Medicare Expenditures and Health Care Utilization in a Multiethnic Community-based Population With Dementia From Incidence to Death.
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ABSTRACT:
SUBMITTER: Ornstein KA
PROVIDER: S-EPMC6215747 | biostudies-literature | 2018 Oct-Dec
REPOSITORIES: biostudies-literature
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Medicare Expenditures and Health Care Utilization in a Multiethnic Community-based Population With Dementia From Incidence to Death.
Ornstein Katherine A KA Zhu Carolyn W CW Bollens-Lund Evan E Aldridge Melissa D MD Andrews Howard H Schupf Nicole N Stern Yaakov Y
Alzheimer disease and associated disorders 20181001 4
<h4>Introduction</h4>While individuals live with dementia for many years, utilization and expenditures from disease onset through the end-of-life period have not been examined in ethnically diverse samples.<h4>Methods</h4>We used a multiethnic, population-based, prospective study of cognitive aging (Washington Heights-Inwood Columbia Aging Project) linked to Medicare claims to examine total Medicare expenditures and health care utilization among individuals with clinically diagnosed incident dem ...[more]
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Project description:BackgroundClinical features of dementia (cognition, function, and behavioral/psychological symptoms [BPSD]) may differentially affect Medicare expenditures/health care utilization.MethodsWe linked cross-sectional data from the Aging, Demographics, and Memory Study to Medicare data to evaluate the association between dementia clinical features among those with dementia and Medicare expenditures/health care utilization (n = 234). Cognition was evaluated using the Mini-Mental State Examination (MMSE). Function was evaluated as the number of functional limitations (0-10). BPSD was evaluated as the number of symptoms (0-12). Expenditures were estimated with a generalized linear model (log-link and gamma distribution). Number of hospitalizations, institutional outpatient visits, and physician visits were estimated with a negative binomial regression. Medicare covered skilled nursing days were estimated with a zero-inflated negative binomial model.ResultsCognition and BPSD were not associated with expenditures. Among individuals with less than seven functional limitations, one additional limitation was associated with $123 (95% confidence interval: $19-$227) additional monthly Medicare spending. Better cognition and poorer function were associated with more hospitalizations among those with an MMSE less than three and less than six functional limitations, respectively. BPSD had no effect on hospitalizations. Poorer function and fewer BPSD were associated with more skilled nursing among individuals with one to seven functional limitations and more than four symptoms, respectively. Cognition had no effect on skilled nursing care. No clinical feature was associated with institutional outpatient care. Of individuals with an MMSE less than 15, poorer cognition was associated with fewer physician visits. Among those with more than six functional limitations, poorer function was associated with fewer physician visits.ConclusionsPoorer function, not cognition or BPSD, was associated with higher Medicare expenditures.
| S-EPMC6075208 | biostudies-literature
Project description:BACKGROUND:Few studies have examined how dementia and comorbidities may interact to affect healthcare expenditures. OBJECTIVE:To examine whether effects of dementia severity on Medicare expenditures differed for individuals with different levels of comorbidities. METHODS:Data are drawn from the Washington Heights-Inwood Columbia Aging Project (WHICAP). Comprehensive clinical assessments of dementia severity were systematically carried out at ?18 month intervals. Dementia severity was measured by Clinical Dementia Rating (CDR). Comorbidities were measured by a modified Elixhauser comorbidities index. Generalized linear models examined effects of dementia severity, comorbidities, and their interactions on Medicare expenditures (1999-2010). RESULTS:At baseline, 1,280 subjects were dementia free (CDR?=?0, 66.4%), 490 had very mild dementia (CDR?=?0.5, 25.4%), 108 had mild dementia (CDR?=?1, 5.6%), and 49 had moderate/severe dementia (CDR?=?2/3, 2.5%). Average annual Medicare expenditures for individuals with moderate/severe dementia were more than twice as high as those who were dementia free (CDR?=?0: $9,108, CDR?=?0.5/1: $11,664, CDR?2: $19,604, p?<?0.01). Expenditures were approximately 10 times higher among those with?3 comorbidities than among those with no comorbidities ($2,612 for those with no comorbidities, to $6,109 for those with 1, $10,656 for those with 2, and $30,244 for those with?3 comorbidities, p?<?0.001). Dementia severity was associated with higher expenditures, but comorbidities were the most important predictor of expenditures. We did not find strong interaction effects between number of comorbidities and dementia severity. CONCLUSIONS:Increasing dementia severity and higher comorbidities are associated with higher Medicare expenditures. Care of individuals with dementia should focus on management of comorbidities.
