Identifying neuropsychiatric disorders in the Medicare Current Beneficiary Survey: the benefits of combining health survey and claims data

Correlates of missed or late versus timely diagnosis of dementia in healthcare settings

INTRODUCTION

There is limited evidence about factors related to the timeliness of dementia diagnosis in healthcare settings.

METHODS

In five prospective cohorts at Rush Alzheimer's Disease Center, we identified participants with incident dementia based on annual assessments and examined the timing of healthcare diagnoses in Medicare claims. We assessed sociodemographic, health, and psychosocial correlates of timely diagnosis.

RESULTS

Of 710 participants, 385 (or 54%) received a timely claims diagnosis within 3 years prior to or 1 year following dementia onset. In logistic regressions accounting for demographics, we found Black participants (odds ratio [OR] = 2.15, 95% confidence interval [CI]: 1.21 to 3.82) and those with better cognition at dementia onset (OR = 1.48, 95% CI: 1.10 to 1.98) were at higher odds of experiencing a diagnostic delay, whereas participants with higher income (OR = 0.89, 95% CI: 0.81 to 0.97) and more comorbidities (OR = 0.94, 95% CI: 0.89 to 0.98) had lower odds.

DISCUSSION

We identified characteristics of individuals who may miss the optimal window for dementia treatment and support.

HIGHLIGHTS

We compared the timing of healthcare diagnosis relative to the timing of incident dementia based on rigorous annual evaluation. Older Black adults with lower income, higher cognitive function, and fewer comorbidities were less likely to be diagnosed in a timely manner by the healthcare system.

Availability and use of telehealth services among patients with ADRD enrolled in traditional Medicare vs. Medicare advantage during the COVID-19 pandemic

Background

The objective of this study was to examine differences in availability and use of telehealth services among Medicare enrollees according to Alzheimer's disease and related dementias (ADRD) status and enrollment in Medicare Advantage (MA) versus Traditional Medicare (TM) during the period surrounding the COVID-19 pandemic.

Methods

This was a retrospective cross-sectional analysis of data from community-dwelling MA and TM enrollees with and without ADRD from the Medicare Current Beneficiary Survey (MCBS) Fall 2020 and Winter 2021 COVID-19 Supplement Public Use Files. We examined self-reported availability of telehealth service before and during the COVID-19 pandemic and use of telehealth services during COVID-19. We analyzed marginal effects under multivariable logistic regression.

Results

There were 13,700 beneficiaries with full-year enrollment in MA (6,046) or TM (7,724), 518 with ADRD and 13,252 without ADRD. Telehealth availability during COVID-19 was positively associated with having a higher income (2.81 pp. [percentage points]; 95% CI: 0.57, 5.06), having internet access (7.81 pp.; 95% CI: 4.96, 10.66), and owning telehealth-related technology (3.86; 95% CI: 1.36, 6.37); it was negatively associated with being of Black Non-Hispanic ethnicity (-8.51 pp.; 95% CI: -12.31, -4.71) and living in a non-metro area (-8.94 pp.; 95% CI: -13.29, -4.59). Telehealth availability before COVID-19 was positively associated with being of Black Non-Hispanic ethnicity (9.34 pp.; 95% CI: 3.74, 14.94) and with enrollment in MA (4.72 pp.; 95% CI: 1.63, 7.82); it was negatively associated having dual-eligibility (-5.59 pp.; 95% CI: -9.91, -1.26). Telehealth use was positively associated with being of Black Non-Hispanic ethnicity (6.47 pp.; 95% CI: 2.92, 10.01); it was negatively associated with falling into the age group of 75+ years (-4.98 pp.; 95% CI: -7.27, -2.69) and with being female (-4.98 pp.; 95% CI: -7.27, -2.69).

Conclusion

Telehealth services were available to and used by Medicare enrollees with ADRD to a similar extent compared to their non-ADRD counterparts. Telehealth services were available to MA enrollees to a greater extent before COVID-19 but not during COVID-19, and this group did not use telehealth services more than TM enrollees during COVID-19.

