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Background Guidelines recommend adults who discontinue statin therapy because of statin-associated symptoms be reinitiated. Low-density lipoprotein cholesterol (LDL-C) levels achieved after statin reinitiation are unknown. Objective The objective of this study was to determine LDL-C levels after statin reinitiation. Methods We analyzed data from 5498 participants in the REasons for Geographic And Racial Differences in Stroke study who reported ever taking a statin. We categorized participants according to their pattern of statin use including those taking a statin who did not experience statin-associated symptoms and continued treatment, and those who discontinued statins because of statin-associated symptoms and were not reinitiated, reinitiated and remained on treatment, and discontinued treatment after being reinitiated. Mortality and vascular event reduction with statin reinitiation was estimated using data from the Cholesterol-Lowering Treatment Trialists Collaboration. Results After multivariable adjustment, LDL-C was 14.1 (95% CI: 9.9–18.3) mg/dL higher among participants reinitiated and taking a statin compared with those without statin-associated symptoms who continued statin therapy. Mean LDL-C was 18.1 mg/dL (95% CI: 13.0–23.1) and 27.5 mg/dL (95% CI: 20.7–34.4) lower among participants reinitiated and taking a statin compared with those who discontinued statin therapy and were not reinitiated and those who discontinued statins after being reinitiated, respectively. An LDL-C reduction of 18.1 mg/dL with statin reinitiation was projected to reduce all-cause and coronary heart disease mortality by 5.6% and 8.9%, respectively, and myocardial infarction or coronary heart disease death and major vascular events by 10.7% and 9.8%, respectively, over 5 years. Conclusion Reinitiating individuals who discontinue statin therapy may reduce LDL-C and cardiovascular risk.

Background The evidence-based beta-blockers carvedilol, bisoprolol, and metoprolol succinate reduce mortality and hospitalizations among patients with heart failure with reduced ejection fraction (HFrEF). Use of these medications is not well described in the general population of patients with HFrEF, especially among patients with potential contraindications. Objectives Our goal was to describe the patterns of prescription fills for carvedilol, bisoprolol, and metoprolol succinate among Medicare beneficiaries hospitalized for HFrEF, as well as to estimate the associations between specific contraindications for beta-blocker therapy and those patterns. Methods and Results With the use of the cohort of 15,205 Medicare beneficiaries hospitalized for HFrEF from 2007 to 2013 in the 5% Medicare random sample, we described prescription fills (30 days after discharge) and dosage patterns (1 year after discharge) for beta-blockers. By means of of Fine and Gray competing risk models, we estimated the associations between potential contraindications (hypotension, chronic obstructive pulmonary disease [COPD], asthma, and syncope) and prescription fill and dosing patterns while adjusting for demographics, comorbidities, and health care utilization. For beneficiaries who did not die or readmitted to the hospital, 38% of hospitalizations were followed by a prescription fill for an evidence-based beta-blocker within 30 days, 12% were followed by prescription fills for at least 50% of the recommended dose of an evidence-based beta-blocker within 1 year, and 9% were followed by a prescription fill for an up-titrated dose of an evidence-based beta-blocker within 1 year. The prevalence of the contraindications were 21% for hypotension, 48% for COPD, 15% for asthma, and 12% for syncope. Among beneficiaries who did not fill a prescription for an evidence-based beta-blocker within 30 days, 67% had at least 1 of these contraindications. Hypotension, COPD, and syncope were each associated with a ∼10% lower risk of filling a prescription for an evidence-based beta-blocker. Conclusions Prescription fill and up-titration rates for evidence-based beta-blockers are low among Medicare beneficiaries with HFrEF, but contraindications explain only a minor part of these low rates.

Supplemental Digital Content is Available in the Text., Among nonelderly adults with diabetes, we compared hospitalizations for ambulatory care–sensitive conditions from 2013 (pre-Medicaid expansion) and 2014 (post-Medicaid expansion) for 13 expansion and 4 nonexpansion states using State Inpatient Databases. Medicaid expansion was associated with decreases in proportions of hospitalizations for chronic conditions (difference between 2014 and 2013 −0.17 percentage points in expansion and 0.37 in nonexpansion states, P = .04), specifically diabetes short-term complications (difference between 2014 and 2013 −0.05 percentage points in expansion and 0.21 in nonexpansion states, P = .04). Increased access to care through Medicaid expansion may improve disease management in nonelderly adults with diabetes.

Background HIV-related maternal deaths and HIV infection among infants remain unacceptably high across sub-Saharan Africa despite increased antenatal care attendance and provision of antiretroviral therapy to pregnant women. In the Jamii Bora (“Better Family” in Swahili) Study, we seek to test the efficacy of an interdependence theory-based couple intervention. The intervention reaches pregnant women and male partners through home visits by male-female pairs of lay health workers. The aim is to increase access to home-based couples’ HIV testing and counseling services to improve family health. Methods This is a three-arm randomized control trial among 1080 pregnant women 15 years of age or older, living with their male partners, and who have not undergone couples’ HIV testing and counseling in Kisumu and Migori Counties in Kenya. Couples will be randomized into three groups: home-based couple visits, HIV self-testing kits for couple use, or standard care (male partner clinic invitation letters). Participants will be followed up to 18 months postpartum. The study has three aims: in aim 1, we will determine the effects of the intervention on our primary outcome of couple HIV testing, compared to HIV self-testing kits and standard care; in aim 2, we will examine the intervention impact on HIV prevention behaviors, facility delivery, and postnatal healthcare utilization, as well as secondary health outcomes of maternal viral suppression and HIV-free child survival up to 18 months for couples living with HIV; and in aim 3, we will compare the cost-effectiveness of the home-based couple intervention to the less resource-intensive strategies used in the other two study arms. Assessments with couples are conducted at baseline, late pregnancy, and at months 3, 6, 12, and 18 after birth. Discussion The results from this study will inform decision-makers about the cost-effective strategies to engage pregnant couples in the prevention of mother-to-child transmission and family health, with important downstream benefits for maternal, paternal, and infant health. Trial registration ClinicalTrials.gov NCT03547739. Registered on May 9, 2018

BACKGROUND Living donor kidney transplantation has declined in the United States since 2004, but the relationship between population characteristics and rate of living donation is unknown. The goal of our study was to use data on general population health and socioeconomic status to investigate the association with living donation. METHODS This cross-sectional, ecological study used population health and socioeconomic status data from the CDC Behavioral Risk Factor Surveillance System to investigate the association with living donation. Transplant centers performing 10 or greater kidney transplants reported to the Scientific Registry of Transplant Recipients in 2015 were included. Center rate of living donation was defined as the proportion of all kidney transplants performed at a center that were from living donors. RESULTS In a linear mixed-effects model, a composite index of health and socioeconomic status factors was negatively associated with living donation, with a rate of living donation that was on average 7.3 percentage points lower among centers in areas with more comorbid disease and poorer socioeconomic status (95% confidence interval, -12.2 to -2.3, P = 0.004). Transplant centers in areas with higher prevalence of minorities had a rate of living donation that was 7.1 percentage points lower than centers with fewer minorities (95% confidence interval, -11.8 to -2.3, P = 0.004). CONCLUSIONS Center-level variation in living donation was associated with population characteristics and minority prevalence. Further examination of these factors in the context of patient and center-level barriers to living donation is warranted.

Annually in the United States, over 6,000 healthy individuals undergo living donor nephrectomy for the purposes of kidney transplantation.1,2 Living kidney donors gain no medical benefit from donation, exposing themselves to health risks associated with major surgery and reduced renal mass, including chronic kidney disease (CKD), entirely for the benefit of another individual.3,4 Essential to this process is proper medical evaluation and informed consent to promote donor autonomy in medical decision-making, requirements that mandate accurate quantification and communication of donor candidate risk for CKD. This is particularly crucial for young potential living kidney donors, who have the lengthiest remaining risk exposure, and African Americans (AA), who are at enhanced risk of CKD.5 Recently, an online risk tool was developed using population-based data that quantified the combined effect of 10 health characteristics to estimate the risk of end-stage renal disease (ESRD) among living kidney donor candidates.6 While informative, this study of seven cohorts was limited by short follow-up (median 4 to 16 years), heterogeneity of cohort design (incorporating both longitudinal and cross-sectional cohorts), no data on family history, and older age of potential living kidney donors (40–63 years-old). These limitations compromise the accuracy of lifetime estimates for ESRD among young living kidney donors and do not address the risk of the more proximate endpoint of CKD. Beyond the predictive value of baseline health characteristics is the rapidly evolving understanding of an individual’s genetic-risk profile.7–9 Recently, apolipoprotein L1 gene (APOL1) variants have been associated with nondiabetic CKD in AAs.10,11 About 40% of AAs have one of these renal-risk variants, with 13% of AAs demonstrating two.10,12,13 Previous work indicates that odds of CKD among individuals with one renal-risk variant were 1.3-fold higher and 7.3-fold higher among individuals with two variants compared to individuals without a variant allele.14 Independent of other risk factors, it is hypothesized that AA potential living kidney donors with APOL1 variants may be at particularly high risk of CKD;15 however, incorporation of APOL1 genotype into risk prediction models has not been done. The goal of this study was to develop a novel CKD risk prediction tool for young potential living kidney donors by leveraging data from a longitudinal cohort of adults ages 18–30 with more than 25 years of follow-up and availability of APOL1 genotyping.

