Emergency Department Use After Outpatient Surgery Among Dually Enrolled VA and Medicare Patients.
Ontology highlight
ABSTRACT: Background
Emergency department (ED) use following outpatient surgery may be associated with a surgery-related patient safety problem. We characterized ED use within 7 days of general, urology, orthopedic, ear/nose/throat, and podiatry surgical procedures and assessed factors associated with these visits by specialty.Methods
We calculated the 2011-2013 postoperative ED visit rate for Veterans older than 65 years dually enrolled in the Veterans Health Administration (VA) and Medicare, examined diagnoses, and used logistic regression to model patient, procedure, and facility factors associated with ED care.Results
Among 63 279 outpatient surgical procedures, 2778 (4.4%) resulted in an ED visit within 7 days; 23% of these were to non-VA facilities. Rates varied from more than 5% for urology and ear/nose/throat, to less than 3% for orthopedic and podiatry specialties. Genitourinary symptoms and surgical complications were common diagnoses across specialties. No patient, procedure, or facility factors were associated with ED use for every specialty.Conclusions
A small proportion of VA outpatient surgical procedures result in ED use. Notably, nearly one-fourth of the postoperative ED visits may be missed by the VA because they occur in non-VA facilities. ED visits for urinary issues or surgical complications may be preventable; however, factors associated with ED use vary by specialty, suggesting different approaches may be needed to improve outcomes.
SUBMITTER: Mull HJ
PROVIDER: S-EPMC8454274 | biostudies-literature |
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:Background:There is systemic undercoding of medical comorbidities within administrative claims in the Department of Veterans Affairs (VA). This leads to bias when applying claims-based risk adjustment indices to compare outcomes between VA and non-VA settings. Our objective was to compare the accuracy of a medication-based risk adjustment index (RxRisk-VM) to diagnostic claims-based indices for predicting mortality.Methods:We modified the RxRisk-V index (RxRisk-VM) by incorporating VA and Medicare pharmacy and durable medical equipment claims in Veterans dually-enrolled in VA and Medicare in 2012. Using the concordance (C) statistic, we compared its accuracy in predicting 1 and 3-year all-cause mortality to the following models: demographics only, demographics plus prescription count, or demographics plus a diagnostic claims-based risk index (e.g., Charlson, Elixhauser, or Gagne). We also compared models containing demographics, RxRisk-VM, and a claims-based index.Results:In our cohort of 271,184 dually-enrolled Veterans (mean age?=?70.5 years, 96.1% male, 81.7% non-Hispanic white), RxRisk-VM (C?=?0.773) exhibited greater accuracy in predicting 1-year mortality than demographics only (C?=?0.716) or prescription counts (C?=?0.744), but was less accurate than the Charlson (C?=?0.794), Elixhauser (C?=?0.80), or Gagne (C?=?0.810) indices (all P?<?0.001). Combining RxRisk-VM with claims-based indices enhanced its accuracy over each index alone (all models C???0.81). Relative model performance was similar for 3-year mortality.Conclusions:The RxRisk-VM index exhibited a high level of, but slightly less, accuracy in predicting mortality in comparison to claims-based risk indices.Implications:Its application may enhance the accuracy of studies examining VA and non-VA care and enable risk adjustment when diagnostic claims are not available or biased.Level of evidence:Level 3.
| S-EPMC6814520 | biostudies-literature
Project description:Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems.We aimed to establish a typology of VA and Medicare utilization among dually enrolled Veterans with type 2 diabetes.This was a retrospective cohort.316,775 community-dwelling Veterans age ? 65 years with type 2 diabetes who were dually enrolled in the VA and FFS Medicare in 2008-2009.Using latent class analysis, we identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. We compared the amount of healthcare use between classes and identified factors associated with class membership using multinomial regression.We identified four distinct latent classes: class 1 (53.9%) had high probabilities of VA use and low probabilities of Medicare use; classes 2 (17.2%), 3 (21.8%), and 4 (7.0%) had high probabilities of VA and Medicare use, but differed in their Medicare services used. For example, Veterans in class 3 received test strips exclusively through Medicare, while Veterans in class 4 were reliant on Medicare for medications. Living ? 40 miles from a VA predicted membership in classes 3 (OR 1.1, CI 1.06-1.15) and 4 (OR 1.11, CI 1.04-1.18), while Medicaid eligibility predicted membership in class 4 (OR 4.30, CI 4.10-4.51).Veterans with diabetes can be grouped into four distinct classes of dual health system use, representing a novel way to characterize how patients use multiple services across healthcare systems. This classification has applications for identifying patients facing differential risk from care fragmentation.
