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 The effects of the Medicare NCS reimbursement policy

Neurology ◽  
2020 ◽  
Vol 95 (7) ◽  
pp. e930-e935 ◽  
Author(s):  
Evan L. Reynolds ◽  
Kevin A. Kerber ◽  
Chloe Hill ◽  
Lindsey B. De Lott ◽  
Brandon Magliocco ◽  
...  
Keyword(s):  
Evoked Potential ◽  
Annual Number ◽  
Reimbursement Policy ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Coding System ◽  
Common Procedure ◽  
Medicare Data ◽  
The Mean ◽  
Service Data

ObjectiveTo determine whether the 2013 nerve conduction study (NCS) reimbursement reduction changed Medicare use, payments, and patient access to Medicare physicians by performing a retrospective analysis of Medicare data (2012–2016 fee-for-service data from the CMS Physician and Other Supplier Public Use File).MethodsIndividual billable services were identified by Healthcare Common Procedure Coding System Current Procedural Terminology and G codes. Medicare use and payments were stratified by specialty and type of service (electrodiagnostic tests, including NCS and EMG, and other neurologic procedures). We also assessed access to Medicare physicians using the annual number of unique beneficiaries receiving initial Evaluation and Management (E/M) services.ResultsWe identified 676,113 Medicare providers included in all analysis years from 2012 to 2016 (10,599 neurologists, 5,881 physiatrists, and 659,633 other specialties). Comparing 2016 to 2012 showed that 21.1% fewer neurologists, 28.6% fewer physiatrists, and 69.3% fewer other specialists performed NCS and 3.8% fewer neurologists, 21.7% fewer physiatrists, and 5.6% fewer other specialists performed EMG. For NCS providers in 2012, the mean number of unique Medicare beneficiaries increased for neurologists (1.2%) and physiatrists (4.8%) but decreased for other specialists (−6.5%) by 2016. After the NCS cut, the number of providers performing autonomic and evoked potential testing increased substantially.ConclusionsThe Medicare NCS reimbursement policy resulted in a larger decrease in NCS providers than in EMG providers. Despite fewer neurologists and physiatrists performing NCS, Medicare access to these physicians for E/M services was not affected. Increased autonomic and evoked potential testing may be an unintended consequence of NCS reimbursement change.

scholarly journals Patient mortality after surgery on the surgeon’s birthday: observational study

BMJ ◽  
2020 ◽  
pp. m4381
Author(s):  
Hirotaka Kato ◽  
Anupam B Jena ◽  
Yusuke Tsugawa
Keyword(s):  
Mortality Rate ◽  
Observational Study ◽  
Life Events ◽  
Fixed Effects ◽  
Severity Of Illness ◽  
Patient Characteristics ◽  
Critical Access Hospitals ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Study Analysis

Abstract Objective To determine whether patient mortality after surgery differs between surgeries performed on surgeons’ birthdays compared with other days of the year. Design Retrospective observational study. Setting US acute care and critical access hospitals. Participants 100% fee-for-service Medicare beneficiaries aged 65 to 99 years who underwent one of 17 common emergency surgical procedures in 2011-14. Main outcome measures Patient postoperative 30 day mortality, defined as death within 30 days after surgery, with adjustment for patient characteristics and surgeon fixed effects. Results 980 876 procedures performed by 47 489 surgeons were analyzed. 2064 (0.2%) of the procedures were performed on surgeons’ birthdays. Patient characteristics, including severity of illness, were similar between patients who underwent surgery on a surgeon’s birthday and those who underwent surgery on other days. The overall unadjusted 30 day mortality on the operating surgeon’s birthday was 7.0% (145/2064) and that on other days was 5.6% (54 824/978 812). After adjusting for patient characteristics and surgeon fixed effects (effectively comparing outcomes of patients treated by the same surgeon on different days), patients who underwent surgery on a surgeon’s birthday exhibited higher mortality compared with patients who underwent surgery on other days (adjusted mortality rate, 6.9% v 5.6%; adjusted difference 1.3%, 95% confidence interval 0.1% to 2.5%; P=0.03). Event study analysis of patient mortality by day of surgery relative to a surgeon’s birthday found similar results. Conclusions Among Medicare beneficiaries who underwent common emergency surgeries, those who received surgery on the surgeon’s birthday experienced higher mortality compared with patients who underwent surgery on other days. These findings suggest that surgeons might be distracted by life events that are not directly related to work.