Background Less intensive treatment for heart failure with reduced ejection fraction (HFrEF) may be appropriate for patients in long-term care settings because of limited life expectancy, frailty, comorbidities, and emphasis on quality of life. Methods We compared treatment patterns between REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants discharged to long-term care versus home following HFrEF hospitalizations. We examined medical records and Medicare pharmacy claims for 147 HFrEF hospitalizations among 80 participants to obtain information about discharge disposition and medication prescriptions and fills. Results Discharge to long-term care followed 22 of 147 HFrEF hospitalizations (15%). Participants discharged to long-term care were more likely to be prescribed beta-blockers and less likely to be prescribed aldosterone receptor antagonists and hydralazine/isosorbide dinitrate (96%, 14%, and 5%, respectively) compared to participants discharged home (81%, 22%, and 23%, respectively). The percentages of participants discharged to long-term care and home who had claims for filled prescriptions were similar for beta-blockers (68% versus 66%) and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARBs) (45% versus 47%) after 1 year. Smaller percentages of participants discharged to long-term care had claims for filled prescriptions of other medications compared to participants discharged home (diuretics: long-term care-50%, home-72%; hydralazine/isosorbide dinitrate: long-term care-5%, home-23%; aldosterone receptor antagonists: long-term care-5%, home-23%). Conclusions Differences in medication prescriptions and fills among individuals with HFrEF discharged to long-term care versus home may reflect prioritization of some medical therapies over others for patients in long-term care.

To compare the costs associated with adjunctive azithromycin compared with standard cefazolin antibiotic prophylaxis alone for unscheduled and scheduled cesarean deliveries.A decision analytic model was created to compare cefazolin alone with azithromycin plus cefazolin. Published incidences of surgical site infection after cesarean delivery were used to estimate the baseline incidence of surgical site infection in scheduled and unscheduled cesarean delivery using standard antibiotic prophylaxis. The effectiveness of adjunctive azithromycin prophylaxis was obtained from published randomized controlled trials for unscheduled cesarean deliveries. No randomized study of its use in scheduled procedures has been completed. Cost estimates were obtained from published literature, hospital estimates, and the Healthcare Cost and Utilization Project and considered costs of azithromycin and surgical site infections. A series of sensitivity analyses were conducted by varying parameters in the model based on observed distributions for probabilities and costs. The outcome was cost per cesarean delivery from a health system perspective.For unscheduled cesarean deliveries, cefazolin prophylaxis alone would cost $695 compared with $335 for adjunctive azithromycin prophylaxis, resulting in a savings of $360 (95% CI $155-451) per cesarean delivery. In scheduled cesarean deliveries, cefazolin prophylaxis alone would cost $254 compared with $111 for adjunctive azithromycin prophylaxis, resulting in a savings of $143 (95% CI 98-157) per cesarean delivery, if proven effective. These findings were robust to a multitude of inputs; as long as adjunctive azithromycin prevented as few as seven additional surgical site infections per 1,000 unscheduled cesarean deliveries and nine additional surgical site infections per 10,000 scheduled cesarean deliveries, adjunctive azithromycin prophylaxis was cost-saving.Adjunctive azithromycin prophylaxis is a cost-saving strategy in both unscheduled and scheduled cesarean deliveries.

The Effectiveness of Discontinuing Bisphosphonates (EDGE) study is a planned pragmatic clinical trial to guide “drug holiday” clinical decision making. This pilot study assessed work flow and feasibility of such a study. While participant recruitment and treatment adherence were suboptimal, administrative procedures were generally feasible and minimally disrupted clinic flow. The comparative effectiveness of continuing or discontinuing long-term alendronate (ALN) on fractures is unknown. A large pragmatic ALN discontinuation study has potential to answer this question. We conducted a 6-month pilot study of the planned the EDGE study among current long-term ALN users (women aged ≥65 with ≥3 years of ALN use) to determine study work flow and feasibility including evaluating the administrative aspects of trial conduct (e.g., time to contract, institutional review board (IRB) approval), assessing rates of site and participant recruitment, and evaluating post-randomization outcomes, including adherence, bisphosphonate-associated adverse events, and participant and site satisfaction. We assessed outcomes 1 and 6 months after randomization. Nine sites participated, including seven community-based medical practices and two academic medical centers. On average (SD), contract execution took 3.4 (2.3) months and IRB approval took 13.9 (4.1) days. Sites recruited 27 participants (13 to continue ALN and 14 to discontinue ALN). Over follow-up, 22% of participants did not adhere to their randomization assignment: 30.8% in the continuation arm and 14.3% in the discontinuation arm. No fractures or adverse events were reported. Sites reported no issues regarding work flow, and participants were highly satisfied with the study. Administrative procedures of the EDGE study were generally feasible, with minimal disruption to clinic flow. In this convenience sample, participant recruitment was suboptimal across most practice sites. Accounting for low treatment arm adherence, a comprehensive recruitment approach will be needed to effectively achieve the scientific goals of the EDGE study.

Background After older adults experience episodes of poor health or are hospitalized, they may not return to premorbid or prehospitalization eating behaviors. Furthermore, poor nutrition increases hospital readmission risk, but evidence-based interventions addressing these risks are limited. Objective This pilot study's objective was to evaluate the feasibility of conducting a randomized controlled trial assessing a post-discharge home-delivered meal program's impact on older adults' nutritional intake and hospital readmissions and to assess patient acceptability and satisfaction with the program. The aims of the study were to evaluate successful recruitment, randomization, and retention of at least 80% of the 24 participants sought; to compare the outcomes of hospital readmission and total daily caloric intake between participants in the intervention and control groups; and to assess patient acceptability and satisfaction with the program. Design This study used a two-arm randomized controlled trial design, and baseline data were collected at enrollment; three 24-hour food recalls were collected during the intervention period; and health services utilization and intervention satisfaction was evaluated 45 days post-discharge. Participants/setting Twenty-four patients from the University of Alabama at Birmingham Hospital's Acute Care for Elders (ACE) Unit were enrolled from May 2014 to June 2015. They were 65 years or older; at risk for malnutrition; cognitively intact; able to communicate; discharged to a place where the patient or family was responsible for preparing meals; and diagnosed with congestive heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, or pneumonia. Final analysis included 21 participants. Intervention The intervention group received 10 days of home-delivered meals and nutrition education; the control group received usual care and nutrition education. Main outcome measures The main outcome was intervention feasibility, measured by recruitment and retention goals. Hospital readmissions, caloric intake, and satisfaction with the intervention were also evaluated. Statistical analyses performed Univariate and bivariate parametric statistics were used to evaluate differences between groups. Goals for success were identified to assess feasibility of conducting a full-scale study and outcomes were measured against the goals. Results Of the randomized participants, 87.5% were retained for final data collection, indicating that this intervention study is feasible. There were no significant differences between groups for hospital readmissions; however, caloric intake during the intervention period was greater for intervention vs control participants (1,595 vs 1,235; P =0.03). Participants were overwhelmingly satisfied (82% to 100% satisfied or very satisfied) with staff performance, meal quality, and delivery processes. Conclusions Conducting a randomized controlled trial to assess outcomes of providing home-delivered meals to older adults after hospital discharge in partnership with a small nonprofit organization is feasible and warrants future research.

Introduction: The best strategy to increase awareness of and access to living kidney donation remains unknown. To build upon the existing strategies, we developed the Living Donor Navigator program, combining advocacy training of patient advocates with enhanced health-care systems training of patient navigators to address potential living donor concerns during the evaluation process. Herein, we describe a systematic assessment of the delivery and content of the program through focus group discussion. Methods: We conducted focus groups with 9 advocate participants in the Living Donor Navigator program to identify knowledge, skills, and abilities needed for both advocates and navigators. We focused on 2 organizational levels: (1) the participant level or the advocacy training of the advocates and (2) the programmatic level or the support role provided by the navigators and administration of the program. Findings: From 4 common themes (communication, education, support, and commitment), we identified several core competencies and promising practices, at both the participant and programmatic levels. These themes highlighted the potential for several improvements of program content and delivery, the importance of cultural sensitivity among the Living Donor navigators, and the opportunity for informal caregiver support and accountability provided by the program. Discussion: These competencies and promising practices represent actionable strategies for content refinement, optimal training of advocates, and engagement of potential living donors through the Living Donor Navigator program. These findings may also assist with program implementation at other transplant centers in the future.

