Identifying chronic conditions in Medicare claims data: evaluating the Chronic Condition Data Warehouse algorithm

State Department of Motor Vehicles Reporting Mandates of Dementia Diagnoses and Dementia Underdiagnosis

Importance

With older drivers representing the fastest growing segment of the driver population and dementia prevalence increasing with age, policymakers face the challenge of balancing road safety and mobility of older adults. In states that require reporting a dementia diagnosis to the Department of Motor Vehicles (DMV), individuals with dementia may be reluctant to disclose symptoms of cognitive decline, and clinicians may be reluctant to probe for those symptoms, which may be associated with missed or delayed diagnoses.

Objective

To assess whether DMV reporting policies for drivers with dementia are associated with primary care clinicians' underdiagnosing dementia.

Design, Setting, and Participants

This cross-sectional study used data from the 100% Medicare fee-for-service program and the Medicare Advantage plans from 2017 to 2019 on 223 036 primary care clinicians with at least 25 Medicare patients. Statistical analysis was performed from July to October 2023.

Exposures

State DMV reporting policies for drivers with dementia.

Main Outcomes and Measures

The main outcome was a binary variable indicating whether the clinician underdiagnosed dementia or not. Each clinician's expected number of dementia cases was estimated using a predictive model based on patient characteristics. Comparing the estimation with observed dementia diagnoses identified clinicians who underdiagnosed dementia vs those who did not, after accounting for sampling errors.

Results

Four states have clinician reporting mandates, 14 have mandates requiring drivers to self-report dementia diagnoses, and 32 states and the District of Columbia do not have explicit requirements. Among primary care clinicians in states with clinician reporting mandates (n = 35 620), 51.4% were female, 91.9% worked in a metropolitan area, and 19.9% of the patient panel were beneficiaries dually eligible for Medicare and Medicaid. Among primary care clinicians in states with patient self-reporting mandates (n = 57 548), 55.7% were female, 83.1% worked in a metropolitan area, and 15.4% of the patient panel were dually eligible for Medicare and Medicaid. Among clinicians in states without mandates, 55.7% were female, 83.0% worked in a metropolitan area, and 14.6% of the patient panel were dually eligible for Medicare and Medicaid. Clinicians in states with clinician reporting mandates had an adjusted 12.4% (95% CI, 10.5%-14.2%) probability of underdiagnosing dementia compared with 7.8% (95% CI, 6.9%-8.7%) in states with self-reporting and 7.7% (95% CI, 6.9%-8.4%) in states with no mandates, an approximately 4-percentage point difference (P < .001).

Conclusions and Relevance

Results of this cross-sectional study of primary care clinicians suggest that mandatory DMV policies for clinicians to report patients with dementia may be associated with a higher risk of missed or delayed dementia diagnoses. Future research is needed to better understand the unintended consequences and the risk-benefit tradeoffs of these policies.

Racial and Ethnic Differences in Telemedicine Use

Importance

Individuals of racial and ethnic minority groups may be less likely to use telemedicine in part due to lack of access to technology (ie, digital divide). To date, some studies have found less telemedicine use by individuals of racial and ethnic minority groups compared with White individuals, and others have found the opposite. What explains these different findings is unclear.

Objective

To quantify racial and ethnic differences in the receipt of telemedicine and total visits with and without accounting for demographic and clinical characteristics and geography.

Design, Setting, and Participants

This cross-sectional study included individuals who were continuously enrolled in traditional Medicare from March 2020 to February 2022 or until death.

Exposure

Race and ethnicity, which was categorized as Black non-Hispanic, Hispanic, White non-Hispanic, other (defined as American Indian/Pacific Islander, Alaska Native, and Asian), and unknown/missing.

Main Outcomes and Measures

Total telemedicine visits (audio-video or audio); total visits (telemedicine or in-person) per individual during the study period. Multivariable models were used that sequentially adjusted for demographic and clinical characteristics and geographic area to examine their association with differences in telemedicine and total visit utilization by documented race and ethnicity.

Results

In this national sample of 14 305 819 individuals, 7.4% reported that they were Black, 5.6% Hispanic, and 4.2% other race. In unadjusted results, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 16.7 (95% CI, 16.1-17.3), 32.9 (95% CI, 32.3-33.6), and 20.9 (95% CI, 20.2-21.7) more telemedicine visits per 100 beneficiaries, respectively. After adjustment for clinical and demographic characteristics and geography, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 7.9 (95% CI, -8.5 to -7.3), 13.2 (95% CI, -13.9 to -12.6), and 9.2 (95% CI, -10.0 to -8.5) fewer telemedicine visits per 100 beneficiaries, respectively. In unadjusted and fully adjusted models, and in 2019 and the second year of the COVID-19 pandemic, Black individuals, Hispanic individuals, and individuals of other racial groups continued to have fewer total visits than White individuals.

Conclusions and Relevance

The results of this cross-sectional study of US Medicare enrollees suggest that although nationally, Black individuals, Hispanic individuals, and individuals of other racial groups received more telemedicine visits during the pandemic and disproportionately lived in geographic regions with higher telemedicine use, after controlling for geographic region, Black individuals, Hispanic individuals, and individuals of other racial groups received fewer telemedicine visits than White individuals.

Detection Rates of Mild Cognitive Impairment in Primary Care for the United States Medicare Population

BACKGROUND

Existing evidence points to substantial gaps in detecting mild cognitive impairment in primary care but is based on limited or self-reported data. The recent emergence of disease-modifying treatments for the Alzheimer's disease, the most common etiology of mild cognitive impairment, calls for a systematic assessment of detection rates in primary care.

OBJECTIVES

The current study aims to examine detection rates for mild cognitive impairment among primary care clinicians and practices in the United States using Medicare claims and encounter data.

DESIGN

Observational study.

SETTING

Medicare administrative data.

PARTICIPANTS

The study sample includes a total of 226,756 primary care clinicians and 54,597 practices that had at least 25 patients aged 65 or older, who were enrolled in Medicare fee-for-service or a Medicare Advantage plan between 2017 and 2019.

MEASUREMENTS

The detection rate for mild cognitive impairment is assessed as the ratio between the observed diagnosis rate of a clinician or practice as documented in the data, and the expected rate based on a predictive model.

RESULTS

The average detection rates for mild cognitive impairment is 0.08 (interquartile range=0.00-0.02) for both clinicians and practices, suggesting that only about 8% of expected cases were diagnosed on average. Only 0.1% of clinicians and practices had diagnosis rates within the expected range.

CONCLUSIONS

Mild cognitive impairment is vastly underdiagnosed, pointing to an urgent need to improve early detection in primary care.

Association of opioid or other substance use disorders with health care use among patients with suicidal symptoms

INTRODUCTION

Prior literature establishes noteworthy relationships between suicidal symptoms and substance use disorders (SUDs), particularly opioid use disorder (OUD). However, engagement with health care services among this vulnerable population remains underinvestigated. This study sought to examine patterns of health care use, identify risk factors in seeking treatment, and assess associations between outpatient service use and emergency department (ED) visits.

METHODS

Using electronic health records (EHRs) derived from five health systems across New York City, the study selected 7881 adults with suicidal symptoms (including suicidal ideation, suicide attempt, or self-harm) and SUDs between 2010 and 2019. To examine the association between SUDs (including OUD) and all-cause service use (outpatient, inpatient, and ED), we performed quasi-Poisson regressions adjusted for age, gender, and chronic disease burden, and we estimated the relative risks (RR) of associated factors. Next, the study evaluated cause-specific utilization within each resource category (SUD-related, suicide-related, and other-psychiatric) and compared them using Mann-Whitney U tests. Finally, we used adjusted quasi-Poisson regression models to analyze the association between outpatient and ED utilization among different risk groups.

RESULTS

Among patients with suicidal symptoms and SUD diagnoses, relative to other SUDs, a diagnosis of OUD was associated with higher all-cause outpatient visits (RR: 1.22), ED visits (RR: 1.54), and inpatient hospitalizations (RR: 1.67) (ps < 0.001). Men had a lower risk of having outpatient visits (RR: 0.80) and inpatient hospitalizations (RR: 0.90), and older age protected against ED visits (RR range: 0.59-0.69) (ps < 0.001). OUD was associated with increased SUD-related encounters across all settings, and increased suicide-related ED visits and inpatient hospitalizations (p < 0.001). Individuals with more mental health outpatient visits were less likely to have suicide-related ED visits (RR: 0.86, p < 0.01), however this association was not found among younger and male patients with OUD. Although few OUD patients received medications for OUD (MOUD) treatment (9.9 %), methadone composed the majority of MOUD prescriptions (77.7 %), of which over 70 % were prescribed during an ED encounter.

CONCLUSIONS

This study reinforces the importance of tailoring SUD and suicide risk interventions to different age groups and types of SUDs, and highlights missed opportunities for deploying screening and prevention resources among the male and OUD populations. Redressing underutilization of MOUD remains a priority to reduce acute health outcomes among younger patients with OUD.