Health plan, physician, and medical care ratings among end-of-life (EOL) cancer survivors.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 80-80
Author(s):  
Michael T. Halpern ◽  
Matthew Urato ◽  
Margot Schwartz ◽  
Erin E. Kent
Keyword(s):  
Mental Health ◽  
Medical Care ◽  
Healthcare Providers ◽  
Patient Characteristics ◽  
Cancer Site ◽  
Future Research ◽  
Health Plans ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Poor General Health

80 Background: High-quality EOL care is critical for patients and families. However, little is known about factors influencing patient satisfaction with their healthcare near EOL. This study’s objective is to assess the role of characteristics of individuals with cancer near EOL on their ratings for medical care, health plans, and physicians. Methods: Retrospective analyses of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Survey linked to NCI’s Surveillance, Epidemiology, and End Results (SEER) Program. CAHPS collected Medicare beneficiaries’ ratings for overall care, physicians, health plans, and 5 composite scores of aspects of care; SEER provided data on cancer diagnosis and characteristics. The study included 5,102 Medicare beneficiaries diagnosed with cancer in SEER regions 1997-2011 who completed CAHPS following diagnosis and within one year before death. Logistic regression was used to examine associations of EOL patient characteristics with their ratings. Results: Self-reported very good or excellent (vs. poor) general health significantly (p < 0.05) predicted greater likelihood of higher ratings for all measures (ORs ranged 1.5 to 2.2). Very good/excellent mental health also predicted increased likelihood of higher ratings for all except one category (ORs 1.8 to 2.7). Other patient factors were significantly associated with a subset of ratings. For example, Hispanics (vs. Whites) were more likely to provide higher ratings for health plans (OR 1.5) and specialist physicians (OR 1.7) but lower ratings for getting needed care (OR 0.62). Fee-for-service (vs. Medicare Advantage) beneficiaries were more likely to provide higher ratings for health plans, getting needed care, and getting care quickly (ORs 1.4, 1.3, 1.6). Patient age, cancer site, and time since diagnosis had few or no significant associations with any measure. Conclusions: Among cancer patients near EOL, better self-reported general and mental health consistently predicted higher ratings. Fee-for-service Medicare patients provided higher ratings for several important categories. These results may help guide future research on interventions to improve the EOL experience among Medicare beneficiaries.

scholarly journals Cost Analysis and Clinical Outcomes of Ambulatory Care Monitoring in Medicare Patients: Describing the Diagnostic Odyssey

10.36469/9897 ◽  
2015 ◽  
Vol 2 (2) ◽  
pp. 161-169 ◽  
Author(s):  
Renée JG Arnold ◽  
Andrew Layton
Keyword(s):  
Holter Monitoring ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Claims Analysis ◽  
Diagnostic Odyssey ◽  
Clinical Events ◽  
Ambulatory Ecg Monitoring ◽  
Number Of Patients ◽  
Medicare Patients ◽  
Additional Monitoring

Objectives: The diagnostic sequence and costs for arrhythmia detection utilizing Holter ambulatory ECG monitoring have not been well studied. The objective of the current study was to characterize the number of patients and associated costs incurred in the diagnosis, additional monitoring, clinical events and sequelae after an initial Holter monitor in Medicare patients with arrhythmia—the diagnostic odyssey. Methods: We performed a retrospective, longitudinal claims analysis using a 5% random sample of Medicare beneficiaries’ claims from the Fee-for-Service (FFS) Standard Analytic Files. The analysis was limited to patients with full benefits for 1 year prior and 2 years post the index 24- or 48-hour Holter event, no prior arrhythmia or Holter. Results: The group of greatest interest was the “No results” category, since these 1,976 patients (11.1% of the total 17,887 patients evaluated) reflected the failure of repeat Holter monitoring to either detect clinical events or diagnose disease. In spite of this failure, there was a total allowed charge of more than $45 million or slightly more than $23,000 per involved patient. When extrapolated over the entire Medicare FFS population, this category was estimated to cost more than $900 million over the 2-year study period. Conclusions: Additional diagnostic paradigms need to be explored to improve upon these patient and system outcomes, where repeat monitoring frequently did not yield a diagnosis and patients continued to experience clinical events.

scholarly journals Surgeon Case Volume and 30-Day Mortality After Carotid Endarterectomy Among Contemporary Medicare Beneficiaries