| S-EPMC4835371 | biostudies-literature
Project description:OBJECTIVE: To examine how service accessibility measured by geographic distance affects service sector choices for veterans who are dually eligible for veterans affairs (VA) and Medicare services and who are diagnosed with mental health and/or substance abuse (MH/SA) disorders. DATA SOURCES: Primary VA data sources were the Patient Treatment (acute care), Extended Care (long-term care), and Outpatient Clinic files. VA cost data were obtained from (1) inpatient and outpatient cost files developed by the VA Health Economics and Resource Center and (2) outpatient VA Decision Support System files. Medicare data sources were the denominator, Medicare Provider Analysis Review (MEDPAR), Provider-of-Service, Outpatient Standard Analytic and Physician/Supplier Standard Analytic files. Additional sources included the Area Resource File and Census Bureau data. STUDY DESIGN: We identified dually eligible veterans who had either an inpatient or outpatient MH/SA diagnosis in the VA system during fiscal year (FY)'99. We then estimated one- and two-part regression models to explain the effects of geographic distance on both VA and Medicare total and MH/SA costs. PRINCIPAL FINDINGS: Results provide evidence for substitution between the VA and Medicare, demonstrating that poorer geographic access to VA inpatient and outpatient clinics decreased VA expenditures but increased Medicare expenditures, while poorer access to Medicare-certified general and psychiatric hospitals decreased Medicare expenditures but increased VA expenditures. CONCLUSIONS: As geographic distance to VA medical facility increases, Medicare plays an increasingly important role in providing mental health services to veterans.
| S-EPMC2517276 | biostudies-other
Project description:Background:Over the past decade, a growing number of older Medicare beneficiaries visit the Emergency Department (ED) and have been placed in observation care. We investigated and compared the prevalence and factors associated with patients age ? 65 years with Medicare insurance who are placed in the hospital, observation care, or discharged following an ED visit. Methods:We conducted a retrospective cohort study using data from a nationally representative 5% sample of Medicare patients age ? 65 years during the year 2013. We performed multiple generalized estimating equation (GEE) logistic regression analyses to assess the relationship between placement in a hospital vs. discharge, observation care vs. discharge, and observation care vs. admission. Results:Of 537,455 Medicare beneficiaries age ? 65 years who visited an ED in 2013, 48.0% (N= 258,083) were discharged, 10.5% (N=56,184) placed in observation care, and 41.5% (N=223,188) were admitted to the inpatient service following the ED visit. The top 2 diagnoses associated with placement in the hospital vs. discharge were ischemic heart disease and renal disease. Patients with symptomatic diagnoses such as chest pain and dizziness were more likely to be placed in observation care following an ED visit as compared to admission to the hospital. Conclusion:Compared to prior studies, we found a greater number of older Medicare ED patients placed in observation care and a lower number admitted to the hospital. Most common diagnoses of placement in observation care were symptom-based as compared to being admitted to the hospital which were disease-based.
| S-EPMC5935261 | biostudies-literature
Project description:There has been a strong push to move outpatient surgery from hospital settings to ambulatory surgery centers (ASCs). Despite the efficiency advantages of ASCs, many are concerned that these facilities could increase overall utilization.To assess the impact of ASC opening on rates of outpatient surgery.This was a retrospective cohort study of Medicare beneficiaries undergoing outpatient surgery between 2001 and 2010. We compared population-based rates of outpatient surgery in Hospital Service Areas (HSAs) with freestanding ASCs to those without. After adjusting for differences using multiple propensity score methods, we assessed the impact of ASC opening in an HSA previously without one on rates of outpatient surgery.Patients included were Medicare beneficiaries with Part B eligibility.Adjusted HSA-level rates of outpatient surgery.Adjusted outpatient surgery rates increased from 2806 to 3940 per 10,000 and the number of ASC operating rooms grew from 7036 to 11,223 (both P<0.001 for trend). By the fourth year after opening, rates of outpatient surgery increased by 10.9% (from 3338 to 3701 per 10,000) in HSAs adding an ASC for the first time. In contrast, outpatient surgery rates grew by only 2.4% and 0.6% in HSAs where an ASC was always or never present, respectively (P<0.001 for test between 3 slopes).Rather than redistributing patients from one setting to another, the opening of ASCs increases outpatient surgery use. However, the 10.9% increase is more modest than previously suggested by state-level data.