Importance High-intensity statin use after myocardial infarction (MI) varies by patient characteristics, but little is known about differences in use by hospital or region. Objective To explore the relative strength of associations of region and hospital and patient characteristics with high-intensity statin use after MI. Design, Setting, and Participants This retrospective cohort analysis used Medicare administrative claims and enrollment data to evaluate fee-for-service Medicare beneficiaries 66 years or older who were hospitalized for MI from January 1, 2011, through June 30, 2015, with a statin prescription claim within 30 days of discharge. Data were analyzed from January 4, 2017, through May 12, 2019. Exposures Beneficiary characteristics were abstracted from Medicare data. Hospital characteristics were obtained from the 2014 American Hospital Association Survey and Hospital Compare quality metrics. Nine regions were defined according to the US Census. Main Outcomes and Measures Intensity of the first statin claim after discharge characterized as high (atorvastatin calcium, 40-80 mg, or rosuvastatin calcium, 20-40 mg/d) vs low to moderate (all other statin types and doses). Trends in high-intensity statins were examined from 2011 through 2015. Associations of region and beneficiary and hospital characteristics with high-intensity statin use from January 1, 2014, to June 15, 2015, were examined using Poisson distribution mixed models. Results Among the 139 643 fee-for-service beneficiaries included (69 968 men [50.1%] and 69 675 women [49.9%]; mean [SD] age, 76.7 [7.5] years), high-intensity statin use overall increased from 23.4% in 2011 to 55.6% in 2015, but treatment gaps persisted across regions. In models considering region and beneficiary and hospital characteristics, region was the strongest correlate of high-intensity statin use, with 66% higher use in New England than in the West South Central region (risk ratio [RR], 1.66; 95% CI, 1.47-1.87). Hospital size of at least 500 beds (RR, 1.15; 95% CI, 1.07-1.23), medical school affiliation (RR, 1.11; 95% CI, 1.05-1.17), male sex (RR, 1.10; 95% CI, 1.07-1.13), and patient receipt of a stent (RR, 1.35; 95% CI, 1.31-1.39) were associated with greater high-intensity statin use. For-profit hospital ownership, patient age older than 75 years, prior coronary disease, and other comorbidities were associated with lower use. Conclusions and Relevance This study’s findings suggest that geographic region is the strongest correlate of high-intensity statin use after MI, leading to large treatment disparities.

The evidence regarding recommendations of calorie restriction as part of a comprehensive lifestyle intervention to promote weight loss in obese older adults has remained equivocal for more than a decade. The older adult population is the fastest growing segment of the US population and a greater proportion of them are entering old age obese. These older adults require treatments based on solid evidence. Therefore the purpose of this review is three-fold: 1) to provide a more current status of the knowledge regarding recommendations of calorie restriction as part of a comprehensive lifestyle intervention to promote weight loss in obese older adults, 2) to determine what benefits and/or risks calorie restriction adds to exercise interventions in obese older adults, and 3) to consider not only outcomes related to changes in body composition, bone health, cardiometabolic disease risk, markers of inflammation, and physical function, but, also patient-centered outcomes that evaluate changes in cognitive status, quality of life, out-of-pocket costs, and mortality. Seven randomized controlled trials were identified that examined calorie restriction while controlling for exercise intervention effects. Overall, the studies found that calorie restriction combined with exercise is effective for weight loss. Evidence was mixed regarding other outcomes. The risk-benefit ratio regarding calorie restriction in older adults remains uncertain. Greater long-term follow-up is necessary, and complementary effectiveness studies are needed to identify strategies currently used by obese older adults in community settings.

This study examined whether access to and use of patient-centered medical home (PCMH) practices is associated with reduced nonurgent emergency department (ED) use, especially among the uninsured population. This retrospective study used 2010-2011 Medical Expenditure Panel Survey data. Difference-in-difference methods, multivariate logit model, marginal effect, and survey procedures were employed. A total of 1287 adults had any ED visit in 2011, which represented weighted 29 463 684 people in the population. Reductions in odds of nonurgent ED use between the full PCMH group and the “no regular provider” group was significantly larger for the uninsured group than publicly and privately insured groups (β = −1.70, P = .009, and β = −1.04, P = .040, respectively). Similar results were found between the partial PCMH group and the “no regular provider” group for the uninsured group compared to the public group (β = −1.67, P = .019). PCMH models demonstrate higher odds of reduced nonurgent ED use among uninsured individuals compared to public and private enrollees nationwide.

OBJECTIVES Assess the validity of Medicare claims for identifying myocardial infarction (MI). METHODS We used data from 9951 Medicare beneficiaries 65 years and above in the Reasons for Geographic And Racial Differences in Stroke study. Between 2003 and 2012, 669 participants had an MI identified and adjudicated through study procedures (ie, the gold standard), and 552 had an overnight inpatient claim with a code for MI (ICD-9 code 410.x0 or 410.x1) in any discharge diagnosis position. RESULTS Using Medicare claims with a discharge diagnosis code for MI in any position, the positive predictive value (PPV) was 84.3% [95% confidence interval (CI), 80.9%-87.3%] and the sensitivity was 49.0% (95% CI, 44.9%-53.1%). Sensitivity was lower for men (45.8%) versus women (55.1%), microsize MIs (13.7%) versus other MIs (64.7%), type 2 (30.9%), and 4-5 MIs (11.1%) versus type 1 MIs (76.6%), and MIs occurring in-hospital (28.8%) versus out-of-hospital (66.7%). Using Medicare claims with a code for MI in the primary discharge diagnosis position, the PPV was 89.7% (95% CI, 86.3%-92.5%) and sensitivity was 40.1% (95% CI, 36.1%-44.2%). The sensitivity of claims with a code for MI in the primary discharge diagnosis position was lower for microsize versus other MIs, type 2 and 4-5 MIs versus type 1 MIs and MIs occurring in-hospital versus out-of-hospital. Hazard ratios for MI associated with participant characteristics were similar using adjudicated MIs identified through study procedures or claims for MI without further adjudication. CONCLUSIONS Medicare claims have a high PPV but low sensitivity for identifying MI and can be used to investigate individual-level characteristics associated with MI.

Compare medical expenditures among adults with statin-associated adverse effects (SAAE) and high statin adherence (HSA) following myocardial infarction (MI). We analyzed expenditures in 2016 US dollars among Medicare beneficiaries with SAAE (n = 1741) and HSA (n = 55,567) who were ≥ 66 years of age and initiated moderate/high-intensity statins following an MI in 2007–2013. SAAE were identified through a claims-based algorithm, which included down-titrating statins and initiating ezetimibe, switching to ezetimibe monotherapy, having a rhabdomyolysis or antihyperlipidemic adverse event followed by statin down-titration or discontinuation, or switching between ≥ 3 statin types within 365 days following MI. HSA was defined by having a statin available to take for ≥ 80% of the days in the 365 days following MI. Expenditures among beneficiaries with SAAE and HSA were $40,776 (95% CI $38,329–$43,223) and $26,728 ($26,482–$26,974), respectively, in the 365 days following MI, and $34,238 ($31,396–$37,080) and $29,053 ($28,605–$29,500), respectively, for every year after the first 365 days. Multivariable-adjusted ratios comparing expenditures among beneficiaries with SAAE versus HSA in the first 365 days and after the first 365 days following MI were 1.51 (95% CI 1.43–1.59) and 1.23 (1.12–1.34), respectively. Inpatient and outpatient expenditures were higher among beneficiaries with SAAE versus HSA during and after the first 365 days following MI. Compared to beneficiaries with HSA, medication expenditures among those with SAAE were similar in the 365 days following MI, but higher afterwards. Other medical expenditures were higher among beneficiaries with SAAE versus HSA. SAAE are associated with increased expenditures following MI compared with HSA.

A 9-point risk assessment identified persons with a history of injection drug use who were safe for discharge. "Low-risk" patients were discharged with outpatient antibiotics; others continued inpatient treatment. Use of the assessment reduced the mean length of stay by 20 days and total direct cost by 33%, creating capacity for an additional 333 patients.

Background Contact with the healthcare system represents an opportunity for individuals who discontinue statins to re‐initiate treatment. To help identify opportunities for healthcare providers to emphasize the risk‐lowering benefits accrued through restarting statins, we determined the types of healthcare utilization associated with statin re‐initiation among patients with history of a myocardial infarction. Methods and Results Medicare beneficiaries with a statin pharmacy fill claim within 30 days of hospital discharge for a myocardial infarction in 2007 to 2012 (n=158 795) were followed for 182 days postdischarge to identify treatment discontinuation, defined as 60 continuous days without statins (n=24 461). Re‐initiation was defined as a statin fill within 365 days of the discontinuation date (n=13 136). Using a case‐crossover study design and each beneficiary as their own control, healthcare utilization during 0 to 14 days before statin re‐initiation (case period) was compared with healthcare utilization 30 to 44 days before statin re‐initiation (control period). The mean age of beneficiaries was 75.4 years; 52.8% were women and 81.9% were white. For routine healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with lipid panel testing was 2.65 (1.93–3.65), outpatient primary care was 1.31 (1.23–1.40), and outpatient cardiologist care was 1.38 (1.28–1.50). For acute healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with emergency department visits was 1.77 (1.31–2.40), coronary heart disease ( CHD ) hospitalizations was 3.16 (2.41–4.14) and non–coronary heart disease hospitalizations was 1.73 (1.49–2.01). Conclusions The weaker association of routine versus acute healthcare utilization with statin re‐initiation suggests missed opportunities to reinforce the importance of statin therapy for secondary prevention.