| S-EPMC5461168 | biostudies-literature
Project description:ObjectiveTo examine the effect of Part D on 65-78-year-old noninstitutionalized dual eligibles' prescription utilization and expenditures.Data sourceRandom sample of unique pharmacy customers of a national retail pharmacy chain who filled at least one prescription during both 2005 and 2006. For each subject, we obtained claims data for every prescription filled between January 1, 2005, and April 31, 2007.Study designGeneralized estimating equations were used to examine the experience of a "treatment" group (dual eligibles between 65 and 78 years on January 1, 2005) with that of a "control" group (near-elderly patients with Medicaid coverage between 60 and 63 years on January 1, 2005) during the first 18 months after Part D implementation.Principal findingsExpenditures for the treatment and control groups tracked each other closely in the pre-Part D period. Immediately following the implementation of Part D, expenditures for both groups decreased and then leveled off. There were no significant changes in trends in the dual eligibles' out-of-pocket expenditures, total monthly expenditures, pill-days, or total number of prescriptions due to Part D.ConclusionsWe find no evidence that Part D adversely affected pharmaceutical utilization or out-of-pocket expenditures of dual eligibles during the transition period, nor during the 16 months subsequent to Part D implementation.
| S-EPMC2813441 | biostudies-literature
Project description:ObjectiveTo disentangle the relationships among food insecurity, health care utilization, and health care expenditures.Data sources/study settingWe use national data on 13 465 adults (age ≥ 18) from the 2016 Medical Expenditure Panel Survey (MEPS), the first year of the food insecurity measures.Study designWe employ two-stage empirical models (probit for any health care use/expenditure, ordinary least squares, and generalized linear models for amount of utilization/expenditure), controlling for demographics, health insurance, poverty status, chronic conditions, and other predictors.Principal findingsOur results show that the likelihood of any health care expenditure (total, inpatient, emergency department, outpatient, and pharmaceutical) is higher for marginal, low, and very low food secure individuals. Relative to food secure households, very low food secure households are 5.1 percentage points (P < .001) more likely to have any health care expenditure, and have total health care expenditures that are 24.8 percent higher (P = .011). However, once we include chronic conditions in the models (ie, high blood pressure, heart disease, stroke, emphysema, high cholesterol, cancer, diabetes, arthritis, and asthma), these underlying health conditions mitigate the differences in expenditures by food insecurity status (only the likelihood of any having any health care expenditure for very low food secure households remains statistically significant).ConclusionsPolicy makers and government agencies are focused on addressing deficiencies in social determinants of health and the resulting impacts on health status and health care utilization. Our results indicate that chronic conditions are strongly associated with food insecurity and higher health care spending. Efforts to alleviate food insecurity should consider the dual burden of chronic conditions. Finally, future research can address specific mechanisms underlying the relationships between food security, health, and health care.
| S-EPMC7518817 | biostudies-literature
Project description:Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia.To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia.This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1?416?369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included.Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles.Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician).Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22?004 vs $24?371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P?<?.001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups.Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.
