Telemedicine Use Among Older Adults During the COVID-19 Pandemic

Objective Although technology adoption among older adults is improving, ethnic minorities and those with socioeconomic disadvantages may have lower utilization of telemedicine. Here, we evaluate telemedicine uptake amongst community-based older adults. Materials and Methods Using a retrospective cohort design, we examined electronic medical records (EMR) for documentation of telemedicine use among patients > 65 years old at Geriatric practices in the New York metropolitan area from January-November 2020. Demographic details and insurance payer were captured for telemedicine visits and compared to in-person encounters. Multivariable regression was used to evaluate the association of demographic, socioeconomic factors and visit type. Results A total of 712 patients (32.3%) engaged in 1,085 telemedicine visits. Telemedicine represented 80% and 66% of all encounters during April and May, respectively and averaged 11.8% between June and November. Use was similar across age groups, gender, race and insurance payer status between telemedicine versus in-person encounters. Patients with greater number of comorbidities were more likely to use telemedicine-. Medicaid recipients had preference for video visits. 47.5% of patients who engaged in video visits had another person/family member present during an encounter. Conclusions Telemedicine augmented access to health care for older individuals during the peak of the COVID pandemic and continues to be utilized to improve access to care for older Americans. Given the distinct preference for video visits among patients with multiple medical conditions and those who have Medicaid, telemedicine has potential to serve as a tool to reduce enduring health care disparities beyond the pandemic.

Incident Strokes Among American Indian Individuals With Atrial Fibrillation

BACKGROUND American Indian individuals experience a relatively high risk for cardiovascular disease and have exhibited a higher risk of stroke compared with other racial and ethnic minorities. Although this population has the highest incidence of atrial fibrillation (AF) compared with other groups, the relationship between AF and nonhemorrhagic stroke among American Indian individuals compared with other groups has not been thoroughly studied. METHODS and RESULTS We used the Healthcare Cost and Utilization Project to evaluate risk of nonhemorrhagic stroke among American Indian individuals, with comparisons to White, Black, Hispanic, and Asian individuals, among all adult California residents receiving care in an emergency department, inpatient hospital unit, or ambulatory surgery setting from 2005 to 2011. Of 16 951 579 patients followed for a median 4.1 years, 105 822 (0.6%) were American Indian. After adjusting for age, sex, income level, insurance payer, hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, cardiac surgery, valvular heart disease, chronic kidney disease, smoking, obstructive sleep apnea, pulmonary disease, and alcohol use, American Indian individuals with AF exhibited the highest risk of nonhemorrhagic stroke when compared with either non‐American Indian individuals with AF (hazard ratio, 1.38; 95% CI, 1.23–1.55; P <0.0001) or to each race and ethnicity with AF. American Indian individuals also experienced the highest overall risk for stroke, with no evidence that AF disproportionately heightened that risk in interaction analyses. CONCLUSIONS American Indian individuals experienced the highest risk of nonhemorrhagic stroke, whether in the presence or absence of AF. Our findings likely suggest an opportunity to further study, if not immediately address, guideline‐adherent anticoagulation prescribing patterns among American Indian individuals with AF.

Insurance Payer Status Predicts Postoperative Speech Outcomes in Adult Cochlear Implant Recipients

Background Cochlear implant qualifying criteria for adult patients with public insurance policies are stricter than the labeled manufacturer criteria. It remains unclear whether insurance payer status affects expedient access to implants for adult patients who could derive benefit from the devices. Purpose This study examined whether insurance payer status affected access to cochlear implant services and longitudinal speech-perception outcomes in adult cochlear implant recipients. Research Design Retrospective cross-sectional study. Study Sample Sixty-eight data points were queried from the Health Insurance Portability and Accountability Act–Secure, Encrypted, Research Management and Evaluation Solution database which consists of 12,388 de-identified data points from adult and pediatric cochlear implant recipients. Data Analysis Linear mixed-effects models were used to determine whether insurance payer status affected expedient access to cochlear implants and whether payer status predicted longitudinal postoperative speech-perception scores in quiet and noise. Results Results from linear mixed-effects regression models indicated that insurance payer status was a significant predictor of behavioral speech-perception scores in quiet and in background noise, with patients with public insurance experiencing poorer outcomes. In addition, extended wait time to receive a cochlear implant was predicted to significantly decrease speech-perception outcomes for patients with public insurance. Conclusion This study documented patients covered by public health insurance wait longer to receive cochlear implants and experience poorer postoperative speech-perception outcomes. These results have important clinical implications regarding the cochlear implant candidacy criteria and intervention protocols.

