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Importance: In 2014, Maryland initiated the global budget revenue (GBR) model, placing caps on total hospital expenditures across all care sites. The GBR program aims to reduce unnecessary utilization while maintaining or improving care quality. To date, there has been limited examination of program effects on cancer care., Objective: To compare changes in spending, clinical outcomes, and acute care utilization through 4 years of the GBR program among Medicare beneficiaries who undergo cancer-directed surgery in Maryland vs matched control states., Design, Setting, and Participants: Drawing from a matched pool of hospitals in Maryland (n = 35) and 24 control states with a similar timing of Medicaid expansion (n = 101), we identified Medicare beneficiaries from Maryland and control states who underwent any cancer-directed surgery from 2011 through 2018. Using difference-in-differences analysis, we compared changes in outcomes from before (2011-2013) to after (2015-2018) GBR implementation between patients treated in Maryland and control states. We also performed a subgroup analysis among patients who underwent major surgical procedures that are usually performed in the inpatient setting (cystectomy, esophagectomy, gastrectomy, colorectal resection, nephrectomy, pancreatectomy, and lung resection)., Main Outcomes and Measures: Thirty-day episode spending, mortality, readmissions, and emergency department (ED) visits., Results: Relative to Medicare beneficiaries undergoing cancer surgery in control states (n = 4737; 3323 [70.1%] female; 571 [12.1%] dual-eligible; mean [SD] age 74.9 [6.5] years), patients in Maryland (n = 20 320; 14 068 [69.2%] female; 1705 [8.4%] dual-eligible; mean [SD] age 74.9 [6.5] years) had a statistically significant reduction of 2.2 percentage points (95% CI, -4.3 to -0.1) in the 30-day readmission rate. We found no statistically significant changes in 30-day spending, mortality, or ED visits. We report no significant results in the subgroup analysis of patients undergoing major surgical procedures., Conclusions and Relevance: Global budget revenue was not associated with changes in expenditures, ED utilization, or clinical outcomes after cancer-directed surgery through 4 years. There was a modest decline in 30-day readmissions. Specialty-specific definitions of care quality and better alignment across the entire care delivery value chain (ie, physician incentives) may be strategies that could improve delivery of high-value care for beneficiaries undergoing cancer surgery.

Background: Studying team-based primary care using 100% national outpatient Medicare data is not feasible, due to limitations in the availability of this dataset to researchers., Methods: We assessed whether analyses using different sets of Medicare data can produce results similar to those from analyses using 100% data from an entire state, in identifying primary care teams through social network analysis. First, we used data from 100% Medicare beneficiaries, restricted to those within a primary care services area (PCSA), to identify primary care teams. Second, we used data from a 20% sample of Medicare beneficiaries and defined shared care by 2 providers using 2 different cutoffs for the minimum required number of shared patients, to identify primary care teams., Results: The team practices identified with social network analysis using the 20% sample and a cutoff of 6 patients shared between 2 primary care providers had good agreement with team practices identified using statewide data (F measure: 90.9%). Use of 100% data within a small area geographic boundary, such as PCSAs, had an F measure of 83.4%. The percent of practices identified from these datasets that coincided with practices identified from statewide data were 86% versus 100%, respectively., Conclusions: Depending on specific study purposes, researchers could use either 100% data from Medicare beneficiaries in randomly selected PCSAs, or data from a 20% national sample of Medicare beneficiaries to study team-based primary care in the United States., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: It is unclear whether Medicare data can be used to identify type and degree of collaboration between primary care providers (PCPs) [medical doctors (MDs), nurse practitioners, and physician assistants] in a team care model., Methods: We surveyed 63 primary care practices in Texas and linked the survey results to 2015 100% Medicare data. We identified PCP dyads of 2 providers in Medicare data and compared the results to those from our survey. Sensitivity, specificity, and positive predictive value (PPV) of dyads in Medicare data at different threshold numbers of shared patients were reported. We also identified PCPs who work in the same practice by Social Network Analysis (SNA) of Medicare data and compared the results to the surveys., Results: With a cutoff of sharing at least 30 patients, the sensitivity of identifying dyads was 27.8%, specificity was 91.7%, and PPV 72.2%. The PPV was higher for MD-nurse practitioner/physician assistant pairs (84.4%) than for MD-MD pairs (61.5%). At the same cutoff, 90% of PCPs identified in a practice from the survey were also identified by SNA in the corresponding practice. In 5 of 8 surveyed practices with at least 3 PCPs, about ≤20% PCPs identified in the practices by SNA of Medicare data were not identified in the survey., Conclusions: Medicare data can be used to identify shared care with low sensitivity and high PPV. Community discovery from Medicare data provided good agreement in identifying members of practices. Adapting network analyses in different contexts needs more validation studies.

