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Kaufman BG, Hastings SN, Meyer C, Stechuchak KM, Choate A, Decosimo K, Sullivan C, Wang V, Allen KD, Van Houtven CH. The business case for hospital mobility programs in the veterans health care system: Results from multi-hospital implementation of the STRIDE program. Health Serv Res 2024. [PMID: 38632179 DOI: 10.1111/1475-6773.14307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE To conduct a business case analysis for Department of Veterans Affairs (VA) program STRIDE (ASsisTed EaRly MobIlization for hospitalizeD older VEterans), which was designed to address immobility for hospitalized older adults. DATA SOURCES AND STUDY SETTING This was a secondary analysis of primary data from a VA 8-hospital implementation trial conducted by the Function and Independence Quality Enhancement Research Initiative (QUERI). In partnership with VA operational partners, we estimated resources needed for program delivery in and out of the VA as well as national implementation facilitation in the VA. A scenario analysis using wage data from the Bureau of Labor Statistics informs implementation decisions outside the VA. STUDY DESIGN This budget impact analysis compared delivery and implementation costs for two implementation strategies (Replicating Effective Programs [REP]+CONNECT and REP-only). To simulate national budget scenarios for implementation, we estimated the number of eligible hospitalizations nationally and varied key parameters (e.g., enrollment rates) to evaluate the impact of uncertainty. DATA COLLECTION Personnel time and implementation outcomes were collected from hospitals (2017-2019). Hospital average daily census and wage data were estimated as of 2022 to improve relevance to future implementation. PRINCIPAL FINDINGS Average implementation costs were $9450 for REP+CONNECT and $5622 for REP-only; average program delivery costs were less than $30 per participant in both VA and non-VA hospital settings. Number of walks had the most impact on delivery costs and ranged from 1 to 5 walks per participant. In sensitivity analyses, cost increased to $35 per participant if a physical therapist assistant conducts the walks. Among study hospitals, mean enrollment rates were higher among the REP+CONNECT hospitals (12%) than the REP-only hospitals (4%) and VA implementation costs ranged from $66 to $100 per enrolled. CONCLUSIONS STRIDE is a low-cost intervention, and program participation has the biggest impact on the resources needed for delivering STRIDE. TRIAL REGISTRATION ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017.
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Affiliation(s)
- Brystana G Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Cassie Meyer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Ashley Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Kasey Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Caitlin Sullivan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
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Goetz ME, Ford CB, Greiner MA, Clark A, Johnson KG, Kaufman BG, Mantri S, Xian Y, O'Brien RJ, O'Brien EC, Lusk JB. Racial Disparities in Low-Value Care in the Last Year of Life for Medicare Beneficiaries With Neurodegenerative Disease. Neurol Clin Pract 2024; 14:e200273. [PMID: 38524836 PMCID: PMC10955333 DOI: 10.1212/cpj.0000000000200273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 03/26/2024]
Abstract
Background and Objectives There are racial disparities in health care services received by patients with neurodegenerative diseases, but little is known about disparities in the last year of life, specifically in high-value and low-value care utilization. This study evaluated racial disparities in the utilization of high-value and low-value care in the last year of life among Medicare beneficiaries with dementia or Parkinson disease. Methods This was a retrospective, population-based cohort analysis using data from North and South Carolina fee-for-service Medicare claims between 2013 and 2017. We created a decedent cohort of beneficiaries aged 50 years or older at diagnosis with dementia or Parkinson disease. Specific low-value utilization outcomes were selected from the Choosing Wisely initiative, including cancer screening, peripheral artery stenting, and feeding tube placement in the last year of life. Low-value outcomes included hospitalization, emergency department visits, neuroimaging services, and number of days receiving skilled nursing. High-value outcomes included receipt of occupational and physical therapy, hospice care, and medications indicated for dementia and/or Parkinson disease. Results Among 70,650 decedents, 13,753 were Black, 55,765 were White, 93.1% had dementia, and 7.7% had Parkinson disease. Adjusting for age, sex, Medicaid dual enrollment status, rural vs urban location, state (NC and SC), and comorbidities, Black decedents were more likely to receive low-value care including colorectal cancer screening (adjusted hazard ratio [aHR] 1.46 [1.32-1.61]), peripheral artery stenting (aHR 1.72 [1.43-2.08]), and feeding tube placement (aHR 2.96 [2.70-3.24]) and less likely to receive physical therapy (aHR 0.73 [0.64-0.85)], dementia medications (aHR 0.90 [0.86-0.95]), or Parkinson disease medications (aHR 0.88 [0.75-1.02]) within the last year of life. Black decedents were more likely to be hospitalized (aHR 1.28 [1.25-1.32]), more likely to be admitted to skilled nursing (aHR 1.09 [1.05-1.13]), and less likely to be admitted to hospice (aHR 0.82 [0.79-0.85]) than White decedents. Discussion We found racial disparities in care utilization among patients with neurodegenerative disease in the last year of life, such that Black decedents were more likely to receive specific low-value care services and less likely to receive high-value supportive care than White decedents, even after adjusting for health status and socioeconomic factors.
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Affiliation(s)
- Margarethe E Goetz
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Cassie B Ford
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Melissa A Greiner
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Amy Clark
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Kim G Johnson
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Brystana G Kaufman
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Sneha Mantri
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Ying Xian
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Richard J O'Brien
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Emily C O'Brien
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Jay B Lusk
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
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Hebert PL, Kumbier KE, Smith VA, Hynes DM, Govier DJ, Wong E, Kaufman BG, Shepherd-Banigan M, Rowneki M, Bohnert ASB, Ioannou GN, Boyko EJ, Iwashyna TJ, O’Hare AM, Bowling CB, Viglianti EM, Maciejewski ML. Changes in Outpatient Health Care Use After COVID-19 Infection Among Veterans. JAMA Netw Open 2024; 7:e2355387. [PMID: 38334995 PMCID: PMC10858406 DOI: 10.1001/jamanetworkopen.2023.55387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/18/2023] [Indexed: 02/10/2024] Open
Abstract
Importance The association of COVID-19 infection with outpatient care utilization is unclear. Many studies reported population surveillance studies rather than comparing outpatient health care use between COVID-19-infected and uninfected cohorts. Objective To compare outpatient health care use across 6 categories of care (primary care, specialty care, surgery care, mental health, emergency care, and diagnostic and/or other care) between veterans with or without COVID-19 infection. Design, Setting, and Participants In a retrospective cohort study of Veterans Affairs primary care patients, veterans with COVID-19 infection were matched to a cohort of uninfected veterans. Data were obtained from the Veterans Affairs Corporate Data Warehouse and the Centers for Medicare & Medicaid Services Fee-for-Service Carrier/Physician Supplier file from January 2019 through December 2022. Data analysis was performed from September 2022 to April 2023. Exposure COVID-19 infection. Main Outcomes and Measures The primary outcome was the count of outpatient visits after COVID-19 infection. Negative binomial regression models compared outpatient use over a 1-year preinfection period, and peri-infection (0-30 days), intermediate (31-183 days), and long-term (184-365 days) postinfection periods. Results The infected (202 803 veterans; mean [SD] age, 60.5 [16.2] years; 178 624 men [88.1%]) and uninfected (202 803 veterans; mean [SD] age, 60.4 [16.5] years; 178 624 men [88.1%]) cohorts were well matched across all covariates. Outpatient use in all categories (except surgical care) was significantly elevated during the peri-infection period for veterans with COVID-19 infection compared with the uninfected cohort, with an increase in all visits of 5.12 visits per 30 days (95% CI, 5.09-5.16 visits per 30 days), predominantly owing to primary care visits (increase of 1.86 visits per 30 days; 95% CI, 1.85-1.87 visits per 30 days). Differences in outpatient use attenuated over time but remained statistically significantly higher at 184 to 365 days after infection (increase of 0.25 visit per 30 days; 95% CI, 0.23-0.27 visit per 30 days). One-half of the increased outpatient visits were delivered via telehealth. The utilization increase was greatest for veterans aged 85 years and older (6.1 visits, 95% CI, 5.9-6.3 visits) vs those aged 20 to 44 years (4.8 visits, 95% CI, 4.7-4.8 visits) and unvaccinated veterans (4.5 visits, 95% CI, 4.3-4.6 visits) vs vaccinated veterans (3.2 visits; 95% CI, 3.4-4.8 visits). Conclusions and Relevance This study found that outpatient use increased significantly in the month after infection, then attenuated but remained greater than the uninfected cohorts' use through 12 months, which suggests that there are sustained impacts of COVID-19 infection.