State Medicaid programs increasingly use case management to manage enrollees with chronic conditions who may become cost intensive for the program. The authors examined the impact of Alabama Department of Public Health (ADPH)'s case management on care expenditures for Medicaid enrollees with various chronic diseases, over 2011 to 2014. The authors matched case-managed enrollees with three controls per case using health conditions and sociodemographics. Thereafter, the authors used a quasi-experimental approach to estimate how per-member-per-month costs changed following case management. Case -management appeared to result in program savings, driven largely by inpatient and emergency department cost-savings. There was noticeable variation in savings for members with different chronic conditions.

Purpose Intensity modulated radiation therapy (IMRT) is widely used in the treatment of head and neck cancers (HNC). There is not enough evidence to suggest that some radiation oncologists (ROs) are associated with better outcomes in patients with HNC. We conducted a cross-sectional analysis to evaluate the effect of ROs' characteristics on outcomes in patients with HNC treated with IMRT. Methods and materials The study used the Surveillance Epidemiology and End Results-Medicare linked database to identify patient characteristics. Physician records were obtained from the American Medical Association. Logistic regression models with propensity scores were analyzed to look for an association between RO characteristics and patient outcomes. Results RO characteristics showed that approximately 30% of ROS completed their training in or after the year 2000 (recently trained), and 17% were in top decile of treatment volume (high volume). Less than 3% of ROs work in academic settings. We found that ROs who were recently trained have higher odds (odds ratio [OR]: 1.10; 95% confidence interval [CI], 1.011-1.191) compared with those who were not. In addition, ROs who were treating high volumes of patients have higher odds (OR: 1.08; 95% CI, 1.010-1.165) compared with those treating low volumes of an event of adverse effect of IMRT or death among patients. ROs who work in academic settings have a protective effect (OR: 0.72; 95% CI, 0.569-0.925). Conclusions ROs who were recently trained and had a high treatment volume are associated with poorer outcomes among patients with HNC who receive IMRT treatment.

BackgroundChronic pain is a common, disabling, and costly comorbidity, particularly in people living with HIV (PLWH). This study developed and pilot tested a pain self-management intervention for chronic pain tailored to PLWH called Skills TO Manage Pain (STOMP).ObjectivesGiven the additional resources needed to deliver STOMP in HIV clinical settings, an important objective of the pilot study was to assess not only STOMP's preliminary efficacy, but also its cost-effectiveness.Research design and subjectsThe present study draws from a 44-participant, 2-arm randomized pilot trial of the STOMP intervention vs usual care among PLWH and at least moderate chronic pain (Clinicaltrials.gov: NCT02824562). Cost-effectiveness is presented as the incremental cost-effectiveness ratio (ICER). Costs were considered from the clinic perspective over a 1-year time horizon using real costs from the pilot trial. It was conservatively assumed there would be no costs savings. The Standard Gamble (SG) method was used to directly measure utilities.ResultsThirty-six participants met inclusion criteria for the present analyses. Mean age was 52 years; 61% were female and 86% were black. The total cost of STOMP was $483.83 per person. Using the SG method, the change in QALYs was 0.15, corresponding to an ICER of $3,225.ConclusionsSTOMP's cost/QALY is substantially lower than the $50,000 to $100,000/QALY benchmark often used to indicate cost-effectiveness. Although based on a pilot trial and, therefore, preliminary, these findings are promising, and suggest the importance of cost analyses in future STOMP trials.

Chronic pain is an important and understudied comorbidity in people living with HIV (PLWH). We conducted a pilot trial of Skills TO Manage Pain (STOMP), an innovative social cognitive theory-based pain self-management intervention tailored to PLWH, to assess feasibility, acceptability, and preliminary efficacy. Eligibility criteria included being HIV+, ≥ moderate pain for ≥ 3 months and a score of ≥ 4 on the three-item PEG pain severity and interference scale. Participants were randomized in a 1:1 fashion to STOMP or a usual care comparison. Among 22 participants randomized to STOMP, median session attendance was 9/12 (75%). Of 19 STOMP participants surveyed, 13 reported being "much better" overall since beginning treatment. Brief pain inventory-total scores decreased by 2 points in the intervention group and 0.9 in the control group (p = 0.11). STOMP is feasible, acceptable, and shows preliminary evidence of efficacy and promise for a full-scale trial.

Purpose We sought to determine the long-term risk of cardiovascular disease (CVD)—stroke and myocardial infarction—and congestive heart failure (CHF) in older patients with colorectal cancer, as well as to understand the roles that preexisting comorbidities and cancer therapy play in increasing this risk. Patients and Methods We evaluated individuals from the SEER-Medicare database with incident stage I to III colorectal cancer at age older than 65 years between January 1, 2000, and December 31, 2011 (n = 72,408) and compared these patients with a matched cohort of Medicare patients without cancer (n = 72,408). Results Median age at diagnosis of colorectal cancer was 78 years (range, 66 years to 106 years), and median follow-up was 8 years since diagnosis. The 10-year cumulative incidence of new-onset CVD and CHF were 57.4% and 54.5% compared with 22% and 18% for control, respectively ( P < .001). The interaction between hypertension and chemotherapy was significant ( P < .001) for CVD, and that between diabetes and chemotherapy was significant ( P < .001) for CHF. Within the first 2 years since diagnosis, exposure to capecitabine alone increased CHF hazard (hazard ratio [HR], 3.6; 95% CI, 12.76 to 4.38) compared with exposure to fluorouracil alone. Conversely, patients who were treated with fluorouracil alone had a higher CVD hazard at < 2 years and > 2 years since diagnosis compared with patients who received capecitabine alone (< 2 years HR, 0.63; 95% CI, 0.53 to 0.75; > 2 years HR, 0.72; 95% CI, 0.62 to 0.84). Conclusion Older patients with colorectal cancer are at increased risk of developing CVD and CHF. Diabetes and hypertension interact with chemotherapy to increase the risk of cardiovascular morbidity. Future studies should assess the potential for personalized therapeutic options for those with preexisting morbidities and for structured monitoring for patients with a history of exposure to chemotherapy regimens, as well as explore the management of preexisting comorbidities to address long-term cardiovascular morbidity.

We examined claims-based approaches for identifying a study population free of coronary heart disease (CHD) using data from 8,937 US blacks and whites enrolled during 2003–2007 in a prospective cohort study linked to Medicare claims. Our goal was to minimize the percentage of persons at study entry with self-reported CHD (previous myocardial infarction or coronary revascularization). We assembled 6 cohorts without CHD claims by requiring 6 months, 1 year, or 2 years of continuous Medicare fee-for-service insurance coverage prior to study entry and using either a fixed-window or all-available look-back period. We examined adding CHD-related claims to our “base algorithm,” which included claims for myocardial infarction and coronary revascularization. Using a 6-month fixed-window look-back period, 17.8% of participants without claims in the base algorithm reported having CHD. This was reduced to 3.6% using an all-available look-back period and adding other CHD claims to the base algorithm. Among cohorts using all-available look-back periods, increasing the length of continuous coverage from 6 months to 1 or 2 years reduced the sample size available without lowering the percentage of persons with self-reported CHD. This analysis demonstrates approaches for developing a CHD-free cohort using Medicare claims.

Background A well-functioning primary care system has the capacity to provide effective care for patients to avoid nonurgent emergency department (ED) use and related costs. Objective This study examined how patients' perceived deficiency in ambulatory care is associated with nonurgent ED care costs nationwide. Methods This retrospective cohort study used data from the 2010–2011 Medical Expenditure Panel Survey. This study chose usual source of care, convenience of needed medical care, and patient evaluation of care quality as the main independent variables. The marginal effect following a multivariate logit model was employed to analyze the urgent vs. nonurgent ED care costs in 2011, after controlling for covariates in 2010. The endogeneity was accounted for by the time lag effect and controlling for education levels. Sample weights and variance were adjusted with the survey procedures to make results nationally representative. Results Patient-perceived poor and intermediate levels of primary care quality had higher odds of nonurgent ED care costs (odds ratio [OR] = 2.22, p = 0.035, and OR = 2.05, p = 0.011, respectively) compared to high-quality care, with a marginal effect (at means) of 13.0% and 11.5% higher predicted probability of nonurgent ED care costs. Costs related to these ambulatory care quality deficiencies amounted to $229 million for private plans (95% confidence interval [CI] $100 million–$358 million), $58.5 million for public plans (95% CI $33.9 million–$83.1 million), and an overall of $379 million (95% CI $229 million–$529 million) nationally. Conclusions These findings highlight the improvement in ambulatory care quality as the potential target area to effectively reduce nonurgent ED care costs.