Stroke ◽  
2015 ◽  
Vol 46 (5) ◽  
pp. 1288-1294 ◽  
Author(s):  
Hiraku Kumamaru ◽  
Jessica J. Jalbert ◽  
Louis L. Nguyen ◽  
Marie D. Gerhard-Herman ◽  
Lauren A. Williams ◽  
...  
Keyword(s):  
Cohort Study ◽  
Carotid Endarterectomy ◽  
Retrospective Cohort ◽  
Patient Characteristics ◽  
Medicare Beneficiaries ◽  
Revascularization Procedure ◽  
Case Volume ◽  
Medicare Data ◽  
Before And After ◽  
Over Time

Background and Purpose— After the 2005 National Coverage Determination to reimburse carotid artery stenting (CAS) for Medicare beneficiaries, the number of CAS procedures increased and carotid endarterectomy (CEA) decreased. We evaluated trends in surgeons’ past-year CEA case-volume and 30-day mortality after CEA, and their association before and after the National Coverage Determination. Methods— In a retrospective cohort study of patients undergoing CEA (2001–2008) and CAS (2005–2008) using Medicare data, we described yearly trends of CEA and CAS rates, patient characteristics, and 30-day mortality after CEA. We used logistic regression adjusting for patient- and surgeon-level factors to assess the effect of surgeon case volume on 30-day mortality after CEA. Results— We identified 454 717 CEA and 27 943 CAS patients. Patients undergoing CEA in recent years were older and had more comorbidities than earlier years. CEA rates per 10 000 beneficiaries declined from 18.1 in 2002 to 12.7 in 2008, whereas median surgeon past-year case-volume declined from 27 to 21. The CAS rates peaked at 2.3 per 10 000 beneficiaries in 2006 but declined to 1.8 in 2008, resulting in declining overall revascularization procedure rates during 2005 to 2008. Thirty day post-CEA mortality was 1.40% (95% confidence interval, 1.34–1.47) in 2001 to 2002 and 1.17% (1.10–1.24) in 2007 to 2008. Surgeon’s past-year case-volume of <10 was associated with higher 30-day mortality consistently during 2001 to 2008. Conclusions— The rate of CEA procedures decreased substantially during 2001 to 2008, as did surgeon past-year case-volume. The postprocedural mortality in Medicare beneficiaries was high compared with trial patients but somewhat improved over time. Those operated by lower past-year case-volume surgeons had increased mortality.

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.

Abstract 339: Urban and Rural Patients Receive Different Care for Atrial Fibrillation

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Emily P Zeitler ◽  
Ashleigh C King ◽  
Lauren Gilstrap ◽  
Andrea Austin
Keyword(s):  
Atrial Fibrillation ◽  
Management Strategies ◽  
Patient Characteristics ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Af Ablation ◽  
Treatment Disparities ◽  
Substantial Resource ◽  
Definition Of ◽  
The Impact

Background: Atrial fibrillation (AF) accounts for substantial resource utilization that is expected to increase as the US population ages. Management strategies for AF vary widely based on patient preference, physician specialty training, available resources, and other factors, but the impact that geography has on treatment variations for AF is unknown. Objective: We seek to evaluate differences in AF patient characteristics and management between urban and non-urban Medicare beneficiaries. Methods: Our cohort included all Medicare fee-for-service beneficiaries meeting the CMS chronic conditions warehouse definition of AF from 2013-2017. Beneficiaries were designated as urban and non-urban by rural-urban commuting area codes. AF procedures were tabulated based on CPT codes. The use of AF related medications was tabulated based on prescriptions for drugs of interest in Medicare Part D. Results: During our period of interest, Medicare AF patients were average age 79 yrs, and 52% were female. Urban patients were more likely to be black and have chronic kidney disease, diabetes, and ischemic heart disease. The average CHADS2VA2SC score was high (4.90 SD 1.71) and not meaningfully different between urban and non-urban groups. Most advanced interventions for AF increased over time driven mostly by increases in AF ablation (Figure). However, compared with non-urban patients, urban patients were more likely to undergo AF ablation (1.81 vs 1.42%, p<0.001), Watchman implantation (0.15 vs 0.11%, p<0.001), and cardioversion (0.06 vs 0.05%, p=0.015). Non-urban patients were more likely to be prescribed amiodarone (7.08 vs 6.09%, p=0.002) and warfarin (8.84 vs 7.40%, p<0.001) compared with urban patients and were less likely to be prescribed a direct oral anticoagulant. Conclusions: Despite urban and non-urban Medicare patients with AF being similar with regard to demographic and clinical characteristics, treatment of AF varied in important ways between these groups. In general, urban patients were more likely to receive interventional care for AF which, in some cases, has known associated benefits with regard to quality of life, morbidity, and mortality. Further work is needed to understand differences in outcomes between these two groups and to develop policy solutions to reduce treatment disparities.

