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Patterns and trends of potentially inappropriate high-density lipoprotein cholesterol testing in Australian adults at high risk of cardiovascular disease from 2008 to 2014: analysis of linked individual patient data from the Australian Medicare Benefits Schedule and Pharmaceutical Benefits Scheme.

ABSTRACT: OBJECTIVES:We examine the extent to which the adult Australian population on lipid-lowering medications receives the level of high-density lipoprotein cholesterol (HDL-C) testing recommended by national guidelines. DATA:We analysed records from 7?years (2008-2014) of the 10% publicly available sample of deidentified, individual level, linked Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) electronic databases of Australia. METHODS:The PBS data were used to identify individuals on stable prescriptions of lipid-lowering treatment. The MBS data were used to estimate the annual frequency of HDL-C testing. We developed a methodology to address the issue of 'episode coning' in the MBS data, which causes an undercounting of pathology tests. We used a published figure on the proportion of unreported HDL-C tests to correct for the undercounting and estimate the probability that an HDL-C test was performed. We judged appropriateness of testing frequency by comparing the HDL-C testing rate to guidelines' recommendations of annual testing for people at high risk for cardiovascular disease. RESULTS:We estimated that approximately 49% of the population on stable lipid-lowering treatment did not receive any HDL-C test in a given year. We also found that approximately 19% of the same population received two or more HDL-C tests within the year. These levels of underutilisation and overutilisation have been changing at an average rate of 2% and -4% a year, respectively, since 2009. The yearly expenditure associated with test overutilisation was approximately $A4.3 million during the study period, while the cost averted because of test underutilisation was approximately $A11.3 million a year. CONCLUSIONS:We found that approximately half of Australians on stable lipid-lowering treatment may be having fewer HDL-C testing than recommended by national guidelines, while nearly one-fifth are having more tests than recommended.

SUBMITTER: Hajati F

PROVIDER: S-EPMC5855213 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Project description:BackgroundFoot and ankle problems are highly prevalent in the general community and a substantial proportion of people seek surgical treatment to alleviate foot pain and deformity. However, the epidemiology of foot and ankle surgery has not been examined in detail. Therefore, the aim of this study was to examine patterns and costs of private sector foot surgery provision in Australia.MethodsData pertaining to all foot and ankle surgical procedures for the calendar years 1997-2006 were extracted from the Australian Medicare Benefits Schedule (MBS) database and were cross-tabulated by sex and age. Descriptive analyses were undertaken to assess sex and age differences in the number and type of procedures performed and to assess for temporal trends over the ten year assessment period. The total cost to Medicare of subsiding surgeons' fees in 2006 was also determined.ResultsDuring the 1997-2006 period, 996,477 surgical procedures were performed on the foot and ankle by private surgeons in Australia. Approximately equal numbers of procedures were performed on males (52%) and females (48%). However, males were more likely to undergo toenail, ankle, clubfoot, tarsal coalition and congenital vertical talus surgery, whereas females were more likely to undergo lesser toe, first metatarsophalangeal joint (MPJ), neuroma, heel, rearfoot and lesser MPJ surgery. The total number of procedures was stable over the assessment period, however there was a relative increase in the number of procedures performed on people aged over 55 years. The total contribution of Medicare to subsiding surgeons' fees for procedures performed in 2006 was $14 M.ConclusionFoot and ankle surgery accounts for a considerable degree of healthcare expenditure in Australia, and the number of procedures in those aged over 55 years is increasing. Given the ageing demographics of the Australian population, the future public health and economic impact of foot morbidity is likely to be substantial. Strategies need to be implemented to ensure that the surgical labour force is adequate to address this increasing demand.

