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Low-value care: antipsychotic medication use among community-dwelling medicare beneficiaries with Alzheimer's disease and related dementias and without severe mental illness.

ABSTRACT: Background: Antipsychotic medication use among elderly with Alzheimer's disease and related dementias (ADRD) and without severe mental illness is considered as low-value care. Our objective was to assess the factors associated with this inappropriate use of antipsychotic medications among community-dwelling Medicare beneficiaries with ADRD and without severe mental illness.Methods: This study used a retrospective cross-sectional design. Data for this study were derived from the nationally representative Medicare Current Beneficiary Survey (MCBS) and linked Medicare claims. Logistic regression models were used to examine factors associated with low-value care.Results: Overall 8.5% had low-value care. In the final adjusted logistic regression model, race other than Hispanic or Non-Hispanic White (AOR =0.54, 95% CI = [0.30,0.98]), individuals over 80?years of age (AOR =0.53, 95% CI = [0.36,0.76]), and obese individuals (AOR =0.55, 95% CI = [0.35,0.85]) had significantly lower odds of receiving low-value care. Those with depression (AOR =1.71, 95% CI = [1.21, 2.43]), who lived in the Midwest (AOR =1.7, 95% CI = [1.08,2.68]), and with a higher number of ADL limitations (AOR =1.28, 95% CI = [1.19,1.38]) had significantly higher odds of low-value care.Conclusions: There were subgroup differences in low-value care. Interventions may target these subgroups to reduce low-value care.

SUBMITTER: Nili M

PROVIDER: S-EPMC6551311 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Low-value care: antipsychotic medication use among community-dwelling medicare beneficiaries with Alzheimer's disease and related dementias and without severe mental illness.

Nili Mona M Shen Chan C Sambamoorthi Usha U

Aging & mental health 20181206 3

<b>Background:</b> Antipsychotic medication use among elderly with Alzheimer's disease and related dementias (ADRD) and without severe mental illness is considered as low-value care. Our objective was to assess the factors associated with this inappropriate use of antipsychotic medications among community-dwelling Medicare beneficiaries with ADRD and without severe mental illness.<b>Methods:</b> This study used a retrospective cross-sectional design. Data for this study were derived from the nat ...[more]

PMID: 30521375

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Project description:BackgroundThe Medicare Advantage (MA) program is rapidly growing. Limited evidence exists about the care experiences of MA beneficiaries with Alzheimer's Disease and Related Dementia (ADRD). Our objective was to compare care experiences for MA beneficiaries with and without ADRD.MethodsWe examined MA beneficiaries who completed the Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) and used inpatient, nursing home, or home health services in the past 3 years. We classified beneficiaries with ADRD using the presence of diagnosis codes in hospitals, nursing homes, and home health records. Our key measures included overall ratings of care and health plan, and indices of receiving timely care, care coordination, receiving needed care, and customer service. We compared differences between beneficiaries with and without ADRD using regression analysis adjusting for demographic, health, and plan characteristics, and stratifying by proxy response status.ResultsAmong beneficiaries sampled by CAHPS, 22.2% with ADRD completed the survey compared to 38.5% without ADRD. Among proxy responses, beneficiaries with ADRD were 4.2 (95% CI: 0.1-8.4) percentage points less likely to report a high score for receiving needed care, and 3.5 percentage points (95% CI: 0.2-6.9) less likely to report a high score for customer service. Among non-proxy responses, those with ADRD were 9.0 (95% CI: 5.5-12.5) percentage points less likely to report a high score for needed care, and 8.5 (95% CI: 5.4-11.5) percentage points less likely to report a high score for customer service.ConclusionsADRD respondents to the CAHPS were more likely to be excluded from CAHPS performance measures because they did not meet eligibility requirements and rates of non-response were higher. Among responders with or without a proxy, MA enrollees with an ADRD diagnosis reported worse care experiences in receiving needed care and in customer service than those without an ADRD diagnosis.

Project description:ImportanceCompared with traditional Medicare (TM) fee-for-service plans, Medicare Advantage (MA) plans may provide more-efficient care for beneficiaries with Alzheimer disease and related dementias (ADRD) without compromising care quality.ObjectiveTo determine differences in health care utilization, care satisfaction, and health status for MA and TM beneficiaries with and without ADRD.Design, setting, and participantsA cohort study was conducted of MA and TM beneficiaries with and without ADRD from all publicly available years of the Medicare Current Beneficiary Survey between 2010 and 2016. To address advantageous selection into MA plans, county-level MA enrollment rate was used as an instrument. Data were analyzed between July 2019 and December 2019.ExposuresEnrollment in MA.Main outcomes and measuresSelf-reported health care utilization, care satisfaction, and health status.ResultsThe sample included 47 100 Medicare beneficiaries (25 900 women [54.9%]; mean [SD] age, 72.2 [11.4] years). Compared with TM beneficiaries with ADRD, MA beneficiaries with ADRD had lower utilization across the board, including a mean of -22.3 medical practitioner visits (95% CI, -24.9 to -19.8 medical practitioner visits), -2.3 outpatient hospital visits (95% CI, -3.6 to -1.1 outpatient hospital visits), -0.2 inpatient hospital admissions (95% CI, -0.3 to -0.1 inpatient hospital admissions), and -0.1 long-term care facility stays (95% CI, -0.2 to -0.1 long-term care facility stays). A similar trend was observed among beneficiaries without ADRD, but the difference was greater between MA and TM beneficiaries with ADRD than between MA and TM beneficiaries without ADRD (mean, -15.0 medical practitioner visits [95% CI, -18.7 to -11.3 medical practitioner visits], -1.7 outpatient hospital visits [95% CI, -3.0 to -0.3 outpatient hospital visits], and -0.1 inpatient hospital admissions [95% CI, -1.0 to 0.0 inpatient hospital admissions]). Overall, no or negligible differences were detected in care satisfaction and health status between MA and TM beneficiaries with and without ADRD.Conclusions and relevanceCompared with TM beneficiaries, MA beneficiaries had lower health care utilization without compromising care satisfaction and health status. This difference was more pronounced among beneficiaries with ADRD. These findings suggest that MA plans may be delivering health care more efficiently than TM, especially for beneficiaries with ADRD.