Assessment of Joint and Interactive Effects of Multimorbidity and Chronic Pain on ADRD Risk in the Elder Population

Objective

Multimorbidity and non-cancer chronic pain conditions (NCPC) are independently linked to elevated risk for cognitive impairment and incident Alzheimer's Disease and Related Dementias (ADRD)-both - We present the study of potential joint and interactive effects of these conditions on the risk of incident ADRD in older population.

Methods

This retrospective-cohort study drew baseline and 2-year follow-up data from linked Medicare claims and Medicare Current Beneficiary Survey (MCBS). Baseline multimorbidity and NCPC were ascertained using claims data. ADRD was ascertained at baseline and follow-up.

Results

NCPC accompanied by multimorbidity (vs. absence of NCPC or multimorbidity) had a significant and upward association with incident ADRD (adjusted odds ratio (AOR): 1.72, 95% CI 1.38, 2.13, p < 0.0001). Secondary analysis by number of comorbid conditions suggested that the joint effects of NCPC and multimorbidity on ADRD risk may increase with rising number contributing chronic conditions. Interaction analyses indicated significantly elevated excess risk for incident ADRD.

Reproducibility of the medical cost estimation from the Medicare Current Beneficiary Survey: Comparing claims and survey

Background

The Medicare Current Beneficiary Survey (MCBS) limited-access data provides the unique opportunity to utilize administrative claims and adjusted survey data to investigate trends in utilization and medical expenditure across time. The adjusted survey data is a synthesized, matched version of the original survey data and claims. Researchers may choose adjusted survey data or original claims for cost evaluations according to their research purpose. However, limited research has examined methodological issues when estimating medical cost using different MCBS data sources.

Objective

The study objective was to examine the reproducibility of individual-level medical cost using both MCBS data sources: adjusted survey and claims data.

Methods

This serial cross-sectional study design analyzed 2006-2012 MCBS data. The sample included noninstitutionalized older Medicare beneficiaries (≥65 years old), with a cancer diagnosis and annually enrolled in Medicare Parts A, B, and D. The population was stratified by diabetes diagnosis. The primary outcome was annual medical cost. We investigated the discrepancies of medical cost estimated from the adjusted survey and original claims data. The agreement between cost estimates from the two sources in each year was determined using the Wilcoxon signed-rank test.

Results

A total of 4918 eligible Medicare beneficiaries were included in this study, and 26% of beneficiaries also had diabetes (N = 1275). Significant disagreements in cost estimates between adjusted survey and claims data were present regardless of disease complexity (with or without diabetes). Significant disagreements in medical cost estimates were present in most years, except in 2010 (p = 0.467) and 2011 (p = 0.098), for beneficiaries with cancer and diabetes (p < 0.001 for all). Significant disagreements in medical cost estimates were present in all years for beneficiaries with cancer without diabetes (p < 0.001 for all).

Conclusions

Based on discrepant cost estimates across data sources, researchers using MCBS to estimate costs should be cautious when using claims or adjusted survey data alone.

Treatment adequacy and remission of depression and anxiety disorders and quality of life in primary care older adults

BACKGROUND

Studies on the long-term outcomes of receiving adequate treatment for depression and anxiety disorders are scarce. The aims of this study were to assess the association between adequacy of care and remission of common mental disorders (CMD) and change in quality of life among a population of older adults consulting in primary care.

METHODS

The study was conducted among 225 older adults with a CMD who participated in the longitudinal ESA-Services study. Adequacy of care was assessed using administrative and self-reported data and was based on Canadian guidelines and relevant literature. CMD were measured at baseline and follow-up using self-reported measures (DSM-5 criteria) and physician diagnostic codes (International Classification of Diseases, 9^th and 10^th revisions) for depression and anxiety disorders. The remission of CMD was defined by the presence of at least one disorder at baseline and absence at follow-up. Quality of life was measured at baseline and follow-up using a visual analog scale and the Satisfaction With Life Scale. To estimate the probability to receive adequate/inadequate care, a propensity score was calculated, and analyses were weighted by the inverse probability. Weighted multivariable analyses were carried out to assess the remission of CMD and change in quality of life as a function of adequacy of care controlling for individual and health system factors.

