Dataset Information

Temporal Trends in Heart Failure Incidence Among Medicare Beneficiaries Across Risk Factor Strata, 2011 to 2016.

ABSTRACT: Importance:Heart failure (HF) incidence is declining among Medicare beneficiaries. However, the epidemiological mechanisms underlying this decline are not well understood. Objective:To evaluate trends in HF incidence across risk factor strata. Design, Setting, and Participants:Retrospective, national cohort study of 5% of all fee-for-service Medicare beneficiaries with no prior HF followed up from 2011 to 2016. The study examined annual trends in HF incidence among groups with and without primary HF risk factors (hypertension, diabetes, and obesity) and predisposing cardiovascular conditions (acute myocardial infarction [MI] and atrial fibrillation [AF]). Exposures:The presence of comorbid HF risk factors including hypertension, diabetes, obesity, acute MI, and AF identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. Main Outcomes and Measures:Incident HF, defined using at least 1 inpatient HF claim or at least 2 outpatient HF claims among those without a previous diagnosis of HF. Results:Of 1?799?027 unique Medicare beneficiaries at risk for HF (median age, 73 years [interquartile range, 68-79 years]; 56% female [805 060-796 253 participants during the study period]), 249?832 had a new diagnosis of HF. The prevalence of all 5 risk factors increased over time (0.8% mean increase in hypertension per year, 1.9% increase in diabetes, 2.9% increase in obesity, 0.2% increase in acute MI, and 0.4% increase in AF). Heart failure incidence declined from 35.7 cases per 1000 beneficiaries in 2011 to 26.5 cases per 1000 beneficiaries in 2016, consistent across subgroups based on sex and race/ethnicity. A greater decline in HF incidence was observed among patients with prevalent hypertension (relative excess decline, 12%), diabetes (relative excess decline, 3%), and obesity (relative excess decline, 16%) compared with those without corresponding risk factors. In contrast, there was a relative increase in HF incidence among individuals with acute MI (26% vs no acute MI) and AF (22% vs no AF). Conclusions and Relevance:Findings of this study suggest that the temporal decline in HF incidence among Medicare beneficiaries reflects a decrease in HF incidence among those with primary HF risk factors. The increase in HF incidence among those with acute MI and those with AF highlights potential targets for future HF prevention strategies.

SUBMITTER: Khera R

PROVIDER: S-EPMC7584929 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Temporal Trends in Heart Failure Incidence Among Medicare Beneficiaries Across Risk Factor Strata, 2011 to 2016.

Khera Rohan R Kondamudi Nitin N Zhong Lin L Vaduganathan Muthiah M Parker Joshua J Das Sandeep R SR Grodin Justin L JL Halm Ethan A EA Berry Jarett D JD Pandey Ambarish A

JAMA network open 20201001 10

<h4>Importance</h4>Heart failure (HF) incidence is declining among Medicare beneficiaries. However, the epidemiological mechanisms underlying this decline are not well understood.<h4>Objective</h4>To evaluate trends in HF incidence across risk factor strata.<h4>Design, setting, and participants</h4>Retrospective, national cohort study of 5% of all fee-for-service Medicare beneficiaries with no prior HF followed up from 2011 to 2016. The study examined annual trends in HF incidence among groups w ...[more]