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Affiliation(s)
- Paul L. Hebert
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle
| | - Kyle E. Kumbier
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- Health Management and Policy, Health Data and Informatics Program, Center for Quantitative Life Sciences, College of Health, Oregon State University, Corvallis
| | - Diana J. Govier
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- School of Nursing, Oregon Health & Science University, Portland
| | - Edwin Wong
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle
| | - Brystana G. Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Amy S. B. Bohnert
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - George N. Ioannou
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, University of Washington, Seattle
| | - Edward J. Boyko
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle
| | - Theodore J. Iwashyna
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Ann M. O’Hare
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle
| | - C. Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Elizabeth M. Viglianti
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- School of Nursing, Oregon Health & Science University, Portland
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Kaufman BG, Grant M. GUIDE dementia model: Opportunities for serious illness care. J Am Geriatr Soc 2024. [PMID: 38315037 DOI: 10.1111/jgs.18787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 02/07/2024]
Affiliation(s)
- Brystana G Kaufman
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Institute for Health Policy, Duke University, Washington, DC, USA
| | - Marian Grant
- Coalition to Transform Advanced Care (C-TAC), Washington, DC, USA
- University of Maryland School of Nursing, Baltimore, Maryland, USA
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Kappler CB, Coffman CJ, Stechuchak KM, Choate A, Meyer C, Zullig LL, Hughes JM, Drake C, Sperber NR, Kaufman BG, Van Houtven CH, Allen KD, Hastings SN. Evaluation of strategies to support implementation of a hospital walking program: protocol for a type III effectiveness-implementation hybrid trial. Implement Sci Commun 2024; 5:8. [PMID: 38216967 PMCID: PMC10790254 DOI: 10.1186/s43058-024-00544-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/29/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND STRIDE is a supervised walking program designed to address the negative consequences of immobility during hospitalization for older adults. In an 8-hospital stepped wedge randomized controlled trial, STRIDE was associated with reduced odds of hospital discharge to skilled nursing facility. STRIDE has the potential to become a system-wide approach to address hospital-associated disability in Veteran's Affairs; however, critical questions remain about how best to scale and sustain the program. The overall study goal is to compare the impact of two strategies on STRIDE program penetration (primary), fidelity, and adoption implementation outcomes. METHODS Replicating Effective Programs will be used as a framework underlying all implementation support activities. In a parallel, cluster randomized trial, we will use stratified blocked randomization to assign hospitals (n = 32) to either foundational support, comprised of standard, low-touch activities, or enhanced support, which includes the addition of tailored, high-touch activities if hospitals do not meet STRIDE program benchmarks at 6 and 8 months following start date. All hospitals begin with foundational support for 6 months until randomization occurs. The primary outcome is implementation penetration defined as the proportion of eligible hospitalizations with ≥ 1 STRIDE walks at 10 months. Secondary outcomes are fidelity and adoption with all implementation outcomes additionally examined at 13 and 16 months. Fidelity will be assessed for STRIDE hospitalizations as the percentage of eligible hospital days with "full dose" of the program, defined as two or more documented walks or one walk for more than 5 min. Program adoption is a binary outcome defined as ≥ 5 patients with a STRIDE walk or not. Analyses will also include patient-level effectiveness outcomes (e.g., discharge to nursing home, length of stay) and staffing and labor costs. We will employ a convergent mixed-methods approach to explore and understand pre-implementation contextual factors related to differences in hospital-level adoption. DISCUSSION Our study results will dually inform best practices for promoting successful implementation of an evidence-based hospital-based walking program. This information may support other programs by advancing our understanding of how to apply and scale-up national implementation strategies. TRIAL REGISTRATION This study was registered on June 1, 2021, at ClinicalTrials.gov (identifier NCT04868656 ).
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Affiliation(s)
- Caitlin B Kappler
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA.
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Ashley Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Cassie Meyer
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jaime M Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Section On Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Nina R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Brystana G Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
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6
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Kaufman BG, Holland DE, Vanderboom CE, Ingram C, Wild EM, Dose AM, Stiles C, Gustavson AM, Chun A, Langan EM, Baer-Benson HA, Mandrekar J, Griffin JM. Implementation Costs of Technology-Enhanced Transitional Palliative Care for Rural Caregivers. Am J Hosp Palliat Care 2024; 41:38-44. [PMID: 36798053 PMCID: PMC10427729 DOI: 10.1177/10499091231156145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVES Compared to urban family caregivers (FCG), rural FCG experience greater burdens accessing coordinated care for their loved ones during and after hospitalization. The impact of technology-enhanced transitional palliative care (TPC) on caregiver outcomes is currently being evaluated in a randomized control trial. This study evaluates resource use and health system costs of this FCG-focused TPC intervention and potential Medicare reimbursement mechanisms. METHODS Rural caregivers of hospitalized patients were randomized into an 8-week intervention consisting of video visits conducted by a registered nurse certified in palliative care, supplemented with phone calls and texts (n = 215), or attentional control. Labor costs were estimated for a registered nurse and compared to scenario analyses using a nurse practitioner or social worker wages. Medicare reimbursement scenarios included Transitional Care Management (TCM) and Chronic Care Management (CCM) CPT codes. RESULTS In the base case, TPC cost was $395 per FCG facilitated by a registered nurse, compared to $337 and $585 if facilitated by a social worker or nurse practitioner, respectively. Mean Medicare reimbursement in the TCM-only scenario was $322 and $260 for high or moderate complexity patients, respectively. Reimbursement in the CCM only scenario was $348 and $274 for complex and non-complex patients, respectively. Reimbursement in the TCM+CCM scenario was $496 and $397, for high/complex and moderate/non-complex patients, respectively. CONCLUSION TPC is a feasible, low cost and sustainable strategy to enhance FCG support in rural areas. Potential reimbursement mechanisms are available to offset the costs to the health system for providing transitional palliative care to caregivers of patients recently hospitalized.
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Affiliation(s)
- Brystana G Kaufman
- Population Health Sciences, Duke University School of Medicine, Durham NC, USA
- Margolis Center for Health Policy, Duke University, Durham NC, USA
- Durham VA HSR&D
| | - Diane E Holland
- Kern Center for the Science of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Catherine E Vanderboom
- Kern Center for the Science of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Cory Ingram
- Department of Community Internal Medicine Geriatrics, Palliative Care Mayo Clinic, Rochester, MN, USA
| | - Ellen M Wild
- Department of Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ann Marie Dose
- Kern Center for the Science of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Carole Stiles
- Kern Center for the Science of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Allison M Gustavson
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alice Chun
- Margolis Center for Health Policy, Duke University, Durham NC, USA
| | - Erica M Langan
- Margolis Center for Health Policy, Duke University, Durham NC, USA
| | - Henry A Baer-Benson
- Kern Center for the Science of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Jay Mandrekar
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Joan M Griffin
- Kern Center for the Science of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
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7
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Dennis PA, Stechuchak KM, Van Houtven CH, Decosimo K, Coffman CJ, Grubber JM, Lindquist JH, Sperber NR, Hastings SN, Shepherd‐Banigan M, Kaufman BG, Smith VA. Informing a home time measure reflective of quality of life: A data driven investigation of time frames and settings of health care utilization. Health Serv Res 2023; 58:1233-1244. [PMID: 37356820 PMCID: PMC10622302 DOI: 10.1111/1475-6773.14196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023] Open
Abstract
OBJECTIVE To evaluate short- and long-term measures of health care utilization-days in the emergency department (ED), inpatient (IP) care, and rehabilitation in a post-acute care (PAC) facility-to understand how home time (i.e., days alive and not in an acute or PAC setting) corresponds to quality of life (QoL). DATA SOURCES Survey data on community-residing veterans combined with multipayer administrative data on health care utilization. STUDY DESIGN VA or Medicare health care utilization, quantified as days of care received in the ED, IP, and PAC in the 6 and 18 months preceding survey completion, were used to predict seven QoL-related measures collected during the survey. Elastic net machine learning was used to construct models, with resulting regression coefficients used to develop a weighted utilization variable. This was then compared with an unweighted count of days with any utilization. PRINCIPAL FINDINGS In the short term (6 months), PAC utilization emerged as the most salient predictor of decreased QoL, whereas no setting predominated in the long term (18 months). Results varied by outcome and time frame, with some protective effects observed. In the 6-month time frame, each weighted day of utilization was associated with a greater likelihood of activity of daily living deficits (0.5%, 95% CI: 0.1%-0.9%), as was the case with each unweighted day of utilization (0.6%, 95% CI: 0.3%-1.0%). The same was true in the 18-month time frame (for both weighted and unweighted, 0.1%, 95% CI: 0.0%-0.3%). Days of utilization were also significantly associated with greater rates of instrumental ADL deficits and fair/poor health, albeit not consistently across all models. Neither measure outperformed the other in direct comparisons. CONCLUSIONS These results can provide guidance on how to measure home time using multipayer administrative data. While no setting predominated in the long term, all settings were significant predictors of QoL measures.
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Affiliation(s)
- Paul A. Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Karen M. Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
| | - Courtney H. Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Duke‐Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Kasey Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
| | - Cynthia J. Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Biostatistics and BioinformaticsDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Janet M. Grubber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Cooperative Studies Program Coordinating Center, Veterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
| | - Jennifer H. Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
| | - Nina R. Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - S. Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Geriatrics Research, Education, and Clinical Center, Durham VA Health Care SystemDurhamNorth CarolinaUSA
- Center for the Study of Aging and Human DevelopmentDuke UniversityDurhamNorth CarolinaUSA
| | - Megan Shepherd‐Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Duke‐Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Brystana G. Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Duke‐Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
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8
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Webb S, Drake C, Coffman CJ, Sullivan C, Sperber N, Tucker M, Zullig LL, Hughes JM, Kaufman BG, Pura JA, Anderson L, Hastings SN, Van Houtven CH, Abbate LM, Hoenig H, Ballengee LA, Wang V, Allen KD. Group physical therapy for knee osteoarthritis: protocol for a hybrid type III effectiveness-implementation trial. Implement Sci Commun 2023; 4:125. [PMID: 37828564 PMCID: PMC10571277 DOI: 10.1186/s43058-023-00502-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/09/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Knee osteoarthritis (OA) is a leading cause of chronic pain and disability and one of the most common conditions treated in outpatient physical therapy (PT). Because of the high and growing prevalence of knee OA, there is a need for efficient approaches for delivering exercise-based PT to patients with knee OA. A prior randomized controlled trial (RCT) showed that a 6-session Group Physical Therapy Program for Knee OA (Group PT) yields equivalent or greater improvements in pain and functional outcomes compared with traditional individual PT, while requiring fewer clinician hours per patient to deliver. This manuscript describes the protocol for a hybrid type III effectiveness-implementation trial comparing two implementation packages to support delivery of Group PT. METHODS In this 12-month embedded trial, a minimum of 16 Veterans Affairs Medical Centers (VAMCs) will be randomized to receive one of two implementation support packages for their Group PT programs: a standard, low-touch support based on Replicating Effective Programs (REP) versus enhanced REP (enREP), which adds tailored, high-touch support if sites do not meet Group PT adoption and sustainment benchmarks at 6 and 9 months following launch. Implementation outcomes, including penetration (primary), adoption, and fidelity, will be assessed at 6 and 12 months (primary assessment time point). Additional analyses will include patient-level effectiveness outcomes (pain, function, satisfaction) and staffing and labor costs. A robust qualitative evaluation of site implementation context and experience, as well as site-led adaptations to the Group PT program, will be conducted. DISCUSSION To our knowledge, this study is the first to evaluate the impact of tailored, high-touch implementation support on implementation outcomes when compared to standardized, low-touch support for delivering a PT-based intervention. The Group PT program has strong potential to become a standard offering for PT, improving function and pain-related outcomes for patients with knee OA. Results will provide information regarding the effectiveness and value of this implementation approach and a deeper understanding of how healthcare systems can support wide-scale adoption of Group PT. TRIAL REGISTRATION This study was registered on March 7, 2022 at ClinicalTrials.gov (identifier NCT05282927 ).
