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Niznik JD, Lund JL, Hanson LC, Colón-Emeric C, Kelley CJ, Gilliam M, Thorpe CT. A comparison of dementia diagnoses and cognitive function measures in Medicare claims and the Minimum Data Set. J Am Geriatr Soc 2024. [PMID: 38814274 DOI: 10.1111/jgs.19019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 04/11/2024] [Accepted: 05/03/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Gold standard dementia assessments are rarely available in large real-world datasets, leaving researchers to choose among methods with imperfect but acceptable accuracy to identify nursing home (NH) residents with dementia. In healthcare claims, options include claims-based diagnosis algorithms, diagnosis indicators, and cognitive function measures in the Minimum Data Set (MDS), but few studies have compared these. We evaluated the proportion of NH residents identified with possible dementia and concordance of these three. METHODS Using a 20% random sample of 2018-2019 Medicare beneficiaries, we identified MDS admission assessments for non-skilled NH stays among individuals with continuous enrollment in Medicare Parts A, B, and D. Dementia was identified using: (1) Chronic Conditions Warehouse (CCW) claims-based algorithm for Alzheimer's disease and non-Alzheimer's dementia; (2) MDS active diagnosis indicators for Alzheimer's disease and non-Alzheimer's dementias; and (3) the MDS Cognitive Function Scale (CFS) (at least mild cognitive impairment). We compared the proportion of admissions with evidence of possible dementia using each criterion and calculated the sensitivity, specificity, and agreement of the CCW claims definition and MDS indicators for identifying any impairment on the CFS. RESULTS Among 346,013 non-SNF NH admissions between 2018 and 2019, 57.2% met criteria for at least one definition (44.7% CFS, 40.7% CCW algorithm, 26.0% MDS indicators). The MDS CFS uniquely identified the greatest proportion with evidence of dementia. The CCW claims algorithm had 63.7% sensitivity and 78.1% specificity for identifying any cognitive impairment on the CFS. Active diagnosis indicators from the MDS had lower sensitivity (47.0%), but higher specificity (91.0%). CONCLUSIONS Claims- and MDS-based methods for identifying NH residents with possible dementia have only partial overlap in the cohorts they identify, and neither is an obvious gold standard. Future studies should seek to determine whether additional functional assessments from the MDS or prescriptions can improve identification of possible dementia in this population.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cathleen Colón-Emeric
- Division of Geriatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina, USA
| | - Casey J Kelley
- Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Meredith Gilliam
- Division of Geriatric Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Xu H, Bowblis JR, Becerra AZ, Intrator O. Developing a Machine Learning Risk-adjustment Method for Hospitalizations and Emergency Department Visits of Nursing Home Residents With Dementia. Med Care 2023; 61:619-626. [PMID: 37440719 PMCID: PMC10526959 DOI: 10.1097/mlr.0000000000001882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND Long-stay nursing home (NH) residents with Alzheimer disease and related dementias (ADRD) are at high risk of hospital transfers. Machine learning might improve risk-adjustment methods for NHs. OBJECTIVES The objective of this study was to develop and compare NH risk-adjusted rates of hospitalizations and emergency department (ED) visits among long-stay residents with ADRD using Extreme Gradient Boosting (XGBoost) and logistic regression. RESEARCH DESIGN Secondary analysis of national Medicare claims and NH assessment data in 2012 Q3. Data were equally split into the training and test sets. Both XGBoost and logistic regression predicted any hospitalization and ED visit using 58 predictors. NH-level risk-adjusted rates from XGBoost and logistic regression were constructed and compared. Multivariate regressions examined NH and market factors associated with rates of hospitalization and ED visits. SUBJECTS Long-stay Medicare residents with ADRD (N=413,557) from 14,057 NHs. RESULTS A total of 8.1% and 8.9% residents experienced any hospitalization and ED visit in a quarter, respectively. XGBoost slightly outperformed logistic regression in area under the curve (0.88 vs. 0.86 for hospitalization; 0.85 vs. 0.83 for ED visit). NH-level risk-adjusted rates from XGBoost were slightly lower than logistic regression (hospitalization=8.3% and 8.4%; ED=8.9% and 9.0%, respectively), but were highly correlated. Facility and market factors associated with the XGBoost and logistic regression-adjusted hospitalization and ED rates were similar. NHs serving more residents with ADRD and having a higher registered nurse-to-total nursing staff ratio had lower rates. CONCLUSIONS XGBoost and logistic regression provide comparable estimates of risk-adjusted hospitalization and ED rates.
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Affiliation(s)
- Huiwen Xu
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
| | - John R. Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, OH
- Scripps Gerontology Center, Miami University, Oxford, OH
| | - Adan Z. Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
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Hua CL, Thomas KS, Bunker J, Gozalo PL, Belanger E, Mitchell SL, Teno JM. Dementia diagnosis in the hospital and outcomes among patients with advanced dementia documented in the Minimum Data Set. J Am Geriatr Soc 2022; 70:846-853. [PMID: 34797565 PMCID: PMC8904279 DOI: 10.1111/jgs.17564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/20/2021] [Accepted: 10/24/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Individuals with dementia do not always have a diagnosis of dementia noted on their hospital claims. Whether this lack of documentation is associated with patient outcomes is unknown. We examined the association between a dementia diagnosis listed on a hospital claim and patient outcomes among individuals with a Minimum Data Set (MDS) assessment. METHODS A retrospective cohort study was conducted using administrative claims data and nursing home MDS assessments. Hospitalized patients aged 66 and older with advanced dementia noted on an MDS assessment completed within 120 days prior to their first hospitalization in 2017 were included. Advanced dementia was defined based on an MDS diagnosis of dementia, dependency in four or more activities of daily living, and a Cognitive Function Scale score indicative of moderate to severe impairment. Multilevel regression with a random intercept at the hospital level was used to examine the relationship between documentation of dementia in inpatient hospital Medicare claims and the following patient outcomes after adjusting for patient and hospital characteristics: invasive mechanical ventilation (IMV) use, intensive care unit or coronary care unit (ICU/CCU) use, 30-day mortality, and hospital length of stay (LOS). RESULTS In 2017, among 120,989 patients with advanced dementia and a nursing home stay, 90.57% had a dementia diagnosis on their hospital claims. In adjusted models, documentation of a dementia diagnosis was associated with lower use of the ICU/CCU (adjusted odds ratio [AOR]: 0.78 [95% confidence interval 0.74, 0.81]), use of IMV (AOR: 0.50 [0.47, 0.54]), and 30-day mortality (AOR: 0.81 [0.77, 0.85]). Patients with a dementia diagnosis had a shorter LOS. CONCLUSIONS Among patients with advanced dementia, those whose dementia diagnosis was documented on their inpatient hospital Medicare claim experienced lower use of ICU/CCU, use of IMV, lower 30-day mortality, and shorter LOS than those whose diagnosis was not documented.
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Affiliation(s)
- Cassandra L. Hua
- School of Public Health, Brown University, Providence, Rhode Island,Corresponding author: Cassandra Hua: Box G-S121-4, 121 S. Main Street, Providence, RI 02912, , Twitter: @CassandraHua
| | - Kali S. Thomas
- School of Public Health, Brown University, Providence, Rhode Island,Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Jennifer Bunker
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland
| | - Pedro L. Gozalo
- School of Public Health, Brown University, Providence, Rhode Island,Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | | | - Susan L. Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland
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