The disproportionate burden of Alzheimer's disease and related dementias (ADRD) in diverse older adults diagnosed with cancer

INTRODUCTION

Older adults living with Alzheimer's disease and related dementias (ADRD) who are then diagnosed with cancer are an understudied population. While the role of cognitive impairment during and after cancer treatment have been well-studied, less is understood about patients who are living with ADRD and then develop cancer. The purpose of this study is to contribute evidence about our understanding of this vulnerable population.

MATERIALS AND METHODS

This was a retrospective cohort study of a linked, representative family of databases of cancer registries and Medicare administrative claims that make up the SEER-Medicare database. Older adults ages 68 and older with a first primary cancer type: breast, cervical, colorectal, lung, oral, or prostate were eligible for inclusion (N = 337,932). Prevalence estimates of ADRD across cancer types and a 5% non-cancer comparison sample were compared by patient factors.

RESULTS

The overall prevalence of patients who had an ADRD diagnosis anytime in the three years prior to their cancer diagnosis was 5.6%. Patients with ADRD were more likely to be female, older (over age 75), a racial/ethnic minority, single, with multiple chronic conditions, and a tumor diagnosed early (stage I) or were unstaged. Black patients with colorectal and oral cancer had the highest and second highest prevalence of ADRD compared to White patients (13.46% vs 7.95% and 12.64% vs 7.82% respectively, p < .0001). We observed the highest prevalence of ADRD among Black patients for breast (11.85%), cervical (11.98%), lung (8.41%), prostate (4.83), and the 5% sample (9.50%, p > .0001).

DISCUSSION

The higher prevalence of ADRD among Black and Latine older adults with cancer not only aligns with the trend observed in our non-cancer comparison sample, but also, these findings demonstrate the compounded risk experienced by minoritized older adults over the life course. The greater than expected prevalence of patients with ADRD who go on to develop cancer demonstrates better assessment of cognition is urgently needed. Accurate identification of these vulnerable populations is critical to improve assessment, care coordination, and address inequities in screening and treatment planning.

Cardiovascular Disease Burden and Outcomes Among American Indian and Alaska Native Medicare Beneficiaries

Importance

American Indian and Alaska Native persons face significant health disparities; however, data regarding the burden of cardiovascular disease in the current era is limited.

Objective

To determine the incidence and prevalence of cardiovascular disease, the burden of comorbid conditions, including cardiovascular disease risk factors, and associated mortality among American Indian and Alaska Native patients with Medicare insurance.

Design, Setting, and Participants

This was a population-based cohort study conducted from January 2015 to December 2019 using Medicare administrative data. Participants included American Indian and Alaska Native Medicare beneficiaries 65 years and older enrolled in both Medicare part A and B fee-for-service Medicare. Statistical analyses were performed from November 2022 to April 2023.

Main Outcomes and Measures

The annual incidence, prevalence, and mortality associated with coronary artery disease (CAD), heart failure (HF), atrial fibrillation/flutter (AF), and cerebrovascular disease (stroke or transient ischemic attack [TIA]).

Results

Among 220 598 American Indian and Alaska Native Medicare beneficiaries, the median (IQR) age was 72.5 (68.5-79.0) years, 127 402 were female (57.8%), 78 438 (38.8%) came from communities in the most economically distressed quintile in the Distressed Communities Index. In the cohort, 44.8% of patients (98 833) were diagnosed with diabetes, 61.3% (135 124) were diagnosed with hyperlipidemia, and 72.2% (159 365) were diagnosed with hypertension during the study period. The prevalence of CAD was 38.6% (61 125 patients) in 2015 and 36.7% (68 130 patients) in 2019 (P < .001). The incidence of acute myocardial infarction increased from 6.9 per 1000 person-years in 2015 to 7.7 per 1000 patient-years in 2019 (percentage change, 4.79%; P < .001). The prevalence of HF was 22.9% (36 288 patients) in 2015 and 21.4% (39 857 patients) in 2019 (P < .001). The incidence of HF increased from 26.1 per 1000 person-years in 2015 to 27.0 per 1000 person-years in 2019 (percentage change, 4.08%; P < .001). AF had a stable prevalence of 9% during the study period (2015: 9.4% [14 899 patients] vs 2019: 9.3% [25 175 patients]). The incidence of stroke or TIA decreased slightly throughout the study period (12.7 per 1000 person-years in 2015 and 12.1 per 1000 person-years in 2019; percentage change, 5.08; P = .004). Fifty percent of patients (110 244) had at least 1 severe cardiovascular condition (CAD, HF, AF, or cerebrovascular disease), and the overall mortality rate for the cohort was 19.8% (43 589 patients).

Conclusions and Relevance

In this large cohort study of American Indian and Alaska Native patients with Medicare insurance in the US, results suggest a significant burden of cardiovascular disease and cardiometabolic risk factors. These results highlight the critical need for future efforts to prioritize the cardiovascular health of this population.

Additive effects of 10-year exposures to PM2.5 and NO2 and primary cancer incidence in American older adults

Epidemiologic evidence on the relationships between air pollution and the risks of primary cancers other than lung cancer remained largely lacking. We aimed to examine associations of 10-year exposures to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) with risks of breast, prostate, colorectal, and endometrial cancers.

Methods

For each cancer, we constructed a separate cohort among the national Medicare beneficiaries during 2000 to 2016. We simultaneously examined the additive associations of six exposures, namely, moving average exposures to PM2.5 and NO2 over the year of diagnosis and previous 2 years, previous 3 to 5 years, and previous 6 to 10 years, with the risk of first cancer diagnosis after 10 years of follow-up, during which there was no cancer diagnosis.

Results

The cohorts included 2.2 to 6.5 million subjects for different cancers. Exposures to PM2.5 and NO2 were associated with increased risks of colorectal and prostate cancers but were not associated with endometrial cancer risk. NO2 was associated with a decreased risk of breast cancer, while the association for PM2.5 remained inconclusive. At exposure levels below the newly updated World Health Organization Air Quality Guideline, we observed substantially larger associations between most exposures and the risks of all cancers, which were translated to hundreds to thousands new cancer cases per year within the cohort per unit increase in each exposure.

Conclusions

These findings suggested substantial cancer burden was associated with exposures to PM2.5 and NO2, emphasizing the urgent need for strategies to mitigate air pollution levels.

Expected and diagnosed rates of mild cognitive impairment and dementia in the U.S. Medicare population: observational analysis

BACKGROUND

With the emergence of disease-modifying Alzheimer's treatments, timely detection of early-stage disease is more important than ever, as the treatment will not be indicated for later stages. Contemporary population-level data for detection rates of mild cognitive impairment (MCI), the stage at which treatment would ideally start, are lacking, and detection rates for dementia are only available for subsets of the Medicare population. We sought to compare documented diagnosis rates of MCI and dementia in the full Medicare population with expected rates based on a predictive model.

METHODS

We performed an observational analysis of Medicare beneficiaries aged 65 and older with a near-continuous enrollment over a 3-year observation window or until death using 100% of the Medicare fee-for-service or Medicare Advantage Plans beneficiaries from 2015 to 2019. Actual diagnoses for MCI and dementia were derived from ICD-10 codes documented in those data. We used the 2000-2016 data of the Health and Retirement Study to develop a prediction model for expected diagnoses for the included population. The ratios between actually diagnosed cases of MCI and dementia over number of cases expected, the observed over expected ratio, reflects the detection rate.

RESULTS

Although detection rates for MCI cases increased from 2015 to 2019 (0.062 to 0.079), the results mean that 7.4 of 8 million (92%) expected MCI cases remained undiagnosed. The detection rate for MCI was 0.039 and 0.048 in Black and Hispanic beneficiaries, respectively, compared with 0.098 in non-Hispanic White beneficiaries. Individuals dually eligible for Medicare and Medicaid had lower estimated detection rates than their Medicare-only counterparts for MCI (0.056 vs 0.085). Dementia was diagnosed more frequently than expected (1.086 to 1.104) from 2015 to 2019, mostly in non-Hispanic White beneficiaries (1.367) compared with 0.696 in Black beneficiaries and 0.758 in Hispanic beneficiaries.

CONCLUSIONS

These results highlight the need to increase the overall detection rates of MCI and of dementia particularly in socioeconomically disadvantaged groups.

Enrichment of a Data Lake to Support Population Health Outcomes Studies Using Social Determinants Linked EHR Data

The integration of electronic health records (EHRs) with social determinants of health (SDoH) is crucial for population health outcome research, but it requires the collection of identifiable information and poses security risks. This study presents a framework for facilitating de-identified clinical data with privacy-preserved geocoded linked SDoH data in a Data Lake. A reidentification risk detection algorithm was also developed to evaluate the transmission risk of the data. The utility of this framework was demonstrated through one population health outcomes research analyzing the correlation between socioeconomic status and the risk of having chronic conditions. The results of this study inform the development of evidence-based interventions and support the use of this framework in understanding the complex relationships between SDoH and health outcomes. This framework reduces computational and administrative workload and security risks for researchers and preserves data privacy and enables rapid and reliable research on SDoH-connected clinical data for research institutes.