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Affiliation(s)
- Sara Webb
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Caitlin Sullivan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Nina Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Matthew Tucker
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jaime M Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Section On Gerontology and Geriatric Medicine, Division of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Brystana G Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - John A Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- AstraZeneca, Durham, NC, USA
| | - Livia Anderson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Lauren M Abbate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center and University of Colorado School of Medicine, Aurora, CO, USA
| | - Helen Hoenig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Physical Medicine and Rehabilitation Services, Durham VA Health Care System, Durham, NC, USA
| | - Lindsay A Ballengee
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA.
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
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Lusk JB, Choi S, Clark AG, Johnson K, Ford CB, Greiner MA, Goetz M, Kaufman BG, O'Brien R, O'Brien EC. Dementia and Parkinson's disease diagnoses in electronic health records vs. Medicare claims data: a study of 101,980 linked patients. BMC Neurol 2023; 23:325. [PMID: 37700254 PMCID: PMC10496225 DOI: 10.1186/s12883-023-03361-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/07/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Medicare claims and electronic health record data are both commonly used for research and clinical practice improvement; however, it is not known how concordant diagnoses of neurodegenerative diseases (NDD, comprising dementia and Parkinson's disease) are in these data types. Therefore, our objective was to determine the sensitivity and specificity of neurodegenerative disease (NDD) diagnoses contained in structured electronic health record (EHR) data compared to Medicare claims data. METHODS This was a retrospective cohort study of 101,980 unique patients seen at a large North Carolina health system between 2013-2017, which were linked to 100% North and South Carolina Medicare claims data, to evaluate the accuracy of diagnoses of neurodegenerative diseases in EHRs compared to Medicare claims data. Patients age > 50 who were enrolled in fee-for-service Medicare were included in the study. Patients were classified as having or not having NDD based on the presence of validated ICD-CM-9 or ICD-CM-10 codes associated with NDD or claims for prescription drugs used to treat NDD. EHR diagnoses were compared to Medicare claims diagnoses. RESULTS The specificity of any EHR diagnosis of NDD was 99.0%; sensitivity was 61.3%. Positive predictive value and negative predictive value were 90.8% and 94.1% respectively. Specificity of an EHR diagnosis of dementia was 99.0%, and sensitivity was 56.1%. Specificity of an EHR diagnosis of PD was 99.7%, while sensitivity was 76.1%. CONCLUSIONS More research is needed to investigate under-documentation of NDD in electronic health records relative to Medicare claims data, which has major implications for clinical practice (particularly patient safety) and research using real-world data.
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Affiliation(s)
- Jay B Lusk
- Duke University School of Medicine, DUMC 3710, Durham, NC, 27710, USA.
- Duke University Fuqua School of Business, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Department of Neurology, Duke University, Durham, NC, USA.
| | - Sujung Choi
- Janssen Scientific Affairs, Inc, Titusville, NJ, USA
| | - Amy G Clark
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Kim Johnson
- Department of Neurology, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Brystana G Kaufman
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Emily C O'Brien
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
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Ramos K, Kaufman BG, Winger JG, Boggins A, Van Houtven CH, Porter LS, Hastings SN. Knowledge, goals, and misperceptions about palliative care in adults with chronic disease or cancer. Palliat Support Care 2023:1-7. [PMID: 37559194 PMCID: PMC10858297 DOI: 10.1017/s1478951523001141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
OBJECTIVES Limited evidence investigates how knowledge, misconceptions, and beliefs about palliative care vary across patients with cancerous versus non-cancerous chronic disease. We examined the knowledge of and misconceptions about palliative care among these groups. METHODS We used weighted data from the National Cancer Institute Health Information National Trends Survey 5 (Cycle 2) for nationally representative estimates and logistic regression to adjust for respondent characteristics. We identified respondents who reported having (1) cancer ([n = 585]; breast, lung, and colorectal), (2) chronic conditions ([n = 543]; heart failure, lung disease, or chronic obstructive pulmonary disorder), or (3) neither cancer nor other chronic conditions (n = 2,376). RESULTS Compared to cancer respondents, chronic condition respondents were more likely to report being Black or Hispanic, report a disability, and have lower socioeconomic status. In the sample, 65.6% of cancer respondents and 72.8% chronic conditions respondents reported they had never heard of palliative care. Chronic condition respondents were significantly (p < 0.05) less likely to report high palliative care knowledge than cancer respondents (9.1% vs. 16.6%, respectively). In adjusted analyses, cancer respondents had greater odds of high palliative care knowledge (odd ratio [OR] = 1.70; 95% confidence interval [CI] = 1.01, 2.86) compared to respondents with neither cancer nor chronic disease; chronic condition respondents did not have increased odds (OR = 0.96; CI = 0.59, 1.54). SIGNIFICANCE OF RESULTS Disparities in palliative care knowledge exist among people with non-cancerous chronic disease compared to cancer. Supportive educational efforts to boost knowledge about palliative care remains urgent and is critical for promoting equity, particularly for underserved people with chronic illnesses.
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Affiliation(s)
- Katherine Ramos
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, 27705, USA
- Geriatric Research, Education, and Clinical Center, (GRECC) Durham VA Health Care System, Durham, NC, 27705, USA
- Center for the Study of Human Aging and Development, Duke University, Durham, NC, 27705, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, 27705, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, 27705, USA
- Duke Cancer Institute, Duke University Health System, Durham, NC, 27705, USA
| | - Brystana G. Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, 27705, USA
| | - Joseph G. Winger
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, 27705, USA
- Duke Cancer Institute, Duke University Health System, Durham, NC, 27705, USA
| | - Abby Boggins
- University of Utah, Salt Lake City, UT, 84112, USA
| | - Courtney H. Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, 27705, USA
| | - Laura S. Porter
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, 27705, USA
- School of Nursing, Duke University Durham NC, 27705, USA
| | - S. Nicole Hastings
- Geriatric Research, Education, and Clinical Center, (GRECC) Durham VA Health Care System, Durham, NC, 27705, USA
- Center for the Study of Human Aging and Development, Duke University, Durham, NC, 27705, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, 27705, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, 27705, USA
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11
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Kaufman BG, Jones KA, Greiner MA, Giri A, Stewart L, He A, Clark AG, Taylor DH, Bundorf MK, Whitaker RG, Van Houtven CH, Higgins A. Health Care Use and Spending Among Need-Based Subgroups of Medicare Beneficiaries With Full Medicaid Benefits. JAMA Health Forum 2023; 4:e230973. [PMID: 37171797 PMCID: PMC10182424 DOI: 10.1001/jamahealthforum.2023.0973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Importance Beneficiaries dual eligible for Medicare and Medicaid account for a disproportionate share of expenditures due to their complex care needs. Lack of coordination between payment programs creates misaligned incentives, resulting in higher costs, fragmented care, and poor health outcomes. Objective To inform the design of integrated programs by describing the health care use and spending for need-based subgroups in North Carolina's full benefit, dual-eligible population. Design, Setting, and Participants This cross-sectional study using Medicare and North Carolina Medicaid 100% claims data (2014-2017) linked at the individual level included Medicare beneficiaries with full North Carolina Medicaid benefits. Data were analyzed between 2021 and 2022. Exposure Need-based subgroups: community well, home- and community-based services (HCBS) users, nursing home (NH) residents, and intensive behavioral health (BH) users. Measures Medicare and Medicaid utilization and spending per person-year (PPY). Results The cohort (n = 333 240) comprised subgroups of community well (64.1%, n = 213 667), HCBS users (15.0%, n = 50 095), BH users (15.2%, n = 50 509), and NH residents (7.5%, n = 24 927). Overall, 61.1% reported female sex. The most common racial identities included Asian (1.8%), Black (36.1%), and White (58.7%). Combined spending for Medicare and Medicaid was $26 874 PPY, and the funding of care was split evenly between Medicare and Medicaid. Among need-based subgroups, combined spending was lowest among community well at $19 734 PPY with the lowest portion (38.5%) of spending contributed by Medicaid ($7605). Among NH residents, overall spending ($68 359) was highest, and the highest portion of spending contributed by Medicaid (70.1%). Key components of spending among HCBS users' combined total of $40 069 PPY were clinician services on carrier claims ($14 523) and outpatient facility services ($9012). Conclusions and relevance Federal and state policy makers and administrators are developing strategies to integrate Medicare- and Medicaid-funded health care services to provide better care to the people enrolled in both programs. Substantial use of both Medicare- and Medicaid-funded services was found across all need-based subgroups, and the services contributing a high proportion of the total spending differed across subgroups. The diversity of health care use suggests a tailored approach to integration strategies with comprehensive set benefits that comprises Medicare and Medicaid services, including long-term services and supports, BH, palliative care, and social services.
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Affiliation(s)
- Brystana G Kaufman
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina
| | - Kelley A Jones
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Melissa A Greiner
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Abhigya Giri
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Lucas Stewart
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Amanda He
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Amy G Clark
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Donald H Taylor
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Sanford School of Public Health Policy, Duke University, Durham, North Carolina
| | - M Kate Bundorf
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Sanford School of Public Health Policy, Duke University, Durham, North Carolina
| | - Rebecca G Whitaker
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Courtney H Van Houtven
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina
| | - Aparna Higgins
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Founder, Ananya Health Solutions LLC, Dunn Loring, Virginia
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Griffin JM, Vanderboom CE, Gustavson A, Kaufman BG, Ingram C, Wild E, Dose AM, Mandrekar J, Holland DE. A Methodological Approach for Documenting Multi-Component Interventions Targeting Family Caregivers. J Appl Gerontol 2023; 42:487-492. [PMID: 36341961 PMCID: PMC9957899 DOI: 10.1177/07334648221137882] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Managing the complex care needs of seriously ill patients transitioning from hospital to home can have detrimental effects on family caregivers (FCG). Multi-component interventions tailored to FCG needs are most effective at reducing caregiver burden, distress, and depression. However, gaps exist in determining best methods to assess, document, and analyze intervention components for FCGs. Common methods used to capture patient data during transitions in care may not be appropriate or allowed for FCG needs. As such, we present a methodological approach for electronically capturing, reporting, and analyzing multiple intervention components. This approach uses a standardized terminology and pathway for tailoring intervention components in real time while evaluating intervention effects across time. We use examples from a randomized controlled trial to illustrate the benefits of the current approach for analyzing the effectiveness of multi-component interventions in the context of caregiving research.