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.

scholarly journals Impacts of COVID-19 on the Utilization of the Medicare Hospice Benefit

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 63-63
Author(s):  
Michael Plotzke ◽  
Betty Fout ◽  
Thomas Christian
Keyword(s):  
Healthcare Services ◽  
Public Health Emergency ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Skilled Nursing ◽  
Substantial Impact ◽  
Profound Impact ◽  
Time Period ◽  
Medicare Patients ◽  
Utilization Of Healthcare

Abstract The Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE) has had a substantial impact on the provision and utilization of healthcare services. Given the high mortality rate associated with COVID-19 amongst older adults, COVID-19 is likely to have a profound impact on all hospice users due to disruptions in providing services. Our work describes how Medicare beneficiaries have utilized the Medicare Hospice Benefit (MHB) during the PHE and how that compares to utilization of the MHB prior to the PHE. We conducted a retrospective analysis of 100% Part A and Part B Fee-for-Service (FFS) Medicare claims from January 1, 2019 – December 31, 2020. We identified approximately 42.3 million unique Medicare FFS beneficiaries from January 2019 through December 2020. Of these, 1.6 million (3.8%) had at least one hospice claim and 1.7 million (4.0%) had at least one Medicare Part A or Part B claim with a COVID-19 diagnosis during the same time period. The rate of COVID-19 amongst FFS Medicare patients who utilized hospice was 8.3%. Average per-beneficiary per-month hospice visits fell by 28.2% for aides and 15.4% for nurses from December 2019 (7.1 aide visits, 6.5 skilled nursing visits) through December 2020 (5.1 aide visits, 5.5 skilled nursing visits). CMS should continue to monitor the prevalence of COVID-19 amongst hospice users and measures of hospice utilization amongst all hospice users in order to better understand how the PHE impacts the provision of the MHB and ensure beneficiaries continue to have access to needed services.

scholarly journals Outcomes after carotid endarterectomy among elderly dual Medicare-Medicaid–eligible patients

Neurology ◽  
2018 ◽  
Vol 91 (17) ◽  
pp. e1553-e1558 ◽  
Author(s):  
Erica C. Leifheit ◽  
Yun Wang ◽  
George Howard ◽  
Virginia J. Howard ◽  
Larry B. Goldstein ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Mixed Models ◽  
Significant Interaction ◽  
Clinical Characteristics ◽  
Study Cohort ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
All Cause Mortality ◽  
Dual Eligible ◽  
The Relationship

ObjectiveTo determine whether patients who are dual eligible for Medicare and Medicaid benefits have outcomes after carotid endarterectomy (CEA) that are comparable to the outcomes of those eligible for Medicare alone.MethodsThe study cohort included fee-for-service Medicare beneficiaries ≥65 years of age who underwent CEA (ICD-9-CM code 38.12) between 2003 and 2010. Beneficiaries with ≥1 month of Medicaid coverage were considered dual eligible. We fit mixed models to assess the relationship between coverage (dual eligible vs Medicare only) and outcomes over time after adjustment for demographic and clinical characteristics.ResultsThere were 53,773 dual-eligible and 452,182 Medicare-only beneficiaries hospitalized for CEA. The percentage of dual-eligible patients receiving CEA increased from 10.1% in 2003 to 11.5% in 2010, with no change in geographic distribution across the country. In adjusted analyses, dual-eligible vs Medicare-only beneficiaries had a higher rate of 30-day ischemic stroke or death; higher in-hospital, 30-day, and 1-year all-cause mortality; and higher 30-day all-cause readmission. Relative annual reductions in outcomes from 2003 to 2010 ranged from 2% to 5%, but there was no significant interaction between dual-eligible status and time.ConclusionsDual-eligible beneficiaries had worse outcomes than those eligible for Medicare alone. Additional work is necessary to understand the reasons for this difference.

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