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Predictors of high-risk prescribing among elderly Medicare Advantage beneficiaries.

ABSTRACT: To examine patient, community, and insurance plan predictors of high-risk prescribing in the elderly Medicare Advantage population.Cohort study.Using a sample of 203 Medicare Advantage plans from the 2006-2008 Health Outcomes Survey, we compared patient, community, and insurance plan characteristics of 77,247 respondents with and without new Medicare Part D claims for high-risk medications from June 2006 to May 2007.Of the Medicare Advantage enrollee respondents, 15.6% received a new prescription for a high-risk medication during 12 months of follow-up. In adjusted analyses, new users of high-risk medications were more likely to be women (OR = 1.35; 95% CI,1.28-1.42), and they reported poorer general health (Physical Component Summary score 37.3 vs 40.4, P <.05) than did individuals who never received a high-risk prescription. Being aged ? 85 years was protective against receipt of a high-risk medication (OR relative to persons aged 65-69 years = 0.69; 95% CI, 0.64-0.75). Incidence of high-risk prescribing varied by census division, with a 2-fold difference between regions with the lowest and highest rates (9% in New England vs 18% in the West South Central region). Muscle relaxants, antihistamines, and opiates accounted for over 71% of new dispensing of high-risk medications. Approximately 67% of new users of high-risk medications received only 1 dispensing.High-risk prescribing varies widely by geography and drug class in the Medicare Advantage population. Women, persons with poorer self-reported health, and those residing in the Southern regions of the United States more frequently receive high-risk medications. Variations may highlight areas for targeted interventions to reduce high-risk prescribing to the elderly.

SUBMITTER: Cooper AL

PROVIDER: S-EPMC5402891 | biostudies-literature | 2014 Oct

REPOSITORIES: biostudies-literature

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Predictors of high-risk prescribing among elderly Medicare Advantage beneficiaries.

Cooper Alicia L AL Dore David D DD Kazis Lewis E LE Mor Vincent V Trivedi Amal N AN

The American journal of managed care 20141001 10

<h4>Objectives</h4>To examine patient, community, and insurance plan predictors of high-risk prescribing in the elderly Medicare Advantage population.<h4>Study design</h4>Cohort study.<h4>Methods</h4>Using a sample of 203 Medicare Advantage plans from the 2006-2008 Health Outcomes Survey, we compared patient, community, and insurance plan characteristics of 77,247 respondents with and without new Medicare Part D claims for high-risk medications from June 2006 to May 2007.<h4>Results</h4>Of the M ...[more]

PMID: 25414985

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Project description:BackgroundSince 2005, the Centers for Medicare and Medicaid Services (CMS) has required all Medicare Advantage (MA) plans to report prescribing rates of high risk medications (HRM).ObjectiveTo determine predictors of receipt of HRMs, as defined by the National Committee for Quality Assurance's "Drugs to Avoid in the Elderly" quality indicator, in a national sample of MA enrollees.Design and participantsRetrospective analysis of Healthcare Effectiveness Data and Information Set (HEDIS) data for 6,204,824 enrollees, aged 65 years or older, enrolled in 415 MA plans in 2009. To identify predictors of HRM use, we fit generalized linear models and modeled outcomes on the risk-difference scale.Main outcome measuresReceipt or non-receipt of one or two HRMs.Key resultsApproximately 21 % of MA enrollees received at least one HRM and 4.8 % received at least two. In fully adjusted models, females had a 10.6 (95 % CI: 10.0-11.2) higher percentage point rate of receipt than males, and residence in any of the Southern United States divisions was associated with a greater than 10 percentage point higher rate, as compared with the reference New England division. Higher rates were also observed among enrollees with low personal income (6.5 percentage points, 95 % CI: 5.5-7.5), relative to those without low income and those residing in areas in the lowest quintile of socioeconomic status (2.7 points, 95 % CI: 1.9-3.4) relative to persons residing in the highest quintile. Enrollees ? 85 years old, black enrollees, and other minority groups were less likely to receive these medications. Over 38 % of MA enrollees residing in the hospital referral region of Albany, Georgia received at least one HRM, a rate four times higher than the referral region with the lowest rate (Mason City, Iowa).ConclusionsUse of HRMs among MA enrollees varies widely by geographic region. Persons living in the Southern region of the U.S., whites, women, and persons of low personal income and socioeconomic status are more likely to receive HRMs.