Objective: To investigate the effects of facility-level factors on 30-day unplanned risk-adjusted hospital readmission after discharge from inpatient rehabilitation facilities (IRFs)., Design: Study using 100% Medicare claims data, covering 269,306 discharges from 1094 IRFs between October 2010 and September 2011., Setting: IRFs with at least 30 discharges., Participants: A total number of 1094 IRFs (N=269,306) serving Medicare fee-for-service beneficiaries., Interventions: Not applicable., Main Outcome Measures: Risk-standardized readmission rate (RSRR) for 30-day hospital readmission., Results: Profit status was the only provider-level IRF characteristic significantly associated with unplanned readmissions. For-profit IRFs had a significantly higher RSRR (13.26±0.51) than did nonprofit IRFs (13.15±0.47) (P<.001). After controlling for all other facility characteristics (except for accreditation status because of its collinearity with facility type), for-profit IRFs had a 0.1% point higher RSRR than did nonprofit IRFs, and census region was the only significant region-level characteristic, with the South showing the highest RSRR of all regions (type III test, P=.005 for both)., Conclusions: Our findings support the inclusion of profit status on the IRF Compare website (a platform including IRF comparators to indicate quality of services). For-profit IRFs had a higher RSRR than did nonprofit IRFs for Medicare beneficiaries. The South had a higher RSRR than did other regions. The RSRR difference between for-profit and nonprofit IRFs could be due to the combined effects of organizational and regional factors., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood., Objective: To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care., Design: This was a retrospective cohort study., Setting: Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013., Participants: Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406)., Interventions: Not applicable., Main Measures: Thirty-day unplanned rehospitalization following post-acute rehabilitation., Key Results: The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %)., Conclusions: The functional domains identified in the IMPACT Act were associated with 30-day unplanned rehospitalization following post-acute care in this large national sample. Further research is needed to better understand and improve the functional measures, and to determine if their association with rehospitalizations varies across post-acute settings, patient populations, or episodes of care., Competing Interests: Compliance with Ethical Standards Funders The study was supported by the National Institutes of Health (R24-HD065702, R01-HD069443 and 5K12HD055929-09, PI, K. Ottenbacher) and the National Institute for Disability, Independent Living, and Rehabilitation Research (H133G140127, PI, K. Ottenbacher). Conflict of Interest The authors declare no conflicts of interest.

