The influence of primary care quality on nursing home admissions in a multimorbid population with and without dementia in Germany: a retrospective cohort study using health insurance claims data

Background Multimorbidity poses a challenge for high quality primary care provision for nursing care-dependent people with (PWD) and without (PWOD) dementia. Evidence on the association of primary care quality of multimorbid PWD and PWOD with the event of a nursing home admission (NHA) is missing. This study aimed to investigate the contribution of individual quality of primary care for chronic diseases in multimorbid care-dependent PWD and PWOD on the duration of ongoing residence at home before the occurrence of NHA. Methods We conducted a retrospective cohort study among elderly care-dependent PWD and PWOD in Germany for six combinations of chronic diseases using statutory health insurance claims data (2007–2016). Primary care quality was measured by 21 process and outcome indicators for hypertension, diabetes, depression, chronic obstructive pulmonary disease and heart failure. The primary outcome was time to NHA after initial onset of care-dependency. Multivariable Cox proportional hazard models were used to compare the time-to-event between PWD and PWOD. Results Among 5876 PWD and 12,837 PWOD 5130 NHA occurred. With the highest proportion of NHA for PWD with hypertension and depression and for PWOD with hypertension, diabetes and depression. Average duration until NHA ranged from 6.5 to 8.9 quarters for PWD and from 9.6 to 13.5 quarters for PWOD. Adjusted analyses show consistent associations of the quality of diabetes care with the duration of remaining in one’s own home regardless of the presence of dementia. Process indicators assessing guideline-fidelity are associated with remaining in one’s home longer, while indicators assessing complications, such as emergency inpatient treatment (HR = 2.67, 95% CI 1.99–3.60 PWD; HR = 2.81, 95% CI 2.28–3.47 PWOD) or lower-limb amputation (HR = 3.10, 95% CI 1.78–5.55 PWD; HR = 2.81, 95% CI 1.94–4.08 PWOD) in PWD and PWOD with hypertension and diabetes, increase the risk of NHA. Conclusions The quality of primary care provided to care-dependent multimorbid PWD and POWD, influences the time individuals spend living in their own homes after onset of care-dependency before a NHA. Health care professionals should consider possibilities and barriers of guideline-based, coordinated care for multimorbid care-dependent people. Further research on quality indicator sets that acknowledge the complexity of care for multimorbid elderly populations is needed.

Using machine learning to examine drivers of inappropriate outpatient antibiotic prescribing in acute respiratory illnesses

Using a machine-learning model, we examined drivers of antibiotic prescribing for antibiotic-inappropriate acute respiratory illnesses in a large US claims data set. Antibiotics were prescribed in 11% of the 42 million visits in our sample. The model identified outpatient setting type, patient age mix, and state as top drivers of prescribing.

Use of Palliative Care Among Commercially Insured Patients With Metastatic Cancer Between 2001 and 2016

PURPOSE: Early palliative care, concomitant with disease-directed treatments, is recommended for all patients with advanced cancer. This study assesses population-level trends in palliative care use among a large cohort of commercially insured patients with metastatic cancer, applying an expanded definition of palliative care services based on claims data. METHODS: Using nationally representative commercial insurance claims data, we identified patients with metastatic breast, colorectal, lung, bronchus, trachea, ovarian, esophageal, pancreatic, and liver cancers and melanoma between 2001 and 2016. We assessed the annual proportions of these patients who received services specified as, or indicative of, palliative care. Using Cox proportional hazard models, we assessed whether the time from diagnosis of metastatic cancer to first encounter of palliative care differed by demographic characteristics, socioeconomic factors, or region. RESULTS: In 2016, 36% of patients with very poor prognosis cancers received a service specified as, or indicative of, palliative care versus 18% of those with poor prognosis cancers. Being diagnosed in more recent years (2009-2016 v 2001-2008: hazard ratio [HR], 1.8; P < .001); a diagnosis of metastatic esophagus, liver, lung, or pancreatic cancer, or melanoma ( v breast cancer, eg, esophagus HR, 1.89; P < .001); a greater number of comorbidities (American Hospital Formulary Service classes > 10 v 0: HR, 1.71; P < .001); and living in the Northeast (HR, 1.43; P < .001) or Midwest ( v South: HR, 1.39; P < .001) were the strongest predictors of shorter time from diagnosis to palliative care. CONCLUSION: Use of palliative care among commercially insured patients with advanced cancers has increased since 2001. However, even with an expanded definition of services specified as, or indicative of, palliative care, < 40% of patients with advanced cancers received palliative care in 2016.