Project description:Use of opioids during and shortly after an acute hospitalization is warranted in some clinical settings. However, given the potential of opioids for short-term adverse events and long-term physiologic tolerance, it is important to understand the frequency of opioid prescribing at hospital discharge, hospital variation, and patient and hospital factors associated with opioid prescribing, which is currently unknown in the United States.To estimate the frequency of opioid prescribing at hospital discharge among Medicare beneficiaries without an opioid prescription claim 60 days prior to hospitalization; to document hospital variation in prescribing; and to analyze patient and hospital factors associated with prescribing, including hospital average performance on pain-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures.Analysis of pharmacy claims of a 20% random sample of Medicare beneficiaries hospitalized in 2011 without an opioid prescription claim in the 60 days before hospitalization.Our main outcome was a new opioid claim within 7 days of hospital discharge. We estimated a multivariable linear probability model of patient factors associated with new opioid use and described hospital variation in adjusted rates of new opioid use. In multivariable linear regression analysis, we also analyzed hospital factors associated with average adjusted new opioid use at the hospital level, including the percentage of each hospital's patients who reported that their pain during hospitalization was always well controlled in the 2011 HCAHPS surveys.Among 623?957 hospitalizations, 92?882 (14.9%) were associated with a new opioid claim. Among those hospitalizations with an associated opioid claim within 7 days of hospital discharge, 32?731 (42.5%) of 77?092 were associated with an opioid claim after 90 days postdischarge. Across 2512 hospitals, the average adjusted rate of new opioid use within 7 days of hospitalization was 15.1% (interquartile range, 12.3%-17.4%; interdecile range, 10.5%-20.0%). A hospital's adjusted rate of new opioid use was modestly positively associated with the percentage of its inpatients reporting that their pain was always well managed (increase from 25th to the 75th percentile in the HCAHPS measure was associated with an absolute increase in new opioid use of 0.89 percentage points or a relative increase of 6.0%; P?<?.001).New opioid use after hospitalization is common among Medicare beneficiaries, with substantial variation across hospitals and a large proportion of patients using a prescription opioid 90 days after hospitalization. The degree to which observed hospital variation in short- and longer-term opioid use reflects variation in inappropriate prescribing at hospital discharge is unknown.