PMID: 33095250

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Project description:ImportanceThere is little evidence regarding how total costs of care associated with an emergency department (ED) visit have changed, despite increasing policy focus on the value of acute care.ObjectiveTo examine trends in total standardized 30-day costs of care associated with an ED visit.Design, setting, and participantsThis cross-sectional study of 14 113 088 ED visits at 4730 EDs from 2011 to 2016 included a 20% national sample of traditional Medicare beneficiaries aged 65 years and older. Data analysis was conducted from August 2018 to April 2020.ExposuresTime (year) as a continuous variable.Main outcomes and measuresTrends in disposition from the ED and 30-day total standardized costs for all ED visits as well as the following spending components: index visit cost, physician costs, subsequent ED visit costs, subsequent inpatient costs, subsequent observation costs, non-ED outpatient care, postacute care, and aggregated total spending after the index ED visit.ResultsThe analytic sample consisted of 14 113 088 ED visits at 4730 EDs. The mean (SD) beneficiary age was 78.6 (8.6) years, 8 573 652 visits (60.7%) were among women, and 11 908 691 visits (84.7%) were among white patients. The proportion of patients discharged from the ED rose from 1 233 701 of 2 309 563 visits (53.4%) in 2011 to 1 279 701 of 2 268 363 visits (56.4%) in 2016. Total adjusted 30-day standardized costs of care declined from a mean (SE) of $8851 ($35.3) in 2011 to a mean (SE) of $8143 ($35.4) in 2016 (-$126/y; 95% CI, -$130 to -$121; P < .001) for all ED visits. This decrease was primarily associated with a decline in total spending on the index ED visit (-$48/y; 95% CI, -$50 to -$47; P < .001) as well as lower spending on postacute care (-$42/y; 95% CI, -$44 to -$41; P < .001) and subsequent inpatient care (-$34/y; 95% CI, -$36 to -$32; P < .001). There was an increase in spending after the index visit on downstream observation care ($3.6/y; 95% CI, $3.5 to $3.7; P < .001), outpatient ED care ($4.6/y; 95% CI, $4.4 to $4.8; P < .001), and other outpatient care ($15/y; 95% CI, $12 to $18; P < .001).Conclusions and relevanceIn this study, total 30-day standardized costs of ED care for Medicare beneficiaries decreased in recent years. It may be that more intensive ED spending up front is associated with reductions in total costs of an acute episode.

Project description:BackgroundHeart failure (HF) is the leading cause of hospitalization among older adults in the United States and results in high rates of post-acute care (PAC) utilization. Federal policies have focused on shifting PAC to less intensive settings and reducing length of stay to lower spending. This study evaluates the impact of policy changes on PAC use among Medicare beneficiaries hospitalized with HF between 2008 and 2015 by (1) characterizing trends in PAC use and cost and (2) evaluating changes in readmission, mortality, and days in the community, overall and by frailty.MethodsAnnual cross-section prospective cohorts of all HF admissions between 1/1/2008 and 9/30/2015 among a 20% random sample of all Medicare Fee-for-Service beneficiaries (n = 718,737). The Claims-based Frailty Index (CFI) was used to classify frailty status. Multivariable regression models were used to evaluate trends in first discharge location, readmissions, mortality, days alive in the community, and costs; overall and by frailty status.ResultsFrailty was prevalent among HF patients: 54.1% were prefrail, 37.0% mildly frail, and 6.9% moderate to severely frail. Between 2008 and 2015, almost 4% more HF beneficiaries received PAC, with most of the increase concentrated in skilled nursing facilities (SNF) (+2.3%) and home health agencies (HHA) (+1.1%), and PAC cost increased by $123 (3.5%). Over the 180-days follow-up after hospitalization, hospital readmissions decreased significantly (-3.4% at 30-day; -6.3% at 180-day), days alive in the community increased (+1.5), and 180-day Medicare costs declined $2948 (-18.7%) without negative impact in mortality (except a minor increase in the pre-frail group). Gains were greatest among the frailest patients.ConclusionsMedicare beneficiaries hospitalized with HF spent more time in the community and experienced lower rehospitalization rates at lower cost without significant increases in mortality. However, important opportunities remain to optimize care for frail older adults hospitalized with HF.

