scholarly journals Personalizing Evidence for Shoulder Fracture Patients Using an Extended Instrumental Variable Causal Forest Algorithm

2021 ◽  
Author(s):  
John M. Brooks ◽  
Cole G. Chapman ◽  
Sarah Floyd ◽  
Brian K. Chen ◽  
Charles A. Thigpen ◽  
...  
Keyword(s):  
Instrumental Variable ◽  
Day Treatment ◽  
Early Surgery ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Reference Class ◽  
Shoulder Fracture ◽  
Population Classification ◽  
Reference Classes ◽  
Surgery Rates

Objective: To assess the ability of an extended Instrumental Variable Causal Forest Algorithm (IV-CFA) to provide personalized evidence of early surgery effects on benefits and detriments for elderly shoulder fracture patients. Data Sources/Study Setting: Population of 72,751 fee-for-service Medicare beneficiaries with proximal humerus fractures (PHFs) in 2011 who survived a 60-day treatment window after an index PHF and were continuously Medicare fee-for-service eligible over the period 12 months prior to index to the minimum of 12 months after index or death. Study Design: IV-CFA estimated early surgery effects on both beneficial and detrimental outcomes for each patient in the study population. Classification and regression trees (CART) were applied to these estimates to create patient reference classes. Two-stage least squares (2SLS) estimators were applied to patients in each reference class to scrutinize the estimates relative to the known 2SLS properties. Principal Findings: This approach uncovered distinct reference classes of elderly PHF patients with respect to early surgery effects on benefit and detriment. Older, frailer patients with more comorbidities, and lower utilizers of healthcare were less likely to gain benefit and more likely to have detriment from early surgery. Reference classes were characterized by the appropriateness of early surgery rates with respect to benefit and detriment. Conclusions: Extended IV-CFA provides an illuminating method to uncover reference classes of patients based on treatment effects using observational data with a strong instrumental variable. This study isolated reference classes of new PHF patients in which changes in early surgery rates would improve patient outcomes. The inability to measure fracture complexity in Medicare claims means providers will need to discuss the appropriateness of these estimates to patients within a reference class in context of this missing information.

scholarly journals Personalizing Evidence for Shoulder Fracture Patients Using an Extended Instrumental Variable Causal Forest Algorithm

2021 ◽  
Author(s):  
John M. Brooks ◽  
Cole G. Chapman ◽  
Sarah Floyd ◽  
Brian K. Chen ◽  
Charles A. Thigpen ◽  
...  
Keyword(s):  
Instrumental Variable ◽  
Day Treatment ◽  
Early Surgery ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Reference Class ◽  
Shoulder Fracture ◽  
Population Classification ◽  
Reference Classes ◽  
Surgery Rates

Objective: To assess the ability of an extended Instrumental Variable Causal Forest Algorithm (IV-CFA) to provide personalized evidence of early surgery effects on benefits and detriments for elderly shoulder fracture patients. Data Sources/Study Setting: Population of 72,751 fee-for-service Medicare beneficiaries with proximal humerus fractures (PHFs) in 2011 who survived a 60-day treatment window after an index PHF and were continuously Medicare fee-for-service eligible over the period 12 months prior to index to the minimum of 12 months after index or death. Study Design: IV-CFA estimated early surgery effects on both beneficial and detrimental outcomes for each patient in the study population. Classification and regression trees (CART) were applied to these estimates to create patient reference classes. Two-stage least squares (2SLS) estimators were applied to patients in each reference class to scrutinize the estimates relative to the known 2SLS properties. Principal Findings: This approach uncovered distinct reference classes of elderly PHF patients with respect to early surgery effects on benefit and detriment. Older, frailer patients with more comorbidities, and lower utilizers of healthcare were less likely to gain benefit and more likely to have detriment from early surgery. Reference classes were characterized by the appropriateness of early surgery rates with respect to benefit and detriment. Conclusions: Extended IV-CFA provides an illuminating method to uncover reference classes of patients based on treatment effects using observational data with a strong instrumental variable. This study isolated reference classes of new PHF patients in which changes in early surgery rates would improve patient outcomes. The inability to measure fracture complexity in Medicare claims means providers will need to discuss the appropriateness of these estimates to patients within a reference class in context of this missing information.