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Affiliation(s)
- Joan M. Griffin
- Professor of Health Services Research, Division of Health Care Delivery Research (HCDR) and Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota,Corresponding and reprint request author: Joan M. Griffin, PhD, 200 1 Street SW, Rochester, MN 55905, , Phone: 507-538-1490, Fax: 507-284-1731
| | - Catherine E. Vanderboom
- Principal Health Services Analyst, Health Services Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Allison Gustavson
- Core Investigator, Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System and Assistant Professor, Department of Medicine, University of Minnesota
| | - Brystana G Kaufman
- Assistant Professor of Population Health Sciences, Duke University, Durham, North Carolina
| | - Cory Ingram
- Assistant Professor of Family Medicine and Palliative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ellen Wild
- Research Interventionist, Mayo Clinic, Rochester, Minnesota
| | - Ann Marie Dose
- Principal Health Services Analyst, Health Services Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Jay Mandrekar
- Professor, Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Diane E. Holland
- Principal Health Services Analyst, Health Services Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
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Lusk JB, Ford C, Clark AG, Greiner MA, Johnson K, Goetz M, Kaufman BG, Mantri S, Xian Y, O'Brien R, O'Brien EC. Racial/ethnic disparities in dementia incidence, outcomes, and health‐care utilization. Alzheimers Dement 2022. [DOI: 10.1002/alz.12891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Jay B. Lusk
- Duke University School of Medicine Durham North Carolina USA
- Duke University Fuqua School of Business Durham North Carolina USA
| | - Cassie Ford
- Department of Population Health Sciences Duke University Durham North Carolina USA
| | - Amy G. Clark
- Department of Population Health Sciences Duke University Durham North Carolina USA
| | - Melissa A. Greiner
- Department of Population Health Sciences Duke University Durham North Carolina USA
| | - Kim Johnson
- Department of Neurology Duke University Durham North Carolina USA
- Department of Psychiatry and Behavioral Sciences Duke University Duke University Medical Center Durham North Carolina USA
| | - Margarethe Goetz
- Department of Neurology Duke University Durham North Carolina USA
| | - Brystana G. Kaufman
- Department of Population Health Sciences Duke University Durham North Carolina USA
| | - Sneha Mantri
- Department of Neurology Duke University Durham North Carolina USA
| | - Ying Xian
- Department of Neurology University of Texas‐Southwestern Dallas Texas USA
- Department of Population and Data Sciences University of Texas‐Southwestern Dallas Texas USA
| | - Richard O'Brien
- Department of Neurology Duke University Durham North Carolina USA
| | - Emily C. O'Brien
- Department of Population Health Sciences Duke University Durham North Carolina USA
- Department of Neurology Duke University Durham North Carolina USA
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14
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Freed SS, Kaufman BG, Van Houtven CH, Saunders R. Using a home time measure to differentiate ACO performance for seriously ill populations. J Am Geriatr Soc 2022; 70:2666-2676. [PMID: 35620814 DOI: 10.1111/jgs.17882] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/16/2022] [Accepted: 04/23/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Alternative Payment Models (APMs) piloted by the Centers for Medicare and Medicaid Services (CMS) such as ACO Realizing Equity, Access and Community Health (REACH) seek to improve care and quality of life among seriously ill populations (SIP). Days at Home (DAH) was proposed for use in this model to evaluate organizational performance. It is important to assess the utility and feasibility of person-centered outcomes measures, such as DAH, as CMS seeks to advance care models for seriously ill beneficiaries. We leverage existing Accountable Care Organization (ACO) contracts to evaluate the feasibility of ACO-level DAH measure and examine characteristics associated with ACOs with more DAH. METHODS We calculated DAH for Medicare fee-for-service beneficiaries aged 68 and over who were retrospectively attributed to a Medicare ACO between 2014 and 2018 and met the seriously ill criteria. We then aggregated to the ACO level DAH for each ACO's seriously ill beneficiaries and risk-adjusted this aggregated measure. Finally, we evaluated associations between risk-adjusted DAH per person-year and ACO, beneficiary, and market characteristics. RESULTS ACOs' seriously ill beneficiaries spent an average of 349.3 risk-adjusted DAH per person-year. Risk-adjusted ACO variation, defined as the interquartile range, was 4.21 days (IQR = 347.32-351.53). Beneficiaries of ACOs are composed of a less racially diverse beneficiary cohort, opting for two-sided risk models, and operating in markets with fewer hospital and Skilled Nursing Facility beds had more DAH. CONCLUSIONS Substantial variation across ACOs in the DAH measure for seriously ill beneficiaries suggests the measure can differentiate between high and low performing provider groups. Key to the success of the metric is accurate risk adjustment to ensure providers have adequate resources to care for seriously ill beneficiaries. Organizational factors, such as the ACO size and level of risk, are strongly associated with more days at home.
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Affiliation(s)
- Salama S Freed
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,National Pharmaceutical Council, Washington, District of Columbia, USA
| | - Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Courtney H Van Houtven
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Robert Saunders
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
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15
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Golla V, Allen Lapointe NM, Silberberg M, Wang V, Lentz TA, Kaye DR, Sorenson C, Saunders R, Kaufman BG. Improving health equity for older people with serious illness through value based payment reform. J Am Geriatr Soc 2022; 70:2180-2185. [PMID: 35474173 DOI: 10.1111/jgs.17815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Vishnukamal Golla
- National Clinician Scholars Program, Duke University, Durham, North Carolina, USA.,Department of Surgery, Division of Urology, Duke University School of Medicine, Durham, North Carolina, USA.,Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Nancy M Allen Lapointe
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mina Silberberg
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Virginia Wang
- Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Trevor A Lentz
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Deborah R Kaye
- Department of Surgery, Division of Urology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA.,Duke Cancer Institute, Durham, North Carolina, USA
| | - Corinna Sorenson
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA.,Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - Robert Saunders
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Brystana G Kaufman
- Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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16
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Kaufman BG, Allen KD, Coffman CJ, Woolson S, Caves K, Hall K, Hoenig HM, Huffman KM, Morey MC, Hodges NJ, Ramasunder S, van Houtven CH. Cost and Quality of Life Outcomes of the STepped Exercise Program for Patients With Knee OsteoArthritis Trial. Value Health 2022; 25:614-621. [PMID: 35365305 DOI: 10.1016/j.jval.2021.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/31/2021] [Accepted: 09/30/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aimed to evaluate the cost-effectiveness of the randomized clinical trial STEP-KOA (STepped Exercise Program for patients with Knee OsteoArthritis). METHODS The trial included 230 intervention and 115 control participants from 2 Veterans Affairs (VA) medical centers. A decision tree simulated outcomes for cohorts of patients receiving arthritis education (control) or STEP-KOA (intervention), which consisted of an internet-based exercise training program (step 1), phone counseling (step 2), and physical therapy (step 3) according to patient's response. Intervention costs were assessed from the VA perspective. Quality of life (QOL) was measured using 5-level EQ-5D US utility weights. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in costs divided by the difference in quality-adjusted life-years (QALYs) between arms at 9 months. A Monte Carlo probabilistic sensitivity analysis was used to generate a cost-effectiveness acceptability curve. RESULTS The adjusted model found differential improvement in QOL utility weights of 0.042 (95% confidence interval 0.003-0.080; P=.03) for STEP-KOA versus control at 9 months. In the base case, STEP-KOA resulted in an incremental gain of 0.028 QALYs and an incremental cost of $279 per patient for an ICER of $10 076. One-way sensitivity analyses found the largest sources of variation in the ICER were the impact on QOL and the need for a VA-owned tablet. The probabilistic sensitivity analysis found a 98% probability of cost-effectiveness at $50 000 willingness-to-pay per QALY. CONCLUSIONS STEP-KOA improves QOL and has a high probability of cost-effectiveness. Resources needed to implement the program will decline as ownership of mobile health devices increases.
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Affiliation(s)
- Brystana G Kaufman
- Duke University, Durham, NC, USA; Durham VA Medical Center, Durham, NC, USA.
| | - Kelli D Allen
- Durham VA Medical Center, Durham, NC, USA; University of North Carolina, Chapel Hill, NC
| | - Cynthia J Coffman
- Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | | | - Kevin Caves
- Durham VA Medical Center, Durham, NC, USA; Duke Older Americans Independence Center, Duke University Medical Center, Durham, NC, USA
| | - Katherine Hall
- Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA; Duke Older Americans Independence Center, Duke University Medical Center, Durham, NC, USA
| | - Helen M Hoenig
- Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA; Duke Older Americans Independence Center, Duke University Medical Center, Durham, NC, USA
| | - Kim M Huffman
- Duke University, Durham, NC, USA; Durham VA Medical Center, Durham, NC, USA; Duke Older Americans Independence Center, Duke University Medical Center, Durham, NC, USA
| | - Miriam C Morey
- Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA; Duke Older Americans Independence Center, Duke University Medical Center, Durham, NC, USA
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17
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Griffin JM, Kaufman BG, Bangerter L, Holland DE, Vanderboom CE, Ingram C, Wild E, Dose AM, Stiles C, Thompson V. Improving Transitions in Care for Patients and Family Caregivers Living in Rural and Underserved Areas: The Caregiver Advise, Record, Enable (CARE) Act. J Aging Soc Policy 2022:1-8. [PMID: 35156557 PMCID: PMC9374844 DOI: 10.1080/08959420.2022.2029272] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
In this Perspective, we contend bold action is needed to improve transitions from hospitals to home for aging patients and their family caregivers living in rural and underserved areas. The Caregiver Advise, Record, Enable (CARE) Act, passed in over 40 US states, is intended to provide family caregivers of hospitalized patients with the knowledge and skills needed for safe and efficient transitions. It has broken important ground for family caregivers who assist with transitions in patient care. It may fall short, however, in addressing the unique needs of family caregivers living in rural and underserved areas. We contend that to realize the intended safety, cost, and care quality benefits of the CARE Act, especially for those living in rural and underserved areas, states need to expand the Act's scope. We provide three recommendations: 1) modify hospital information systems to support the care provided by family caregivers; 2) require assessments of family caregivers that reflect the challenges of family caregiving in rural and underserved areas; and 3) identify local resources to improve discharge planning. We describe the rationale for each recommendation and the potential ways that an expanded CARE Act could reduce the risks associated with transitions in care for aging patients.