Project description:OBJECTIVES:The purpose of this study was to examine the association of 30-day payments for an episode of heart failure (HF) care at the hospital level with patient outcomes. BACKGROUND:There is increased focus among policymakers on improving value for HF care, given its rising prevalence and associated financial burden in the United States; however, little is known about the relationship between payments and mortality for a 30-day episode of HF care. METHODS:Using Medicare claims data for all fee-for-service beneficiaries hospitalized for HF between July 1, 2011, and June 30, 2014, we examined the association between 30-day Medicare payments at the hospital level (beginning with a hospital admission for HF and across multiple settings following discharge) and patient 30-day mortality using mixed-effect logistic regression models. RESULTS:We included 1,343,792 patients hospitalized for HF across 2,948 hospitals. Mean hospital-level 30-day Medicare payments per beneficiary were $15,423 ± $1,523. Overall observed mortality in the cohort was 11.3%. Higher hospital-level 30-day payments were associated with lower patient mortality after adjustment for patient characteristics (odds ratio per $1,000 increase in payments: 0.961; 95% confidence interval [CI]: 0.954 to 0.967). This relationship was slightly attenuated after accounting for hospital characteristics and HF volume, but remained significant (odds ratio per $1,000 increase: 0.968; 95% CI: 0.962 to 0.975). Additional adjustment for potential mediating factors, including cardiac service capability and post-acute service use, did not significantly affect the relationship. CONCLUSIONS:Higher hospital-level 30-day episode payments were associated with lower patient mortality following a hospitalization for HF. This has implications for policies that incentivize reduction in payments without considering value. Further investigation is needed to understand the mechanisms that underlie this relationship.

Project description:Importance:Emergency department (ED) visits are common and increasing. Whether outcomes associated with care in the ED are improving over time is largely unknown to date. Objective:To examine trends in 30-day mortality rates associated with ED care among Medicare beneficiaries aged 65 years or older. Design, Setting, and Participants:This cross-sectional study used a random 5% sample in 2009 and 2010 and a 20% sample from 2011 to 2016, for a total of 15?416?385 ED visits from 2009 to 2016 among Medicare beneficiaries aged 65 years or older. Exposures:Time (year) as a continuous variable. Main Outcomes and Measures:The primary outcome was 30-day mortality, overall and stratified by illness severity and hospital characteristics. Secondary outcomes included mortality rates on the day of the ED visit (day 0) as well as at 7 and 14 days. Changes in disposition from the ED (admission, observation, transfer, died in the ED, and discharged) over time were also examined. Results:The sample included 15?416?385 ED visits (60.8% women and 39.2% men; mean [SD] age, 78.6 [8.5] years) at 4828 acute care hospitals. The percentage of patients discharged from the ED increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality declined from 5.1% in 2009 to 4.6% in 2016 (-0.068% per year; 95% CI, -0.074% to -0.063% per year; P?<?.001). After adjusting for hospital random effects, patient demographics, and chronic conditions, the adjusted 30-day mortality trend was -0.198% per year (95% CI, -0.204% to -0.193% per year; P?<?.001). The magnitude of this trend was greatest for patients with a high severity of illness (-0.662%; 95% CI, -0.681% to -0.644%; P?<?.001), followed by those with a medium severity of illness (-0.103% per year; 95% CI, -0.108% to -0.097% per year; P?<?.001) and those with a low severity of illness (-0.009% per year; 95% CI, -0.006% to -0.011% per year; P?<?.001). Declines in mortality were seen in each category of ED disposition, including visits resulting in admission (-0.356% per year; 95% CI, -0.368% to -0.343% per year; P?<?.001) as well as those resulting in discharge (-0.059% per year; 95% CI, -0.064% to -0.055% per year; P?<?.001). The decline was greater for major teaching hospitals (compared with nonteaching hospitals), nonprofit hospitals (compared with for-profit hospitals), and urban hospitals (compared with rural hospitals). Conclusions and Relevance:Among Medicare beneficiaries receiving ED care in the United States, mortality within 30 days of an ED visit appears to have declined in recent years, particularly for patients with the highest severity of illness, even as fewer patients are being admitted from an ED visit. This study's findings suggest that further study is needed to understand the reasons for this decline and why certain types of hospitals are seeing greater improvements in outcomes.

Dataset Information

Temporal Trends in Heart Failure Incidence Among Medicare Beneficiaries Across Risk Factor Strata, 2011 to 2016.

Publications

Temporal Trends in Heart Failure Incidence Among Medicare Beneficiaries Across Risk Factor Strata, 2011 to 2016.

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