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<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<0.001; mild cognitive impairment in cohort evaluation=72% versus 44%, p<0.001; mean comorbidities=7 versus 4, p<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.

Rural and Urban Difference in Longitudinal Trends in Prevalence of Dementia in Medicare Claims and Survey Data

Shortage of physicians in rural areas can lead to lower diagnosis and underestimation of dementia prevalence in these communities. We used data from the nationally representative Health and Retirement Study and a 20-percent sample of Medicare claims to study rural-urban differences in dementia prevalence. The survey dementia diagnosis is free from medical assessment while the claims diagnosis needs a physician diagnosis. We estimated the trends in dementia prevalence from (2002-2016) based on cognitive tests (using survey data) and diagnosis codes (using claims data) utilizing ordinary least squares regression. Dementia prevalence based on diagnosis codes declined in both urban and rural areas over the course of the study, with a sharper decline in urban areas. Dementia prevalence using diagnosis codes showed significantly higher rates in urban areas during all years (0.024 vs 0.018 in 2002 and 0.017 vs 0.013 in 2014 in rural vs urban areas, respectively). Dementia in the cognitive test sample was higher in rural areas (0.11 vs 0.08 in 2000 and 0.08 vs 0.7 in 2014 in rural vs urban areas), a difference that was significant only in 2004. Our results indicate lower dementia prevalence rates in rural areas in claims based sample compared to survey sample which its dementia prevalence is free medical assessment. Claims data are valuable sources for tracking dementia in the US population, however they are based on medical diagnosis.In rural areas, where there is shortage of physicians and a lack of access to health care services, claims based studies may underestimate dementia rates.

Risk of hospitalized and non-hospitalized gastrointestinal bleeding in ALLHAT trial participants receiving diuretic, ACE-inhibitor, or calcium-channel blocker

Objectives This post-trial data linkage analysis was to utilize the data of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants linked with their Medicare data to examine the risk of hospitalized and non-hospitalized gastrointestinal (GI) bleeding associated with antihypertensives. Settings ALLHAT was a multicenter, randomized, double-blind, active-controlled trial conducted in a total of 42,418 participants aged ≥55 years with hypertension in 623 North American centers. Data for ALLHAT participants who were aged at ≥65 have been linked with their Medicare claims data. Participants A total of 16,676 patients (4,480 for lisinopril, 4,537 for amlodipine, and 7,659 for chlorthalidone) with complete Medicare claims data were available for the final analysis. Results The cumulative incidences through March 31, 2002 of hospitalized GI bleeding were 5.4%, 5.8% and 5.4% for amlodipine, lisinopril, and chlorthalidone arms, respectively, but were not statistically significant among the 3 arms after adjusting for confounders in Cox regression models. The cumulative incidences of non-hospitalized GI bleeding were also similar across the 3 arms (12.0%, 12.2% and 12.0% for amlodipine, lisinopril, and chlorthalidone, respectively). The increased risk of GI bleeding by age was statistically significant after adjusting for confounders (HR = 1.04 per year, 95% CI: 1.03–1.05). Smokers also had a significantly higher risk of having hospitalized GI bleeding (1.45, 1.19–1.76). Hispanics, those who used aspirin or atenolol in-trial, had diabetes, more education, and a history of stroke had a significantly lower risk of having GI bleeding than their counterparts. Other factors such as gender, history of CHD, prior antihypertensive use, use of estrogen in women, and obesity did not have significant effects on the risk of GI bleeding. Conclusion There were no statistically significant differences on the risk of hospitalized or non-hospitalized GI bleeding among the 3 ALLHAT trial arms (amlodipine, lisinopril, and chlorthalidone) during the entire in-trial follow-up.