Abstract 14164: Trends in U.S. Spending on Diabetes Therapies by Insurance Payer From 2007 to 2017

Importance: Diabetes mellitus is an important cardiovascular risk factor, and diabetes therapies are among the most commonly prescribed medications in the U.S. While the introduction of new, high-cost therapies has increased costs, recent trends in national spending on diabetes medications by insurance payer have not been examined. Understanding the burden of costs amongst all payers may help inform strategies to optimize drug expenditures in the US. Objective: To produce nationally representative estimates of US spending on diabetes therapies from 2007 to 2017, stratified by insurance payers (Medicare, Medicaid, Private, VA, and TRICARE—a program for civilian health benefits for US Armed Forces). Trends in out-of-pocket costs were also examined. Design/Setting: Retrospective analysis of patient-level data from the Medical Expenditure Panel Survey, a nationally representative survey that is the most complete source of data on healthcare costs in the US, from 2007 to 2017. Participants: All patients receiving one or more classes of diabetes therapies. Outcomes: Inflation-adjusted total national expenditures on all diabetes therapies. Results: There were substantial increases in total expenditures on diabetes therapies for all payers during the study period, ranging from +165.6% for VA & TRICARE ($380.6 million to $1.0 billion) to +460.4% for Medicaid ($1.1 to $6.1 billion). Private insurers increased spending by +346.6% ($5.7 to $25.5 billion), and Medicare increased spending by +389.9% ($5.4 to $25.2 billion). Out-of-pocket spending increased more modestly (+15.7%, from $4.7 to $5.7 billion). Conclusions/Relevance: Spending on diabetes therapies increased dramatically between 2007-2017, with Medicare spending increasing by 389.9%. In contrast, increases in out-of-pocket costs have been more modest. Reasons for the rapid rate of rise in Medicare and private spending compared to out-of-pocket spending should be examined in future studies.

A Descriptive Analysis of Outpatient Antimicrobial Use for Urinary Tract Infections in Virginia

Background: Data regarding outpatient antibiotic prescribing for urinary tract infections (UTIs) are limited, and they have never been formally summarized in Virginia. Objective: We describe outpatient antibiotic prescribing trends for UTIs based on gender, age, geographic region, insurance payer and International Classification of Disease, Tenth Revision (ICD-10) codes in Virginia. Methods: We used the Virginia All-Payer Claims Database (APCD), administered by Virginia Health Information (VHI), which holds data for Medicare, Medicaid, and private insurance. The study cohort included Virginia residents who had a primary diagnosis of UTI, had an antibiotic claim 0–3 days after the date of the diagnosis and who were seen in an outpatient facility in Virginia between January 1, 2016, and December 31, 2016. A diagnosis of UTI was categorized as cystitis, urethritis or pyelonephritis and was defined using the following ICD-10 codes: N30.0, N30.00, N30.01, N30.9, N30.90, N30.91, N39.0, N34.1, N34.2, and N10. The following antibiotics were prescribed: aminoglycosides, sulfamethoxazole/trimethoprim (TMP-SMX), cephalosporins, fluoroquinolones, macrolides, penicillins, tetracyclines, or nitrofurantoin. Patients were categorized based on gender, age, location, insurance payer and UTI type. We used χ2 and Cochran-Mantel-Haenszel testing. Analyses were performed in SAS version 9.4 software (SAS Institute, Cary, NC). Results: In total, 15,580 patients were included in this study. Prescriptions for antibiotics by drug class differed significantly by gender (P < .0001), age (P < .0001), geographic region (P < .0001), insurance payer (P < .0001), and UTI type (P < .0001). Cephalosporins were prescribed more often to women (32.48%, 4,173 of 12,846) than to men (26.26%, 718 of 2,734), and fluoroquinolones were prescribed more often to men (53.88%, 1,473 of 2,734) than to women (47.91%, 6,155 of 12,846). Although cephalosporins were prescribed most frequently (42.58%, 557 of 1,308) in northern Virginia, fluoroquinolones were prescribed the most in eastern Virginia (50.76%, 1677 of 3,304). Patients with commercial health insurance, Medicaid, and Medicare were prescribed fluoroquinolones (39.31%, 1,149 of 2,923), cephalosporins (56.33%, 1,326 of 2,354), and fluoroquinolones (57.36%, 5,910 of 10,303) most frequently, respectively. Conclusions: Antibiotic prescribing trends for UTIs varied by gender, age, geographic region, payer status and UTI type in the state of Virginia. These data will inform future statewide antimicrobial stewardship efforts.Funding: NoneDisclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.

Disparities in Access to Autologous Breast Reconstruction

Background and objectives: This study aimed to determine if age, race, region, insurance, and comorbidities affect the type of breast reconstruction that patients receive. Materials and methods: This analysis used the Florida Inpatient Discharge Dataset from 1 January 2013 to 30 September 2017, which contains deidentified patient-level administrative data from all acute care hospitals in the state of Florida. We included female patients, diagnosed with breast cancer, who underwent mastectomy and a subsequent breast reconstruction. We performed an χ2 test and logistic regression in this analysis. Results: On the multivariable analysis, we found that age, race, patient region, insurance payer, and Elixhauser score were all variables that significantly affected the type of reconstruction that patients received. Our results show that African American (odds ratio (OR): 0.68, 95%CI: 0.58–0.78, p < 0.001) and Hispanic or Latino (OR: 0.82, 95%CI: 0.72–0.93, p = 0.003) patients have significantly lower odds of receiving implant reconstruction when compared to white patients. Patients with Medicare (OR: 1.57, 95%CI: 1.33–1.86, p < 0.001) had significantly higher odds and patients with Medicaid (OR: 0.61, 95%CI: 0.51–0.74, p < 0.001) had significantly lower odds of getting autologous reconstruction when compared to patients with commercial insurance. Conclusions: Our study demonstrated that, in the state of Florida over the past years, variables, such as race, region, insurance, and comorbidities, play an important role in choosing the reconstruction modality. More efforts are needed to eradicate disparities and give all patients, despite their race, insurance payer, or region, equal access to health care.