Project description:BackgroundPatients with serious mental illness (i.e., SMI; bipolar disorder, major depressive disorder, and schizophrenia) are at increased risk of readmission, yet little is known about the extent to which readmission rates among these patients vary across hospitals. The purpose of this study was to examine the variation across hospitals in readmissions for patients with SMI and differences in the characteristics of hospitals with the highest and lowest adjusted readmission rates.MethodsWe conducted a cross-sectional analysis of pooled inpatient claims from 2013-2016. Mixed logit models with hospital random effects were used to estimate the hospital-level variance. The sample included patients with SMI from a 5% sample of fee-for-service Medicare beneficiaries.ResultsWe identified 2066 hospitals with at least 30 index admissions for Medicare beneficiaries with SMI. In multivariate analyses, factors most strongly associated with increased risk of readmission included substance use disorder (OR 2.311; p < 0.001) and end stage renal disease (OR 2.024; p < 0.001). Unadjusted readmission for hospitals at the 5th and 95th percentiles of performance were 7.05% and 15.24%, respectively, constituting an 8.2% difference. Adjusting for patient and community characteristics reduced the spread in readmission rates between the 5th and 95th percentiles of hospitals by 1.0% (i.e. to 7.2%). Hospitals in the lowest vs. highest quintiles of adjusted readmission rates were more likely to be teaching hospitals (11.1% vs. 16.7%; p < 0.05) and located in the South (37.7% vs. 40.4%) or Midwest (19.8% vs. 30.0%; p < 0.001 for region differences).ConclusionsThere is substantial hospital-level variation in readmission rates among patients with serious mental illness, even after adjusting for patient and community characteristics. This has implications for policy guiding investment in hospital-based services and community resources, to improve transitions of care for patients with SMI.

Project description:ImportanceLow-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care.ObjectivesTo compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care.Design, setting, and participantsThis cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022.ExposuresEnrollment in MA vs TM.Main outcomes and measuresLow-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries.ResultsAmong a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements.Conclusions and relevanceIn this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.

Project description:ObjectivesMedicare beneficiaries recovering from a critical illness are increasingly being discharged home instead of to post-acute care facilities. Rehabilitation services are commonly recommended for intensive care unit (ICU) survivors; however, little is known about the frequency and dose of home-based rehabilitation in this population.DesignRetrospective analysis of 2012 Medicare hospital and home health (HH) claims data, linked with assessment data from the Medicare Outcomes and Assessment Information Set.SettingParticipant homes.ParticipantsMedicare beneficiaries recovering from an ICU stay longer than 24 hours, who were discharged directly home with HH services within 7 days of discharge and survived without readmission or hospice transfer for at least 30 days (n = 3,176).MeasurementsCount of rehabilitation visits received during HH care episode.ResultsA total of 19,564 rehabilitation visits were delivered to ICU survivors over 118,145 person-days in HH settings, a rate of 1.16 visits per week. One-third of ICU survivors received no rehabilitation visits during HH care. In adjusted models, those with the highest baseline disability received 30% more visits (rate ratio [RR] = 1.30; 95% confidence interval [CI] = 1.17-1.45) than those with the least disability. Conversely, an inverse relationship was found between multimorbidity (Elixhauser scores) and count of rehabilitation visits received; those with the highest tertile of Elixhauser scores received 11% fewer visits (RR = .89; 95% CI = .81-.99) than those in the lowest tertile. Participants living in a rural setting (vs urban) received 6% fewer visits (RR = .94; 95% CI = .91-.98); those who lived alone received 11% fewer visits (RR = .89; 95% CI = .82-.96) than those who lived with others.ConclusionOn average, Medicare beneficiaries discharged home after a critical illness receive few rehabilitation visits in the early post-hospitalization period. Those who had more comorbidities, who lived alone, or who lived in rural settings received even fewer visits, suggesting a need for their consideration during discharge planning. J Am Geriatr Soc 68:1512-1519, 2020.

Dataset Information

Low-value care: antipsychotic medication use among community-dwelling medicare beneficiaries with Alzheimer's disease and related dementias and without severe mental illness.

Publications

Low-value care: antipsychotic medication use among community-dwelling medicare beneficiaries with Alzheimer's disease and related dementias and without severe mental illness.

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