| S-EPMC5061498 | biostudies-literature
Project description:Importance:Descriptive population-level health data are critical components of the evidence base for population health policy. Human populations often display marked heterogeneity in their health status among subgroups of the population. The recent widespread adoption of electronic health records provides opportunities to use routine real-world health care data to examine population health. Objective:To report population sociodemographic characteristics, health conditions, health care utilization, and health care costs for different population segments of a multiethnic Asian population divided according to a modified British Columbia Population Segmentation Framework. Design, Setting, and Participants:This population-based cross-sectional study used 2016 data from the Singapore Eastern Regional Health System, the largest Regional Health System in Singapore. Data were obtained from deidentified national-level electronic health records at the Ministry of Health Singapore. Participants included all residents in the Singapore Eastern Regional Health System catchment area in 2016. The descriptive analysis was conducted in August 2018. Main Outcomes and Measures:Socioeconomic profiles, disease prevalence, health care utilization, and cost patterns of population segments. Results:The total size of the study population in 2016 was 1?181?024 residents (576 663 [48.83%] male; median [interquartile range] age, 40 [22-57] years). The population was divided into 8 segments: healthy with no outpatient utilization (493?483 residents), healthy with outpatient utilization (259?909 residents), healthy with inpatient admissions (49?588 residents), low complex (215?134 residents), medium complex (79?350 residents), high complex (44?445 residents), cancer (34?217 residents), and end of life (4898 residents). Overall, the 3 most prevalent conditions were chronic kidney disease (31.89%), hypertension (18.52%), and lipid disorders (18.33%). Distributions of chronic conditions differed across the segments. Different segments had varying health care utilization patterns: the high-complex segment had the highest number of primary care clinic visits (mean [SD], 4.25 [5.46] visits), the cancer segment had the highest number of specialist outpatient clinic visits (mean [SD], 5.55 [8.49] visits), and the end-of-life segment had the highest numbers of accident and emergency department visits (mean [SD], 1.80 [1.88] visits) and inpatient admissions (mean [SD], 1.99 [1.89] admissions) during 2016. For health care costs, specialist outpatient clinic and inpatient care together made up more than 85% of the total cost of nearly 2 billion Singapore dollars. The end-of-life segment contributed approximately 50% of the health care cost per capita of 60?000 Singapore dollars. Conclusions and Relevance:Different population segments displayed heterogeneity in sociodemographic characteristics, health conditions, health care utilization, and health care cost patterns. This critical health information can be used as baseline data to inform regional and national health priorities for health services research and policy.
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Project description:BackgroundThe purpose of this study was to examine the extent to which patterns of intensive end-of-life care explain geographic variation in end-of-life care expenditures among cancer decedents.MethodsUsing the SEER-Medicare database, we identified 90,465 decedents who were diagnosed with cancer in 2004-2011. Measures of intensive end-of-life care included chemotherapy received within 14 days of death; more than 1 emergency department visit, more than 1 hospitalization, or 1 or more intensive care unit (ICU) admissions within 30 days of death; in-hospital death; and hospice enrollment less than 3 days before death. Using hierarchical generalized linear models, we estimated risk-adjusted expenditures in the last month of life for each hospital referral region and identified key contributors to variation in expenditures.ResultsThe mean expenditure per cancer decedent in the last month of life was $10,800, ranging from $8,300 to $15,400 in the lowest and highest expenditure quintile areas, respectively. There was considerable variation in the percentage of decedents receiving intensive end-of-life care intervention, with 41.7% of decedents receiving intensive care in the lowest quintile of expenditures versus 57.9% in the highest quintile. Regional patterns of late chemotherapy or late hospice use explained only approximately 1% of the expenditure difference between the highest and lowest quintile areas. In contrast, the proportion of decedents who had ICU admissions within 30 days of death was a major driver of variation, explaining 37.6% of the expenditure difference.ConclusionsPromoting appropriate end-of-life care has the potential to reduce geographic variation in end-of-life care expenditures.
| S-EPMC5577560 | biostudies-literature
Project description:BackgroundMelanoma incidence has increased in recent decades in the U.S.A. Uncertainty remains regarding how much of this increase is attributable to greater melanoma screening activities, potential detection bias and overdiagnosis.ObjectivesTo use a cross-sectional ecological analysis to evaluate the relationship between skin biopsy and melanoma incidence rates over a more recent time period than prior reports.MethodsExamination of the association of biopsy rates and melanoma incidence (invasive and in situ) in SEER-Medicare data (including 10 states) for 2002-2009.ResultsThe skin biopsy rate increased by approximately 50% (6% per year) throughout this 8-year period, from 7012 biopsies per 100 000 persons in 2002 to 10 528 biopsies per 100 000 persons in 2009. The overall melanoma incidence rate increased approximately 4% (< 1% per year) over the same time period. The incidence of melanoma in situ increased approximately 10% (1% per year), while the incidence of invasive melanoma increased from 2002 to 2005 then decreased from 2006 to 2009. Regression models estimated that, on average, for every 1000 skin biopsies performed, an additional 5·2 (95% confidence interval 4·1-6·3) cases of melanoma in situ were diagnosed and 8·1 (95% confidence interval 6·7-9·5) cases of invasive melanoma were diagnosed. When considering individual states, some demonstrated a positive association between biopsy rate and invasive melanoma incidence, others an inverse association, and still others a more complex pattern.ConclusionsIncreased skin biopsies over time are associated with increased diagnosis of in situ melanoma, but the association with invasive melanoma is more complex.