Background Health care claims data may provide a cost-efficient approach for studying chronic kidney disease (CKD). Study Design Prospective cohort study. Setting & Participants We compared characteristics and outcomes for individuals with CKD defined using laboratory measurements versus claims data from 6,982 REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study participants who had Medicare fee-for-service coverage. Predictors Presence of CKD as defined by both the REGARDS Study (CKD REGARDS ) and Medicare data (CKD Medicare ), presence of CKD REGARDS but not CKD Medicare , and presence of CKD Medicare but not CKD REGARDS , and absence of both CKD REGARDS and CKD Medicare . Outcomes Mortality and incident end-stage renal disease (ESRD). Measurements The research study definition of CKD (CKD REGARDS ) included estimated glomerular filtration rate (eGFR) 2 or albumin-creatinine ratio > 30mg/g at the REGARDS Study visit. CKD in Medicare (CKD Medicare ) was identified during the 2 years before each participant's REGARDS visit using a claims-based algorithm. Results Overall, 32% of participants had CKD REGARDS and 6% had CKD Medicare . Sensitivity, specificity, and positive and negative predictive values of CKD Medicare for identifying CKD REGARDS were 15.5% (95% CI, 14.0%-17.1%), 97.7% (95% CI, 97.2%-98.1%), 75.6% (95% CI, 71.4%-79.5%), and 71.5% (95% CI, 70.4%-72.6%), respectively. Mortality and ESRD incidence rates, expressed per 1,000 person-years, were higher for participants with versus without CKD Medicare (mortality: 72.5 [95% CI, 61.3-83.7] vs 33.3 [95% CI, 31.5-35.2]; ESRD: 16.4 [95% CI, 11.2-21.6] vs 1.3 [95% CI, 0.9-1.6]) and with versus without CKD REGARDS (mortality: 59.9 [95% CI, 55.4-64.4] vs 25.5 [95% CI, 23.6-27.4]; ESRD: 6.8 [95% CI, 5.4-8.3] vs 0.1 [95% CI, 0.0-0.3]). Among participants with CKD REGARDS , those with abdominal obesity, diabetes, anemia, lower eGFR, more outpatient visits, hospitalization, and a nephrologist visit in the 2 years before their REGARDS visit were more likely to have CKD Medicare . Limitations CKD REGARDS relied on eGFR and albuminuria assessed at a single visit. Conclusions CKD, whether defined in claims or through research study measurements, was associated with increased mortality and ESRD. However, individuals with CKD identified in claims may represent a select high-risk population.

Background National guidelines recommend use of high-intensity statins after hospitalization for coronary heart disease (CHD) events. Objectives This study sought to estimate the proportion of Medicare beneficiaries filling prescriptions for high-intensity statins after hospital discharge for a CHD event and to analyze whether statin intensity before hospitalization is associated with statin intensity after discharge. Methods We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries between 65 and 74 years old. Beneficiaries were included in the analysis if they filled a statin prescription after a CHD event (myocardial infarction or coronary revascularization) in 2007, 2008, or 2009. High-intensity statins included atorvastatin 40 to 80 mg, rosuvastatin 20 to 40 mg, and simvastatin 80 mg. Results Among 8,762 Medicare beneficiaries filling a statin prescription after a CHD event, 27% of first post-discharge fills were for a high-intensity statin. The percent filling a high-intensity statin post-discharge was 23.1%, 9.4%, and 80.7%, for beneficiaries not taking statins pre-hospitalization, taking low/moderate-intensity statins, and taking high-intensity statins before their CHD event, respectively. Compared with beneficiaries not on statin therapy pre-hospitalization, multivariable adjusted risk ratios for filling a high-intensity statin were 4.01 (3.58–4.49) and 0.45 (0.40–0.52) for participants taking high-intensity and low/moderate-intensity statins before their CHD event, respectively. Only 11.5% of beneficiaries whose first post-discharge statin fill was for a low/moderate-intensity statin filled a high-intensity statin within 365 days of discharge. Conclusions The majority of Medicare beneficiaries do not fill high-intensity statins after hospitalization for CHD.

We had previously developed an algorithm for Medicare claims data to detect bone metastases associated with breast, prostate, or lung cancer. This study was conducted to examine whether this algorithm accurately documents bone metastases on the basis of diagnosis codes in Medicare claims data.We obtained data from Medicare claims and electronic medical records of patients 65 years or older with a breast, prostate, or lung cancer diagnosis at a teaching hospital and/or affiliated clinics during 2005 or 2006. We calculated the sensitivity and positive predictive value (PPV) of our algorithm using medical records as the "gold standard." The κ statistic was used to measure agreement between claims and medical record data.The agreement between claims and medical record data for bone metastases among breast, prostate, and lung cancer patients was 0.93, 0.90, and 0.69, respectively. The sensitivities of our algorithm for bone metastasis in patients with breast, prostate, and lung were 96.8% [95% confidence interval (CI)=83.8% to 99.4%], 91.7% (95% CI=78.2% to 97.1%), and 74.1% (95% CI=55.3% to 86.8%), respectively; and the PPVs were 90.9% (95% CI=76.4% to 96.9%), 91.7% (95% CI=78.2% to 97.1%), and 71.4% (95% CI=52.9% to 84.8%), respectively.The algorithm for detecting bone metastases in claims data had high sensitivity and PPV for breast and prostate cancer patients. Sensitivity and PPV were lower but still moderate for lung cancer patients.

BackgroundMeta-analyses of general population studies report mean low-density lipoprotein cholesterol (LDL-C) reductions of 30% to

Background— Although the benefits of statins accrue over time, treatment discontinuation is common. Examining the patterns of statin discontinuation, reinitiation, and persistence after reinitiation among Medicare beneficiaries after hospital discharge for a myocardial infarction may help increase statin use in high-risk patients. Methods and Results— Medicare beneficiaries with a statin fill claim within 30 days after hospital discharge for myocardial infarction in 2007 to 2012 (n=158 795) were followed for 182 days post-discharge to identify discontinuation, defined as 60 continuous days without statins available. Reinitiation, defined by a statin fill, was identified in the 365 days post-discontinuation. High persistence was defined as proportion of days covered ≥80% with ≥1 day of statin supply 182 days after reinitiation. Follow-up ended on December 31, 2014. In the 182 days after myocardial infarction hospital discharge, 15.4% of beneficiaries discontinued statins. Of this group, 53.7% reinitiated statins. On reinitiation, 27.1% changed statin type, 6.9% up-titrated intensity, 14.4% down-titrated intensity, and 66.0% had the same statin and intensity. In the 182 days after reinitiation, 45.8% had high persistence. Moderate- and high- versus low-intensity statins were associated with a lower risk for statin discontinuation (moderate intensity: relative risk [RR], 0.93; 95% confidence interval [CI], 0.89–0.96; high-intensity: RR, 0.95; 95% CI, 0.91–0.99). High persistence was less common after reinitiating high- versus low-intensity statins (RR, 0.80; 95% CI, 0.75–0.86), but no association was present for those reinitiating a moderate- versus low-intensity statin (RR, 0.95; 95% CI, 0.90–1.01). Down-titrating versus reinitiating the same statin intensity (RR, 1.10; 95% CI, 1.05–1.16) and reinitiating a different versus the same statin (RR, 1.10; 95% CI, 1.06–1.14) were associated with high persistence after treatment reinitiation. Conclusions— Although many people who discontinue a statin reinitiate treatment, statin persistence after reinitiation was low. Reinitiating therapy with moderate-intensity statins, down-titration, and using a different statin may promote persistence.

Antihypertensive medication decreases risk of cardiovascular disease (CVD) events in adults with hypertension. Although black adults have higher prevalence of hypertension and worse CVD outcomes compared with whites, limited attention has been given to the cost-effectiveness of antihypertensive medication for blacks.To compare the cost-effectiveness of antihypertensive medication treatment versus no-treatment in white and black adults.We constructed a State Transition Model to assess the costs and quality-adjusted life-years (QALYs) associated with either antihypertensive medication treatment or no-treatment using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study and published literature. CVD events and health states considered in the model included stroke, coronary heart disease, heart failure, chronic kidney disease, and end-stage renal disease.White and black adults with hypertension in the United States, 45 years of age and above.Yearly risk of CVD was determined using REGARDS data and published literature. Antihypertensive medication costs were determined using Medicare claims. Event and health state costs were estimated from published literature. All costs were adjusted to 2012 US dollars. Effectiveness was assessed using QALYs.Antihypertensive medication treatment was cost-saving and increased QALYs compared with no-treatment for white men ($7387; 1.14 QALYs), white women ($7796; 0.89 QALYs), black men ($8400; 1.66 QALYs), and black women ($10,249; 1.79 QALYs).Antihypertensive medication treatment is cost-saving and increases QALYs for all groups considered in the model, particularly among black adults.