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Affiliation(s)
- Joan M. Griffin
- Division of Health Care Delivery Research (HCDR) and Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1 Street SW, Rochester, MN 55905
| | | | | | - Diane E. Holland
- Health Services Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Catherine E. Vanderboom
- Health Services Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | | | | | - Ann Marie Dose
- Health Services Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
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18
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Granger BB, Tulsky JA, Kaufman BG, Clare RM, Anstrom K, Mark DB, Johnson KA, Patel CB, Fiuzat M, Steinhauser K, O’Connor C, Rogers JG, Mentz RJ. Polypharmacy in Palliative Care for Advanced Heart Failure: The PAL-HF Experience. J Card Fail 2022; 28:334-338. [PMID: 34628013 PMCID: PMC8898052 DOI: 10.1016/j.cardfail.2021.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/20/2021] [Accepted: 08/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Palliative care (PC) in advanced heart failure (HF) aims to improve symptoms and quality of life (QOL), in part through medication management. The impact of PC on polypharmacy (>5 medications) remains unknown. METHODS AND RESULTS We explored patterns of polypharmacy in the Palliative Care in HF (PAL-HF) randomized controlled trial of standard care vs interdisciplinary PC in advanced HF (N = 150). We describe differences in medication counts between arms at 2, 6, 12, and 24 weeks for HF (12 classes) and PC (6 classes) medications. General linear mixed models were used to evaluate associations between treatment arm and polypharmacy over time. The median age of the patients was 72 years (interquartile range 62-80 years), 47% were female, and 41% were Black. Overall, 48% had ischemic etiology, and 55% had an ejection fraction of 40% or less. Polypharmacy was present at baseline in 100% of patients. HF and PC medication counts increased in both arms, with no significant differences in counts by drug class at any time point between arms. CONCLUSIONS In a trial of patients with advanced HF considered eligible for PC, polypharmacy was universal at baseline and increased during follow-up with no effect of the palliative intervention on medication counts relative to standard care.
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Affiliation(s)
- Bradi B. Granger
- School of Nursing, Duke University, 307 Trent Drive, Durham, NC 27710, USA,Margolis Center for Health Policy, Duke University, 100 Fuqua Drive, Box 90120, Durham, NC 27708, USA
| | - James A. Tulsky
- Dana-Farber Institute, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA,Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Brystana G. Kaufman
- Margolis Center for Health Policy, Duke University, 100 Fuqua Drive, Box 90120, Durham, NC 27708, USA,Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC 27701, USA
| | - Robert M. Clare
- Duke Clinical Research Institute, 200 Morris Street, Durham, NC 27701, USA
| | - Kevin Anstrom
- Duke Clinical Research Institute, 200 Morris Street, Durham, NC 27701, USA
| | - Daniel B. Mark
- Duke Clinical Research Institute, 200 Morris Street, Durham, NC 27701, USA,Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA
| | - Kimberly A. Johnson
- Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA
| | - Chetan B. Patel
- Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA
| | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA
| | - Karen Steinhauser
- Margolis Center for Health Policy, Duke University, 100 Fuqua Drive, Box 90120, Durham, NC 27708, USA
| | - Christopher O’Connor
- Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA
| | - Joseph G. Rogers
- Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA
| | - Robert J. Mentz
- Duke Clinical Research Institute, 200 Morris Street, Durham, NC 27701, USA,Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA
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19
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Brown K, El Husseini N, Grimley R, Ranta A, Kass-Hout T, Kaplan S, Kaufman BG. Alternative Payment Models and Associations With Stroke Outcomes, Spending, and Service Utilization: A Systematic Review. Stroke 2021; 53:268-278. [PMID: 34727742 DOI: 10.1161/strokeaha.121.033983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.
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Affiliation(s)
- Kelby Brown
- Duke University School of Medicine, Durham, NC (K.B., N.E.H., S.K.).,Margolis Center for Health Policy Duke University, Durham, NC (K.B., B.G.K.)
| | - Nada El Husseini
- Duke University School of Medicine, Durham, NC (K.B., N.E.H., S.K.).,Department of Neurology, Duke University, Durham, NC (N.E.H.)
| | - Rohan Grimley
- School of Medicine, Griffith University, Birtinya, Queensland, Australia (R.G.)
| | - Annemarei Ranta
- University of Otago School of Medicine, Wellington, New Zealand (A.R.)
| | - Tareq Kass-Hout
- Department of Neurology, The University of Chicago Pritzker School of Medicine, Chicago, IL (T.K.-H.)
| | - Samantha Kaplan
- Duke University School of Medicine, Durham, NC (K.B., N.E.H., S.K.)
| | - Brystana G Kaufman
- Margolis Center for Health Policy Duke University, Durham, NC (K.B., B.G.K.).,Population Health Sciences, Duke University School of Medicine, Durham NC (B.G.K.).,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, NC (B.G.K.)
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20
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Kaufman BG, Whitaker R, Mahendraratnam N, Hurewitz S, Yi J, Smith VA, McClellan M. State variation in effects of state social distancing policies on COVID-19 cases. BMC Public Health 2021; 21:1239. [PMID: 34182972 PMCID: PMC8237534 DOI: 10.1186/s12889-021-11236-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/08/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The novel coronavirus disease 2019 (COVID-19) sickened over 20 million residents in the United States (US) by January 2021. Our objective was to describe state variation in the effect of initial social distancing policies and non-essential business (NEB) closure on infection rates early in 2020. METHODS We used an interrupted time series study design to estimate the total effect of all state social distancing orders, including NEB closure, shelter-in-place, and stay-at-home orders, on cumulative COVID-19 cases for each state. Data included the daily number of COVID-19 cases and deaths for all 50 states and Washington, DC from the New York Times database (January 21 to May 7, 2020). We predicted cumulative daily cases and deaths using a generalized linear model with a negative binomial distribution and a log link for two models. RESULTS Social distancing was associated with a 15.4% daily reduction (Relative Risk = 0.846; Confidence Interval [CI] = 0.832, 0.859) in COVID-19 cases. After 3 weeks, social distancing prevented nearly 33 million cases nationwide, with about half (16.5 million) of those prevented cases among residents of the Mid-Atlantic census division (New York, New Jersey, Pennsylvania). Eleven states prevented more than 10,000 cases per 100,000 residents within 3 weeks. CONCLUSIONS The effect of social distancing on the infection rate of COVID-19 in the US varied substantially across states, and effects were largest in states with highest community spread.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA.
- Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.
| | - Rebecca Whitaker
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
| | - Nirosha Mahendraratnam
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
| | - Sophie Hurewitz
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
| | - Jeremy Yi
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
| | - Valerie A Smith
- Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
- General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Mark McClellan
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
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21
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Miller KEM, Miller KL, Knocke K, Pink GH, Holmes GM, Kaufman BG. Access to outpatient services in rural communities changes after hospital closure. Health Serv Res 2021; 56:788-801. [PMID: 34173227 DOI: 10.1111/1475-6773.13694] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/19/2021] [Accepted: 05/22/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Between January 2005 and July 2020, 171 rural hospitals closed across the United States. Little is known about the extent that other providers step in to fill the potential reduction in access from a rural hospital closure. The objective of this analysis is to evaluate the trends of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) in rural areas prior to and following hospital closure. DATA SOURCES/STUDY SETTING We used publicly available data from Centers for Medicare and Medicaid Provider of Services files, Cecil G. Sheps Center rural hospital closures list, and Small Area Income and Poverty Estimates. STUDY DESIGN We described the trends over time in the number of hospitals, hospital closures, FQHC sites, and RHCs in rural and urban ZIP codes, 2006-2018. We used two-way fixed effects and pooled generalized linear models with a logit link to estimate the probabilities of having any RHC and any FQHC within 10 straight-line miles. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS Compared to hospitals that never closed, the predicted probability of having any FQHC within 10 miles increased post closure by 5.95 and 11.57 percentage points at 1 year and 5 years, respectively (p < 0.05). The predicted probability of having any RHC within 10 miles was not significantly different following rural hospital closure. A percentage point increase in poverty rate was associated with a 1.98 and a 1.29 percentage point increase in probabilities of having an FQHC or RHC, respectively (p < 0.001). CONCLUSIONS In areas previously served by a rural hospital, there is a higher probability of new FQHC service-delivery sites post closure. This suggests that some of the potential reductions in access to essential preventive and diagnostic services may be filled by FQHCs. However, many rural communities may have a persistent unmet need for preventive and therapeutic care.
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Affiliation(s)
- Katherine E M Miller
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | | | - Kathleen Knocke
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - George H Pink
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - G Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brystana G Kaufman
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
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22
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Langan E, Kamal AH, Miller KEM, Kaufman BG. Comparing Palliative Care Knowledge in Metropolitan and Nonmetropolitan Areas of the United States: Results from a National Survey. J Palliat Med 2021; 24:1833-1839. [PMID: 34061644 DOI: 10.1089/jpm.2021.0114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Despite recent growth in access to specialty palliative care (PC) services, awareness of PC by patients and caregivers is limited and misconceptions about PC persist. Identifying gaps in PC knowledge may help inform initiatives that seek to reduce inequities in access to PC in rural areas. Objective: We compared knowledge of PC in metropolitan and nonmetropolitan areas of the United States using a nationally representative sample of U.S. adults. Design: We used data from the 2018 Health Information National Trends Survey (HINTS) 5 Cycle 2 to compare prevalence and predictors of PC knowledge and misconceptions in nonmetropolitan and metropolitan areas as defined by the 2013 Urban-Rural Classification (URC) Scheme for Counties. We estimated the association between nonmetro status and knowledge of PC, adjusted for respondent characteristics, using multivariable logistic regression. Results: More respondents reported that they had never heard of PC in nonmetro (78.8%) than metro (70.1%) areas (p < 0.05). Controlling for other factors, nonmetro residence was associated with a 41% lower odds of PC knowledge (odds ratio [OR] = 0.59; 95% confidence interval [CI] = 0.37-0.94), and Hispanic respondents also demonstrated significantly lower odds of PC knowledge conditional on rural status (OR = 0.47; CI = 0.27-0.83). Misconceptions about PC were high in both metro and nonmetro areas. Conclusion: Awareness of PC was lower in rural and micropolitan areas compared with metropolitan areas, suggesting the need for tailored educational strategies. The reduced awareness of PC among Hispanic respondents regardless of rural status raises concerns about equitable access to PC services for this population.
