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Bakillah E, Sharpe J, Wirtalla C, Goldberg D, Altieri MS, Aarons CB, Keele LJ, Kelz RR. Minimally invasive colorectal cancer surgery: an observational study of medicare advantage and fee-for-service beneficiaries. Surg Endosc 2024:10.1007/s00464-024-11168-0. [PMID: 39160311 DOI: 10.1007/s00464-024-11168-0] [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: 02/01/2024] [Accepted: 08/05/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Enrollment of Medicare beneficiaries in medicare advantage (MA) plans has been steadily increasing. Prior research has shown differences in healthcare access and outcomes based on Medicare enrollment status. This study sought to compare utilization of minimally invasive colorectal cancer (CRC) surgery and postoperative outcomes between MA and Fee-for-Service (FFS) beneficiaries. METHODS A retrospective cohort study of beneficiaries ≥ 65.5 years of age enrolled in FFS and MA plans was performed of patients undergoing a CRC resection from 2016 to 2019. The primary outcome was operative approach, defined as minimally invasive (laparoscopic) or open. Secondary outcomes included robotic assistance, hospital length-of-stay, mortality, discharge disposition, and hospital readmission. Using balancing weights, we performed a tapered analysis to examine outcomes with adjustment for potential confounders. RESULTS MA beneficiaries were less likely to have lymph node (12.9 vs 14.4%, p < 0.001) or distant metastases (15.5% vs 17.0%, p < 0.001), and less likely to receive chemotherapy (6.2% vs 6.7%, p < 0.001), compared to FFS beneficiaries. MA beneficiaries had a higher risk-adjusted likelihood of undergoing laparoscopic CRC resection (OR 1.12 (1.10-1.15), p < 0.001), and similar rates of robotic assistance (OR 1.00 (0.97-1.03), p = 0.912), compared to FFS beneficiaries. There were no differences in risk-adjusted length-of-stay (β coefficient 0.03 (- 0.05-0.10), p = 0.461) or mortality at 30-60-and 90-days (OR 0.99 (0.95-1.04), p = 0.787; OR 1.00 (0.96-1.04), p = 0.815; OR 0.98 (0.95-1.02), p = 0.380). MA beneficiaries had a lower likelihood of non-routine disposition (OR 0.77 (0.75-0.78), p < 0.001) and readmission at 30-60-and 90-days (OR 0.76 (0.73-0.80), p < 0.001; OR 0.78 (0.75-0.81), p < 0.001; OR 0.79 (0.76-0.81), p < 0.001). CONCLUSIONS MA beneficiaries had less advanced disease at the time of CRC resection and a greater likelihood of undergoing a laparoscopic procedure. MA enrollment is associated with improved health outcomes for elderly beneficiaries undergoing operative treatment for CRC.
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Affiliation(s)
- Emna Bakillah
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA.
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - James Sharpe
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Chris Wirtalla
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Drew Goldberg
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Maria S Altieri
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Cary B Aarons
- Department of Surgery, Columbia University, New York, NY, USA
| | - Luke J Keele
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Agarwal R, Connolly J, Gupta S, Navathe AS. Comparing Medicare Advantage And Traditional Medicare: A Systematic Review. Health Aff (Millwood) 2021; 40:937-944. [PMID: 34097516 DOI: 10.1377/hlthaff.2020.02149] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare Advantage enrollment has almost doubled since 2010 and now accounts for more than a third of all Medicare beneficiaries. We performed a systematic review to compare Medicare Advantage and traditional Medicare on key metrics. Evidence from forty-eight studies showed that in most or all comparisons, Medicare Advantage was associated with more preventive care visits, fewer hospital admissions and emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending. Medicare Advantage outperformed traditional Medicare in most studies comparing quality-of-care metrics. However, the evidence on patient experience, readmission rates, mortality, and racial/ethnic disparities did not show a trend of better performance in Medicare Advantage. Evidence to date might not fully account for selection bias, unobserved differences in social determinants of health, or risk adjustment challenges, in part because of differences in data quality that limit the comparability of outcomes between Medicare Advantage and traditional Medicare. With Medicare Advantage plans expected to grow in popularity, policy makers should support policies to improve data completeness and comparability, and health plans should focus on improving patient experience.