Background Better cardiovascular health is associated with lower cardiovascular disease risk. Methods and Results We determined the association between cardiovascular health and healthcare utilization and expenditures in the RE asons for Geographic And Racial Differences in Stroke (REGARDS) study. We included 6262 participants ≥65 years with Medicare fee‐for‐service coverage for the year after their baseline study visit in 2003‐2007. Cardiovascular health at baseline was assessed using the American Heart Association's Life's Simple 7 ( LS 7) metric, which includes 7 factors: cigarette smoking, physical activity, diet, body mass index, blood pressure, cholesterol, and glucose. Healthcare utilization and expenditures were ascertained using Medicare claims in the year following baseline. Overall, 17.2%, 31.1%, 29.0%, 16.4% and 6.4% of participants had 0 to 1, 2, 3, 4, and 5 to 7 ideal LS 7 factors, respectively. The multivariable‐adjusted relative risk (95% confidence interval [ CI ]) for having any inpatient and outpatient encounters comparing participants with 5 to 7 versus 0 to 1 ideal LS 7 factors were 0.55 (0.39, 0.76) and 1.00 (0.98, 1.02), respectively. Among participants with 0 to 1 and 5 to 7 ideal LS 7 factors, mean inpatient expenditures were $3995 and $1250, respectively, mean outpatient expenditures were $5166 and $2853, respectively, and mean total expenditures were $9147 and $4111, respectively. After multivariable adjustment, the mean (95% CI ) cost difference comparing participants with 5 to 7 versus 0 to 1 ideal LS 7 factors was −$2551 (−$3667, −$1435) for inpatient, −$2410 (−$3089, −$1731) for outpatient, and −$5016 (−$6577, −$3454) for total expenditures. Conclusions Better cardiovascular health is associated with lower risk for inpatient encounters and lower inpatient and outpatient healthcare expenditures.

We analyzed a standard children's quality measure for attention-deficit/hyperactivity disorder (ADHD) using data from a single state to understand the characteristics of those meeting the measure, potential barriers to meeting the measure, and how meeting the measure affected outcomes.Retrospective study using claims from Alabama's Children's Health Insurance Program from 1999 to 2012.We calculated the quality measure for ADHD care, as specified within CMS' Child Core Set and with an expanded denominator. We described the eligible population meeting the measure, assessed potential barriers, and measured the association with health expenditures using logit regressions and log-Poisson models.Among those receiving ADHD medication, 11% of enrollees were eligible for annual measure calculation during our study period. Calculated as specified by CMS, 38% of enrollees met the measure. Using an expanded denominator of 7615 eligible medication episodes, 14% met all aspects of the measure. Primary reasons for failing to meet the measure were lacking medication coverage (64%) and lacking a follow-up visit within 30 days (62%). The rate of meeting the measure decreased with age and was lower for black enrollees. Health service utilization and costs were greater among children meeting the measure.Too few children are eligible for inclusion, and systematic differences exist among those who meet the measure. The measure may be sensitive to arbitrary criteria while missing potentially relevant clinical care. Refinements to the measure should be considered to improve generalizability to all children with ADHD and improve clinical relevance. States must consider additional analyses to direct quality improvement.

Background— Little is known about associations of calcium channel blockers (CCBs) with outcomes in patients with heart failure and preserved ejection fraction (EF). Methods and Results— Of the 10 570 hospitalized patients with heart failure and preserved EF, ≥65 years, EF ≥40%, in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF; 2003–2004), linked to Medicare data (through December 31, 2008), 7514 had no prior history of CCB use. Of these, 815 (11%) patients received new discharge prescriptions for CCBs. Propensity scores for CCB initiation, calculated for each of the 7514 patients, were used to assemble a matched cohort of 1620 (810 pairs) patients (mean age, 80 years; mean EF, 56%; 65% women; 10% black) receiving and not receiving CCBs, balanced on 114 baseline characteristics. The primary composite end point of all-cause mortality or heart failure hospitalization occurred in 82% and 81% of patients receiving and not receiving CCBs (hazard ratio for CCBs, 1.03; 95% confidence interval, 0.92–1.14). Hazard ratios (95% confidence intervals) for all-cause mortality, heart failure hospitalization, and all-cause hospitalization were 1.05 (0.94–1.18), 1.05 (0.91–1.21), and 1.03 (0.93–1.14), respectively. Similar associations were observed when we categorized patients into those receiving amlodipine and nonamlodipine CCBs. Among 7514 prematch patients, multivariable-adjusted and propensity-adjusted hazard ratios (95% confidence interval) for primary composite end point were 1.03 (0.95–1.12) and 1.02 (0.94–1.11), respectively. Conclusions— In hospitalized older patients with heart failure, new discharge prescriptions for CCBs had no associations with composite or individual end points of mortality or heart failure hospitalization, regardless of the class of CCBs.

The strategy of evaluating every donation opportunity warrants an investigation into the financial feasibility of this practice. The purpose of this investigation is to measure resource utilization required for procurement of transplantable organs in an organ procurement organization (OPO).Donors were stratified into those that met OPTN-defined eligible death criteria (ED donors, n=589) and those that did not (NED donors, n=703). Variable direct costs and time utilization by OPO staff for organ procurement were measured and amortized per organ transplanted using permutation methods and statistical bootstrapping/resampling approaches.More organs per donor were procured (3.66±1.2 vs. 2.34±0.8, P0.0001) and transplanted (3.51±1.2 vs. 2.08±0.8, P0.0001) in ED donors compared with NED donors. The variable direct costs were significantly lower in the NED donors ($29,879.4±11590.1 vs. $19,019.6±7599.60, P0.0001). In contrast, the amortized variable direct costs per organ transplanted were significantly higher in the NED donors ($8,414.5±138.29 vs. $9,272.04±344.56, P0.0001). The ED donors where thoracic organ procurement occurred were 67% more expensive than in abdominal-only organ procurement. The total time allocated per donor was significantly shorter in the NED donors (91.2±44.9 hr vs. 86.8±78.6 hr, P=0.01). In contrast, the amortized time per organ transplanted was significantly longer in the NED donors (23.1±0.8 hr vs. 36.9±3.2 hr, P0.001).The variable direct costs and time allocated per organ transplanted is significantly higher in donors that do not meet the eligible death criteria.

Objective: This study examines temporal trends in hip fracture related utilization and outcomes among elderly fee-for-service Medicare beneficiaries. Method: The study uses claims data for a 5% sample of Medicare beneficiaries with an incident hip fracture hospitalization between 2000 and 2008. We present annual mean patient characteristics, health services utilization, and outcomes and use ordinary least squares regressions to examine adjusted trends in utilization and outcomes after controlling for changes in patient characteristics. Results: We observe a statistically significant temporal decline in inpatient acute days and a statistically significant increase in inpatient post-acute days following hip fractures. In models that control for patient characteristics, we observe statistically significant declines in 1-year hip fracture readmission and mortality rates. Rates of nursing home residence 1-year following fracture were unchanged and remain high. Discussion: Hip fractures remain highly debilitating events and pose significant challenges for the financing of public health insurance programs.

Background Although low-density lipoprotein cholesterol (LDL-C) is recommended as the primary marker to guide lipid-lowering therapy, some data suggest non–high-density lipoprotein cholesterol (non–HDL-C) may better reflect coronary heart disease risk. Discordance between these measures has not been evaluated. Methods We used data from the National Health and Nutrition Examination Surveys 2005–2010 (n = 4986) to examine the discordance between these lipid parameters. Elevated levels of non–HDL-C and LDL-C were defined by using the 2004 Adult Treatment Panel III guidelines. Results The prevalence of high non–HDL-C and LDL-C was 22.7% and 24.5%, respectively. Of participants with high non–HDL-C, 9.7% had normal LDL-C, whereas 15.7% of participants with high LDL-C had normal non–HDL-C. We estimate 3.9 million US adults had high non–HDL-C and normal LDL-C, whereas 6.8 million US adults had high LDL-C and normal non–HDL-C. Persons with high non–HDL-C and normal LDL-C were older, more likely to be men, Hispanic, and have impaired fasting glucose, diabetes metabolic syndrome, and more risk factors for coronary heart disease. Conclusions Substantial discordance exists between high non–HDL-C and high LDL-C among US adults. Reliance on either single measure could result in failure to classify cardiovascular heart disease risks appropriately.

Marked increases in the awareness, treatment, and control of high low-density lipoprotein (LDL) cholesterol occurred among United States (US) adults from 1988-1994 to 1999-2004. An update to the Third Adult Treatment Panel guidelines was published in 2004, and it is unknown if these improvements have continued since the publication of these revised treatment recommendations. The aim of this study was to determine trends in the awareness, treatment, and control of high LDL cholesterol among US adults from 1999-2000 to 2009-2010 using nationally representative samples of US adults aged ≥20 years from 6 consecutive National Health and Nutrition Examination Surveys (NHANES) in 1999-2000 (n = 1,659), 2001-2002 (n = 1,897), 2003-2004 (n = 1,698), 2005-2006 (n = 1,692), 2007-2008 (n = 2,044), and 2009-2010 (n = 2,318). LDL cholesterol was measured after an overnight fast, and high LDL cholesterol and controlled LDL cholesterol were defined using the 2004 updated Third Adult Treatment Panel guidelines. Awareness and treatment of high cholesterol were defined using self-report. Among US adults, the prevalence of high LDL cholesterol did not change from 1999-2000 (37.2%) to 2009-2010 (37.8%). Awareness of high LDL cholesterol increased from 48.9% in 1999-2000 to 62.8% in 2003-2004 but did not increase further through 2009-2010 (61.5%). Among those aware of having high LDL cholesterol, treatment increased from 41.3% in 1999-2000 to 72.6% in 2007-2008 and was 70.0% in 2009-2010. Among US adults receiving treatment for high LDL cholesterol, the percentage with controlled LDL cholesterol increased from 45.0% in 1999-2000 to 65.3% in 2005-2006 and had decreased slightly by 2009-2010 (63.6%). In conclusion, high LDL cholesterol remains common among US adults. Additional efforts are needed to prevent high LDL cholesterol and increase the awareness, treatment, and control of high LDL cholesterol among US adults.