Objectives: To describe impairment-specific patterns in shorter- and longer-than-expected lengths of stay in inpatient rehabilitation, and examine the independent effects of social support on deviations from expected lengths of stay., Design: Retrospective cohort study., Setting: Inpatient rehabilitation facilities., Participants: Medicare fee-for-service beneficiaries (N=119,437) who were discharged from inpatient rehabilitation facilities in 2012 after stroke, lower extremity fracture, or lower extremity joint replacement., Intervention: Not applicable., Main Outcome Measure: Relative length of stay (actual minus expected). The Centers for Medicare & Medicaid Services posts annual expected lengths of stay based on patients' clinical profiles at admission. We created a 3-category outcome variable: short, expected, long. Our primary independent variable (social support) also included 3 categories: family/friends, paid/other, none., Results: Mean ± SD actual lengths of stay for joint replacement, fracture, and stroke were 9.8±3.6, 13.8±4.5, and 15.8±7.3 days, respectively; relative lengths of stay were -1.2±3.1, -1.6±3.7, and -1.7±5.2 days. Nearly half of patients (47%-48%) were discharged more than 1 day earlier than expected in all 3 groups, whereas 14% of joint replacement, 15% of fracture, and 20% of stroke patients were discharged more than 1 day later than expected. In multinomial regression analysis, using family/friends as the reference group, paid/other support was associated (P<.05) with higher odds of long stays in joint replacement. No social support was associated with lower odds of short stays in all 3 impairment groups and higher odds of long stays in fracture and joint replacement., Conclusions: Inpatient rehabilitation experiences and outcomes can be substantially affected by a patient's level of social support. More research is needed to better understand these relationships and possible unintended consequences in terms of patient access issues and provider-level quality measures., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: All authorities recommend against prostate specific antigen (PSA) screening in men 75 years and older. However, some primary care physicians (PCPs) continue to have high rates of PSA, with large variation in testing. We assessed the tests, treatments, and payments for prostate cancer care in men aged 75 or older who have PCPs with high or low PSA testing rates., Methods: We performed a retrospective cohort study using the 2010 Medicare beneficiaries aged 75 or older in Texas, United States who had no prostate cancer in 2007-2009 and had an identifiable PCP. We first identified high vs. low PSA testing PCPs, and then grouped older men in the two PCP groups. We determined health care visits to any provider and to urologists in office and outpatient settings. We estimated the direct medical payments for prostate cancer care for diagnostics, treatments and visits to providers in 2010-2011 using the generalized gamma model with log link function., Results: In multilevel, multivariable analyses, 25.4% (n = 550) of PCPs had PSA testing rates in men aged 75 or older that were significantly higher than the mean rate of all 2,169 Texas PCPs; 29.4% (n = 638) had rates that were significantly lower. In all, 22,853 vs. 23,929 older men were cared for by PCPs with high vs. low testing rates. Older men cared for by high PSA rate PCPs were more likely to receive a PSA test (OR 3.64, 95% CI 3.48-3.80), a biopsy (OR 1.16, 95% CI 1.02-1.31), an ultrasound (OR 1.19, 95% CI 1.07-1.32) or any radiation treatment (OR 1.31, 95% CI 1.03-1.66) than men cared for by low PSA rate PCPs. Men with high PSA rate PCPs were 1.21 (95% CI 1.05-1.39) times more likely to have such outpatient visits. The average annual adjusted Medicare payments for prostate cancer care was $25.60 higher for patients cared for by PCPs with high PSA test rates., Conclusions: Older men seeing PCPs with high rates of PSA testing undergo more testing and treatments for prostate cancer, with higher Medicare insurance payments. Future studies are needed to delineate whether men seeing PCPs with low testing rates likely received PSA tests from other providers.

Background: The characteristics of primary care providers (PCPs) who use hospitalists are unknown., Methods: Retrospective study using 100% Texas Medicare claims from 2001 through 2009. Descriptive statistics characterized proportion of PCPs using hospitalists over time. Trajectory analysis and multilevel models of 1172 PCPs with ≥20 inpatients in every study year characterized how PCPs adopted the hospitalist model and PCP factors associated with this transition., Results: Hospitalist use increased between 2001 and 2009. PCPs who adopted the hospitalist model transitioned rapidly. In multilevel models, hospitalist use was associated with US training (odds ratio [OR] 1.46, 95% confidence interval [CI]: 1.23-1.73 in 2007-2009), family medicine specialty (OR: 1.46, 95% CI: 1.25-1.70 in 2007-2009), and having high outpatient volumes (OR: 1.32, 95% CI: 1.20-1.44 in 2007-2009). Over time, relative hospitalist use decreased among female PCPs (OR: 1.91, 95% CI: 1.46-2.50 in 2001-2003; OR: 1.50, 95% CI: 1.15-1.95 in 2007-2009), those in urban locations (OR: 3.34, 95% CI: 2.72-4.09 in 2001-2003; OR: 2.22, 95% CI: 1.82-2.71 in 2007-2009), and those with higher inpatient volumes (OR: 1.05, 95% CI: 0.95-1.18 in 2001-2003; OR: 0.55, 95% CI: 0.51-0.60 in 2007-2009). Longest-practicing PCPs were more likely to transition in the early 2000s, but this effect disappeared by the end of the study period (OR: 1.35, 95% CI: 1.06-1.72 in 2001-2003; OR: 0.92, 95% CI: 0.73-1.17 in 2007-2009). PCPs with practice panels dominated by patients who were white, male, or had comorbidities are more likely to use hospitalists., Conclusions: PCP characteristics are associated with hospitalist use. The association between PCP characteristics and hospitalist use has evolved over time., (© 2015 Society of Hospital Medicine.)