scholarly journals Obstructive Sleep Apnea Treatment and Dementia Risk in Older Adults

SLEEP ◽  
2021 ◽  
Author(s):  
G L Dunietz ◽  
R D Chervin ◽  
J F Burke ◽  
A S Conceicao ◽  
T J Braley
Keyword(s):  
Older Adults ◽  
Statistical Significance ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Lower Odds ◽  
Logistic Regression Models ◽  
Not Otherwise Specified ◽  
Dementia Risk ◽  
Obstructive Sleep ◽  
Study Participants

Abstract Study Objectives To examine associations between PAP therapy, adherence and incident diagnoses of Alzheimer’s disease (AD), mild cognitive impairment (MCI), and dementia not-otherwise-specified (DNOS) in older adults. Methods This retrospective study utilized Medicare 5% fee-for-service claims data of 53,321 beneficiaries, aged 65+, with an OSA diagnosis prior to 2011. Study participants were evaluated using ICD-9 codes for neurocognitive syndromes [AD(n=1,057), DNOS(n=378), and MCI(n=443)] that were newly-identified between 2011-2013. PAP treatment was defined as presence of ≥1 durable medical equipment (HCPCS) code for PAP supplies. PAP adherence was defined as ≥2 HCPCS codes for PAP equipment, separated by≥1 month. Logistic regression models, adjusted for demographic and health characteristics, were used to estimate associations between PAP treatment or adherence and new AD, DNOS, and MCI diagnoses. Results In this sample of Medicare beneficiaries with OSA, 59% were men, 90% were non-Hispanic whites and 62% were younger than 75y. The majority (78%) of beneficiaries with OSA were prescribed PAP (treated), and 74% showed evidence of adherent PAP use. In adjusted models, PAP treatment was associated with lower odds of incident diagnoses of AD and DNOS (OR=0.78, 95% CI:0.69-0.89; and OR=0.69, 95% CI:0.55-0.85). Lower odds of MCI, approaching statistical significance, were also observed among PAP users (OR=0.82, 95% CI:0.66-1.02). PAP adherence was associated with lower odds of incident diagnoses of AD (OR=0.65, 95% CI:0.56-0.76). Conclusions PAP treatment and adherence are independently associated with lower odds of incident AD diagnoses in older adults. Results suggest that treatment of OSA may reduce risk of subsequent dementia.

Race, sex and age disparities in echocardiography among Medicare beneficiaries in an integrated healthcare system

Heart ◽  
2021 ◽  
pp. heartjnl-2021-319951
Author(s):  
Patrick M Hyland ◽  
Jiaman Xu ◽  
Changyu Shen ◽  
Lawrence J Markson ◽  
Warren J Manning ◽  
...  
Keyword(s):  
Black Women ◽  
Healthcare System ◽  
Chronic Obstructive ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Older Individuals ◽  
Integrated Healthcare ◽  
Obstructive Pulmonary Disease ◽  
White Race ◽  
Age Disparities

ObjectiveTo identify potential race, sex and age disparities in performance of transthoracic echocardiography (TTE) over several decades.MethodsTTE reports from five academic and community sites within a single integrated healthcare system were linked to 100% Medicare fee-for-service claims from 1 January 2005 to 31 December 2017. Multivariable Poisson regression was used to estimate adjusted rates of TTE utilisation after the index TTE according to baseline age, sex, race and comorbidities among individuals with ≥2 TTEs. Non-white race was defined as black, Asian, North American Native, Hispanic or other categories using Medicare-assigned race categories.ResultsA total of 15 870 individuals (50.1% female, mean 72.2±12.7 years) underwent a total of 63 535 TTEs (range 2–55/person) over a median (IQR) follow-up time of 4.9 (2.4–8.5) years. After the index TTE, the median TTE use was 0.72 TTEs/person/year (IQR 0.43–1.33; range 0.12–26.76). TTE use was lower in older individuals (relative risk (RR) for 10-year increase in age, 0.91, 95% CI 0.89 to 0.92, p<0.001), women (RR 0.97, 95% CI 0.95 to 0.99, p<0.001) and non-white individuals (RR 0.95, 95% CI 0.93 to 0.97, p<0.001). Black women in particular had the lowest relative use of TTE (RR 0.92, 95% CI 0.88 to 0.95, p<0.001). The only clinical conditions associated with increased TTE use after multivariable adjustment were heart failure (RR 1.04, 95% CI 1.00 to 1.08, p=0.04) and chronic obstructive pulmonary disease (RR 1.05, 95% CI 1.00 to 1.10, p=0.04).ConclusionsAmong Medicare beneficiaries with multiple TTEs in a single large healthcare system, the median TTE use after the index TTE was 0.72 TTEs/person/year, although this varied widely. Adjusted for comorbidities, female sex, non-white race and advancing age were associated with decreased TTE utilisation.