Hip fractures in older adults are associated with increased mortality (1,2), morbidity (1), risk of second fracture (2), and decreased ability to perform activities of daily living (3–5). One-year mortality risk following hip fracture in patients aged 65 and over has been estimated between 12% and 37% (6,7), and 5-year mortality risk can reach upwards of 60% in some elderly populations (2,8–10). Among hip fracture survivors, half do not regain their pre-fracture functionality, and approximately, 20% require some type of long-term care (3,11). Becoming dependent on institutional long-term care is an undesirable outcome that can itself result in lower quality of life. Moreover, long-term care is expensive. Estimates of private long-term care costs range between $60,000 and $72,000 per year (12). Long-term care insurance is available, but only about 2.3% of the U.S. population and 12.4% of individuals aged 65 and over have this type of insurance (13,14). Thus, many people who experience a hip fracture run the risk of exhausting their financial resources paying for care and can subsequently become eligible for Medicaid, adding to the social costs. Medicaid pays approximately $109 billion a year for long-term care of the elderly adults (15). As many as 50% of hip fractures may be preventable (16,17): so some of the adverse outcomes and the financial burden associated with hip fractures can potentially be avoided. This article examines the effects of hip fracture on death, debility (new dependence long-term institutional care), and destitution (entry into Medicaid or eligibility for low-income drug subsidies). A unique contribution of this study is its estimation of the proportion of hip fracture patients who require not just short-term rehabilitation in a nursing facility, but who become dependent on long-term institutional care within 1 year after hip fracture. Another unique feature of this study is its determination of the risk of becoming newly impoverished following hip fracture within 1 year.

BACKGROUND AND OBJECTIVE: Although preventive dental visits are considered important for maintaining pediatric oral health, there is relatively little research showing that they reduce subsequent nonpreventive dental visits or costs. At least 1 study seemed to find that early preventive dental care is associated with more restorative and emergency visits. Previous studies are limited by their inability to account for unmeasurable factors that may lead children to “select” into using both more preventive and nonpreventive dental care. We used econometric techniques that minimize selection bias to assess the effectiveness of preventive dental care in reducing subsequent nonpreventive dental service utilization among children. METHODS: Using data from Alabama’s Children’s Health Insurance Program (CHIP), 1998–2010., a cohort study of children’s dental service utilization was conducted. Outcomes were 1-year lagged nonpreventive dental care and expenditures, and overall dental and medical expenditures. Children who were continuously enrolled for at least 3 years were included. Separate models were estimated for children aged RESULTS: More preventive visits were associated with fewer subsequent nonpreventive dental visits and lower nonpreventive dental expenditures for both groups. However, more preventive visits did not reduce overall dental or medical (inclusive of dental) expenditures. CONCLUSIONS: Preventive dental visits can reduce subsequent nonpreventive visits and expenditures for children continuously enrolled in CHIP. However, they may not reduce overall program costs. Effective empirical research in this area must continue to address unobserved confounders and selection issues.

Background The role of angiotensin-converting enzyme (ACE) inhibitors in patients with heart failure and preserved ejection fraction remains unclear. Methods Of the 10,570 patients aged ≥65 years with heart failure and preserved ejection fraction (≥40%) in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (2003-2004) linked to Medicare (through December 2008), 7304 were not receiving angiotensin receptor blockers and had no contraindications to ACE inhibitors. After excluding 3115 patients with pre-admission ACE inhibitor use, the remaining 4189 were eligible for new discharge prescriptions for ACE inhibitors, and 1706 received them. Propensity scores for the receipt of ACE inhibitors, calculated for each of the 4189 patients, were used to assemble a cohort of 1337 pairs of patients, balanced on 114 baseline characteristics. Results Matched patients had a mean age of 81 years and mean ejection fraction of 55%, 64% were women, and 9% were African American. Initiation of ACE inhibitor therapy was associated with a lower risk of the primary composite end point of all-cause mortality or heart failure hospitalization during 2.4 years of median follow-up (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84-0.99; P = .028), but not with individual end points of all-cause mortality (HR, 0.96; 95% CI, 0.88-1.05; P = .373) or heart failure hospitalization (HR, 0.93; 95% CI, 0.83-1.05; P = .257). Conclusion In hospitalized older patients with heart failure and preserved ejection fraction not receiving angiotensin receptor blockers, discharge initiation of ACE inhibitor therapy was associated with a modest improvement in the composite end point of total mortality or heart failure hospitalization but had no association with individual end point components.

Background For women who have had a previous low transverse cesarean delivery, the decision to undergo a trial of labor after cesarean (TOLAC) or an elective repeat cesarean delivery (ERCD) has important clinical and economic ramifications. Objectives To evaluate the cost-effectiveness of the alternative choices of a TOLAC and an ERCD for women with low-risk, singleton gestation pregnancies. Methods We searched EMBASE, MEDLINE, CINAHL, Cochrane Library, EconLit, and the Cost-Effectiveness Analysis Registry with no language, publication, or date restrictions up until October 2015. Studies were included if they were primary research, compared a TOLAC with an ERCD, and provided information on the relative cost of the alternatives. Abstracts and partial economic evaluations were excluded. Results Of 310 studies initially reviewed, 7 studies were included in the systematic review. In the base-case analyses, 4 studies concluded that TOLAC was dominant over ERCD, 1 study found ERCD to be dominant, and 2 studies found that although TOLAC was more costly, it offered more benefits and was thus cost-effective from a population perspective when considering societal willingness to pay for better outcomes. In sensitivity analyses, cost-effectiveness was found to be dependent on a high likelihood of TOLAC success, low risk of uterine rupture, and low relative cost of TOLAC compared with ERCD. Conclusions For women who are likely to have a successful vaginal delivery, routine ERCD may result in excess morbidity and cost from a population perspective.

This study assessed the association of the Medicare Part D coverage gap with medication adherence among beneficiaries with chronic obstructive pulmonary disease (COPD).Retrospective observational study based on Medicare claims data.A 5% random sample of Medicare claims data (2006-2010) was used in this study. Beneficiaries diagnosed with COPD and treated with long-acting bronchodilators (LABDs) were assigned to an exposure cohort (at risk of the coverage gap) or a control cohort (otherwise). The exposure and control cohorts were matched using high-dimensional propensity scores. Adherence was defined as ≥80% of the proportion of days covered by LABDs. Logistic regressions controlling for unbalanced covariates post matching were applied to assess the association of the coverage gap with adherence.The final matched exposure and control cohorts each included 4147 patient-year observations with about 42% and 46% of them adherent to LABDs, respectively. About 17% of the exposure cohort hit the coverage gap after October 31. Logistic regression showed that, compared with the control cohort, the beneficiaries in the exposure cohort had a significantly lower likelihood of being adherent if they hit the coverage gap later in the year (odds ratio [OR], 0.603; 95% CI, 0.493-0.738), or had a lower likelihood without statistical significance if otherwise (OR, 0.931; 95% CI, 0.846-1.024).The findings suggest that the Part D coverage gap was associated with lower adherence in patients with COPD, which may serve as evidentiary support for phasing out the coverage gap by 2020.

BACKGROUND: Apparent treatment-resistant hypertension (aTRH) is associated with an increased risk of adverse cardiovascular outcomes. We studied the frequency and intensity of care for aTRH among participants aged 65 years and older in the US-based REGARDS study linked with Medicare claims. METHODS: Blood pressure (BP) was measured twice and averaged. aTRH was defined by the use of ≥3 classes of antihypertensive medication and uncontrolled BP (UaTRH, systolic/diastolic BP ≥140/90 mmHg), or ≥4 classes with controlled BP (CaTRH). Participants were categorized as not having aTRH (no aTRH), CaTRH or UaTRH. RESULTS: Among 4650 participants with hypertension, 468 (10.1%) had UaTRH, 247 (5.3%) had CaTRH, and 3935 (84.6%) had hypertension but did not have aTRH. For hypertension-related visits, those with UaTRH saw primary care physicians and cardiologists more frequently than those without aTRH (mean primary care visits per year: 2.77 vs 2.27, P < .001; cardiologists: 0.50 vs 0.35, P = .014). Among those with UaTRH, CaTRH, and no aTRH, respectively 73.5%, 68.0%, and 67.5% had >1 hypertension-related visit per year. Among those with UaTRH, males vs females (prevalence ratio = 0.78; 95% CI 0.69–0.89), whites vs blacks (0.88; 95% CI 0.78–0.99), and current smokers vs non-smokers (0.66; 95% CI 0.48–0.89) were less likely to receive >1 hypertension-related visit per year. Diagnostic intensity, measured by testing for end organ damage and secondary hypertension, was similar between groups. CONCLUSIONS: Many people with UaTRH are not seen more than once per year for hypertension and may benefit from increased care. (Am Heart J 2017;186:29–39.)