Background: The risk of readmission varies among hospitals. This variation has led the Centers of Medicare and Medicaid services to reduce payments to hospitals with excess readmissions. The contribution of patient characteristics, hospital characteristics and provider type to the variation in risk of readmission among hospitals has not been determined., Objective: To describe the variation in risk of readmission among hospitals and partition it by patient characteristics, hospital characteristics and provider type., Design: Retrospective research design of 100% Texas Medicare data using multilevel, multivariable models., Subjects: A total of 514,064 admissions of Medicare beneficiaries to 272 hospitals in Texas for medical diagnoses during the years 2008 and 2009., Main Measures: Using hierarchical generalized linear models, we describe the hospital-specific variation in risk of readmission that is attributable to patients characteristics, hospital characteristics and provider type by measuring the variance and intraclass correlation coefficients., Key Results: Of the total variation in risk of readmission, only a small amount (0.84%) is attributed to hospitals. In further analyses modeling the components of this variation among hospitals, differences in patient characteristics in the hospitals explained 56.2% of the variation. Hospital characteristics and the type of provider explained 9.3% of the variation among hospitals and 0.08% of the total variation in risk of readmission., Conclusions: Patient characteristics are the largest contributor to variation in risk of readmission among hospitals. Measurable hospital characteristics and the type of inpatient provider contribute little to variation in risk of readmission among hospitals.

Background & Aims: Life expectancy is an important consideration when assessing appropriateness of preventive programs for older individuals. Most studies on this subject have used age cutoffs as a proxy for life expectancy. We analyzed patterns of utilization of screening colonoscopy in Medicare enrollees by using estimated life expectancy., Methods: We used a 5% random national sample of Medicare claims data to identify average-risk patients who underwent screening colonoscopies from 2008 to 2010. Colonoscopies were considered to be screening colonoscopies in the absence of diagnoses for nonscreening indications, which were based on either colonoscopies or any claims in the preceding 3 months. We estimated life expectancies by using a model that combined age, sex, and comorbidity. Among patients who underwent screening colonoscopies, we calculated the percentage of those with life expectancies <10 years., Results: Among the 57,597 Medicare beneficiaries 66 years old or older who received at least 1 screening colonoscopy, 24.8% had an estimated life expectancy of <10 years. There was a significant positive association between total Medicare per capita costs in hospital referral regions and the proportion of patients with limited life expectancies (<10 years) at the time of screening colonoscopy (R = 0.25; P < .001, Pearson correlation test). In a multivariable analysis, men were substantially more likely than women to have limited life expectancy at the time of screening colonoscopy (odds ratio, 2.25; 95% confidence interval, 2.16-2.34)., Conclusions: Nearly 25% of Medicare beneficiaries, especially men, had life expectancies <10 years at the time of screening colonoscopies. Life expectancy should therefore be incorporated in decision-making for preventive services., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: There are no clear recommendations to guide posttreatment surveillance in patients with pancreatic cancer. Our goal was to describe the posttreatment surveillance patterns in patients undergoing curative-intent resection for pancreatic cancer., Methods: We used Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data (1992-2005) to identify CT scans and physician visits in patients with pancreatic cancer who underwent curative resection (n = 2393). Surveillance began 90 days after surgery, and patients were followed for 2 years at 6-month intervals. Patients were censored if they died, experienced recurrence of disease, or entered hospice., Results: A total of 2045 patients survived uncensored to the beginning of the surveillance period. CT scan use decreased from 20.9% of patients in month 4 to 6.4% in month 27. There was no temporal pattern in CT use to suggest regular surveillance. Twenty-three percent of patients did not receive a CT scan in the year after surgery, increasing to 42% the second year. Patients who underwent adjuvant therapy and patients diagnosed in later years had higher CT scan use over the surveillance periods. Most patients visited both a primary care physician and a cancer specialist in each 6-month surveillance period. Patients who visited cancer specialists were more likely to have any CT scan and to be scanned more frequently., Conclusions: Current surveillance patterns after resection for pancreatic cancer reflect the lack of established guidelines, implying a need for evaluation and standardization of surveillance protocols. The lack of a temporal pattern in CT testing suggests that most were obtained to evaluate symptoms rather than for routine surveillance.