Estimating health spending associated with chronic multimorbidity in 2018: An observational study among adults in the United States

BACKGROUND

The rise in health spending in the United States and the prevalence of multimorbidity-having more than one chronic condition-are interlinked but not well understood. Multimorbidity is believed to have an impact on an individual's health spending, but how having one specific additional condition impacts spending is not well established. Moreover, most studies estimating spending for single diseases rarely adjust for multimorbidity. Having more accurate estimates of spending associated with each disease and different combinations could aid policymakers in designing prevention policies to more effectively reduce national health spending. This study explores the relationship between multimorbidity and spending from two distinct perspectives: (1) quantifying spending on different disease combinations; and (2) assessing how spending on a single diseases changes when we consider the contribution of multimorbidity (i.e., additional/reduced spending that could be attributed in the presence of other chronic conditions).

METHODS AND FINDINGS

We used data on private claims from Truven Health MarketScan Research Database, with 16,288,894 unique enrollees ages 18 to 64 from the US, and their annual inpatient and outpatient diagnoses and spending from 2018. We selected conditions that have an average duration of greater than one year among all Global Burden of Disease causes. We used penalized linear regression with stochastic gradient descent approach to assess relationship between spending and multimorbidity, including all possible disease combinations with two or three different conditions (dyads and triads) and for each condition after multimorbidity adjustment. We decomposed the change in multimorbidity-adjusted spending by the type of combination (single, dyads, and triads) and multimorbidity disease category. We defined 63 chronic conditions and observed that 56.2% of the study population had at least two chronic conditions. Approximately 60.1% of disease combinations had super-additive spending (e.g., spending for the combination was significantly greater than the sum of the individual diseases), 15.7% had additive spending, and 23.6% had sub-additive spending (e.g., spending for the combination was significantly less than the sum of the individual diseases). Relatively frequent disease combinations (higher observed prevalence) with high estimated spending were combinations that included endocrine, metabolic, blood, and immune disorders (EMBI disorders), chronic kidney disease, anemias, and blood cancers. When looking at multimorbidity-adjusted spending for single diseases, the following had the highest spending per treated patient and were among those with high observed prevalence: chronic kidney disease ($14,376 [12,291,16,670]), cirrhosis ($6,465 [6,090,6,930]), ischemic heart disease (IHD)-related heart conditions ($6,029 [5,529,6,529]), and inflammatory bowel disease ($4,697 [4,594,4,813]). Relative to unadjusted single-disease spending estimates, 50 conditions had higher spending after adjusting for multimorbidity, 7 had less than 5% difference, and 6 had lower spending after adjustment.

CONCLUSIONS

We consistently found chronic kidney disease and IHD to be associated with high spending per treated case, high observed prevalence, and contributing the most to spending when in combination with other chronic conditions. In the midst of a surging health spending globally, and especially in the US, pinpointing high-prevalence, high-spending conditions and disease combinations, as especially conditions that are associated with larger super-additive spending, could help policymakers, insurers, and providers prioritize and design interventions to improve treatment effectiveness and reduce spending.

Potentially Inappropriate Medication Use in Community-Dwelling Older Adults Living with Dementia

Background: The Beers Criteria identifies potentially inappropriate medications (PIMs) that should be avoided in older adults living with dementia. Objective: The aim of this study was to provide estimates of the prevalence and persistence of PIM use among community-dwelling older adults living with dementia in 2011-2017. Methods: Medicare claims data were used to create an analytic dataset spanning from 2011 to 2017. The analysis included community-dwelling Medicare fee-for-service beneficiaries aged 65 and older who were enrolled in Medicare Part D plans, had diagnosis for dementia, and were alive for at least one calendar year. Dementia status was determined using Medicare Chronic Conditions Date Warehouse (CCW) Chronic Condition categories and Charlson Comorbidity Index. PIM use was defined as 2 or more prescription fills with at least 90 days of total days-supply in a calendar year. Descriptive statistics were used to report the prevalence and persistence of PIM use. Results: Of 1.6 million person-year observations included in the sample, 32.7% used one or more PIMs during a calendar year in 2011-2017. Breakdown by drug classes showed that 14.9% of the sample used anticholinergics, 14.0% used benzodiazepines, and 11.0% used antipsychotics. Conditional on any use, mean annual days-supply for all PIMs was 270.6 days (SD = 102.7). The mean annual days-supply for antipsychotic use was 302.7 days (SD = 131.2). Conclusion: Significant proportion of community-dwelling older adults with dementia used one or more PIMs, often for extended periods of time. The antipsychotic use in the community-dwelling older adults with dementia remains as a significant problem.

Mortality Risk of Patients Treated in Dialysis Facilities with Payment Reductions under ESRD Quality Incentive Program

BACKGROUND

The Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program (ESRD QIP) measures quality of care delivered by dialysis facilities and imposes Medicare payment reductions for quality lapses. We assessed the association between payment reductions and patient mortality, a quality indicator not included in the ESRD QIP measure set.

METHODS

Association between mortality and ESRD QIP facility payment reduction based on the year of performance was expressed as the unadjusted rate and patient case-mix-adjusted hazard ratio. We also measured association between mortality and 1-year changes in payment reductions. Retrospective patient cohorts were defined by their treating dialysis facility on the first day of each year (2010-2018).

RESULTS

Facility performance resulted in payment reductions for 5%-42% of dialysis facilities over the 9 study years. Patients experienced progressively higher mortality at each payment reduction level. Across all years, unadjusted mortality was 17.3, 18.1, 18.9, 20.3, and 23.9 deaths per 100 patient-years for patients in facilities that received 0%, 0.5%, 1%, 1.5%, and 2% payment reductions, respectively. The adjusted hazard ratio showed a similar stepwise pattern by the level of payment reduction: 1.0 (reference), 1.08 (95% confidence interval [CI], 1.07 to 1.09), 1.15 (95% CI, 1.13 to 1.16), 1.19 (95% CI, 1.16 to 1.21), and 1.34 (95% CI, 1.29 to 1.39). Strength of the association increased from 2010 to 2016. Patients treated in facilities that improved over 1 year generally experienced lower mortality; patients in facilities that performed worse on ESRD QIP measures generally experienced higher mortality.

CONCLUSIONS

Patient mortality was associated with ESRD QIP facility payment reductions in dose-response and temporal patterns.

Characterizing the Accuracy of International Classification of Diseases, Tenth Revision Administrative Claims for Aortic Valve Disease

BACKGROUND

Administrative claims for aortic stenosis (AS) regurgitation may be useful, but their accuracy and ability to identify individuals at risk for valve-related outcomes have not been well characterized.

METHODS

Using echocardiographic (transthoracic echocardiogram [TTE]) reports linked to US Medicare claims, 2017 to 2018, the performance of candidate International Classification of Diseases, Tenth Revision claims to ascertain AS/aortic regurgitation was evaluated. The optimal performing algorithm was tested against outcomes at 1-year after TTE in a separate 100% sample of US Medicare claims, 2017 to 2019.

RESULTS

Of those included in the derivation (N=5497, mean age 74.4±11.0 years, 49.7% female), any AS or aortic regurgitation was present in 24% and 38.8%, respectively. The sensitivity and specificity of International Classification of Diseases, Tenth Revision code I35.0 for identification of any AS was 53.1% and 94.8%, respectively. Among those with an I35.0 code, 40.3% had severe AS. Claims were unable to distinguish disease severity (ie, severe versus nonsevere) or subtype (eg, bicuspid or rheumatic AS), and were insensitive and nonspecific for aortic regurgitation of any severity. Among all beneficiaries who received a TTE (N=4 033 844), adjusting for age, sex, and 27 comorbidities, those with an I35.0 code had a higher adjusted risk of all-cause mortality (adjusted hazard ratio, 1.33 [95% CI, 1.31-1.34]), heart failure hospitalization (adjusted hazard ratio, 1.37 [95% CI, 1.34-1.41]), and aortic valve replacement (adjusted hazard ratio, 34.96 [95% CI, 33.74-36.22]).

CONCLUSIONS

Among US Medicare beneficiaries receiving a TTE, International Classification of Diseases, Tenth Revision claims, though identifying a population at significant greater risk of valve-related outcomes, failed to identify nearly half of individuals with AS and were unable to distinguish disease severity or subtype. These results argue against the widespread use of International Classification of Diseases, Tenth Revision claims to screen for patients with AS and suggests the need for improved coding algorithms and alternative systems to extract TTE data for quality improvement and hospital benchmarking.

Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers

IMPORTANCE

Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity.

OBJECTIVE

To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021.

EXPOSURES

Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index.

MAIN OUTCOMES AND MEASURES

Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity.

RESULTS

The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% - 17.6% = 0.7%) plus those identifying as Black (21.9% - 17.6% = 4.3%) by more than 2-fold (28.0% - 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality.

CONCLUSIONS AND RELEVANCE

Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.

Comparing ascertainment of chronic condition status with problem lists versus encounter diagnoses from electronic health records

OBJECTIVE

To assess and compare electronic health record (EHR) documentation of chronic disease in problem lists and encounter diagnosis records among Community Health Center (CHC) patients.