Project description:Importance:How often enrollees with complex care needs leave the Medicare Advantage (MA) program and what might drive their decisions remain unknown. Objective:To characterize trends in switching to and from MA among high-need beneficiaries and to evaluate the drivers of disenrollment decisions. Design, Setting, and Participants:This cross-sectional study of MA and traditional Medicare (TM) enrollees from January 1, 2014, through December 31, 2015, used a multinomial logit regression stratified by Medicare-Medicaid eligibility status. All 14?589?645 non-high-need MA enrollees and 1?302?470 high-need enrollees in the United States who survived until the end of 2014 were eligible for the analysis. Data were analyzed from November 1, 2017, through August 1, 2018. Exposures:Enrollee dual eligibility and high-need status (based on complex chronic conditions, multiple morbidities, use of health care services, functional impairment, and frailty indicators), MA plan star rating, and cost sharing. Main Outcomes and Measures:The proportion of enrollees who disenrolled into TM, remained in the same MA plan, or who switched plans within the MA program. Results:A total of 13 901 816 enrollees were included in the analysis (56.2% women; mean [SD] age, 70.9 [9.9] years). Among the 1?302?470 high-need enrollees, an adjusted 4.6% (95% CI, 4.5%-4.6%) of Medicare-only and 14.8% (95% CI, 14.5%-15.0%) of Medicare-Medicaid members switched from MA to TM compared with 3.3% (95% CI, 3.3%-3.3%) and 4.6% (95% CI, 4.5%-4.7%), respectively, among non-high-need enrollees. Among enrollees in low-quality plans, 23.0% (95% CI, 22.3%-23.9%) of Medicare and 42.8% (95% CI, 40.5%-45.1%) of dual-eligible high-need enrollees left MA. Even in high-quality plans, high-need members disenrolled at higher rates than non-high-need members (4.9% [95% CI, 4.6%-5.2%] vs 1.8% [95% CI, 1.8%-1.9%] for Medicare-only enrollees and 11.3% vs 2.4% dual eligible enrollees). Enrollment in a 5.0-star rated plan was associated with a 30.1-percentage point reduction (95% CI, -31.7 to -28.4 percentage points) in the probability of disenrollment among high-need individuals. A $100 increase in monthly premiums was associated with a 33.9-percentage point increase (95% CI, -34.9 to -33.0 percentage points) in the likelihood of switching plans, and a small reduction in the likelihood of disenrolling (-2.7 percentage points; 95% CI, -3.2 to -2.2 percentage points). Among Medicare-Medicaid eligible participants, 14.1% (95% CI, 14.0%-14.2%) of high-need and 16.7% (95% CI, 16.6%-16.7%) of non-high-need enrollees switched from TM to MA. Conclusions and Relevance:Results of this study suggest that substantially higher disenrollment from MA plans occurs among high-need and Medicare-Medicaid eligible enrollees. This study's findings suggest that star ratings have the strongest association with disenrollment trends, whereas increases in monthly premiums are associated with greater likelihood of switching plans.

Project description:ImportanceContemporary national clinical practice guidelines recommend direct-acting oral anticoagulants (DOACs) as the first-line anticoagulant strategy over warfarin for most indications, especially among older individuals with an elevated bleeding risk.ObjectiveTo evaluate anticoagulant prescribing and DOAC uptake by US clinicians in the Medicare population.Design, setting, and participantsThis retrospective cohort study included all US clinicians with more than 10 Medicare oral anticoagulant prescription claims, who were included in the national Medicare Provider Utilization and Payment Data (2013-2018). Data analyses were conducted between October 2020 and October 2021.ExposuresDOAC prescription in 2013.Main outcomes and measuresClinicians were categorized based on 2013 prescribing as solely prescribing warfarin, DOAC, or both, and their temporal trajectories of proportionate DOAC use were examined.ResultsThe analysis included 325 666 unique clinicians with more than 10 oral anticoagulant prescriptions between 2013 and 2018 (26 620 [8.2%] cardiologists, 85 563 [26.3%] internal medicine physicians, 84 369 [25.9%] family medicine physicians, and 81 161 [24.9%] advanced practice clinicians, including nurse practitioners and physician assistants). In 2013, among 91 837 prescribers, 54 501 (59.3%) prescribed only warfarin, 1918 (2.1%) prescribed only a DOAC, and 35 418 (38.6%) prescribed both. During the study period, the number of clinicians prescribing DOACs increased, but 19% continued to prescribe only warfarin in 2018. While 359 cardiologists prescribing anticoagulants (1.6%) were warfarin-only prescribers, 10 414 (20.0%) and 6296 (12.6%) of family and internal medicine physicians also prescribed only warfarin, respectively. Clinicians prescribing only warfarin in 2013 had lower proportionate DOAC use throughout the study compared with 2013 DOAC prescribers, which represents a median (IQR) of 41.9% (20.3%-61.9%) of their anticoagulant prescriptions in 2018 vs 67.0% (49.9%-82.8%) for DOAC prescribers.Conclusions and relevanceDespite the increase in DOAC use among Medicare beneficiaries, many clinicians in this study continued to use warfarin as their predominant or only anticoagulant instead of DOACs. There is a need to address barriers to the uptake of these medications to realize their potential benefits for patients.

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Predictors of high-risk prescribing among elderly Medicare Advantage beneficiaries.

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Predictors of high-risk prescribing among elderly Medicare Advantage beneficiaries.

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