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Affiliation(s)
- Rajender Agarwal
- Rajender Agarwal is director of the Center for Health Reform, in Southlake, Texas
| | - John Connolly
- John Connolly is a medical student in the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, in Philadelphia, Pennsylvania
| | - Shweta Gupta
- Shweta Gupta is the fellowship director of the Oncology Program, Department of Medicine, John H. Stroger Jr. Hospital of Cook County, in Chicago, Illinois
| | - Amol S Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center; an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine; and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, all in Philadelphia
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Impact of advance care planning on dying in hospital: Evidence from urgent care records. PLoS One 2020; 15:e0242914. [PMID: 33296395 PMCID: PMC7725362 DOI: 10.1371/journal.pone.0242914] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 11/11/2020] [Indexed: 12/02/2022] Open
Abstract
Place of death is an important outcome of end-of-life care. Many people do not have the opportunity to express their wishes and die in their preferred place of death. Advance care planning (ACP) involves discussion, decisions and documentation about how an individual contemplates their future death. Recording end-of-life preferences gives patients a sense of control over their future. Coordinate My Care (CMC) is London’s largest electronic palliative care register designed to provide effective ACP, with information being shared with urgent care providers. The aim of this study is to explore determinants of dying in hospital. Understanding advance plans and their outcomes can help in understanding the potential effects that implementation of electronic palliative care registers can have on the end-of-life care provided. Retrospective observational cohort analysis included 21,231 individuals aged 18 or older with a Coordinate My Care plan who had died between March 2011 and July 2019 with recorded place of death. Logistic regression was used to explore demographic and end-of-life preference factors associated with hospital deaths. 22% of individuals died in hospital and 73% have achieved preferred place of death. Demographic characteristics and end-of-life preferences have impact on dying in hospital, with the latter having the strongest influence. The likelihood of in-hospital death is substantially higher in patients without documented preferred place of death (OR = 1.43, 95% CI 1.26–1.62, p<0.001), in those who prefer to die in hospital (OR = 2.30, 95% CI 1.60–3.30, p<0.001) and who prefer to be cared in hospital (OR = 2.77, 95% CI 1.94–3.96, p<0.001). “Not for resuscitation” individuals (OR = 0.43, 95% CI 0.37–0.50, p<0.001) and who preferred symptomatic treatment (OR = 0.36, 95% CI 0.33–0.40, p<0.001) had a lower likelihood of in-hospital death. Effective advance care planning is necessary for improved end-of-life outcomes and should be included in routine clinical care. Electronic palliative care registers could empower patients by embedding patients’ wishes and personal circumstances in their care plans that are accessible by urgent care providers.
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Orlovic M, Smith K, Mossialos E. Racial and ethnic differences in end-of-life care in the United States: Evidence from the Health and Retirement Study (HRS). SSM Popul Health 2019; 7:100331. [PMID: 30623009 PMCID: PMC6305800 DOI: 10.1016/j.ssmph.2018.100331] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 01/10/2023] Open
Abstract
Population ageing poses considerable challenges to the provision of quality end-of-life care. The population of the United States is increasingly diverse, making it imperative to design culturally sensitive end-of-life care interventions. We examined participants of the Health and Retirement Study, who died between 2002 and 2014, to examine racial and ethnic differences in end-of-life care utilization and end-of-life planning in the United States. Our study reveals significant disparities in end-of-life care and planning among studied groups. Findings reveal that racial and ethnic minorities are more likely to die in hospital and less likely to engage in end-of-life planning activities. The observed disparities are still significant but have been narrowing between 2002 and 2014. Efforts to reduce these differences should target both medical professionals and diverse communities to ensure that improved models of care acknowledge heterogeneous values and needs of a culturally diverse US population.
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Affiliation(s)
- Martina Orlovic
- Department of Surgery and Cancer, Faculty of Medicine, Institute of Global Health Innovation, 10th Floor, QEQM Wing, St Mary’s Hospital, South Wharf Road, London W2 1NY, United Kingdom
| | - Katharine Smith
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, 10th Floor, QEQM Wing, St Mary’s Hospital, South Wharf Road, London W2 1NY, United Kingdom
| | - Elias Mossialos
- Department of Surgery and Cancer, Faculty of Medicine, Institute of Global Health Innovation, 10th Floor, QEQM Wing, St Mary’s Hospital, South Wharf Road, London W2 1NY, United Kingdom
- Department of Health Policy, London School of Economics and Political Science, Houghton St, London WC2A 2AE, United Kingdom
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