MATERIALS AND METHODS

We assessed patient EHR data in a large clinical research network during 2012-2019. We included CHCs who provided outpatient, older adult primary care to patients age ≥45 years, with ≥2 office visits during the study. Our study sample included 1 180 290 patients from 545 CHCs across 22 states. We used diagnosis codes from 39 Chronic Condition Warehouse algorithms to identify chronic conditions from encounter diagnoses only and compared against problem list records. We measured correspondence including agreement, kappa, prevalence index, bias index, and prevalence-adjusted bias-adjusted kappa.

RESULTS

Overlap of encounter diagnosis and problem list ascertainment was 59.4% among chronic conditions identified, with 12.2% of conditions identified only in encounters and 28.4% identified only in problem lists. Rates of coidentification varied by condition from 7.1% to 84.4%. Greatest agreement was found in diabetes (84.4%), HIV (78.1%), and hypertension (74.7%). Sixteen conditions had <50% agreement, including cancers and substance use disorders. Overlap for mental health conditions ranged from 47.4% for anxiety to 59.8% for depression.

DISCUSSION

Agreement between the 2 sources varied substantially. Conditions requiring regular management in primary care settings may have a higher agreement than those diagnosed and treated in specialty care.

CONCLUSION

Relying on EHR encounter data to identify chronic conditions without reference to patient problem lists may under-capture conditions among CHC patients in the United States.

Midlife Cardiorespiratory Fitness and the Development of Peripheral Artery Disease in Later Life

Background Data are sparse on the prospective associations between physical activity and incidence of lower extremity peripheral artery disease (PAD). Methods and Results Linking participant data from the CCLS (Cooper Center Longitudinal Study) to Medicare claims files, we studied 19 023 participants with objectively measured midlife cardiorespiratory fitness through maximal effort on the Balke protocol who survived to receive Medicare coverage between 1999 and 2009. The study aimed to determine the association between midlife cardiorespiratory fitness and incident PAD with proportional hazards intensity models, adjusted for age, sex, body mass index, and other covariates, to PAD failure time data. During 121 288 person-years of Medicare follow-up, we observed 805 PAD-related hospitalizations/procedures among 19 023 participants (21% women, median age 50 years). Lower midlife fitness was associated with a higher rate of incident PAD in patients aged 65 years and older (low fit [quintile 1]: 11.4, moderate fit [quintile 2 to 3]: 7.8, and high fit [quintile 4 to 5]: 5.7 per 1000 person years). After multivariable adjustment for common predictors of incident PAD such as age, body mass index, hypertension, and diabetes, these findings persisted. Lower risk for PAD per greater metabolic equivalent task of fitness was observed (hazard ratio [HR], 0.93 [95% CI, 0.90-0.97]; P<0.001). Among a subset of patients with an additional fitness assessment, each 1 metabolic equivalent task increase from baseline fitness was associated with decreased risk of incident PAD (HR, 0.90 [95% CI, 0.82-0.99]; P=0.03). Conclusions Cardiorespiratory fitness in healthy, middle-aged adults is associated with lower risk of incident PAD in later life, independent of other predictors of incident PAD.

Association of Race and Ethnicity and Anticoagulation in Patients with Atrial Fibrillation Dually Enrolled in VA and Medicare: Effects of Medicare Part D on Prescribing Disparities

Background: Racial and ethnic disparities in anticoagulation exist in atrial fibrillation (AF) management in Medicare and the Veterans Health Administration (VA), but the influence of dual VA and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare Part D enrollment on anticoagulation disparities. Methods: We identified patients with incident AF (2014-2018) dually enrolled in VA and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants, DOACs) within 90 days of AF diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare Part D enrollment and an interaction term for these variables. Results: In 43,789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare Part D. Overall, 29,680 (67.8%) patients initiated any anticoagulant, of which 17,568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (p= 0.001), and lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (p=0.001) initiated DOACs. Compared to White patients, Black patients had significantly lower initiation of any anticoagulant, adjusted odds ratio (aOR) 0.89; 95% CI 0.82-0.97. The aORs for DOAC initiation were significantly lower for Black (0.72; 95% CI, 0.65-0.81) and Hispanic (0.84; 95% CI, 0.70-1.00) than White patients.The interaction between race and ethnicity and Medicare Part D enrollment was non-significant for any anticoagulant (p=0.99) and DOAC (p=0.27) therapies. Conclusions: In dually enrolled VA and Medicare patients with AF, Black patients were less likely to initiate any anticoagulant and Black and Hispanic patients were less likely to initiate DOACs. Medicare Part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.

Predicting cardiac adverse events in patients receiving immune checkpoint inhibitors: a machine learning approach

BACKGROUND

Treatment with immune checkpoint inhibitors (ICIs) has been associated with an increased rate of cardiac events. There are limited data on the risk factors that predict cardiac events in patients treated with ICIs. Therefore, we created a machine learning (ML) model to predict cardiac events in this at-risk population.

METHODS

We leveraged the CancerLinQ database curated by the American Society of Clinical Oncology and applied an XGBoosted decision tree to predict cardiac events in patients taking programmed death receptor-1 (PD-1) or programmed death ligand-1 (PD-L1) therapy. All curated data from patients with non-small cell lung cancer, melanoma, and renal cell carcinoma, and who were prescribed PD-1/PD-L1 therapy between 2013 and 2019, were used for training, feature interpretation, and model performance evaluation. A total of 356 potential risk factors were included in the model, including elements of patient medical history, social history, vital signs, common laboratory tests, oncological history, medication history and PD-1/PD-L1-specific factors like PD-L1 tumor expression.

RESULTS

Our study population consisted of 4960 patients treated with PD-1/PD-L1 therapy, of whom 418 had a cardiac event. The following were key predictors of cardiac events: increased age, corticosteroids, laboratory abnormalities and medications suggestive of a history of heart disease, the extremes of weight, a lower baseline or on-treatment percentage of lymphocytes, and a higher percentage of neutrophils. The final model predicted cardiac events with an area under the curve-receiver operating characteristic of 0.65 (95% CI 0.58 to 0.75). Using our model, we divided patients into low-risk and high-risk subgroups. At 100 days, the cumulative incidence of cardiac events was 3.3% in the low-risk group and 6.1% in the high-risk group (p<0.001).

CONCLUSIONS

ML can be used to predict cardiac events in patients taking PD-1/PD-L1 therapy. Cardiac risk was driven by immunological factors (eg, percentage of lymphocytes), oncological factors (eg, low weight), and a cardiac history.

Claims-based algorithms for common chronic conditions were efficiently constructed using machine learning methods

Identification of medical conditions using claims data is generally conducted with algorithms based on subject-matter knowledge. However, these claims-based algorithms (CBAs) are highly dependent on the knowledge level and not necessarily optimized for target conditions. We investigated whether machine learning methods can supplement researchers' knowledge of target conditions in building CBAs. Retrospective cohort study using a claims database combined with annual health check-up results of employees' health insurance programs for fiscal year 2016-17 in Japan (study population for hypertension, N = 631,289; diabetes, N = 152,368; dyslipidemia, N = 614,434). We constructed CBAs with logistic regression, k-nearest neighbor, support vector machine, penalized logistic regression, tree-based model, and neural network for identifying patients with three common chronic conditions: hypertension, diabetes, and dyslipidemia. We then compared their association measures using a completely hold-out test set (25% of the study population). Among the test cohorts of 157,822, 38,092, and 153,608 enrollees for hypertension, diabetes, and dyslipidemia, 25.4%, 8.4%, and 38.7% of them had a diagnosis of the corresponding condition. The areas under the receiver operating characteristic curve (AUCs) of the logistic regression with/without subject-matter knowledge about the target condition were .923/.921 for hypertension, .957/.938 for diabetes, and .739/.747 for dyslipidemia. The logistic lasso, logistic elastic-net, and tree-based methods yielded AUCs comparable to those of the logistic regression with subject-matter knowledge: .923-.931 for hypertension; .958-.966 for diabetes; .747-.773 for dyslipidemia. We found that machine learning methods can attain AUCs comparable to the conventional knowledge-based method in building CBAs.