RESULTS

Results showed that 40% of older adults received adequate care for CMD and 55% were in remission at follow-up. Adequacy of care was associated with remission of CMD (AOR: 0.66; CI 0.45-0.97; p-value: 0.032). Participants receiving adequate care had an improvement between baseline and follow-up of 0.7 (beta: 0.69, CI 0.18; 1.20, p = 0.008) point on the Satisfaction With Life Scale, while a marginal association was observed with improvement in HRQOL (beta: 2.83, CI 0.12; 5.79, p = 0.060).

CONCLUSION

The findings contribute to the rare observational studies on the association between adequacy of care for CMD and long-term treatment effects. Future studies on population effectiveness should focus on patient indicators of quality of care which may better predict long-term outcomes for patients with depression and anxiety.

The Association of Osteoarthritis and Related Pain Burden to Incident Alzheimer's Disease and Related Dementias: A Retrospective Cohort Study of U.S. Medicare Beneficiaries

BACKGROUND

Emerging evidence suggests osteoarthritis (OA) and related symptom burden may increase risk for Alzheimer's disease and related dementias (ADRD). However, longitudinal studies are sparse, and none have examined the potential mediating effects of mood or sleep disorders.

OBJECTIVE

To determine the association of OA and related pain to incident ADRD in U.S. elders.

METHODS

In this retrospective cohort study, we used baseline and two-year follow-up data from linked Medicare claims and Medicare Current Beneficiary Survey files (11 pooled cohorts, 2001-2013). The study sample comprised 16,934 community-dwelling adults≥65 years, ADRD-free at baseline and enrolled in fee-for-service Medicare. Logistic regression was used to assess the association of OA and related pain (back, neck, joint, neuropathic) to incident ADRD, explore the mediating inlfuence of mood and insomnia-related sleep disorders, and (sensitivity analyses) account for potential survival bias.

RESULTS

Overall, 25.5% of beneficiaries had OA at baseline (21.0% with OA and pain); 1149 elders (5.7%) were subsequently diagnosed with ADRD. Compared to beneficiaries without OA, those with OA were significantly more likely to receive a diagnosis of incident ADRD after adjustment for sociodemographics, lifestyle characteristics, comorbidities, and medications (adjusted odds ratio (AOR) = 1.23 (95% confidence interval (CI) 1.06, 1.42). Elders with OA and pain at baseline were significantly more likely to be diagnosed with incident ADRD than were those without OA or pain (AOR = 1.31, CI 1.08, 1.58). Sensitivity analyses yielded similar findings. Inclusion of depression/anxiety, but not sleep disorders, substantially attenuated these associations.

CONCLUSION

Findings of this study suggest that: OA is associated with elevated ADRD risk, this association is particularly pronounced in those with OA and pain, and mood disorders may partially mediate this relationship.

Economic burden of diabetes among medicare beneficiaries with cancer

Objectives

Older adults are commonly affected by cancer and diabetes, and an investigation of the economic burden faced by these older adults remains a research gap. Therefore, the objective was to assess the economic burden of diabetes among Medicare beneficiaries with cancer by analyzing annual costs from administrative claims data.

Methods

We conducted a retrospective, serial cross-sectional study using the Medicare Current Beneficiary Survey (MCBS) from 2006 to 2012. Eligible beneficiaries must be currently or previously diagnosed with cancer (of any type), ≥65 years of age, non-institutionalized and continuously enrolled annually in Medicare Parts A, B and D. Diagnoses of cancer and diabetes were determined through self-report or claims. The primary outcome was the total economic burden of diabetes per capita annually, operationalized as the difference in total direct costs between cancer patients with and without diabetes. Simple linear regression was used to analyze trends of costs across the years. Multivariable regression estimated the effect of diabetes and covariates on total annual spending among beneficiaries with cancer from 2006-2012.