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.

Which reference class is evoked?

1996 ◽  
Vol 19 (1) ◽  
pp. 34-35
Author(s):  
Craig R. M. McKenzie ◽  
Jack B. Soll
Keyword(s):  
Search Space ◽  
Reference Class ◽  
Base Rates ◽  
Reference Classes ◽  
Choose People

AbstractAny instance (i.e., event, behavior, trait) belongs to infinitely many reference classes, hence there are infinitely many base rates from which to choose. People clearly do not entertain all possible reference classes, however, so something must be limiting the search space. We suggest some possible mechanisms that determine which reference class is evoked for the purpose of judgment and decision.

Abstract 141: Trends in Left Ventricle Assist Device Use, Outcomes and Costs among Medicare Beneficiaries, 1999 to 2008.

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Julianna F Lampropulos ◽  
Yun Wang ◽  
Mayur Desai ◽  
Nancy Kim ◽  
Jose A Barreto-Filho ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Left Ventricle ◽  
Hospital Mortality ◽  
Age Groups ◽  
Fee For Service ◽  
Technological Advancement ◽  
Medicare Beneficiaries ◽  
Assist Device ◽  
One Year ◽  
Ventricle Assist Device

Background: Over the last decade, left ventricle assist device (LVAD) technology has improved substantially, resulting in smaller devices requiring less invasive procedures, which has broadened its clinical indications to frail populations. During this time of technological advancement, we examined trends in use, mortality, and associated costs of LVADs among Medicare beneficiaries. Methods: Inpatient Medicare standard analytic files were used to identify 100% of fee-for-service (FFS) patients aged ≥65 years that received LVAD (ICD-9-CM codes 37.60, 37.62, 37.65, 37.66 and 37.68) from 1999 to 2008. We constructed a denominator file from Medicare administrative data to report operative rates per 1,000,000 beneficiary-years. Length of stay, hospital mortality, thirty-day and one-year mortality were ascertained through corresponding vital status files. Costs were defined as hospital payments made by Medicare. Results: Among Medicare FFS patients, the overall LVAD procedure rate increased from 13.8 per million beneficiary-years (365 procedures) in 1999 to 19.8 per million beneficiary-years (548 procedures) in 2008, a relative increase of 44 %. In addition, between 1999 and 2008 overall length of stay increased from 19.1 days to 23.8 days; hospital mortality decreased from 42.5% to 33.4%, 30-day mortality decreased from 38.9% to 30.7% and one-year mortality decreased from 54% to 47.1%. Total CMS payments for the hospitalizations in which LVADs were placed increased from $20,188,880 ($55,312/patient) in 1999 to $71,050,392 ($129,654/patient) in 2008. Over the study period, LVAD use increased in all age groups, most strikingly among the ≥75 years old, in whom incidence increased from 151 procedures in 1999 to 192 procedures in 2008, representing 35% of the LVAD implantation in the Medicare population in 2008. Conclusions: From 1999 to 2008, LVAD use increased substantially with a decrease in hospital, 30-day and one-year mortality.

Abstract TP493: Herpes Zoster Vaccine Live And Risk For Stroke Among Medicare Beneficiaries: Population Based Matched Cohort Study

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Quanhe YANG ◽  
Anping Chang ◽  
Xin Tong ◽  
Robert Merritt
Keyword(s):  
Herpes Zoster ◽  
Hemorrhagic Stroke ◽  
Population Based ◽  
Racial Groups ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Zoster Vaccine ◽  
Hazard Ratios ◽  
Increased Risk ◽  
History Of