Gender Disparities in Anti-dementia Medication Use among Older Adults: Health Equity Considerations and Management of Alzheimer's Disease and Related Dementias

Objective: The prevalence of Alzheimer's disease and related dementias (ADRD) in women is higher than men. However, the knowledge of gender disparity in ADRD treatment is limited. Therefore, this study aimed to determine the gender disparities in the receipt of anti-dementia medications among Medicare beneficiaries with ADRD in the U.S. Methods: We used data from the Medicare Current Beneficiary Survey 2016. Anti-dementia medications included cholinesterase inhibitors (ChEIs; including rivastigmine, donepezil, and galantamine) and N-methyl-D-aspartate (NMDA) receptor antagonists (including memantine). Descriptive analysis and multivariate logistic regression models were implemented to determine the possible gender disparities in the receipt of anti-dementia medications. Subgroup analyses were conducted to identify gender disparities among beneficiaries with Alzheimer's disease (AD) and those with only AD-related dementias. Results: Descriptive analyses showed there were statistically significant differences in age, marital status, and Charlson comorbidities index (CCI) between Medicare beneficiaries who received and who did not receive anti-dementia medications. After controlling for covariates, we found that female Medicare beneficiaries with ADRD were 1.7 times more likely to receive anti-dementia medications compared to their male counterparts (odds ratio [OR]: 1.71; 95% confidence interval [CI]: 1.19-2.45). Specifically, among Medicare beneficiaries with AD, females were 1.2 times more likely to receive anti-dementia medications (Odds Radio: 1.20; 95% confidence interval: 0.58-2.47), and among the Medicare beneficiaries with only AD-related dementias, females were 1.9 times more likely to receive anti-dementia medications (OR: 1.90; 95% CI: 1.23-2.95). Conclusion: Healthcare providers should be aware of gender disparities in receiving anti-dementia medications among patients with ADRD, and the need to plan programs of care to support both women and men. Future approaches to finding barriers of prescribing, receiving and, adhering to anti-dementia medications by gender should include differences in longevity, biology, cognition, social roles, and environment.

Preexisting Type 2 Diabetes and Survival among Patients with Colorectal Cancer

BACKGROUND

Type 2 diabetes increases risk of developing colorectal cancer, but the association of preexisting diabetes with colorectal cancer survival remains unclear.

METHODS

We analyzed survival by diabetes status at cancer diagnosis among 4,038 patients with colorectal cancer from two prospective U.S. cohorts. Cox proportional hazards regression was used to calculate HRs and 95% confidence intervals (CI) for overall and cause-specific mortality, with adjustment for tumor characteristics and lifestyle factors.

RESULTS

In the first 5 years after colorectal cancer diagnosis, diabetes was associated with a modest increase in overall mortality in women (HR, 1.22; 95% CI, 1.00-1.49), but not in men (HR, 0.83; 95% CI, 0.62-1.12; P heterogeneity by sex = 0.04). Beyond 5 years, diabetes was associated with substantially increased overall mortality with no evidence of sex heterogeneity; in women and men combined, the HRs were 1.45 (95% CI, 1.09-1.93) during >5-10 years and 2.58 (95% CI, 1.91-3.50) during >10 years. Compared with those without diabetes, patients with colorectal cancer and diabetes had increased mortality from other malignancies (HR, 1.78; 95% CI, 1.18-2.67) and cardiovascular disease (HR, 1.93; 95% CI, 1.29-2.91). Only women with diabetes for more than 10 years had increased mortality from colorectal cancer (HR, 1.33; 95% CI, 1.01-1.76).

CONCLUSIONS

Among patients with colorectal cancer, preexisting diabetes was associated with increased risk of long-term mortality, particularly from other malignancies and cardiovascular disease.

IMPACT

Our findings highlight the importance of cardioprotection and cancer prevention to colorectal cancer survivors with diabetes.

Tip of the Iceberg: Assessing the Global Socioeconomic Costs of Alzheimer's Disease and Related Dementias and Strategic Implications for Stakeholders

While it is generally understood that Alzheimer’s disease (AD) and related dementias (ADRD) is one of the costliest diseases to society, there is widespread concern that researchers and policymakers are not comprehensively capturing and describing the full scope and magnitude of the socioeconomic burden of ADRD. This review aimed to 1) catalogue the different types of AD-related socioeconomic costs described in the literature; 2) assess the challenges and gaps of existing approaches to measuring these costs; and 3) analyze and discuss the implications for stakeholders including policymakers, healthcare systems, associations, advocacy groups, clinicians, and researchers looking to improve the ability to generate reliable data that can guide evidence-based decision making. A centrally emergent theme from this review is that it is challenging to gauge the true value of policies, programs, or interventions in the ADRD arena given the long-term, progressive nature of the disease, its insidious socioeconomic impact beyond the patient and the formal healthcare system, and the complexities and current deficiencies (in measures and real-world data) in accurately calculating the full costs to society. There is therefore an urgent need for all stakeholders to establish a common understanding of the challenges in evaluating the full cost of ADRD and define approaches that allow us to measure these costs more accurately, with a view to prioritizing evidence-based solutions to mitigate this looming public health crisis.

Explaining The Slowdown In Medical Spending Growth Among The Elderly, 1999-2012

We examined trends in per capita spending for Medicare beneficiaries ages sixty-five and older in the United States in the period 1999-2012 to determine why spending growth has been declining since around 2005. Decomposing spending by condition, we found that half of the spending slowdown was attributable to slower growth in spending for cardiovascular diseases. Spending growth also slowed for dementia, renal and genitourinary diseases, and aftercare for people with acute illnesses. Using estimates from the medical literature of the impact of pharmaceuticals on acute disease, we found that roughly half of the reduction in major cardiovascular events was attributable to medications controlling cardiovascular risk factors. Despite this substantial cost-saving improvement in cardiovascular health, additional opportunities remain to lower spending through disease prevention and control.

Trends in prevalence of comorbidities in heart failure clinical trials

AIMS

The primary objective of this systematic review was to estimate the prevalence and temporal changes in chronic comorbid conditions reported in heart failure (HF) clinical trials.

METHODS AND RESULTS

We searched MEDLINE for HF trials enrolling more than 400 patients published between 2001 and 2016.Trials were divided into HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or trials enrolling regardless of ejection fraction. The prevalence of baseline chronic comorbid conditions was categorized according to the algorithm proposed by the Chronic Conditions Data Warehouse, which is used to analyse Medicare data. To test for a trend in the prevalence of comorbid conditions, linear regression models were used to evaluate temporal trends in prevalence of comorbidities. Overall, 118 clinical trials enrolling a cumulative total of 215 508 patients were included. Across all comorbidities examined, data were reported in a mean of 35% of trials, without significant improvement during the study period. Reporting of comorbidities was more common in HFrEF trials (51%) compared with HFpEF trials (27%). Among trials reporting data, hypertension (63%), ischaemic heart disease (44%), hyperlipidaemia (48%), diabetes (33%), chronic kidney disease (25%) and atrial fibrillation (25%) were the major comorbidities. The prevalence of comorbidities including hypertension, atrial fibrillation and chronic kidney disease increased over time while the prevalence of smoking decreased in HFrEF trials.

CONCLUSION

Many HF trials do not report baseline comorbidities. A more rigorous, systematic, and standardized framework needs to be adopted for future clinical trials to ensure adequate comorbidity reporting and improve recruitment of multi-morbid HF patients.

Trends in prevalence of comorbidities in heart failure clinical trials

AIMS

The primary objective of this systematic review was to estimate the prevalence and temporal changes in chronic comorbid conditions reported in heart failure (HF) clinical trials.

METHODS AND RESULTS

We searched MEDLINE for HF trials enrolling more than 400 patients published between 2001 and 2016.Trials were divided into HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or trials enrolling regardless of ejection fraction. The prevalence of baseline chronic comorbid conditions was categorized according to the algorithm proposed by the Chronic Conditions Data Warehouse, which is used to analyse Medicare data. To test for a trend in the prevalence of comorbid conditions, linear regression models were used to evaluate temporal trends in prevalence of comorbidities. Overall, 118 clinical trials enrolling a cumulative total of 215 508 patients were included. Across all comorbidities examined, data were reported in a mean of 35% of trials, without significant improvement during the study period. Reporting of comorbidities was more common in HFrEF trials (51%) compared with HFpEF trials (27%). Among trials reporting data, hypertension (63%), ischaemic heart disease (44%), hyperlipidaemia (48%), diabetes (33%), chronic kidney disease (25%) and atrial fibrillation (25%) were the major comorbidities. The prevalence of comorbidities including hypertension, atrial fibrillation and chronic kidney disease increased over time while the prevalence of smoking decreased in HFrEF trials.

CONCLUSION

Many HF trials do not report baseline comorbidities. A more rigorous, systematic, and standardized framework needs to be adopted for future clinical trials to ensure adequate comorbidity reporting and improve recruitment of multi-morbid HF patients.

Influence of Changes in Sedentary Time on Outcomes of Supervised Exercise Therapy in Individuals with Comorbid Peripheral Artery Disease and Type 2 Diabetes

BACKGROUND

Although supervised exercise therapy (SET) is effective in improving walking distance among adults with symptomatic peripheral artery disease (PAD), some research suggests that individuals with comorbid PAD and type 2 diabetes mellitus (T2DM) may experience a blunted response to SET. It is unknown whether free-living sedentary time changes during SET, and if increases in sedentary time could, in part, explain poor response to SET. The purposes of this pilot study were to (1) determine if older adults with PAD (with and without T2DM) engaging in SET change their sedentary behavior and (2) examine the relationship between changes in sedentary behavior and SET outcomes. We hypothesized that decreased sedentary time during SET would be associated with greater improvements in six-minute walk test (6MWT) total distance and other key SET outcomes.

METHODS

Participants (n = 44) initiating a 12-week SET program completed the 6MWT, Short Physical Performance Battery, Walking Impairment Questionnaire, and accelerometer-assessed sedentary behavior at SET initiation, 6 weeks, and 12 weeks.

