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.

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 Are trends in billing for high-intensity emergency care explained by changes in services provided in the emergency department? An observational study among US Medicare beneficiaries

BMJ Open ◽  
2018 ◽  
Vol 8 (1) ◽  
pp. e019357 ◽  
Author(s):  
Laura G Burke ◽  
Robert C Wild ◽  
E John Orav ◽  
Renee Y Hsia
Keyword(s):  
Emergency Department ◽  
Observational Study ◽  
Emergency Care ◽  
High Intensity ◽  
Patient Characteristics ◽  
Medicare Beneficiaries ◽  
Absolute Increase ◽  
Hospital Admission Rate ◽  
Outpatient Visits ◽  
Change In Mean

ObjectiveThere has been concern that an increase in billing for high-intensity emergency care is due to changes in coding practices facilitated by electronic health records. We sought to characterise the trends in billing for high-intensity emergency care among Medicare beneficiaries and to examine the degree to which trends in high-intensity billing are explained by changes in patient characteristics and services provided in the emergency department (ED).Design, setting and participantsObservational study using traditional Medicare claims to identify ED visits at non-federal acute care hospitals for elderly beneficiaries in 2006, 2009 and 2012.Outcomes measuresBilling intensity was defined by emergency physician evaluation and management (E&M) codes. We tested for overall trends in high-intensity billing (E&M codes 99285, 99291 and 99292) and in services provided over time using linear regression models, adjusting for patient characteristics. Additionally, we tested for time trends in rates of admission to the hospital and to the intensive care unit (ICU). Next, we classified outpatient visits into 39 diagnosis categories and analysed the change in proportion of high-intensity visits versus the change in number of services. Finally, we quantified the extent to which trends in high-intensity billing are explained by changes in patient demographics and services provided in the ED using multivariable modelling.ResultsHigh-intensity visits grew from 45.8% of 671 103 visits in 2006 to 57.8% of 629 010 visits in 2012 (2.0% absolute increase per year; 95% CI 1.97% to 2.03%) as did the mean number of services provided for admitted (1.28 to 1.41; +0.02 increase in procedures per year; 95% CI 0.018 to 0.021) and discharged ED patients (7.1 to 8.6; +0.25 increase in services per year; 95% CI 0.245 to 0.255). There was a reduction in hospital admission rate from 40.1% to 35.9% (−0.68% per year; 95% CI −0.71% to −0.65%; P<0.001), while the ICU rate of admission rose from 11.7% to 12.3% (+0.11% per year; 95% CI 0.09% to 0.12%; P<0.001). When we stratified by diagnosis category, there was a moderate correlation between change in visits billed as high intensity and the change in mean number of services provided per visit (r=0.38; 95% CI 0.07 to 0.63). Trends in patient characteristics and services provided accounted moderately for the trend in practice intensity for outpatient visits (pseudo R2of 0.47) but very little for inpatient visits (0.051) and visits overall (0.148).ConclusionsIncreases in services provided in the ED moderately account for the trends in billing for high-intensity emergency care for outpatient visits.

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 Trends in outpatient antibiotic use and prescribing practice among US older adults, 2011-15: observational study

BMJ ◽  
2018 ◽  
pp. k3155 ◽  
Author(s):  
Scott W Olesen ◽  
Michael L Barnett ◽  
Derek R MacFadden ◽  
Marc Lipsitch ◽  
Yonatan H Grad
Keyword(s):  
Older Adults ◽  
Observational Study ◽  
Inappropriate Prescribing ◽  
Temporal Trends ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Administrative Claims ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Prescribing Practice

AbstractObjectiveTo identify temporal trends in outpatient antibiotic use and antibiotic prescribing practice among older adults in a high income country.DesignObservational study using United States Medicare administrative claims in 2011-15.SettingMedicare, a US national healthcare program for which 98% of older adults are eligible.Participants4.5 million fee-for-service Medicare beneficiaries aged 65 years old and older.Main outcome measurementsOverall rates of antibiotic prescription claims, rates of potentially appropriate and inappropriate prescribing, rates for each of the most frequently prescribed antibiotics, and rates of antibiotic claims associated with specific diagnoses. Trends in antibiotic use were estimated by multivariable regression adjusting for beneficiaries’ demographic and clinical covariates.ResultsThe number of antibiotic claims fell from 1364.7 to 1309.3 claims per 1000 beneficiaries per year in 2011-14 (adjusted reduction of 2.1% (95% confidence interval 2.0% to 2.2%)), but then rose to 1364.3 claims per 1000 beneficiaries per year in 2015 (adjusted reduction of 0.20% over 2011-15 (0.09% to 0.30%)). Potentially inappropriate antibiotic claims fell from 552.7 to 522.1 per 1000 beneficiaries over 2011-14, an adjusted reduction of 3.9% (3.7% to 4.1%). Individual antibiotics had heterogeneous changes in use. For example, azithromycin claims per beneficiary decreased by 18.5% (18.2% to 18.8%) while levofloxacin claims increased by 27.7% (27.2% to 28.3%). Azithromycin use associated with each of the potentially appropriate and inappropriate respiratory diagnoses decreased, while levofloxacin use associated with each of those diagnoses increased.ConclusionAmong US Medicare beneficiaries, overall antibiotic use and potentially inappropriate use in 2011-15 remained steady or fell modestly, but individual drugs had divergent changes in use. Trends in drug use across indications were stronger than trends in use for individual indications, suggesting that guidelines and concerns about antibiotic resistance were not major drivers of change in antibiotic use.