Key findings

From 2006 to 2012, 4918 beneficiaries included in MCBS had cancer, with over 25% (1275) also having diabetes. From 2006 to 2012, the mean economic burden of diabetes was $7815 per capita annually. After adjusting for covariates, beginning in 2006, diagnosis of diabetes significantly predicted higher total annual spending among cancer beneficiaries in 2007 [coefficient (SE) = 0.5768 (0.1918), P = 0.003], 2011 [coefficient (SE) = 0.4303 (0.1817), P = 0.018] and 2012 [coefficient (SE) = 0.3605 (0.1758), P = 0.040].

Conclusions

Medicare beneficiaries with cancer experienced a higher economic burden from concurrent diabetes.

Non-Cancer Chronic Pain Conditions and Risk for Incident Alzheimer's Disease and Related Dementias in Community-Dwelling Older Adults: A Population-Based Retrospective Cohort Study of United States Medicare Beneficiaries, 2001-2013

Accumulating evidence suggests that certain chronic pain conditions may increase risk for incident Alzheimer's disease and related dementias (ADRD). Rigorous longitudinal research remains relatively sparse, and the relation of overall chronic pain condition burden to ADRD risk remains little studied, as has the potential mediating role of sleep and mood disorders. In this retrospective cohort study, we investigated the association of common non-cancer chronic pain conditions (NCPC) at baseline to subsequent risk for incident ADRD, and assessed the potential mediating effects of mood and sleep disorders, using baseline and 2-year follow-up data using 11 pooled cohorts (2001-2013) drawn from the U.S. Medicare Current Beneficiaries Survey (MCBS). The study sample comprised 16,934 community-dwelling adults aged ≥65 and ADRD-free at baseline. NCPC included: headache, osteoarthritis, joint pain, back or neck pain, and neuropathic pain, ascertained using claims data; incident ADRD (N = 1149) was identified using claims and survey data. NCPC at baseline remained associated with incident ADRD after adjustment for sociodemographics, lifestyle characteristics, medical history, medications, and other factors (adjusted odds ratio (AOR) for any vs. no NCPC = 1.21, 95% confidence interval (CI) = 1.04-1.40; p = 0.003); the strength and magnitude of this association rose significantly with increasing number of diagnosed NCPCs (AOR for 4+ vs. 0 conditions = 1.91, CI = 1.31-2.80, p-trend < 0.00001). Inclusion of sleep disorders and/or depression/anxiety modestly reduced these risk estimates. Sensitivity analyses yielded similar findings. NCPC was significantly and positively associated with incident ADRD; this association may be partially mediated by mood and sleep disorders. Additional prospective studies with longer-term follow-up are warranted to confirm and extend our findings.

The Impact Of Medicare's Mental Health Cost-Sharing Parity On Use Of Mental Health Care Services

Before the implementation of cost-sharing parity in Medicare, beneficiaries faced higher cost sharing for mental health services than for other medical services. The Medicare Improvements for Patients and Providers Act of 2008 phased in cost-sharing reductions in Medicare for outpatient mental health services in the period 2010-14. Using data for 2006-15 from the Medical Expenditure Panel Survey and difference-in-differences analyses, we assessed whether this reduction in mental health cost sharing was associated with changes in specialty and primary care outpatient mental health visits and psychotropic medication fills. We compared people with Medicare and with private insurance before and after parity implementation. Medicare beneficiaries' use of psychotropic medication increased after the implementation of cost-sharing parity, but we did not detect a change in visits. Changes in the use of psychotropic medications were greater among people with probable serious mental illness and among Medicare beneficiaries who did not report having supplemental coverage. The increased medication use could signal improvements in mental health care access among Medicare beneficiaries, especially among the subgroups most likely to benefit from the policy change.