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Affiliation(s)
- Erica Langan
- Trinity College of Arts and Sciences, Duke University, Durham, North Carolina, USA
| | - Arif H Kamal
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine E M Miller
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Brystana G Kaufman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
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23
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Kaufman BG, Van Houtven CH, Greiner MA, Hammill BG, Harker M, Anderson D, Petry S, Bull J, Taylor DH. Selection Bias in Observational Studies of Palliative Care: Lessons Learned. J Pain Symptom Manage 2021; 61:1002-1011.e2. [PMID: 32947017 DOI: 10.1016/j.jpainsymman.2020.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/25/2022]
Abstract
CONTEXT Palliative care (PC) programs are typically evaluated using observational data, raising concerns about selection bias. OBJECTIVES To quantify selection bias because of observed and unobserved characteristics in a PC demonstration program. METHODS Program administrative data and 100% Medicare claims data in two states and a 20% sample in eight states (2013-2017). The sample included 2983 Medicare fee-for-service beneficiaries aged 65+ participating in the PC program and three matched cohorts: regional; two states; and eight states. Confounding because of observed factors was measured by comparing patient baseline characteristics. Confounding because of unobserved factors was measured by comparing days of follow-up and six-month and one-year mortality rates. RESULTS After matching, evidence for observed confounding included differences in observable baseline characteristics, including race, morbidity, and utilization. Evidence for unobserved confounding included significantly longer mean follow-up in the regional, two-state, and eight-state comparison cohorts, with 207 (P < 0.001), 192 (P < 0.001), and 187 (P < 0.001) days, respectively, compared with the 162 days for the PC cohort. The PC cohort had higher six-month and one-year mortality rates of 53.5% and 64.5% compared with 43.5% and 48.0% in the regional comparison, 53.4% and 57.4% in the two-state comparison, and 55.0% and 59.0% in the eight-state comparison. CONCLUSION This case study demonstrates that selection of comparison groups impacts the magnitude of measured and unmeasured confounding, which may change effect estimates. The substantial impact of confounding on effect estimates in this study raises concerns about the evaluation of novel serious illness care models in the absence of randomization. We present key lessons learned for improving future evaluations of PC using observational study designs.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.
| | - Courtney H Van Houtven
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew Harker
- Social Science Research Institute, Duke University, Durham, North Carolina, USA
| | - David Anderson
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Sarah Petry
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | - Donald H Taylor
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA; Sanford School of Public Policy, Duke University, Durham, North Carolina, USA; Social Science Research Institute, Duke University, Durham, North Carolina, USA
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Kaufman BG, Granger BB, Sun JL, Sanders G, Taylor DH, Mark DB, Warraich H, Fiuzat M, Steinhauser K, Tulsky JA, Rogers JG, O'Connor C, Mentz RJ. The Cost-Effectiveness of Palliative Care: Insights from the PAL-HF Trial. J Card Fail 2021; 27:662-669. [PMID: 33731305 DOI: 10.1016/j.cardfail.2021.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In a randomized control trial, Palliative Care in Heart Failure (PAL-HF) improved heart failure-related quality of life, though cost-effectiveness remains unknown. The aim of this study was to evaluate the cost-effectiveness of the PAL-HF trial, which provided outpatient palliative care to patients with advanced heart failure. METHODS AND RESULTS Outcomes for usual care and PAL-HF strategies were compared using a Markov cohort model over 36 months from a payer perspective. The model parameters were informed by PAL-HF trial data and supplemented with meta-analyses and Medicare administrative data. Outcomes included hospitalization, place of death, Medicare expenditures, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Simulated mortality rates were the same for PAL-HF and usual care cohorts, at 89.7% at 36 months. In the base case analysis, the PAL-HF intervention resulted in an incremental gain of 0.03 QALYs and an incremental cost of $964 per patient for an incremental cost-effectiveness ratio of $29,041 per QALY. In 1-way sensitivity analyses, an intervention cost of up to $140 per month is cost effective at $50,000 per QALY. Of 1000 simulations, the PC intervention had a 66.1% probability of being cost effective at a $50,000 willingness-to-pay threshold assuming no decrease in hospitalization. In a scenario analysis, PAL-HF decreased payer spending through reductions in noncardiovascular hospitalizations. CONCLUSIONS These results from this single-center trial are encouraging that palliative care for advanced heart failure is an economically attractive intervention. Confirmation of these findings in larger multicenter trials will be an important part of developing the evidence to support more widespread implementation of the PAL-HF palliative care intervention.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina.
| | - Bradi B Granger
- Margolis Center for Health Policy, Duke University, Durham, North Carolina; School of Nursing, Duke University, Durham, North Carolina
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, North Carolina
| | - Gillian Sanders
- Margolis Center for Health Policy, Duke University, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Donald H Taylor
- Margolis Center for Health Policy, Duke University, Durham, North Carolina; Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Daniel B Mark
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Mona Fiuzat
- Duke University School of Medicine, Durham, North Carolina
| | | | - James A Tulsky
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
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25
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Cross SH, Kaufman BG, Quest TE, Warraich HJ. National Trends in Hospice Facility Deaths in the United States, 2003-2017. J Pain Symptom Manage 2021; 61:350-357. [PMID: 32858165 DOI: 10.1016/j.jpainsymman.2020.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT Hospice facilities are increasingly preferred as a location of death, but little is known about the characteristics of patients who die in these facilities in the U.S. OBJECTIVES We sought to examine the trends and factors associated with death in a hospice facility. METHODS Retrospective cross-sectional study using mortality data for years 2003-2017 for deaths attributed to natural causes in the U.S. RESULTS The proportion of natural deaths occurring in hospice facilities increased from 0.2% in 2003 to 8.3% in 2017, resulting in nearly 1.7 million deaths during this time frame. Females had increased odds of hospice facility deaths (odds ratio [OR] = 1.04; 95% CI = 1.04, 1.05). Nonwhite race was associated with lower odds of hospice facility death (black [OR = 0.915; 95% CI = 0.890, 0.940]; Native American [OR = 0.559; 95% CI = 0.515, 0.607]; and Asian [OR = 0.655; 95% CI = 0.601, 0.713]). Being married was associated with hospice facility death (OR = 1.06; 95% CI = 1.04, 1.07). Older age was associated with increased odds of hospice facility death (85 and older [OR = 1.40; 95% CI = 1.39, 1.41]). Having at least some college education was associated with increased odds of hospice facility death (OR = 1.13; 95% CI = 1.11, 1.15). Decedents from cardiovascular disease had the lowest odds of hospice facility death (OR = 0.278; 95% CI = 0.274, 0.282). CONCLUSION Hospice facility deaths increased among all patient groups; however, striking differences exist by age, sex, race, marital status, education level, cause of death, and geography. Factors underlying these disparities should be examined.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA.
| | - Brystana G Kaufman
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia, USA; Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Haider J Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiology Section, Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
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26
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Kaufman BG, Bleser WK, Saunders R, Anderson D, Van Houtven CH, Muhlestein DB, Clough J, McClellan MB. Prospective or retrospective ACO attribution matters for seriously ill patients. Am J Manag Care 2020; 26:534-540. [PMID: 33315328 DOI: 10.37765/ajmc.2020.88541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Since 2019, the Medicare Shared Savings Program (MSSP) has allowed accountable care organizations (ACOs) to choose either retrospectively or prospectively attributed ACO populations. To understand how ACOs' choice of attribution method affects incentives for care among seriously ill Medicare beneficiaries, this study compares beneficiary characteristics and Medicare per capita expenditures between prospective and retrospective ACO populations. STUDY DESIGN This retrospective, cross-sectional analysis describes survival, patient characteristics, and Medicare spending for Medicare fee-for-service beneficiaries identified with serious illness (n = 1,600,629) using 100% Medicare Master Beneficiary Summary and MSSP beneficiary files (2014-2016). METHODS We used generalized linear models with ACO and year fixed effects to estimate the average within-ACO difference between potential retrospective and prospective ACO populations. RESULTS Dying in the first 90 days of the performance year was associated with reduced odds of retrospective ACO attribution (odds ratio [OR], 0.24; 95% CI, 0.24-0.25) relative to beneficiaries surviving 270 days or longer. Similarly, hospice use was associated with reduced odds of retrospective assignment (OR, 0.80; 95% CI, 0.79-0.80). Among ACOs that did not achieve shared savings, average per capita Medicare expenditures (after truncation) were $2459 (95% CI, $2192-$2725) higher for prospective vs retrospective ACO populations. The difference was $834 (95% CI, $402-$1266) greater per capita among ACOs that achieved shared savings. CONCLUSIONS The difference in survival and spending for ACO populations captured by prospective vs retrospective attribution methods means that ACOs may need to employ different care management strategies to improve performance depending on their attribution method.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, 230 Science Dr, Durham, NC 27705.