Background Differences in healthcare utilization after stroke may partly explain race or gender differences in stroke outcomes and identify factors that might reduce post-acute stroke care costs. Aim To examine systematic differences in Medicare claims for healthcare utilization after hospitalization for ischemic stroke in a US population-based sample. Methods Claims were examined over a six-month period after hospitalization for 279 ischemic stroke survivors 65 years or older from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Statistical analyses examined differences in post-acute healthcare utilization, adjusted for pre-stroke utilization, as a function of race (African-American vs. White), gender, age, stroke belt residence, income, Medicaid dual-eligibility, Charlson comorbidity index, and whether the person lived with an available caregiver. Results After adjusting for covariates, women were more likely than men to receive home health care and to use emergency department services during the post-acute care period. These effects were maintained even after further adjustment for acute stroke severity. African-Americans had more home health care visits than Whites among patients who received some home health care. Having a co-residing caregiver was associated with reduced acute hospitalization length of stay and fewer post-acute emergency department and primary care physician visits. Conclusions Underutilization of healthcare after stroke does not appear to explain poorer long-term stroke outcomes for women and African-Americans in this epidemiologically-derived sample. Caregiver availability may contribute to reduced formal care and cost during the post-acute period.

Background US national guidelines call for cost-conscious practices including the selection of antiretroviral therapy. Objective The objective is to analyze the relative cost-effectiveness of contemporary antiretroviral therapy in real-world clinical settings. Design Observational cohort study. Methods Retrospective follow-up study of treatment-naive persons living with HIV initiating antiretroviral therapy (ART) between January 2007 and December 2012 at an academically affiliated HIV clinic was conducted. Analysis was restricted to patients with the five most commonly prescribed regimens (N = 491). Patients were followed until December 14 to determine the durability of the initial regimen prescribed; median durations were calculated using Kaplan-Meier survival analyses. The average 340b price of the ART regimen 30-day supply was used for cost. Sensitivity analyses were performed adjusting for missing data and pricing indices and using mean durability (±1 SD). Results Initial regimens contained emtricitabine and tenofovir, along with a third drug. Median durability was shortest for ritonavir-boosted atazanavir (31.9 months) and longest for ritonavir-boosted darunavir and raltegravir (both 47.8 months). All regimens were dominated, meaning less durable and more costly, relative to efavirenz ($710.64/month) and raltegravir-based regimens ($1075.03/month). These findings were reproduced in sensitivity analysis, although rilpivirine became a valuable option in some scenarios. Relative to the efavirenz-based regimen, raltegravir had an incremental cost of $47/month of additional therapy. Conclusion In this sample, raltegravir and efavirenz-based regimens are the most cost-effective options for treatment-naive patients. Sensitivity analyses suggest rilpivirine is a reasonable choice in limited scenarios. These findings are relevant given changes in recommended regimens for treatment-naive persons, which include raltegravir and darunavir but exclude efavirenz and rilpivirine-based regimens. Summary Of five commonly prescribed regimens for treatment-naive HIV patients in one clinic (2007-2012), emtricitabine and tenofovir with efavirenz and raltegravir were the only consistently cost-effective options; the rilpivirine-based regimen was valuable in limited scenarios. Further data on the comparative effectiveness of efavirenz and rilpivirine are needed before they are abandoned.

Treat to target guidelines recommend achieving remission or low disease activity in rheumatoid arthritis (RA). However, the reduction in adverse events and costs associated with lower disease activity is unclear.We used Corrona linked to Medicare data to identify RA patients. Time varying disease activity was measured using Clinical Disease Activity Index (CDAI); outcomes included all-cause hospitalization, a composite of hospitalization or emergency department (ED) visits, mortality, and medical costs. Outcome-specific Cox proportional models evaluated the adjusted hazard ratios between disease activity and outcomes, controlling for potential confounders including comorbidities grouped into four patient phenotypes. Costs were analyzed with mixed models using a Gaussian distribution with log transformation.Depending on outcome, 4593 RA patients contributed up to 12 001 person years. Median age was 71 years, 75% women. At baseline, approximately 50-60% of patients were in remission or low disease activity. There was a dose-response relationship between RA disease activity (remission, low, moderate, and high) and the incidence of hospitalizations (13.1, 17.8, 21.2, 27.5 per 100 py, respectively); all adjusted hazard ratios were significant: 0.68 (remission), 0.87 (low), and 1.24 (high) compared with moderate disease activity. Similar trends were observed for ED visits and mortality. The crude difference in annual medical costs between remission ($11 145) and moderate disease activity ($17 646) was $-6 500; the adjusted difference (95%CI) was $-3133 (-4737.72, -1528.43).Leveraging the benefits of linking registry and administrative data together, lower disease activity in RA was associated with incrementally reduced risks of all-cause hospitalization, ED visits, mortality, and medical costs in a dose-dependent fashion. Copyright © 2016 John WileySons, Ltd.

Devising effective cost-containment strategies in public insurance programs requires understanding the distribution of health care spending and characteristics of high-cost enrollees. The aim was to characterize high-cost enrollees in a state’s public insurance program and determine whether expenditure inequality changes over time, or with changes in cost-sharing policies or program eligibility. We use 1999-2011 claims and enrollment data from the Alabama Children’s Health Insurance Program, ALL Kids. All children enrolled in ALL Kids were included in our study, including multiple years of enrollment (N = 1,031,600 enrollee-months). We examine the distribution of costs over time, whether this distribution changes after increases in cost sharing and expanded eligibility, patient characteristics that predict high-cost status, and examine health services used by high-cost children to identify what is preventable. The top 10% (1%) of enrollees account for about 65.5% (24.7%) of total program costs. Inpatient and outpatient costs are the largest components of costs incurred by high-cost utilizers. Non-urgent emergency department costs are a relatively small portion. Average expenditure increases over time, particularly after expanded eligibility, and the share of costs incurred by the top 10% and 1% increases slightly. Multivariable logistic regression results indicate that infants and older teens, Caucasian children, and those with chronic conditions are more likely to be high-cost utilizers. Increased cost sharing does not reduce cost concentration or average expenditure among high-cost utilizers. These findings suggest that identifying and targeting potentially preventable costs among high-cost utilizers are called for to help reduce costs in public insurance programs.

Objective To investigate whether early or regular preventive dental visit (PDV) reduces restorative or emergency dental care and costs for low-income children. Study Setting Enrollees during 1998–2012 in the Alabama CHIP program, ALL Kids. Study Design Retrospective cohort study using claims data for children continuously enrolled in ALL Kids for at least 4 years. Analyses are conducted separately for children 0–4 years, 4–9 years, and >9 years. For 0–4 years, the intervention of interest is whether they have at least one PDV before age 3. For the other two age groups, interventions of interest are if they have regular PDVs during each of the first 3 years, and if they have claims for a sealant in the first 3 years. Outcomes—namely restorative and emergency dental service and costs—are measured in the fourth year. To account for selection into PDV, a high-dimensional propensity scores approach is utilized. Data Extraction Claims data were obtained from ALL Kids. Principal Findings Only sealants are associated with a reduced likelihood of using restorative and emergency services and costs. Conclusions Whether PDVs without sealants actually reduce restorative/emergency pediatric dental services is questionable. Further research into benefits of PDV is needed.

Hip fracture incidence has declined among whites in the United States since 1995, but data on recent trends in racial and ethnic minorities are limited. The goal of this analysis was to investigate hip fracture incidence trends in racial/ethnic subgroups of older Medicare beneficiaries. We conducted a cohort study to determine annual hip fracture incidence rates from 2000 through 2009 using the Medicare national random 5% sample. Beneficiaries were eligible if they were ≥65 years of age and had 90 days of consecutive full fee-for-service Medicare coverage with no hip fracture claims. Race/ethnicity was self-reported. The incidence of hip fracture was identified using hospital diagnosis codes or outpatient diagnosis codes paired with fracture repair procedure codes. We computed age-standardized race/ethnicity-specific incidence rates and assessed trends in the rates over time using linear regression. On average, 821,475 women and 632,162 men were included in the analysis each year. Beneficiaries were predominantly white (88%), with African, Hispanic, and Asian Americans making up 8%, 1.5%, and 1.5% of the population, respectively. We identified 102,849, 4,119, 813, and 1,294 hip fractures in white, black, Asian, and Hispanic beneficiaries over the 10 years. A significant decreasing trend (p