BACKGROUND/OBJECTIVES: Peripheral neuropathy is a common diabetes complication that can increase fall risk. Regarding fall risk, the impact of pain management using tricyclic antidepressants (TCAs) or γ‐aminobutyric acid (GABA) analogs is unclear because these medications can also cause falls. This study investigates the impact of these drugs on fall and fracture risk in older diabetic peripheral neuropathy (DPN) patients. DESIGN: Historical cohort study with 1‐to‐1 propensity matching of TCA/GABA‐analog users and nonusers. SETTING: Nationally representative 5% Medicare sample between the years 2008 and 2010. PARTICIPANTS: After applying all selection criteria, 5,550 patients with prescription and 22,200 patients without prescription of TCAs/GABA‐analogs were identified. Both patient groups were then stratified for fall history and matched based on propensity of receiving TCAs/GABA‐analogs within each group. MEASUREMENTS: Patients were followed until the first incidence of fall or the first incidence of fracture during the follow‐up period (for up to 5 years). RESULTS: After matching, users and nonusers were largely similar. After covariate adjustment, TCA/GABA‐analog use was associated with a statistically significant increase in fall risk (adjusted hazard ratio [HR] = 1.11; 95% confidence interval [CI] = 1.03‐1.20), but was not associated with fracture risk (adjusted HR = 1.09; 95% CI = 0.99‐1.19) in the conventional analysis. Treating TCA/GABA‐analog use as a time‐dependent covariate resulted in statistically significant associations of TCA/GABA‐analog use with both fall and fracture risk (HR = 1.26 [95% CI = 1.17‐1.36]; and HR = 1.12 [95% CI = 1.02‐1.24], respectively). CONCLUSION: Among older patients with DPN, GABA‐analogs or TCAs increase fall risk and possibly fracture risk. Use of these medications is therefore a potentially modifiable risk factor for falls and fractures in this population. [ABSTRACT FROM AUTHOR]

Background: The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood.Objective: To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care.Design: This was a retrospective cohort study.Setting: Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013.Participants: Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406).Interventions: Not applicable.Main Measures: Thirty-day unplanned rehospitalization following post-acute rehabilitation.Key Results: The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %).Conclusions: The functional domains identified in the IMPACT Act were associated with 30-day unplanned rehospitalization following post-acute care in this large national sample. Further research is needed to better understand and improve the functional measures, and to determine if their association with rehospitalizations varies across post-acute settings, patient populations, or episodes of care. [ABSTRACT FROM AUTHOR]

Rationale: Imaging intensity after lung cancer resection performed with curative intent is unknown.Objectives: To describe the pattern and trends in the use of computed tomography (CT) and positron emission tomography (PET) scans in patients after resection of early-stage lung cancer.Methods: Retrospective analysis of the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database. Subjects included 8,621 Medicare beneficiaries (age, ≥66 yr) who underwent lung cancer resection with curative intent between 1992 and 2005. A surveillance CT or PET examination was defined as CT or PET imaging performed in an outpatient setting on patients who did not undergo chest radiography in the preceding 30 days.Measurements and Main Results: Overall, imaging use was higher within the first 2 years versus Years 3-5 after surgical resection. Use of surveillance CT scans increased sharply from 13.7 to 57.3% of those diagnosed in 1996-1997 and 2004-2005, respectively. PET scan use increased threefold, from 6.2% in 2000-2001 to 19.6% in 2004-2005. In multivariable analyses, we observed a 32% increase in the odds of undergoing surveillance CT or PET imaging for every year of diagnosis between 1998 and 2005. There was no substantial decline in the odds of having a surveillance CT or PET scan during each successive follow-up period, suggesting no change in the intensity of surveillance over the first 5 years after surgical resection. The proportion of surveillance CT imaging performed at freestanding imaging centers increased from 18.0% in 1998-1999 to 30.6% in 2004-2005.Conclusions: The use of CT and PET imaging for surveillance after curative-intent surgical resection of early-stage lung cancer increased sharply in the United States between 1997-1998 and 2005. In the absence of evidence demonstrating favorable outcomes, this practice was likely driven by prevailing expert opinion embedded in clinical practice guidelines made available during that time. Research is clearly needed to determine the role and optimal approach to surveillance thoracic imaging after surgical resection of lung cancer. [ABSTRACT FROM AUTHOR]