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 35: 30-Day Risk-Standardized Mortality and Readmission after Ischemic Stroke in Critical Access Hospitals

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Judith H Lichtman ◽  
Sara B Jones ◽  
Erica C Leifheit-Limson ◽  
Yun Wang ◽  
Larry B Goldstein
Keyword(s):  
Ischemic Stroke ◽  
Rural Communities ◽  
Patient Characteristics ◽  
Primary Diagnosis ◽  
Critical Access Hospitals ◽  
Fee For Service ◽  
Comorbid Conditions ◽  
Readmission Rates ◽  
Logistic Regression Models ◽  
Critical Access Hospital

Background: Critical access hospital (CAH) designation identifies hospitals providing emergency and inpatient care to residents of rural communities. Patients with cardiovascular disease and pneumonia have poorer outcomes at CAHs, but stroke outcomes have not been assessed. Objective: Compare risk-adjusted 30-day mortality and readmission rates after ischemic stroke for patients treated at critical access and non-critical access hospitals. Methods: The cohort included all fee-for-service Medicare beneficiaries 65+ years of age discharged with a primary diagnosis of ischemic stroke (ICD-9 433, 434, 436) in 2006. Risk-standardized mortality and readmission rates at 30 days were compared for patients treated at CAH versus other hospitals using hierarchical logistic regression models, adjusted for patient demographics, medical history, and comorbid conditions. Results: There were 10,267 ischemic stroke discharges from 1,165 CAHs and 300,114 discharges from 3,381 non-CAHs. Patients discharged from CAHs were older, more often women and white, and generally had more comorbid conditions. CAHs had higher unadjusted in-hospital (6.4% vs. 4.6%, p<0.001) and 30-day (19.9% vs. 10.9%, p<0.001) mortality rates than non-CAHs, but lower 30-day all-cause readmission (12.4% vs. 13.8%, p<0.001). In risk-standardized analyses, the differences were less marked for 30-day mortality (CAHs vs. non-CAHs; 11.9%±1.4% vs. 10.9%±1.7%, p<0.001), with no difference in 30-day readmission (13.7%±0.6% vs. 13.7%±1.4%, p=0.2787). Conclusions: Although there were no differences in readmission rates, stroke patients discharged from CAHs had higher unadjusted mortality than those discharged from non-CAHs. These differences, however, were at least partially explained by differences in patient characteristics. Further research is needed to identify factors contributing to these differences.

scholarly journals Association between physician characteristics and payments from industry in 2015–2017: observational study

BMJ Open ◽  
2019 ◽  
Vol 9 (9) ◽  
pp. e031010 ◽  
Author(s):  
Kosuke Inoue ◽  
Daniel M Blumenthal ◽  
David Elashoff ◽  
Yusuke Tsugawa
Keyword(s):  
Observational Study ◽  
Medical School ◽  
Fixed Effects ◽  
Primary Outcome ◽  
Medicare Beneficiaries ◽  
Orthopaedic Surgeons ◽  
Physician Characteristics ◽  
Male Sex ◽  
To Receive ◽  
Open Payments

ObjectiveTo investigate the association between physician characteristics and the value of industry payments.DesignObservational study.Setting and participantsUsing the 2015–2017 Open Payments reports of industry payments linked to the Physician Compare database, we examined the association between physician characteristics (physician sex, years in practice, medical school attended and specialty) and the industry payment value, adjusting for other physician characteristic and institution fixed effects (effectively comparing physicians practicing at the same institution).Main outcome measuresOur primary outcome was the value of total industry payments to physicians including (1) general payments (all forms of payments other than those classified for research purpose, eg, consulting fees, food, beverage), (2) research payments (payments for research endeavours under a written contract or protocol) and (3) ownership interests (eg, stock or stock options, bonds). We also investigated each category of payment separately.ResultsOf 544 264 physicians treating Medicare beneficiaries, a total of $5.8 billion in industry payments were made to 365 801 physicians during 2015–2017. The top 5% of physicians, by cumulative payments, accounted for 91% of industry payments. Within the same institution, male physicians, physicians with 21–30 years in practice and physicians who attended top 50 US medical schools (based on the research ranking) received higher industry payments. Across specialties, orthopaedic surgeons, neurosurgeons and endocrinologists received the highest payments. When we investigated individual types of payment, we found that orthopaedic surgeons received the highest general payments; haematologists/oncologists were the most likely to receive research payments and surgeons were the most likely to receive ownership interests compared with other types of physicians.ConclusionsIndustry payments to physicians were highly concentrated among a small number of physicians. Male sex, longer length of time in clinical practice, graduated from a top-ranked US medical school and practicing certain specialties, were independently associated with higher industry payments.