Project description:BackgroundInjurious falls among older adults are both common and costly. The prevalence of falls is known to increase with age and with use of fall-risk drugs/potentially inappropriate medications (FRD/PIM). Little is known about the joint effects of these two risk factors.MethodsData for 2013-2015 were obtained from the Truven Health MarketScan® Medicare database comprising utilization and eligibility (enrollment) data for approximately 4 million enrollees annually. A case-control design was used to compare enrollees aged 65-99 years diagnosed with > 1 fall event (n = 110,625) with enrollees without falls (n = 1,567,412). An exploratory analysis of joint age-FRD/PIM effects on fall risks was based on number needed to harm (NNH) calculations for each FRD/PIM therapy class count (compared with 0 FRD/PIMs), stratified by age group. Logistic regression analyses adjusted for demographics, comorbidities, and fracture history, measured in the 1 year prior to the fall date (cases) or a randomly assigned date (controls).ResultsFor each FRD/PIM class count, NNH values decreased with older age (e.g., for 1 FRD/PIM class: from NNH = 333 for ages 65-74 years to NNH = 83 for ages 90-99 years; for 2 FRD/PIM classes: from NNH = 91 for ages 65-74 years to NNH = 38 for ages 90-99 years). NNH decreased to < 15 patients at > 6 classes for age 65-74 years, > 5 classes for age 75-84 years, and > 4 classes for age 85-99 years. Adjusted odds of falling were increased for age-FRD/PIM combinations with smaller NNH values: adjusted odds ratio (AOR) = 1.127 (95% confidence interval [CI] = 1.098-1.156) for NNH = 83-91; AOR = 1.427 (95% CI = 1.398-1.456) for NNH = 17-48; AOR = 1.983 (1.9034-2.032) for NNH < 15.ConclusionFRD/PIM use and age appear to have joint effects on fall risk. Older adults at high risk, indicated by small NNH, may be appropriate for fall prevention initiatives, and clinicians may wish to consider decreasing the number of FRD/PIMs utilized by these patients.

Project description:Rationale: Medical interventions that prolong life without achieving an effect that the patient can appreciate as a benefit are often considered futile or inappropriate by healthcare providers. In recent years, a multicenter guideline has been released with recommendations on how to resolve conflicts between families and clinicians in these situations and to increase public engagement. Although laypeople are acknowledged as important stakeholders, their perceptions and understanding of the terms "potentially inappropriate" or "futile" treatment have received little formal evaluation.Objectives: To evaluate the community perspective about the meaning of futile treatment.Methods: Six focus groups (two groups each of ages <65, 65-75, and >75 yr) were convened to explore what constitutes futile treatment and who should decide in situations of conflict between doctors and families. Focus group discussions were analyzed using grounded theory.Results: There were 39 participants aged 18 or older with at least one previous hospitalization (personal or by immediate relative). When asked to describe futile or inappropriate treatment, community members found the concept difficult to understand and the terminology inadequate, though when presented with a case describing inappropriate treatment, most participants recognized it as the provision of inappropriate treatment. Several themes emerged regarding participant difficulty with the concept, including inadequate physician-patient communication, lack of public emphasis on end-of-life issues, skepticism that medical treatment can be completely inappropriate, and doubts and fears that medical futility could undermine patient and/or family autonomy. Participants also firmly believed that in situations of conflict families should be the ultimate decision-makers.Conclusions: Public engagement in policy development and discourse around medical futility will first require intense education to familiarize the lay public about use of inappropriate treatment at the end of life.

Project description:BackgroundHigh-cost patients account for a disproportionate share of healthcare spending. The proportion and distribution of potentially preventable spending among subgroups of high-cost patients are largely unknown.ObjectiveTo examine the distribution of potentially preventable spending among high-cost Medicare patients overall and potentially preventable spending associated with each high-cost category.DesignA cross-sectional study. We merged Medicare claims and social determinants of health data to group patients into high-cost categories and quantify potentially preventable spending.PatientsA total of 556,053 Medicare fee-for-service and dual-eligible beneficiaries with at least one healthcare encounter in the New York metropolitan area in 2014.Main measuresHigh-cost patients were mapped into 10 non-mutually exclusive categories. The primary outcome was episodic spending associated with preventable ED visits, preventable hospitalizations, and unplanned 30-day readmissions.Key resultsOverall, potentially preventable spending accounted for 10.4% of overall spending in 2014. Preventable spending accounted for 13.3% of total spending among high-cost patients and 4.9% among non-high-cost patients (P < 0.001). Among high-cost patients, 44.0% experienced at least one potentially preventable encounter compared with 11.4% of non-high-cost patients (P < 0.001), and high-cost patients accounted for 71.5% of total preventable spending. High-cost patients had on average $11,502 in potentially preventable spending-more than 20 times more than non-high-cost patients ($510). High-cost patients in the seriously ill, frail, or serious mental illness categories accounted for the highest proportion of potentially preventable spending overall, while end-stage renal disease, serious illness, and opioid use disorder were associated with the highest preventable spending per patient.ConclusionPotentially preventable spending was concentrated among high-cost patients who were seriously ill, frail, or had a serious mental illness. Interventions targeting these subgroups may be helpful for reducing preventable utilization.

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Patterns and trends of potentially inappropriate high-density lipoprotein cholesterol testing in Australian adults at high risk of cardiovascular disease from 2008 to 2014: analysis of linked individual patient data from the Australian Medicare Benefits Schedule and Pharmaceutical Benefits Scheme.

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