BACKGROUND: The risk of readmission varies among hospitals. This variation has led the Centers of Medicare and Medicaid services to reduce payments to hospitals with excess readmissions. The contribution of patient characteristics, hospital characteristics and provider type to the variation in risk of readmission among hospitals has not been determined. OBJECTIVE: To describe the variation in risk of readmission among hospitals and partition it by patient characteristics, hospital characteristics and provider type. DESIGN: Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models. SUBJECTS: A total of 514,064 admissions of Medicare beneficiaries to 272 hospitals in Texas for medical diagnoses during the years 2008 and 2009. MAIN MEASURES: Using hierarchical generalized linear models, we describe the hospital-specific variation in risk of readmission that is attributable to patients characteristics, hospital characteristics and provider type by measuring the variance and intraclass correlation coefficients. KEY RESULTS: Of the total variation in risk of readmission, only a small amount (0.84 %) is attributed to hospitals. In further analyses modeling the components of this variation among hospitals, differences in patient characteristics in the hospitals explained 56.2 % of the variation. Hospital characteristics and the type of provider explained 9.3 % of the variation among hospitals and 0.08 % of the total variation in risk of readmission. CONCLUSIONS: Patient characteristics are the largest contributor to variation in risk of readmission among hospitals. Measurable hospital characteristics and the type of inpatient provider contribute little to variation in risk of readmission among hospitals. [ABSTRACT FROM AUTHOR]

Objective To examine whether having a primary care physician ( PCP) is associated with reduced ethnic disparities for colorectal cancer ( CRC) screening and whether clustering of minorities within PCPs contributes to the disparities. Data Sources/Study Setting Retrospective cohort study of Medicare beneficiaries age 66-75 in 2009 in Texas. Study Design The percentage of beneficiaries up to date in CRC screening in 2009 was stratified by race/ethnicity. Multilevel models were used to study the effect of having a PCP and PCP characteristics on the racial and ethnic disparities on CRC screening. Data Collection/Extraction Methods Medicare data from 2000 to 2009 were used to assess prior CRC screening. Principal Findings Odds of undergoing CRC screening were more than twice as high in patients with a PCP ( OR = 2.05, 95 percent CI 2.03-2.07). After accounting for clustering and PCP characteristics, the black-white disparity in CRC screening rates almost disappears and the Hispanic-white disparity decreases substantially. Conclusions Ethnic disparities in CRC screening in the elderly are mostly explained by decreased access to PCPs and by clustering of minorities within PCPs less likely to screen any of their patients. [ABSTRACT FROM AUTHOR]

Background. The study assessed the impact of prostate-specific antigen (PSA) testing in the United States by comparing the rates of PSA testing in U.S. counties to the rates of prostate biopsies and newly treated prostate cancer and to deaths from prostate cancer. Methods. We examined the association between the percentage of men aged 66–74 from a nationally representative 5% Medicare sample who received PSA testing in each U.S. county in 1997 and the percent of men who received prostate biopsies or treatment for newly diagnosed prostate cancer in 1997 as well as mortality from prostate cancer and from all other causes from 1998 to 2007. Results. Analyses of 1,067 U.S. counties showed a significant relationship between the rate of PSA testing and both the rate of men undergoing treatment for prostate cancer and prostate cancer mortality (both p < .001) but no relationship with mortality from other causes. For every 100,000 men receiving a PSA test in 1997, an additional 4,894 men underwent prostate biopsy and 1,597 additional men underwent prostate cancer treatment in 1997, and 61 fewer men died from prostate cancer during 1998–2006. Analyses stratified by age and race produced similar results. Conclusions. PSA testing was associated with modest reductions in prostate cancer mortality and large increases in the number of men overdiagnosed with and overtreated for prostate cancer. The results are similar to those obtained by the large European randomized prospective trial of PSA testing. [ABSTRACT FROM PUBLISHER]