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27
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Kaufman BG, Shah S, Hellkamp AS, Lytle BL, Fonarow GC, Schwamm LH, Lesén E, Hedberg J, Tank A, Fita E, Bhalla N, Atreja N, Bettger JP. Disease Burden Following Non-Cardioembolic Minor Ischemic Stroke or High-Risk TIA: A GWTG-Stroke Study. J Stroke Cerebrovasc Dis 2020; 29:105399. [PMID: 33254370 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/10/2020] [Accepted: 10/05/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Limited real-world data are available on outcomes following non-cardioembolic minor ischemic stroke (IS) or high-risk transient ischemic attack (TIA), particularly in the United States (US). We examined outcomes and Medicare payments following any severity IS or TIA as well as the subgroup with minor IS or high-risk TIA. METHODS Medicare beneficiaries >65 years were identified using US nationwide Get with the Guidelines (GWTG)-Stroke Registry linked to Medicare claims data. The cohort consisted of patients enrolled in Medicare fee-for-service plan, hospitalized with non-cardioembolic IS or TIA between 2011 and 2014, segmenting a subgroup with minor IS (National Institute of Health Stroke Scale [NIHSS] ≤5) or high-risk TIA (ABCD2-score ≥6) compatible with the THALES clinical trial population. Outcomes included functional status at discharge, clinical outcomes (all-cause mortality, ischemic stroke, and hemorrhagic stroke, individually and as a composite), hospitalizations, and population average inpatient Medicare payments following non-cardioembolic IS or TIA. RESULTS The THALES-compatible cohort included 62,518 patients from 1471 hospitals. At discharge, 37.0% were unable to ambulate without assistance, and 96.2% were prescribed antiplatelet therapy. Cumulative incidences at 30 days, 90 days, and 1 year for the composite outcome were 3.7%, 7.6%, and 17.2% and 2.4%, 4.0%, and 7.3% for subsequent stroke. The mean Medicare payment for the index hospitalization was $7951. The cumulative all-cause inpatient Medicare spending per patient (with or without any subsequent admission) at 30 days and 1 year from discharge was $1451 and $8105, respectively. CONCLUSIONS The burden of illness for minor IS/high-risk TIA patients indicates an important unmet need. Improved therapeutic options may offer a significant impact on both patient outcomes and Medicare spending.
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Affiliation(s)
| | - Shreyansh Shah
- Department of Neurology, Duke University, Durham, NC, USA.
| | | | | | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, CA, USA.
| | | | | | | | | | | | | | | | - Janet Prvu Bettger
- Margolis Center for Health Policy, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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Kaufman BG, Whitaker R, Mahendraratnam N, Smith VA, McClellan MB. Comparing Associations of State Reopening Strategies with COVID-19 Burden. J Gen Intern Med 2020; 35:3627-3634. [PMID: 33021717 PMCID: PMC7537575 DOI: 10.1007/s11606-020-06277-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 09/28/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The novel coronavirus disease 2019 (COVID-19) infected over 5 million United States (US) residents resulting in more than 180,000 deaths by August 2020. To mitigate transmission, most states ordered shelter-in-place orders in March and reopening strategies varied. OBJECTIVE To estimate excess COVID-19 cases and deaths after reopening compared with trends prior to reopening for two groups of states: (1) states with an evidence-based reopening strategy, defined as reopening indoor dining after implementing a statewide mask mandate, and (2) states reopening indoor dining rooms before implementing a statewide mask mandate. DESIGN Interrupted time series quasi-experimental study design applied to publicly available secondary data. PARTICIPANTS Fifty United States and the District of Columbia. INTERVENTIONS Reopening indoor dining rooms before or after implementing a statewide mask mandate. MAIN MEASURES Outcomes included daily cumulative COVID-19 cases and deaths for each state. KEY RESULTS On average, the number of excess cases per 100,000 residents in states reopening without masks is ten times the number in states reopening with masks after 8 weeks (643.1 cases; 95% confidence interval (CI) = 406.9, 879.2 and 62.9 cases; CI = 12.6, 113.1, respectively). Excess cases after 6 weeks could have been reduced by 90% from 576,371 to 63,062 and excess deaths reduced by 80% from 22,851 to 4858 had states implemented mask mandates prior to reopening. Over 50,000 excess deaths were prevented within 6 weeks in 13 states that implemented mask mandates prior to reopening. CONCLUSIONS Additional mitigation measures such as mask use counteract the potential growth in COVID-19 cases and deaths due to reopening businesses. This study contributes to the growing evidence that mask usage is essential for mitigating community transmission of COVID-19. States should delay further reopening until mask mandates are fully implemented, and enforcement by local businesses will be critical for preventing potential future closures.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, NC, USA.
- Population Health Sciences, Duke University, Durham, NC, USA.
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.
| | - Rebecca Whitaker
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | | | - Valerie A Smith
- Population Health Sciences, Duke University, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Mark B McClellan
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
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29
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Kaufman BG, Whitaker R, Mahendraratnam N, Smith VA, McClellan MB. Correction to: Comparing Associations of State Reopening Strategies with COVID-19 Burden. J Gen Intern Med 2020:10.1007/s11606-020-06337-5. [PMID: 33169328 PMCID: PMC7652407 DOI: 10.1007/s11606-020-06337-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the original version of this paper, an author was misidentified. The corrected author listing appears here, and has been updated in the online version.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, NC, USA.
- Population Health Sciences, Duke University, Durham, NC, USA.
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.
| | - Rebecca Whitaker
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | | | - Valerie A Smith
- Population Health Sciences, Duke University, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Mark B McClellan
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
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Kaufman BG, Whitaker R, Pink G, Holmes GM. Half of Rural Residents at High Risk of Serious Illness Due to COVID-19, Creating Stress on Rural Hospitals. J Rural Health 2020; 36:584-590. [PMID: 32603030 PMCID: PMC7361543 DOI: 10.1111/jrh.12481] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose During the COVID‐19 epidemic, it is critical to understand how the need for hospital care in rural areas aligns with the capacity across states. Methods We analyzed data from the 2018 Behavioral Risk Factor Surveillance System to estimate the number of adults who have an elevated risk of serious illness if they are infected with coronavirus in metropolitan, micropolitan, and rural areas for each state. Study data included 430,949 survey responses representing over 255.2 million noninstitutionalized US adults. For data on hospital beds, aggregate survey data were linked to data from the 2017 Area Health Resource Files by state and metropolitan status. Findings About 50% of rural residents are at high risk for hospitalization and serious illness if they are infected with COVID‐19, compared to 46.9% and 40.0% in micropolitan and metropolitan areas, respectively. In 19 states, more than 50% of rural populations are at high risk for serious illness if infected. Rural residents will generate an estimated 10% more hospitalizations for COVID‐19 per capita than urban residents given equal infection rates. Conclusion More than half of rural residents are at increased risk of hospitalization and death if infected with COVID‐19. Experts expect COVID‐19 burden to outpace hospital capacity across the country, and rural areas are no exception. Policy makers need to consider supply chain modifications, regulatory changes, and financial assistance policies to assist rural communities in caring for people affected by COVID‐19.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Rebecca Whitaker
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - George Pink
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center, North Carolina Rural Health Research Program, University of North Carolina, Chapel Hill, North Carolina
| | - G Mark Holmes
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center, North Carolina Rural Health Research Program, University of North Carolina, Chapel Hill, North Carolina
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31
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Cross SH, Kaufman BG, Mentz RJ, Kamal AH, Taylor DH, Warraich HJ. Trends in Place of Death for Individuals With Cardiovascular Disease in the United States. J Am Coll Cardiol 2020; 74:1943-1946. [PMID: 31601374 DOI: 10.1016/j.jacc.2019.08.1015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Arif H Kamal
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Cancer Institute, Durham, North Carolina
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina; Margolis Center for Health Policy, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Haider J Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Cardiology Section, Department of Medicine, Boston Veterans Affairs Healthcare System, Boston, Massachusetts.
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Check DK, Kaufman BG, Kamal AH, Casarett DJ. Top Ten Tips Palliative Care Clinicians Should Know About Integrating Population Health Principles into Practice. J Palliat Med 2020; 23:568-572. [DOI: 10.1089/jpm.2020.0100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Devon K. Check
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | | | - Arif H. Kamal
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - David J. Casarett
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
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Affiliation(s)
- Brystana G Kaufman
- From the Duke University, Margolis Center for Health Policy; Durham, NC (B.G.K., J.P.B.)
| | - Anna Kucharska-Newton
- University of Kentucky, College of Public Health, Lexington (A.K.-N.).,Department of Epidemiology, The Gillings School of Global Public Health, University of North Carolina at Chapel Hill (A.K.-N.)
| | - Janet Prvu Bettger
- From the Duke University, Margolis Center for Health Policy; Durham, NC (B.G.K., J.P.B.).,Duke Clinical Research Institute, Durham, NC (J.P.B.)
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Abstract
While most patients prefer to die at home, trends and factors associated with place of death for patients dying of cardiovascular disease (CVD) remain unknown. Using data from the National Center for Health Statistics from 2003-2017, we described trends and conducted multivariable logistic regression to evaluate associations between demographic characteristics and place of death among CVD patients in the United States. From 2003-2017, the rate of CVD deaths occurring at home increased from 21.3% to 30.9%, and rate of hospice facility deaths increased from practically none to 6.0%. Over the same period, the rate of hospital deaths decreased from 36.5% to 27.3%, and nursing facility deaths decreased from 25.1% to 20.6%. With the exception of conduction disorders, temporal trends in place of death were consistent across CVD diagnosis subgroups: ischemic heart disease, hypertensive heart disease, heart failure/cardiomyopathy, cerebrovascular disease, aortic stenosis, and all other CVDs. Differences between demographic groups persisted over the study period, with reduced odds of home death among Hispanic versus non-Hispanic (OR=.942; 95% CI .929-.955) decedents, Black versus White (OR=.837; CI .809-.866) decedents and greater odds of home death among decedents with some college education or more (OR=1.08; CI 1.06-1.09) versus decedents with a high-school education or less. In 2014, home surpassed hospital as the most common place of death for CVD patients. CVD patients often have acute and intense needs at the end of life that are challenging to manage in the home and the quality of care these patients receive should be further investigated.