RESULTS

Participants' mean age was 72.3 (7.1) years, mean ankle-brachial index was 0.71 (0.25), and 47.7% were female. On average, sedentary time did not change after SET, although there was substantial variability (-40% to +38% change in minutes of sedentary time/day). Participants with T2DM experienced greater improvements in claudication onset distance than participants without T2DM (mean = 35 m, P = 0.044, 95% confidence interval = 1.6 to 115.4 m). Neither changes in sedentary time from baseline to 6 weeks (P = 0.419) nor T2DM (P = 0.154) predicted changes in 6MWT total distance from baseline to 12 weeks.

CONCLUSIONS

As SET availability increases, further examination of factors that may influence SET outcomes will help maximize benefits of this proven therapy.

Vascular Access and Risk of Bloodstream Infection Among Older Incident Hemodialysis Patients

Rationale & Objective

Most new patients with end-stage renal disease (ESRD) initiate hemodialysis (HD) with a central venous catheter (CVC) and later transition to a permanent vascular access with lower infection risk. The benefit of early fistula use in preventing severe infections is incompletely understood. We examined patients' first access and subsequent transitions between accesses during the first year of HD to estimate the risk for bloodstream infection (BSI) associated with incident and time-dependent use of HD access.

Study Design

A retrospective cohort study using enhanced 5% Medicare claims data.

Setting & Participants

New patients with ESRD initiating HD between January 1, 2011, and December 31, 2012, and having complete pre-ESRD Medicare fee-for-service coverage for 2 years.

Exposure

The incident and prevalent use of CVC, graft, or fistula as determined from monthly reports to the Centers for Medicare & Medicaid Services by HD providers.

Outcome

Incident hospitalization with a primary/secondary diagnosis of BSI (International Classification of Diseases, Ninth Revision, Clinical Modification code 038.xx or 790.7).

Analytical Approach

Extended survival analysis accounting for patient confounders.

Results

Of 2,352 study participants, 1,870 (79.5%), 77 (3.3%), and 405 (17.2%) initiated HD with a CVC, graft, and fistula, respectively. During the first year, the incident BSI hospitalization rates per 1,000 person-days were 1.3, 0.8, and 0.3 (P<0.001) in patients initiating with a CVC, graft, and fistula, respectively. After adjusting for confounders, incident fistula use was associated with 61% lower risk for BSI (HR, 0.39; 95% CI, 0.28-0.54; P<0.001) compared with incident CVC or graft use. The prevalent fistula or graft use was associated with lower risk for BSI compared with prevalent CVC use (HRs of 0.30 [95% CI, 0.22-0.42] and 0.47 [95% CI, 0.31-0.73], respectively).

Limitations

Restricted to an elderly population; potential residual confounding.

Conclusions

Incident fistula use was associated with lowest rates of BSI, but the majority of beneficiaries with pre-ESRD insurance initiated HD with a CVC. Strategies are needed to improve pre-ESRD fistula placement.

Measuring racial segregation in health system networks using the dissimilarity index

Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care).

Who Will be the Costliest Patients? Using Recent Claims to Predict Expensive Surgical Episodes

INTRODUCTION

Surgery accounts for almost half of inpatient spending, much of which is concentrated in a subset of high-cost patients. To study the effects of surgeon and hospital characteristics on surgical expenditures, a way to adjust for patient characteristics is essential.

DESIGN

Using 100% Medicare claims data, we identified patients aged 66-99 undergoing elective inpatient surgery (coronary artery bypass grafting, colectomy, and total hip/knee replacement) in 2014. We calculated price-standardized Medicare payments for the surgical episode from admission through 30 days after discharge (episode payments). On the basis of predictor variables from 2013, that is, Elixhauser comorbidities, hierarchical condition categories, Medicare's Chronic Conditions Warehouse (CCW), and total spending, we constructed models to predict the costs of surgical episodes in 2014.

RESULTS

All sources of comorbidity data performed well in predicting the costliest cases (Spearman correlation 0.86-0.98). Models on the basis of hierarchical condition categories had slightly superior performance. The costliest quintile of patients as predicted by the model captured 35%-45% of the patients in each procedure's actual costliest quintile. For example, in hip replacement, 44% of the costliest quintile was predicted by the model's costliest quintile.

CONCLUSIONS

A significant proportion of surgical spending can be predicted using patient factors on the basis of readily available claims data. By adjusting for patient factors, this will facilitate future research on unwarranted variation in episode payments driven by surgeons, hospitals, or other market forces.

Long-term effect of fine particulate matter on hospitalization with dementia

BACKGROUND

New evidence suggests that particulate matter less than 2.5 μm in diameter (PM_2.5) is associated with late-onset dementia (LOD). However, epidemiological studies for the entire population are lacking.

METHODS

We analyzed approximately 94 million follow-up records from fee-for-service Medicare records for 13 million Medicare beneficiaries residing in the southeastern United States (U.S.) from 2000 to 2013. We used spatially and temporally continuous PM_2.5 exposure data. To account for time-varying PM_2.5 levels, we applied an Andersen-Gill counting process proportional hazard model; we stratified our analyses by subtype of dementia and level of urbanization of residence.

RESULTS

During a median follow-up of 6 years, 1,409,599 hospitalizations with dementia occurred. The adjusted hazard ratio (HR) of hospitalization with dementia was 1.049 (95% confidence interval [CI], 1.048 to 1.051) per 1 μg/m³ increase in annual PM_2.5. The hazard ratio for vascular dementia was higher (HR, 1.086; 95% CI, 1.082 to 1.090). In large, the magnitude of the effect grew as the level of urbanization increased (HR, 1.036; 95% CI, 1.031 to 1.041 in rural areas versus HR, 1.052; 95% CI, 1.050 to 1.054 in metropolitan areas).

CONCLUSIONS

Long-term exposure to higher PM_2.5 was associated with increased hospitalizations with dementia.

Medicare Claims Paid by the Federal Black Lung Benefits Program: US Medicare Beneficiaries, 1999 to 2016

OBJECTIVE

To establish the burden of totally disabling respiratory impairment among coal miners, we identified the healthcare utilization and cost for Medicare claims where the Federal Black Lung Program (FBLP) was the primary payer.

METHODS

We extracted FBLP claims from 1999 to 2016 institutional Medicare data along with beneficiary, comorbidity, and claim cost information. Healthcare utilization was evaluated and compared to the 2016 Medicare population.

RESULTS

The FBLP was the primary payer on 75,690 claims from 19,700 beneficiaries and paid an increasing percentage of the total paid to providers annually. Claims decreased from 1999 to 2016 but cost per claim increased. Beneficiaries were hospitalized and visited the ER for respiratory and cardiovascular conditions.

CONCLUSIONS

Medicare beneficiaries with FBLP primary payer claims have higher healthcare utilization and comorbidities compared with Medicare enrollees, indicative of increased financial and healthcare burden.

Aging Adults' Preferences for Wellness Program Activities and Delivery Characteristics: A Cross-Sectional Survey

BACKGROUND

Lifestyle wellness programs help prevent and manage chronic diseases, yet few are designed for aging adults.

PURPOSE

Identify characteristics associated with aging adults' preferences for wellness program activities and delivery characteristics.

SUBJECTS/METHODS

Cross-sectional, self-administered survey of a convenience sample of 386 adults aged ≥55 years. Logistic regression models identified characteristics influencing preferences.

RESULTS

Current healthy behaviors, gender, and age influenced many preferences, while BMI, multiple chronic conditions, self-rated general health status, and quality of life did not.

DISCUSSION

Incorporating aging adults' preferences for wellness programs will help design appealing and engaging programs.

Lab-based and diagnosis-based chronic kidney disease recognition and staging concordance

BACKGROUND

Chronic kidney disease (CKD) is often under-recognized and poorly documented via diagnoses, but the extent of under-recognition is not well understood among Medicare beneficiaries. The current study used claims-based diagnosis and lab data to examine patient factors associated with clinically recognized CKD and CKD stage concordance between claims- and lab-based sources in a cohort of Medicare beneficiaries.

METHODS

In a cohort of fee-for-service (FFS) beneficiaries with CKD based on 2011 labs, we examined the proportion with clinically recognized CKD via diagnoses and factors associated with clinical recognition in logistic regression. In the subset of beneficiaries with CKD stage identified from both labs and diagnoses, we examined concordance in CKD stage from both sources, and factors independently associated with CKD stage concordance in logistic regression.

RESULTS

Among the subset of 206,036 beneficiaries with lab-based CKD, only 11.8% (n = 24,286) had clinically recognized CKD via diagnoses. Clinical recognition was more likely for beneficiaries who had higher CKD stages, were non-elderly, were Hispanic or non-Hispanic Black, lived in core metropolitan areas, had multiple chronic conditions or outpatient visits in 2010, or saw a nephrologist. In the subset of 18,749 beneficiaries with CKD stage identified from both labs and diagnoses, 70.0% had concordant CKD stage, which was more likely if beneficiaries were older adults, male, lived in micropolitan areas instead of non-core areas, or saw a nephrologist.