Date Presented 4/19/2018 This poster describes an inpatient rehabilitation facility (IRF) study examining the relationship between facility-level factors and 30-day unplanned readmission rates among Medicare beneficiaries. Identifying factors related to care process at the organization and region levels could potentially improve the quality of IRF care. Primary Author and Speaker: Chih-Ying Li Additional Authors and Speakers: Amol Karmarkar, Kenneth Ottenbacher, Yong-Fang Kuo, Yu-Li Lin, James Graham [ABSTRACT FROM AUTHOR]

Examine whether the introduction of the Hospital Readmissions Reduction Program (HRRP) is associated with changes in post-acute care (PAC) use and 30-day readmission. A retrospective cohort study examined data prepassage, preimplementation, and postimplementation of the HRRP. In total, 7,851,430 Medicare beneficiaries discharged from 5116 acute hospitals to PAC settings including inpatient rehabilitation, skilled nursing, home health, or a long-term care hospital during 2007‒2015. We examined HRRP-targeted conditions (acute myocardial infarction, heart failure, and pneumonia) and nontargeted conditions (ischemic stroke, total hip arthroplasty/total knee arthroplasty, and hip/femur fractures). The hospital-level of quarterly PAC use and the association with 30-day risk-standardized readmission rates. Outcomes were calculated for HRRP-targeted and nontargeted conditions/diagnoses across 3 phases of HRRP implementation. An increase in quarterly PAC use was significantly (P <.001) associated with a decrease in 30-day risk-standardized readmission rates for acute myocardial infarction, heart failure, and hip/femur fracture. In contrast, an increase in quarterly PAC use was significantly associated with an increase in readmission rate for total hip arthroplasty/total knee arthroplasty (P < 001). PAC quarterly use and readmission rates varied significantly during implementation periods for HRRP- targeted and nontargeted conditions. The impact on readmission after PAC for selected impairment groups may be mediated by the type of PAC services received and whether the diagnoses is included in the HRRP. Additional research is necessary to determine if a reduction in readmission is associated with inclusion in the HRRP or is a side effect related to diagnostic group and/or type of PAC services received. [ABSTRACT FROM AUTHOR]

Abstract Objective Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings. Design Retrospective cohort study. Setting Acute care hospitals. Participants Medicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge. Measurements 90-day unplanned readmissions. Results The cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings. Conclusions We observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care. [ABSTRACT FROM AUTHOR]

Objectives The objectives of this study were to determine the association between patients’ functional status at discharge from skilled nursing facility (SNF) care and 30-day potentially preventable hospital readmissions, and to examine common reasons for potentially preventable readmissions. Design Retrospective cohort study. Setting SNFs and acute care hospitals submitting claims to Medicare. Participants National cohort of Medicare fee-for-service beneficiaries discharged from SNF care between July 15, 2013, and July 15, 2014 (n = 693,808). Average age was 81.4 (SD 8.1) years, 67.1% were women, and 86.3% were non-Hispanic white. Measurements Functional items from the Minimum Data Set 3.0 were categorized into self-care, mobility, and cognition domains. We used specifications for the SNF potentially preventable 30-day postdischarge readmission quality metric to identify potentially preventable readmissions. Results The overall observed rate of 30-day potentially preventable readmissions following SNF discharge was 5.7% (n = 39,318). All 3 functional domains were independently associated with potentially preventable readmissions in the multivariable models. Odds ratios for the most dependent category versus the least dependent category from multilevel models adjusted for patients’ sociodemographic and clinical characteristics were as follows: mobility, 1.54 (95% confidence interval [CI] 1.49–1.59); self-care, 1.50 (95% CI 1.44–1.55); and cognition, 1.12 (95% CI 1.04–1.20). The 5 most common conditions were congestive heart failure (n = 7654, 19.5%), septicemia (n = 7412, 18.9%), urinary tract infection/kidney infection (n = 4297, 10.9%), bacterial pneumonia (n = 3663, 9.3%), and renal failure (n = 3587, 9.1%). Across all 3 functional domains, septicemia was the most common condition among the most dependent patients and congestive heart failure among the least dependent. Conclusions Patients with functional limitations at SNF discharge are at increased risk of hospital readmissions considered potentially preventable. Future research is needed to determine whether improving functional status reduces risk of potentially preventable readmissions among this vulnerable population. [ABSTRACT FROM AUTHOR]