Automobile Fatal Accident and Insurance Claim Analysis Through Artificial Neural Network

This chapter presents a thorough descriptive analysis of automobile fatal accident and insurance claims data. Major components of the artificial neural network (ANN) are discussed, and parameters are investigated and carefully selected to ensure an efficient model construction. A prediction model is constructed through ANN as well as generalized linear model (GLM) for model comparison purposes. The authors conclude that ANN performs better than GLM in predicting data for automobile fatalities data but does not outperform for the insurance claims data because automobile fatalities data has a more complex data structure than the insurance claims data.

Identification Of Dementia In Recent Medicare Claims Data, Compared To Rigorous Clinical Assessments

BACKGROUND Medicare fee-for-service (FFS) claims data are increasingly leveraged for dementia research. Few studies address the validity of recent claims data to identify dementia, or carefully evaluate characteristics of those assigned the wrong diagnosis in claims. METHODS We used claims data from 2014-2018, linked to participants administered rigorous, annual dementia evaluations in five cohorts at the Rush Alzheimer’s Disease Center. We compared prevalent dementia diagnosed through the 2016 cohort evaluation versus claims identification of dementia, applying the Bynum-standard algorithm. RESULTS Of 1,054 participants with Medicare Parts A and B FFS in a 3-year window surrounding their 2016 index date, 136 had prevalent dementia diagnosed during cohort evaluations; the claims algorithm yielded 217. Sensitivity of claims diagnosis was 79%, specificity 88%, positive predictive value 50%, negative predictive value 97%, and overall accuracy 87%. White participants were disproportionately represented among detected dementia cases (true-positive) versus cases missed (false-negative) by claims (90% versus 75%, respectively, p=0.04). Dementia appeared more severe in detected than missed cases in claims (mean MMSE=15.4 versus 22.0, respectively, p&lt;0.001; 28% with no limitations in activities of daily living versus 45%, p=0.046). By contrast, those with “over-diagnosis” of dementia in claims (false-positive) had several worse health indicators than true negatives (eg, self-reported memory concerns=51% versus 29%, respectively, p&lt;0.001; mild cognitive impairment in cohort evaluation=72% versus 44%, p&lt;0.001; mean comorbidities=7 versus 4, p&lt;0.001). CONCLUSIONS Recent Medicare claims perform reasonably well in identifying dementia; however, there are consistent differences in cases of dementia identified through claims than in rigorous cohort evaluations.

Periodontal Disease and Risk of Dementia in Medicare Patients with Hepatitis C Virus

Background: Periodontal disease and hepatitis C virus (HCV) represent chronic infectious states that are common in elderly adults. Both conditions have independently been associated with an increased risk for dementia. Chronic infections are thought to lead to neurodegenerative changes in the central nervous system possibly by promoting a proinflammatory state. This is consistent with growing literature on the etiological role of infections in dementia. Few studies have previously evaluated the association of periodontal disease with dementia in HCV patients. Objective: To examine whether periodontal disease increases the risk of developing Alzheimer’s disease and related dementias (ADRD) among HCV patients in Medicare claims data. Methods: We used Medicare claims data for HCV patients to assess the incidence rate of ADRD with and without exposure to periodontal disease between 2014 and 2017. Cox multivariate regression was used to estimate the association between periodontal disease and development of ADRD, controlling for age, gender, race, ZIP-level income and education, and medical comorbidities. Results: Of 439,760 HCV patients, the incidence rate of ADRD was higher in patients with periodontal diseases compared to those without (10.84% versus 9.26%, p < 0.001), and those with periodontal disease developed ADRD earlier compared to those without periodontal disease (13.99 versus 21.60 months, p < 0.001). The hazard of developing ADRD was 1.35 times higher in those with periodontal disease (95% CI, 1.30 to 1.40, p < 0.001) after adjusting for all covariates, including age. Conclusion: Periodontal disease increased the risk of developing ADRD among HCV patients in a national Medicare claims dataset.