated. This study was undertaken to determine whether low-volume surgeons attain the same outcomes after PD as high-volume surgeons at high-volume hospitals. PDs undertaken from 2010 to 2012 were obtained from the Florida Agency for Health Care Administration. High-volume hospitals were identified. Surgeon volumes within were determined; postoperative length of stay (LOS), in-hospital mortality, discharge status, and hospital charges were examined relative to surgeon volume. Six high-volume hospitals were identified. Each hospital had at least one surgeon undertaking ≥ 12 PDs per year and at least one surgeon undertaking < 12 PDs per year. Within these six hospitals, there were 10 “high-volume” surgeons undertaking 714 PDs over the three-year period (average of 24 PDs per surgeon per year), and 33 “low-volume” surgeons undertaking 225 PDs over the three-year period (average of two PDs per surgeon per year). For all surgeons, the frequency with which surgeons undertook PD did not predict LOS, in-hospital mortality, discharge status, or hospital charges. At the six high-volume hospitals examined from 2010 to 2012, low-volume surgeons undertaking PD did not have different patient outcomes from their high-volume counterparts with respect to patient LOS, in-hospital mortality, patient discharge status, or hospital charges. Although the discussion of volume for complex operations has shifted toward surgeon volume, hospital volume must remain part of the discussion as there seems to be a hospital “field effect.”

scholarly journals The Resolution of International Commercial Disputes – What Role (if any) for Continental Europe?

AJIL Unbound ◽  
2021 ◽  
Vol 115 ◽  
pp. 11-16
Author(s):  
Giesela Rühl
Keyword(s):  
The Netherlands ◽  
Dispute Settlement ◽  
Middle Eastern ◽  
National Level ◽  
High Volume ◽  
Radical Change ◽  
The Past ◽  
The World ◽  
Traditional Market ◽  
Commercial Courts

The past sixteen years have witnessed the proliferation of international commercial courts around the world. However, up until recently, this was largely an Asian and a Middle Eastern phenomenon. Only during the past decade have Continental European countries, notably Germany, France and the Netherlands, joined the bandwagon and started to create new judicial bodies for international commercial cases. Driven by the desire to attract high-volume commercial litigation, these bodies try to offer international businesses a better dispute settlement framework. But what are their chances of success? Will more international litigants decide to settle their disputes in these countries? In this essay, I argue that, despite its recently displayed activism, Continental Europe lags behind on international commercial courts. In fact, although the various European initiatives are laudable, most cannot compete with the traditional market leaders, especially the London Commercial Court, or with new rivals in Asia and the Middle East. If Continental Europe wants a role in the international litigation market, it must embrace more radical change. And this change will most likely have to happen on the European––not the national––level.

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