| S-EPMC4163137 | biostudies-literature
Project description:Background:Displacement after a war or an armed conflict always leads to unexpected health problems, both among migrating people and in places to which new people have migrated. This study aimed to determine the health care needs and trends of Syrian patients. Methods:This retrospective study was conducted in a secondary care hospital in the city of Nev?ehir, in central Turkey, between January 2013 and December 2017. All Syrian patients who visited the outpatient clinics and emergency department (ED) were enrolled in the study. Results:Over a span of five years, 41?723 Syrian patients visited the hospital's outpatient clinics and ED. The patients' median age was 23 (inter-quartile range (IQR)?=?7-34), and 57.7% of them were female. In 2017, one-third of the Syrian patients visited the ED, a rate that was higher than that found among local patients (30.3% vs 25.0%, P?<?0.001, respectively). The rate of pediatric clinic admissions among Syrian patients was about four times greater than the rate of local patients (20.1% vs 5.2%, P?<?0.001, respectively), and Syrians' rate of admission to the obstetrics and gynecology clinic was about three times greater than the rate of local patients' admissions (12.3% vs 4.3%, P?<?0.001, respectively). Conclusions:This study showed that Syrian patients' visits to the hospital, and especially the ED, are increasing. Further, the needs and expectations of these patients in terms of health care are different from local demands. New approaches should be applied to provide an appropriate use of health care facilities.
| S-EPMC6708588 | biostudies-literature
Project description:Importance:Medicare beneficiaries who are also enrolled in Medicaid (dually enrolled beneficiaries) have drawn the attention of policy makers because they comprise the poorest subset of the Medicare population; however, it is unclear how their outcomes have changed over time compared with those only enrolled in Medicare (nondually enrolled beneficiaries). Objective:To evaluate annual changes in all-cause mortality, hospitalization rates, and hospitalization-related mortality among dually enrolled beneficiaries and nondually enrolled beneficiaries. Design, Setting, and Participants:Serial cross-sectional study of Medicare fee-for-service beneficiaries aged 65 years or older between January 2004 and December 2017. The final date of follow-up was September 30, 2018. Exposures:Dual vs nondual enrollment status. Main Outcomes and Measures:Annual all-cause mortality rates; all-cause hospitalization rates; and in-hospital, 30-day, 1-year hospitalization-related mortality rates. Results:There were 71?017?608 unique Medicare beneficiaries aged 65 years or older (mean age, 75.6 [SD, 9.2] years; 54.9% female) enrolled in Medicare for at least 1 month from 2004 through 2017. Of these beneficiaries, 11?697?900 (16.5%) were dually enrolled in Medicare and Medicaid for at least 1 month. After adjusting for age, sex, and race, annual all-cause mortality rates declined from 8.5% (95% CI, 8.45%-8.56%) in 2004 to 8.1% (95% CI, 8.05%-8.13%) in 2017 among dually enrolled beneficiaries and from 4.1% (95% CI, 4.08%-4.13%) in 2004 to 3.8% (95% CI, 3.76%-3.79%) in 2017 among nondually enrolled beneficiaries. The difference in annual all-cause mortality between dually and nondually enrolled beneficiaries increased between 2004 (adjusted odds ratio, 2.09 [95% CI, 2.08-2.10]) and 2017 (adjusted odds ratio, 2.22 [95% CI, 2.21-2.23]) (P?<?.001 for interaction between dual enrollment status and time). All-cause hospitalizations per 100?000 beneficiary-years declined from 49?888 in 2004 to 41?121 in 2017 among dually enrolled beneficiaries (P?<?.001) and from 29?000 in 2004 to 22?601 in 2017 among nondually enrolled beneficiaries (P?<?.001); however, the difference between these groups widened between 2004 (adjusted risk ratio, 1.72 [95% CI, 1.71-1.73]) and 2017 (adjusted risk ratio, 1.83 [95% CI, 1.82-1.83]) (P?<?.001 for interaction). Among hospitalized beneficiaries, the risk-adjusted 30-day mortality rates declined from 10.3% (95% CI, 10.22%-10.33%) in 2004 to 10.1% (95% CI, 10.02%-10.20%) in 2017 among dually enrolled beneficiaries and from 8.5% (95% CI, 8.50%-8.56%) in 2004 to 8.1% (95% CI, 8.06%-8.13%) in 2017 among nondually enrolled beneficiaries. In contrast, 1-year mortality increased among hospitalized beneficiaries from 23.1% (95% CI, 23.05%-23.20%) in 2004 to 26.7% (95% CI, 26.58%-26.84%) in 2017 among dually enrolled beneficiaries and from 18.1% (95% CI, 18.11%-18.17%) in 2004 to 20.3% (95% CI, 20.21%-20.31%) in 2017 among nondually enrolled beneficiaries. The difference in hospitalization-related outcomes between dually and nondually enrolled beneficiaries persisted during the study period. Conclusions and Relevance:Among Medicare fee-for-service beneficiaries aged 65 years or older, dually enrolled beneficiaries had higher annual all-cause mortality, all-cause hospitalizations, and hospitalization-related mortality compared with nondually enrolled beneficiaries. Between 2004 and 2017, these differences did not decrease.