CONCLUSIONS

There is significant under-diagnosis of CKD in Medicare FFS beneficiaries, which can be addressed with the availability of lab results.

Care continuity impacts medicare expenditures of older adults: Fact or fiction?

BACKGROUND

Older adults with cardiometabolic conditions are typically seen by multiple providers. Management by multiple providers may compromise care continuity and increase health expenditures for older adults, which may partly explain the inverse association between continuity and Medicare expenditures found in prior studies. This study sought to examine whether all-cause admission, outpatient expenditures or total expenditures were associated with the number of prescribers of cardiometabolic medications.

METHODS

Medicare fee-for-service beneficiaries with diabetes (n = 100,191), hypertension (n = 299,949) or dyslipidemia (n = 243,598) living in 10 states were identified from claims data. The probability of an all-cause hospital admission in 2011 was estimated via logistic regression and Medicare (outpatient, total) expenditures in 2011 were estimated using generalized linear models, both as a function of the number of prescribers in 2010. Regressions were adjusted for demographic characteristics, Medicaid status, number of prescriptions, and 17 chronic conditions.

RESULTS

In all three cohorts, older adults with more prescribers in 2010 had modestly higher adjusted odds of all-cause inpatient admission than older adults with a single prescriber. Compared to a single prescriber, outpatient and total expenditures in 2011 were 3-10% higher for older adults with diabetes and multiple prescribers, 2-6% higher for older adults with hypertension and multiple prescribers, and 2-5% higher for older adults with dyslipidemia and multiple prescribers.

CONCLUSIONS AND IMPLICATIONS

These results provide some evidence that older adults with multiple prescribers also have modestly higher Medicare utilization than those with a single prescriber; thus care continuity may impact patient utilization.

LEVEL OF EVIDENCE

Level III (retrospective cohort analysis).

Silicosis prevalence and incidence among Medicare beneficiaries

INTRODUCTION

Existing epidemiologic information on silicosis relies on mortality data.

METHODS

We analyzed health insurance claims and enrollment information from 49 923 987 fee-for-service (FFS) Medicare beneficiaries aged ≥65 from 1999 to 2014. Three different definitions were developed to identify silicosis cases and results are presented as ranges of values for the three definitions.

RESULTS

Among FFS beneficiaries, 10 026-19 696 fit the silicosis case definitions (16-year prevalence: 20.1-39.5 per 100 000) with the highest prevalence among North American Natives (87.2-213.6 per 100 000) and those in New Mexico (83.9-203.4 per 100 000). The annual average prevalence had a significant (P < 0.05) 2-5% annual decline from 2005 to 2014. The average annual number of incident cases had a significant 3-16% annual decline from 2007 to 2014.

CONCLUSIONS

Silicosis is a prevalent disease among Medicare beneficiaries aged ≥65, with variation across the country. Morbidity data from health insurance claims can provide a more complete picture of silicosis burden.

Association networks in a matched case-control design - Co-occurrence patterns of preexisting chronic medical conditions in patients with major depression versus their matched controls

OBJECTIVE

We present a method for comparing association networks in a matched case-control design, which provides a high-level comparison of co-occurrence patterns of features after adjusting for confounding factors. We demonstrate this approach by examining the differential distribution of chronic medical conditions in patients with major depressive disorder (MDD) compared to the distribution of these conditions in their matched controls.

MATERIALS AND METHODS

Newly diagnosed MDD patients were matched to controls based on their demographic characteristics, socioeconomic status, place of residence, and healthcare service utilization in the Korean National Health Insurance Service's National Sample Cohort. Differences in the networks of chronic medical conditions in newly diagnosed MDD cases treated with antidepressants, and their matched controls, were prioritized with a permutation test accounting for the false discovery rate. Sensitivity analyses for the associations between prioritized pairs of chronic medical conditions and new MDD diagnosis were performed with regression modeling.

RESULTS

By comparing the association networks of chronic medical conditions in newly diagnosed depression patients and their matched controls, five pairs of such conditions were prioritized among 105 possible pairs after controlling the false discovery rate at 5%. In sensitivity analyses using regression modeling, four out of the five prioritized pairs were statistically significant for the interaction terms.

CONCLUSION

Association networks in a matched case-control design can provide a high-level comparison of comorbid features after adjusting for confounding factors, thereby supplementing traditional clinical study approaches. We demonstrate the differential co-occurrence pattern of chronic medical conditions in patients with MDD and prioritize the chronic conditions that have statistically significant interactions in regression models for depression.

Association of Midlife Cardiorespiratory Fitness With Incident Depression and Cardiovascular Death After Depression in Later Life

IMPORTANCE

Cardiorespiratory fitness (hereinafter referred to as fitness) as estimated by exercise testing is a modifiable risk factor independently associated with chronic diseases, cardiovascular disease (CVD) events, and mortality, but the association of fitness at midlife with incidence of later-life depression and the risk of CVD mortality after a depression diagnosis is unknown.

OBJECTIVE

To determine whether fitness measured in midlife would be inversely associated with later-life CVD mortality with antecedent depression.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study at a single-center, community-based preventive medicine clinic was performed as part of the Cooper Center Longitudinal Study. Data were collected from January 13, 1971, through December 31, 2009, and analyzed from October 6, 2015, through August 14, 2017. Participants included generally healthy men and women who presented for preventive medicine examinations at midlife and who were eligible for Medicare from 1999 to 2010. Those with a self-reported history of depression, myocardial infarction, or stroke at examination were excluded.

EXPOSURES

Objective midlife fitness estimated from results of treadmill exercise testing.

MAIN OUTCOMES AND MEASURES

Depression diagnosis from Medicare claims files using established algorithms and CVD mortality from National Death Index records.

RESULTS

A total of 17 989 participants (80.2% men) with a mean (SD) age of 50.0 (8.7) years were included. After 117 218 person-years of Medicare follow-up, 2701 depression diagnoses, 610 deaths due to CVD without prior depression, and 231 deaths due to CVD after depression were observed. A high level of fitness in midlife was associated with a 16% lower risk of depression (hazard ratio [HR], 0.84; 95% CI, 0.74-0.95) compared with a low level of fitness. A high fitness level was also associated with a 61% lower risk of death due to CVD without depression (HR, 0.39; 95% CI, 0.31-0.48) compared with a low level of fitness. After a diagnosis of depression, a high fitness level was associated with a 56% lower risk of death due to CVD (HR, 0.44; 95% CI, 0.31-0.64) compared with a low fitness level.

CONCLUSIONS AND RELEVANCE

Midlife fitness is associated with a lower risk of later-life depression, CVD mortality, and CVD mortality after incident later-life depression. These findings suggest the importance of midlife fitness in primary prevention of depression and subsequent CVD mortality in older age and should encourage physicians to consider fitness and physical activity in promoting healthy aging.

Helicobacter pylori seropositivity and its association with incident all-cause and Alzheimer's disease dementia in large national surveys

INTRODUCTION

Infectious agents were recently implicated in Alzheimer's disease (AD) and etiology of other dementias, notably Helicobacter pylori.

METHODS

We tested associations of H. pylori seropositivity with incident all-cause and AD dementia and with AD-related mortality among US adults in a retrospective cohort study. Data from the National Health and Nutrition Surveys III, phase 1 (1988-1991) and 1999-2000 linked with Medicare and National Death Index registries, were used (baseline age ≥45 y, follow-up to 2013, N_pooled = 5927).

RESULTS

A positive association between H. pylori seropositivity and AD mortality was found in men (hazard ratio_{adj, pooled} = 4.33, 95% confidence interval: 1.51-12.41, P = .006), which was replicated for incident AD and all-cause dementia, with hazard ratio_{adj, pooled} = 1.45 (95% confidence interval: 1.03-2.04, P = .035) and hazard ratio_{adj, III} = 1.44 (95% confidence interval: 1.05-1.98, P = .022), respectively. These associations were also positive among higher socioeconomic status groups.

DISCUSSION

In sum, H. pylori seropositivity's direct association with AD mortality, all-cause dementia, and AD dementia was restricted to men and to higher socioeconomic status groups.

Does Identification of Previously Undiagnosed Conditions Change Care-Seeking Behavior?

OBJECTIVE

To determine whether identification of previously undiagnosed high cholesterol, hypertension, and/or diabetes during an in-home assessment impacts care seeking among Medicare beneficiaries.

DATA SOURCES/STUDY SETTING

Data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, which recruited African American and white participants across the continental United States from 2003-2007, were linked to Medicare claims.

STUDY DESIGN

We used panel data models to analyze changes in doctor visits for evaluation and management of conditions after participants were assessed, utilizing the study's rolling recruitment to control for secular trends.

DATA EXTRACTION METHODS

We extracted Medicare claims for the 24 months before through 24 months after assessment via REGARDS for 5,884 participants.

PRINCIPAL FINDINGS

Semi-annual doctor visits for previously undiagnosed conditions increased by 22 percentage points (95 percent confidence interval: 16-28) 2 years following assessment. The effect was similar by gender, race, region, and Medicaid, but it may have been lower among participants who lacked a usual health care provider.