No increased risk of Alzheimer’s disease among people with immune-mediated inflammatory diseases: findings from a longitudinal cohort study of U.S. older adults

Objective Immune-mediated inflammatory diseases (IMID) are characterized by systemic inflammation affecting the joints and bodily organs. Studies examining the association between individual IMIDs and the risk of Alzheimer’s disease (AD) have yielded inconsistent findings. This study examines AD risk across a group of IMIDs in a large population-based sample of older adults. Methods Data on a national sample of US adults over age 50 was drawn from the Health and Retirement Study (HRS) and linked Medicare claims from 2006 to 2014. IMIDs include rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, and related conditions. We identified IMIDs from 2006 to 2009 Medicare claims using International Classification of Diseases (ICD9-CM) codes. The date of incident AD was derived from Chronic Conditions Warehouse (CCW) identifiers. We examined the risk of AD from 2009 to 2014 using Cox proportional hazards models, both unadjusted and adjusted for age, gender, education, race, and the genetic risk factor APOE-e4. Results One hundred seventy-one (6.02%) of the 2842 total HRS respondents with Medicare coverage and genetic data were classified with IMIDs. Over the subsequent 6 years, 9.36% of IMID patients developed AD compared to 8.57% of controls (unadjusted hazard ratio (HR): 1.09, 95% CI .66–1.81, p = 0.74). Adjusted HR 1.27 (95% CI 0.76–2.12, p = 0.35). Age (HR for 10-year increment 3.56, p < .001), less than high school education (HR 1.70, p = .007), and APOE-e4 (HR 2.61, p < .001 for one or two copies), were also statistically significant predictors of AD. Conclusion HRS respondents with common IMIDs do not have increased risk of Alzheimer’s disease over a 6-year period.

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

Objective:To examine whether periodontal disease increases the risk of developing Alzheimer’s disease and related dementias (ADRD) among hepatitis C patients in Medicare claims data.Background:Periodontal disease and hepatitis C virus (HCV) represent chronic infectious statesthat 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. No studies have evaluated the association of periodontal disease with dementia in HCV patients.Methods:We used Medicare claims data for HCV patients to assess the incidence rate of ADRDwith and without exposure to periodontal disease between 2014 and 2017. Diagnosis of periodontal disease, HCV, and ADRD were based on ICD-9 and ICD-10 codes. A Cox multivariate regression model 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 the 440,578 patients in the dataset, the incidence rate of ADRD in the periodontal disease group was higher compared to those without periodontal disease (10.77% vs. 9.27%, p<0.001, and those with periodontal disease developed ADRD earlier compared to those withoutperiodontal disease (1.15 vs. 1.78 years, p<0.001). The hazard of developing ADRD was 1.23 times higher in those with periodontal disease (95% CI, 1.19 to 1.27, p< 0.001) after adjusting for all covariates, including age.Conclusion:Periodontal disease increased the risk of developing ADRD in HCV patients in anational Medicare claims dataset.

Effects of Dipeptidyl Peptidase-4 Inhibitors and Sulfonylureas on Cognitive and Physical Function in Nursing Home Residents

Aims: Dipeptidyl peptidase-4 inhibitors (DPP4Is) may mitigate hypoglycemia-mediated declines in cognitive and physical functioning compared to sulfonylureas (SUs), yet comparative studies are unavailable among older adults, especially nursing home (NH) residents. We evaluated the effects of DPP4Is versus SUs on cognitive and physical functioning among NH residents. Materials and Methods: This new-user cohort study included long-stay NH residents aged ≥65 years from the 2007-2010 national US Minimum Data Set (MDS) clinical assessments and linked Medicare claims. We measured cognitive decline from the validated 6-point MDS Cognitive Performance Scale, functional decline from the validated 28-point MDS Activities of Daily Living scale, and hospitalizations or emergency department visits for altered mental status from Medicare claims. We compared 180-day outcomes in residents who initiated a DPP4I versus SU after propensity score matching using Cox regression models. Results: The cohort (N=1,784) had a mean (SD) age of 80 (8) years and was 73% female. Approximately 46% had no or mild cognitive impairment and 35% had no or mild functional impairment before treatment initiation. Compared to SU users, DPP4I users had statistically similar 180-day rates of cognitive decline (HR=0.61, 95%CI 0.31-1.19), altered mental status events (HR=0.71, 95%CI 0.39-1.27), and functional decline (HR=0.89, 95%CI 0.51-1.56). Conclusions: Rates of cognitive and functional decline were not markedly reduced among DPP4I users compared to SU users, but the point estimates and lower 95% confidence bounds do not rule out the possibility that DPP4Is result in reduced rates. Larger studies with greater statistical power should resolve this remaining uncertainty.