| S-EPMC7064881 | biostudies-literature
Project description:ObjectivesTo examine how dual coverage for nonelderly, low-income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care.Data sourcesVeterans Affairs utilization data and Medicaid Analytic Extract Files.Study designA retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006-2010.Data collection/extraction methodsVeterans Affairs reliance, or proportion of care provided by VA, was estimated with beta-binomial models, adjusting for patient and state Medicaid program factors.Principal findingsIn a cohort of 19,890 nonelderly veterans, VA utilization levels were similar before and after enrolling in Medicaid. VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service-connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater Medicaid eligibility generosity, and better Medicaid quality.ConclusionVeterans Affairs utilization following new Medicaid enrollment remained relatively unchanged, and the VA continued to provide the large majority of care for dually enrolled veterans. There was variation among patients as Medicaid eligibility and other program factors influenced their use of Medicaid services.
| S-EPMC5980176 | biostudies-literature
Project description:OBJECTIVE:The study examined whether the number of outpatient addiction programs accepting Medicaid in South Carolina counties is linked to repeat use of the emergency department for addiction-related conditions. METHODS:The study included the population all adult Medicaid enrollees (N=2,401) in South Carolina with at least one addiction-related emergency service visit in 2012 or 2013. A random-effects logistic regression model was used to examine the association between outpatient addiction treatment availability and repeat use by Medicaid enrollees of emergency services for addiction-related conditions. RESULTS:Enrollees in counties with two or more programs that accept Medicaid were less likely to have a repeat addiction-related emergency service visit than enrollees in counties with only one program that accepts Medicaid. CONCLUSIONS:Availability of outpatient addiction treatment may reduce the need for addiction-related emergency services. Research is needed to explore potential causal mechanisms underlying this observed relationship.
| S-EPMC6511360 | biostudies-literature
Project description:To adapt the Assessing Care of Vulnerable Elders project nursing home (NH) specific quality indicators (QIs), for use with routinely collected data, and to evaluate which clinical conditions and types of care were inadequately measured using these data sources.Retrospective cohort study.Nursing homes.NH residents 66 years of age and older dually enrolled in Medicare and Medicaid in 19 California counties between 1999 and 2000.Identification of care inaccessible to measurement by Medicare and Medicaid claims linked to the Minimum Data Set (MDS). Assessment of care provided for measurable QIs by condition (eg, heart failure) and by intervention type (eg, medication use).Only 50 of 283 QIs were captured using linked claims data. The 21,657 patients triggered 152,376 QIs (7.0 QIs/person). The overall QI pass rate (receipt of recommended care) for eligible participants was 76%. In this sample, QIs with the highest pass rates measured avoidance of adverse medications and appropriate medication use. Fewer than half of the QIs were passed for ischemic heart disease, stroke, and osteoporosis. The MDS permitted assessment of 8 QIs that focus on geriatric care. No measured QIs assessed history taking or nursing care.The use of claims data linked to MDS to measure the quality of care process measures is feasible for NH populations, but would be more valuable if additional data elements focused on geriatric and residential care. QIs that could be applied to patients in this study suggested areas of care needing improvement.
| S-EPMC4351736 | biostudies-literature