Measuring multimorbidity in older adults: comparing different data sources

Background

Multimorbidity is a global health issue, particularly for older adults in the primary care setting. An adequate portrayal of its epidemiology is essential to properly identify and understand the health care needs of this population. This study aimed to compare the differences in the prevalence of selected chronic conditions and multimorbidity, including its associated characteristics, using health survey/self-reported (SR) information only, administrative (Adm) data only and the combined (either) sources.

Methods

This was a secondary analysis of survey data from the first cycle of the Longitudinal Survey on Senior’s Health and Health Services Use linked to health-Adm data. The analytical sample consisted of 1625 community-dwelling older adults (≥65 years) recruited in the waiting rooms of primary health clinics in a selected administrative region of the province of Quebec. Seventeen chronic conditions were assessed according to two different data sources. We examined the differences in the observed prevalence of chronic conditions and multimorbidity and the agreement between data sources.

Results

The prevalence of each of the 17 chronic conditions ranged from 1.2 to 68.7% depending on the data source. The agreement between different data sources was highly variable, with kappa coefficients (κ) ranging from 0.05 to 0.73. Multimorbidity was very high in this population, with an estimated prevalence of up to 95.9%. In addition, we found that the association between sociodemographic and behavioural factors and the presence of multimorbidity varied according to the different data sources and thresholds.

Conclusions

This is the first study to simultaneously investigate chronic conditions and multimorbidity prevalence among primary care older adults using combined SR and health-Adm data. Our results call attention to (1) the possibility of underestimating cases when using a single data source and (2) the potential benefits of integrating information from different data sources to increase case identification. This is an important aspect of characterizing the health care needs of this fast-growing population.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1173-4) contains supplementary material, which is available to authorized users.

Patient and health system factors associated with hospital readmission in older adults without cognitive impairment

OBJECTIVE

To study the factors associated with hospital readmission.

METHODS

Data used in this study came from a population-based survey of older adults without cognitive impairment. Cox regression was used to assess the factors associated with readmission within a 2-year follow-up period. According to Andersen's model of healthcare seeking behavior, study variables considered included predisposing, enabling and need factors at the individual and health system levels.

RESULTS

Of the 433 participants with an index hospitalization, 97% were discharged with a physical and 3% with a psychiatric disorder. During follow-up, 29% (128/433) were readmitted with a median time to readmission reaching 83 days. The risk of readmission was associated with the following: age, marital status, attraction index of the region of residence for psychiatric services, the presence of an anxio-depressive and other mental disorder, as well as a disorder of the musculoskeletal system. The presence of a physical and psychiatric comorbidity was also associated with readmission.

CONCLUSIONS

Post-discharge follow-up of vulnerable populations with a history of mental disorders and improved availability of psychiatric services in the community are associated with a reduced risk of readmission.

Secondary Analysis of Existing Datasets for Dementia and Palliative Care Research: High-Value Applications and Key Considerations

OBJECTIVE

To provide a guide to researchers selecting a dataset pertinent to the study of palliative care for people with dementia and to aid readers who seek to critically evaluate a secondary analysis study in this domain.

BACKGROUND

The impact of dementia at end-of-life is large and growing. Secondary dataset analysis can play a critical role in advancing research on palliative care for people with dementia.

METHODS

We conducted a broad search of a variety of resources to: 1. identity datasets that include information germane to dementia and palliative care research; 2. review relevant applications of secondary dataset analysis in the published literature; and 3. explore potential validity and reliability concerns.

RESULTS

We synthesize findings regarding: 1. Methodological approaches for determining the presence of dementia; 2. Inclusion and measurement of key palliative care items as they relate to people with dementia; and 3. Sampling and study design issues, including the role and implications of proxy-respondents. We describe and compare a selection of high-value existing datasets relevant to palliative care and dementia research.

DISCUSSION

While secondary analysis of existing datasets requires consideration of key limitations, it can be a powerful tool for efficiently enhancing knowledge of palliative care needs among people with dementia.