Introduction: Herpes zoster (HZ) is associated with increased risk of stroke, and Zoster Vaccine Live (ZVL) reduces risk of HZ. No study examined the association between ZVL and risk for stroke. The present study examined this association among US older population. Methods: We included 1,382,051 Medicare fee-for-service beneficiaries age ≥66 years without a history of stroke and who received ZVL during 2008-2014, and 1,382,051 matched controls (using a comprehensive list of matching variables) without ZVL followed from ZVL receipt to December 31 2016. We used Cox proportional hazard models to examine the association between ZVL and composite fatal/non-fatal incident stroke outcomes. Results: During a median of 3.9 years follow-up (interquartile range 2.7-5.4), we documented 42,267 stroke events including 33,510 acute ischemic strokes (AIS) and 4,318 hemorrhagic strokes among beneficiaries who received ZVL over 5,890,113 person years. The corresponding numbers for controls were 48,139, 39,334, and 4,713 during 5,693,943 person years. Crude incidence comparing beneficiaries with and without ZVL were 7.18 vs. 8.45 per 1000 person years for all stroke, 5.40 vs. 6.53 for AIS, and 0.73 vs. 0.82 for hemorrhagic stroke (p<0.001 for difference). Adjusted hazard ratios comparing beneficiaries with ZVL to controls were 0.84 (95% CI 0.83-0.85), 0.82 (0.81-0.83), and 0.88 (0.84-0.91) for all stroke, AIS and hemorrhagic stroke respectively. The association between ZVL and risk for stroke appeared to be stronger among beneficiaries 66-79 years compared to those ≥80 years of age (p=0.020 for interaction), but largely consistent across sex, and racial groups. Conclusion: Among Medicare beneficiaries, receipt of ZVL was associated with lower incidence of stroke. Further study is needed to confirm our findings.

Association Between Increased Hospital Reimbursement for Cardiac Rehabilitation and Utilization of Cardiac Rehabilitation by Medicare Beneficiaries

2021 ◽  
Vol 14 (3) ◽  
Author(s):  
Dana R. Fletcher ◽  
Gary K. Grunwald ◽  
Catherine Battaglia ◽  
P. Michael Ho ◽  
Richard C. Lindrooth ◽  
...  
Keyword(s):  
Cardiac Rehabilitation ◽  
Time Window ◽  
Artery Bypass ◽  
Cost Effective ◽  
Coronary Intervention ◽  
Guideline Recommendation ◽  
Annual Growth Rate ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Percentage Points

Background: Although cardiac rehabilitation (CR) is a Class I Guideline recommendation, and has been shown to be a cost-effective intervention after a cardiac event, it has been reimbursed at levels insufficient to cover hospital operating costs. In January 2011, Medicare increased payment for CR in hospital outpatient settings by ≈180%. We evaluated the association between this payment increase and participation in CR of eligible Medicare beneficiaries to better understand the relationship between reimbursement policy and CR utilization. Methods: From a 5% Medicare claims sample, we identified patients with acute myocardial infarction, coronary artery bypass surgery, percutaneous coronary intervention, or cardiac valve surgery between January 1, 2009 and September 30, 2012, alive 30 days after their event, with continuous enrollment in Medicare fee-for-service, Part A/B for 4 months. Trends and changes in CR participation were estimated using an interrupted time series approach with a hierarchical logistic model, hospital random intercepts, adjusted for patient, hospital, market, and seasonality factors. Estimates were expressed using average marginal effects on a percent scale. Results: Among 76 695 eligible patients, average annual CR participation was 19.5% overall. In the period before payment increase, adjusted annual participation grew by 1.1 percentage points (95% CI, 0.48–2.4). No immediate change occurred in CR participation when the new payment was implemented. In the period after payment increase, on average, 20% of patients participated in CR annually. The annual growth rate in CR participation slowed in the post-period by 1.3 percentage points (95% CI, −2.4 to −0.12) compared with the prior period. Results were somewhat sensitive to time window variations. Conclusions: The 2011 increase in Medicare reimbursement for CR was not associated with an increase in participation. Future studies should evaluate whether payment did not reach a threshold to incentivize hospitals or if hospitals were not sensitive to reimbursement changes.