CONCLUSIONS

In-home assessment of cholesterol, blood pressure, and blood glucose can increase doctor visits for individuals with previously undiagnosed conditions. However, biomarker assessment may have more limited impact among individuals with low access to care.

Prescription Drug Use and Cost Trends Among Medicaid-Enrolled Children with Disruptive Behavioral Disorders

Disruptive behavior disorders (DBDs) are the most common mental health conditions in children. These conditions profoundly affect healthcare utilization and costs. Service use, costs, and diagnostic trends among pediatric Medicaid beneficiaries provide information regarding healthcare quality and potential for smarter spending. Using nationwide Medicaid administrative data, this study investigates diagnoses, prescription drug fills, and payments in 49 states and D.C. from 2006 to 2009 in Medicaid beneficiaries age 20 and under. Psychotherapeutic drug prescriptions and payments were calculated as a proportion of prescription totals. Results were considered by age, gender, race, and state. The results show a trend of increasing DBD diagnosis. Among prescription claims for children with diagnosed DBD, psychotherapeutic drug claims represented 30-40% of prescription claims but over half of prescription costs. This study indicates increasing clinical and financial needs for Medicaid-enrolled children with DBDs. Medicaid could potentially foster reforms in pediatric DBD treatments, particularly regarding medication use.

Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries

BACKGROUND

Deintensification of diabetic therapy is often clinically appropriate for older adults, because the benefit of aggressive diabetes treatment declines with age, while the risks increase.

OBJECTIVE

We examined rates of overtreatment and deintensification of therapy for older adults with diabetes, and whether these rates differed by medical, demographic, and socioeconomic characteristics.

DESIGN, SUBJECTS, AND MAIN MEASURES

We analyzed Medicare claims data from 10 states, linked to outpatient laboratory values to identify patients potentially overtreated for diabetes (HbA1c < 6.5% with fills for any diabetes medications beyond metformin, 1/1/2011-6/30/2011). We examined characteristics associated with deintensification for potentially overtreated diabetic patients. We used multinomial logistic regression to examine whether patient characteristics associated with overtreatment of diabetes differed from those associated with undertreatment (i.e. HbA1c > 9.0%).

KEY RESULTS

Of 78,792 Medicare recipients with diabetes, 8560 (10.9%) were potentially overtreated. Overtreatment of diabetes was more common among those who were over 75 years of age and enrolled in Medicaid (p < 0.001), and was less common among Hispanics (p = 0.009). Therapy was deintensified for 14% of overtreated diabetics. Appropriate deintensification of diabetic therapy was more common for patients with six or more chronic conditions, more outpatient visits, or living in urban areas; deintensification was less common for those over age 75. Only 6.9% of Medicare recipients with diabetes were potentially undertreated. Variables associated with overtreatment of diabetes differed from those associated with undertreatment.

CONCLUSIONS

Medicare recipients are more frequently overtreated than undertreated for diabetes. Medicare recipients who are overtreated for diabetes rarely have their regimens deintensified.

Risk of Alzheimer's Disease Among Senior Medicare Beneficiaries Treated With Androgen Deprivation Therapy for Prostate Cancer

Purpose To assess the relative risk of Alzheimer's disease (AD) among patients with prostate cancer who received androgen deprivation therapy (ADT), after adjustment for other cancer therapies. Methods Data from demographics, survival, diagnoses codes, procedure codes, and other information about beneficiaries age 67 years or older in the Medicare claims database was assessed to determine the unadjusted and adjusted risks of AD and of dementia from ADT. The prespecified survival analysis method was competing risk regression. Results Of the 1.2 million fee-for-service Medicare beneficiaries who developed prostate cancer in 2001 to 2014, 35% received ADT. Of these, 109,815 (8.9%) and 223,765 (18.8%) developed AD and dementia, respectively, and 26% to 33% died without either outcome. Unadjusted rates of AD and all-cause mortality per 1,000 patient-years were higher among ADT recipients; the unadjusted rates of AD were 17.0 and 15.5 per 1,000 person-years in recipients and nonrecipients, respectively, and the unadjusted rates of all-cause mortality were 73.0 and 51.6 per 1,000 person-years, respectively. The unadjusted rates for dementia in ADT recipients versus nonrecipients were 38.5 and 32.9, respectively, and the unadjusted rates of mortality were 60.2 versus 40.4, respectively. However, after analysis was adjusted for other cancer therapies and other covariates, patients with ADT treatment had no increased risk of AD (subdistribution hazard ratio [SHR], 0.98; 95% CI, 0.97 to 0.99) and had only a miniscule (1%) risk of dementia (SHR, 1.01; 95% CI, 1.01 to 1.02); patients treated with ADT were more likely to die before progression to AD (SHR, 1.24; 95% CI, 1.23 to 1.24) or dementia (SHR, 1.26; 95% CI, 1.25 to 1.26). The risks of AD and dementia were not associated with duration of ADT (ie, no dose effect). Other secondary analyses confirmed these results. Conclusion These data suggest that ADT treatment has no hazard for AD and no meaningful hazard for dementia among men age 67 years or older who are enrolled in Medicare.

Using Self-reports or Claims to Assess Disease Prevalence: It's Complicated

BACKGROUND

Two common ways of measuring disease prevalence include: (1) using self-reported disease diagnosis from survey responses; and (2) using disease-specific diagnosis codes found in administrative data. Because they do not suffer from self-report biases, claims are often assumed to be more objective. However, it is not clear that claims always produce better prevalence estimates.

OBJECTIVE

Conduct an assessment of discrepancies between self-report and claims-based measures for 2 diseases in the US elderly to investigate definition, selection, and measurement error issues which may help explain divergence between claims and self-report estimates of prevalence.

DATA

Self-reported data from 3 sources are included: the Health and Retirement Study, the Medicare Current Beneficiary Survey, and the National Health and Nutrition Examination Survey. Claims-based disease measurements are provided from Medicare claims linked to Health and Retirement Study and Medicare Current Beneficiary Survey participants, comprehensive claims data from a 20% random sample of Medicare enrollees, and private health insurance claims from Humana Inc.

METHODS

Prevalence of diagnosed disease in the US elderly are computed and compared across sources. Two medical conditions are considered: diabetes and heart attack.

RESULTS

Comparisons of diagnosed diabetes and heart attack prevalence show similar trends by source, but claims differ from self-reports with regard to levels. Selection into insurance plans, disease definitions, and the reference period used by algorithms are identified as sources contributing to differences.

CONCLUSIONS

Claims and self-reports both have strengths and weaknesses, which researchers need to consider when interpreting estimates of prevalence from these 2 sources.

Automated Diabetes Case Identification Using Electronic Health Record Data at a Tertiary Care Facility

Objective

To develop and validate a phenotyping algorithm for the identification of patients with type 1 and type 2 diabetes mellitus (DM) preoperatively using routinely available clinical data from electronic health records.

Patients and Methods

We used first-order logic rules (if-then-else rules) to imply the presence or absence of DM types 1 and 2. The “if” clause of each rule is a conjunction of logical and, or predicates that provides evidence toward or against the presence of DM. The rule includes International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes, outpatient prescription information, laboratory values, and positive annotation of DM in patients’ clinical notes. This study was conducted from March 2, 2015, through February 10, 2016. The performance of our rule-based approach and similar approaches proposed by other institutions was evaluated with a reference standard created by an expert reviewer and implemented for routine clinical care at an academic medical center.

Results

A total of 4208 surgical patients (mean age, 52 years; males, 48%) were analyzed to develop the phenotyping algorithm. Expert review identified 685 patients (16.28% of the full cohort) as having DM. Our proposed method identified 684 patients (16.25%) as having DM. The algorithm performed well—99.70% sensitivity, 99.97% specificity—and compared favorably with previous approaches.

Conclusion

Among patients undergoing surgery, determination of DM can be made with high accuracy using simple, computationally efficient rules. Knowledge of patients’ DM status before surgery may alter physicians’ care plan and reduce postsurgical complications. Nevertheless, future efforts are necessary to determine the effect of first-order logic rules on clinical processes and patient outcomes.

Direct and indirect cost of managing alzheimer's disease and related dementias in the United States

INTRODUCTION

Care of individuals with Alzheimer's Disease and Related Dementias (ADRD) poses special challenges. As the disease progresses, individuals with ADRD require increasing levels of medical care, caregiver support, and long-term care which can lead to substantial economic burden. Areas covered: In this expert review, we synthesized findings from studies of costs of ADRD in the United States that were published between January 2006 and February 2017, highlighted major sources of variation in costs, identified knowledge gaps and briefly outlined directions for future research and implications for policy and program planning. Expert commentary: A consistent finding of all studies comparing individuals with and without ADRD is that the average medical, non-medical, and indirect costs of individuals with ADRD are higher than those without ADRD, despite the differences in the methods of identifying ADRD, duration of the study, payer type and settings of study population. The economic burden of ADRD may be underestimated because many components such as direct non-medical costs for home safety modifications and adult day care services and indirect costs due to the adverse impact of ADRD on caregivers' health and productivity are not included in cost estimates.