| S-EPMC5357200 | biostudies-literature
Project description:Background and purposeFalls are a major health problem in the elderly community; however, questions regarding incidence, risk factors, and provider response to falls exist. The purpose of this study was to examine the incidence of falls, associated factors, health care costs, and provider response to falls among Medicare beneficiaries.ParticipantsThe participants were 12,669 respondents to the Medicare Current Beneficiaries Survey (MCBS).MethodsCategories of number of falls (none, one, recurrent) and injury type (medically injurious versus not medically injurious) were created from the falls supplement to the MCBS. Means and proportions for the entire Medicare population were estimated using sampling weights. The association between sociodemographic variables and fall status was modeled using ordinal or binary logistic regression. Aggregate health costs by fall category were estimated from claims data.ResultsPopulation estimates of falls reported in 2002 ranged from 3.7 million (single fall) to 3.1 million (recurrent falls), with an estimated 2.2 million people having a medically injurious fall. Recurrent falls were more likely with increased age, being female, being nonwhite, reporting fair or poor health, and increased number of limitations in personal activities of daily living and instrumental activities of daily living and comorbidities. Although estimates of the actual costs of falls could not be determined, "fallers" consistently had larger utilization costs than "nonfallers" for the year 2002. Fewer than half (48%) of the beneficiaries reported talking to a health care provider following a fall, and 60% of those beneficiaries reported receiving fall prevention information.Discussion and conclusionFalls are common and may be associated with significant health care costs. Most importantly, health care providers may be missing many opportunities to provide fall prevention information to older people.
| S-EPMC2664994 | biostudies-literature
Project description:Background: In the midst of competing priorities and limited resources in low-middle-income countries (LMIC), convincing epidemiological evidence is critical for urging governments to develop national dementia plans. The majority of primary epidemiological studies on dementia are from high income countries (HIC). Implications for developing countries are typically extrapolated from these outcomes through modeling, meta-analyses, and systematic reviews. In this study, we directly assessed the incidence of dementia, disability adjusted life years (DALYs), and cost of care among community-dwelling Filipino elderly. Methods: This was a follow-up study of the prospective cohort Marikina Memory Ageing Project (MMAP). Baseline assessment was performed in 2011-2012, and follow-up was done in 2015-2016 (N = 748 at follow-up). Incident dementia was determined. Disease burden was computed using the incidence rates and DALYs. Both indirect and direct (medical and non-medical) costs of dementia care were computed. Results: The crude incidence rate was 16 (CI: 13-20) cases per 1,000 person-years (pyr) with 17 (CI: 12-21) per 1,000 pyr for females and 14 (CI: 9-21) per 1,000 pyr for males. Based on this incidence, we project an estimation of 220,632 new cases in 2030, 295,066 in 2040, and 378,461 in 2050. Disease burden was at 2,876 DALYsper 100,000 persons. The economic burden per patient was around Php 196,000 annually (i.e., ~4,070 USD, or 36.7% of average family annual income in the Philippines). The majority (86.29%) of this care expense was indirect cost attributed to estimated lost potential earning of unpaid family caregivers whereas direct medical cost accounted for only 13.48%. Conclusions: We provide the first Filipino community-based data on the incidence of dementia, DALYs, and cost of care to reflect the epidemiologic and economic impact of disease. The findings of this study serve to guide the development of a national dementia plan.
| S-EPMC8160123 | biostudies-literature