scholarly journals Stroke Hospitalizations Before and During COVID-19 Pandemic Among Medicare Beneficiaries in the United States

Stroke ◽  
2021 ◽  
Author(s):  
Quanhe Yang ◽  
Xin Tong ◽  
Sallyann Coleman King ◽  
Benjamin S. Olivari ◽  
Robert K. Merritt
Keyword(s):  
United States ◽  
Patient Characteristics ◽  
The United States ◽  
Emergency Department Visits ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Percent Reduction ◽  
Stroke Patients ◽  
Race Ethnicity ◽  
National Emergency

Background and Purpose: Emergency department visits and hospitalizations for stroke declined significantly following declaration of coronavirus disease 2019 (COVID-19) as a national emergency on March 13, 2020, in the United States. This study examined trends in hospitalizations for stroke among Medicare fee-for-service beneficiaries aged ≥65 years and compared characteristics of stroke patients during COVID-19 pandemic to comparable weeks in the preceding year (2019). Methods: For trend analysis, we examined stroke hospitalizations from week 1 in 2019 through week 44 in 2020. For comparison of patient characteristics, we estimated percent reduction in weekly stroke hospitalizations from 2019 to 2020 during weeks 10 through 23 and during weeks 24 through 44 by age, sex, race/ethnicity, and state. Results: Compared to weekly numbers of hospitalizations for stroke reported during 2019, stroke hospitalizations in 2020 decreased sharply during weeks 10 through 15 (March 1–April 11), began increasing during weeks 16 through 23, and remained at a level lower than the same weeks in 2019 from weeks 24 through 44 (June 7–October 31). During weeks 10 through 23, stroke hospitalizations decreased by 22.3% (95% CI, 21.4%–23.1%) in 2020 compared with same period in 2019; during weeks 24 through 44, they decreased by 12.1% (95% CI, 11.2%–12.9%). The magnitude of reduction increased with age but similar between men and women and among different race/ethnicity groups. Reductions in stroke hospitalizations between weeks 10 through 23 varied by state ranging from 0.0% (95% CI, −16.0%–1.7%) in New Hampshire to 36.2% (95% CI, 24.8%–46.7%) in Montana. Conclusions: One-in-5 fewer stroke hospitalizations among Medicare fee-for-service beneficiaries occurred during initial weeks of the COVID-19 pandemic (March 1–June 6) and weekly stroke hospitalizations remained at a lower than expected level from June 7 to October 31 in 2020 compared with 2019. Changes in stroke hospitalizations varied substantially by state.

scholarly journals Predictors of Disenrollment Among Medicare Fee-for-Service Beneficiaries With Dementia

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 18-18
Author(s):  
Maricruz Rivera-Hernandez ◽  
Aaron Castillo ◽  
Amal Trivedi
Keyword(s):  
Chronic Conditions ◽  
Fixed Effects ◽  
Regression Models ◽  
Primary Outcome ◽  
Fee For Service ◽  
Medicare Advantage ◽  
Medicare Beneficiaries ◽  
Race Ethnicity ◽  
Dual Eligibility ◽  
Care Costs

Abstract Medicare enrollment among people with Alzheimer’s Disease and Related Dementias (ADRD) has reached an all-time high with about 12% of beneficiaries having an ADRD diagnosis. The federal government has special interest in providing healthcare alternatives for Medicare beneficiaries. However, limited studies have focused on understanding disenrollment from fee-for-service, especially among those with high-needs. In this study we identified predictors of disenrollment among beneficiaries with ADRD. We used the 2017-2018 Medicare Master Beneficiary Summary File to determine enrollment, sociodemographic, clinical characteristics and healthcare utilization. We included all fee-for-service beneficiaries enrolled in 2017 who survived the first quarter of 2018. Our primary outcome was disenrollment from fee-for-service between 2017 and 2018. Regression models included age, sex, race/ethnicity, dually eligibility to Medicare and Medicaid, chronic and disabling conditions (categorized by quartiles), total health care costs including outpatient, inpatient, post-acute care and other costs (categorized by quartiles) and county fixed-effects. There were 1,797,047 beneficiaries enrolled in fee-for-service with an ADRD diagnosis. Stronger predictors of disenrollment included race/ethnicity and dual eligibility. Disenrollment rates were 7.9% (95% CI, 7.2 – 8.5) among African Americans, 6.6 (95% CI, 6.2 – 7.0) among Hispanics and 4.3 (95% CI, 4.2 – 4.3) among Whites. Duals were 1.9% (95% CI, 1.4 – 2.3) more likely to disenroll from fee-for-service to Medicare Advantage (MA). The inclusion of MA special need plans and additional benefits for those with ADRD and complex chronic conditions may be valuable for those beneficiaries with ADRD, and who may not have Medigap coverage when enrolling in fee-for-service.

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