Abstract 281: Contemporary Epidemiology of Atrial Fibrillation Among Medicare Beneficiaries, 2004-2013

2018 ◽  
Vol 11 (suppl_1) ◽  
Author(s):  
Joshua Parker ◽  
Rohan Khera ◽  
Ambarish Pandey ◽  
Daniel Cheeran ◽  
Colby Ayers ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Black Men ◽  
White Men ◽  
National Sample ◽  
Outpatient Setting ◽  
Relative Increase ◽  
Racial Groups ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Men And Women

Background: Atrial fibrillation (AF) is the most common dysrhythmia in clinical practice, and is a significant contributor to morbidity and mortality. Prior reports have projected a large increase in AF burden over time. A contemporary assessment of epidemiology is needed to assess if an emphasis of prevention strategies over the last decade has been effective in alleviating this risk. Methods: We used a 5% national sample of all Medicare beneficiaries in the US from 2002 through 2013 to construct a longitudinal cohort of 2.3 million fee-for-service Medicare beneficiaries administratively followed for ≥2 years using claims data. Trends in incident and prevalent AF were assessed for 2004 through 2013. Using ICD-9 codes, encounters with AF were identified from inpatient, outpatient, and physician claims. AF during the first 2 years of entry into the cohort was defined as pre-existing AF. Incident AF was defined as having either 1 inpatient claim with a diagnosis of AF or 2 outpatient or physician claims with AF. Calendar-year prevalence comprised pre-existing and incident AF for the respective years as well as those with incident AF in preceding years. Age-adjusted time trends were assessed using Poisson regression. Results: Between 2002 and 2013, 219,570 patients had incident AF. At incidence, mean age was 79 years, 55% were women, and 92% and 5% were white and black, respectively. Age-adjusted AF incidence decreased by 0.4/1000 per year between 2004 (20/1000) and 2013 (17/1000). While incidence declined for white men and women (P<.05), it has remained unchanged for black men and women (Figure). Proportion of incident events in the outpatient setting increased from 26% to 40%. One-year mortality was 9%, and remained unchanged throughout the study period. Over this period, the overall prevalence of AF decreased by 0.9/1000 per year (p<.05), however, there was a relative increase in AF prevalence among black men. Conclusions: Between years 2004 and 2013, the overall incidence and prevalence of AF among a 5% sample of Medicare beneficiaries stabilized. There were, however, differences across racial groups, with a slight decline in incidence among white men and women, which was not observed in black men and women.

scholarly journals Economic Burden of Osteoporosis-Related Fractures in the US Medicare Population

2020 ◽  
pp. 106002802097051 ◽  
Author(s):  
Setareh A. Williams ◽  
Shanette G. Daigle ◽  
Richard Weiss ◽  
Yamei Wang ◽  
Tarun Arora ◽  
...  
Keyword(s):  
Economic Burden ◽  
Linear Models ◽  
Hospice Care ◽  
Skilled Nursing Facility ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Public Health Burden ◽  
Osteoporosis Related Fracture

Background Osteoporosis-related fractures are an important public health burden. Objective To examine health care costs in Medicare patients with an osteoporosis-related fracture. Methods Medicare fee-for-service members with an osteoporosis-related fracture between January 1, 2010, to September 30, 2014 were included. A nonfracture comparator group was selected by propensity score matching. Generalized linear models using a gamma distribution were used to compare costs between fracture and nonfracture cohorts. Results A total of 885 676 Medicare beneficiaries had fracture(s) and met inclusion criteria. Average age was 80.5 (±8.4) years; 91% were White, and 94% female. Mean all-cause costs were greater in the fracture vs nonfracture cohort ($47 163.25 vs $16 034.61) overall and for men ($52 273.79 vs $17 352.68). The highest mean costs were for skilled nursing facility ($29 216), inpatient costs ($24 190.19), and hospice care ($20 996.83). The highest incremental costs versus the nonfracture cohort were for hip ($71 057.83 vs $16 807.74), spine ($37 543.87 vs $16 860.49), and radius/ulna ($24 505.27 vs $14 673.86). Total medical and pharmacy costs for patients who experienced a second fracture were higher compared with those who did not ($78 137.59 vs $44 467.47). Proportionally more patients in the fracture versus nonfracture cohort died (18% vs 9.3%), with higher death rates among men (20% vs 11%). Conclusion and Relevance The current findings suggest a significant economic burden associated with fractures. Early identification and treatment of patients at high risk for fractures is of paramount importance for secondary prevention and reduced mortality.

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