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Affiliation(s)
- Sarah H Cross
- Duke University, Durham, North Carolina, United States
| | - Brystana G Kaufman
- Duke-Margolis Center for Health Policy, Durham, North Carolina, United States
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35
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Haider J Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Cardiology Section, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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36
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Cross SH, Kaufman BG, Taylor DH, Kamal AH, Warraich HJ. Trends and Factors Associated with Place of Death for Individuals with Dementia in the United States. J Am Geriatr Soc 2019; 68:250-255. [PMID: 31609481 DOI: 10.1111/jgs.16200] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/28/2019] [Accepted: 08/28/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess trends and factors associated with place of death among individuals with Alzheimer's disease-related dementias (ADRD). DESIGN Cross-sectional analysis. SETTING Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research, 2003-2017. PARTICIPANTS Natural deaths occurring between 2003 and 2017 for which ADRD was determined to be the underlying cause. MEASUREMENTS Place of death was categorized as hospital, home, nursing facility, hospice facility, and other. Aggregate data included age, race, Hispanic ethnicity, sex, urbanization, and census division. Individual-level predictors included age, race, Hispanic ethnicity, sex, marital status, and education. RESULTS From 2003 to 2017, nursing facility and hospital deaths declined from 65.7% and 12.7% to 55.0% and 8.0% while home and hospice facility deaths increased from 13.6% and .2% to 21.9% and 6.2%, respectively. Odds of hospital and hospice facility deaths declined with age while odds of nursing facility deaths increased with age. Male sex was associated with higher odds of hospital or hospice facility death and lower odds of home or nursing facility death. Nonwhite race, Hispanic ethnicity, and being married were associated with increased odds of hospital or home death and reduced odds of nursing facility death. More education was associated with higher odds of home or in a hospice facility death and reduced odds of death in a nursing facility or hospital. Significant disparities in place of death by urban-rural status were also noted. CONCLUSION As ADRD deaths at home increase, the need for caregiver support and home-based palliative care may become more critical. Further research should examine the care preferences and experiences of ADRD patients and caregivers, the financial impact of home death on families and insurers, and explore factors that may contribute to differences in actual and preferred place of death. J Am Geriatr Soc 68:250-255, 2020.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Donald H Taylor
- Social Science Research Institute, Duke University, Durham, North Carolina
| | - Arif H Kamal
- Duke Cancer Institute, Durham, North Carolina.,Duke University School of Medicine, Durham, North Carolina
| | - Haider J Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Cardiology Section, Department of Medicine, Boston VA Healthcare System, Boston, Massachusetts
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Taylor DH, Kaufman BG, Olson A, Harker M, Anderson D, Cross SH, Bonsignore L, Bull J. Paying for Palliative Care in Medicare: Evidence From the Four Seasons/Duke CMMI Demonstration. J Pain Symptom Manage 2019; 58:654-661.e2. [PMID: 31254641 DOI: 10.1016/j.jpainsymman.2019.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Palliative care improves patient and family outcomes and may reduce the cost of care, but this service is underutilized among Medicare beneficiaries. OBJECTIVES To describe enrollment patterns and outcomes associated with the Center for Medicare and Medicaid Innovation expansion of a multisetting community palliative care program in North and South Carolina. METHODS This observational study characterizes the Center for Medicare and Medicaid Innovation cohort's care and cost trajectories after enrollment. Program participants were age-eligible Medicare fee-for-service beneficiaries living in Western North Carolina and South Carolina who enrolled in a palliative care program from September 1, 2014, to August 31, 2017. End-of-life costs were compared between enrolled and nonenrolled decedents. Program administrative data and 100% Medicare claims data were used. RESULTS A total of 5243 Medicare beneficiaries enrolled in the program from community (19%), facility (21%), small hospital (27%), or large hospital (33%) settings. Changes in Medicare expenditures in the 30 days after enrollment varied by setting. Adjusted odds of hospice use were 60% higher (OR = 1.60; CI = 1.47, 1.75) for enrolled decedents relative to nonenrolled decedents. Participants discharged to hospice vs. participants not had 17% (OR = 0.83 CI = 0.72, 0.94) lower costs. Among enrolled decedents those enrolled for at least 30 days vs. <30 days had 42% (OR = 0.58, CI = 0.49, 0.69) lower costs in the last 30 days of life. CONCLUSIONS Expansion of community palliative care programs into multiple enrollment settings is feasible. It may improve hospice utilization among enrollees. Heterogeneous program participation by program setting pose challenges to a standardizing reimbursement policy.
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Affiliation(s)
- Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.
| | - Andrew Olson
- Duke Forge, Duke University, Durham, North Carolina, USA
| | - Matthew Harker
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - David Anderson
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
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Shepherd-Banigan M, Kaufman BG, Decosimo K, Dadolf J, Boucher NA, Mahanna EP, Bruening R, Sullivan C, Wang V, Hastings SN, Allen KD, Sperber N, Coffman CJ, Van Houtven CH. Adaptation and Implementation of a Family Caregiver Skills Training Program: From Single Site RCT to Multisite Pragmatic Intervention. J Nurs Scholarsh 2019; 52:23-33. [PMID: 31497935 DOI: 10.1111/jnu.12511] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES). DESIGN Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework. FINDINGS Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention. CONCLUSIONS The emphasis on flexible intervention delivery and standardized materials has been identified as strengths of the adaptation process. Two key challenges have been identifying feasible impact measures and reaching eligible caregivers for intervention recruitment. CLINICAL RELEVANCE This systematic implementation process can be used to rapidly adapt an intervention to diverse clinical sites and contexts. Nursing professionals play a significant role in educating and supporting caregivers and care recipients and can take a leading role to implement interventions that address skills and unmet needs for caregivers.
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Affiliation(s)
- Megan Shepherd-Banigan
- Research Health Scientist, Durham VA Health Care System, and Assistant Professor, Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Brystana G Kaufman
- Postdoctoral Research Fellow, Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Kasey Decosimo
- Research Health Scientist Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Joshua Dadolf
- Clinical Social Worker/Intervention Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Nathan A Boucher
- Research Health Scientist, Durham VA Health Care System, and Assistant Research Professor, Sanford School of Public Policy, Duke University, Durham, NC, USA.,Core Faculty, Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Elizabeth P Mahanna
- Research Health Scientist Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Rebecca Bruening
- Research Health Scientist Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Caitlin Sullivan
- Research Health Scientist Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Virginia Wang
- Research Health Scientist, Durham VA Health Care System, and Associate Professor, Department of Population Health Sciences, Duke University, and Associate Professor, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - S Nicole Hastings
- Research Health Scientist, Durham VA Health Care System, and Associate Professor, Division of Geriatrics, Department of Medicine, Duke University, and Associate Professor, Department of Population Health Sciences, Duke University, and Senior Fellow, Center for the Study of Aging, Duke University School of Medicine, Durham, NC, USA
| | - Kelli D Allen
- Research Health Scientist, Durham VA Health Care System, Durham, NC, and Professor, Division of Rheumatology, Allergy, and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nina Sperber
- Research Health Scientist, Durham VA Health Care System, and Assistant Professor, Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Cynthia J Coffman
- Research Health Scientist, Durham VA Health Care System, and Associate Professor, Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Courtney H Van Houtven
- Core Faculty, Margolis Center for Health Policy, Duke University, Durham, NC, USA.,Research Health Scientist, Durham VA Health Care System, and Professor, Department of Population Health Sciences, Duke University, Durham, NC, USA
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Kaufman BG, Klemish D, Olson A, Kassner CT, Reiter JP, Harker M, Sheble L, Goldstein BA, Taylor DH, Bhavsar NA. Use of Hospital Referral Regions in Evaluating End-of-Life Care. J Palliat Med 2019; 23:90-96. [PMID: 31424316 DOI: 10.1089/jpm.2019.0056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Hospital referral regions (HRRs) are often used to characterize inpatient referral patterns, but it is unknown how well these geographic regions are aligned with variation in Medicare-financed hospice care, which is largely provided at home. Objective: Our objective was to characterize the variability in hospice use rates among elderly Medicare decedents by HRR and county. Methods: Using 2014 Master Beneficiary File for decedents 65 and older from North and South Carolina, we applied Bayesian mixed models to quantify variation in hospice use rates explained by HRR fixed effects, county random effects, and residual error among Medicare decedents. Results: We found HRRs and county indicators are significant predictors of hospice use in NC and SC; however, the relative variation within HRRs and associated residual variation is substantial. On average, HRR fixed effects explained more variation in hospice use rates than county indicators with a standard deviation (SD) of 10.0 versus 5.1 percentage points. The SD of the residual error is 5.7 percentage points. On average, variation within HRRs is about half the variation between regions (52%). Conclusions: The magnitude of unexplained residual variation in hospice use for NC and SC suggests that novel, end-of-life-specific service areas should be developed and tested to better capture geographic differences and inform research, health systems, and policy.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - David Klemish
- Department of Statistical Sciences, Duke University, Durham, North Carolina
| | - Andrew Olson
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | | | - Jerome P Reiter
- Department of Statistical Sciences, Duke University, Durham, North Carolina
| | - Matthew Harker
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Laura Sheble
- School of Information Sciences, Wayne State University, Detroit, Michigan.,Duke Network Analysis Center, Social Science Research Institute, Duke University, Durham, North Carolina
| | | | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Nrupen A Bhavsar
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Bleser WK, Saunders RS, Winfield L, Japinga M, Smith N, Kaufman BG, Crook HL, Muhlestein DB, McClellan M. ACO Serious Illness Care: Survey And Case Studies Depict Current Challenges And Future Opportunities. Health Aff (Millwood) 2019; 38:1011-1020. [DOI: 10.1377/hlthaff.2019.00013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- William K. Bleser
- William K. Bleser is a research associate at the Duke-Margolis Center for Health Policy, Duke University, in Washington, D.C
| | - Robert S. Saunders
- Robert S. Saunders is a research director at the Duke-Margolis Center for Health Policy, Duke University, in Washington, D.C
| | - Lia Winfield
- Lia Winfield is a manager at Leavitt Partners, in Salt Lake City, Utah
| | - Mark Japinga
- Mark Japinga is a senior research assistant in the Duke-Margolis Center for Health Policy, Duke University, in Washington, D.C
| | - Nathan Smith
- Nathan Smith is a research manager at Leavitt Partners, in Salt Lake City
| | - Brystana G. Kaufman
- Brystana G. Kaufman is a postdoctoral research associate in the Duke-Margolis Center for Health Policy, Duke University, in Durham, North Carolina
| | - Hannah L. Crook
- Hannah L. Crook is a research assistant at the Duke-Margolis Center for Health Policy, Duke University, in Durham. She was a student of health policy and management at the University of North Carolina at Chapel Hill when this work was conducted
| | - David B. Muhlestein
- David B. Muhlestein is chief research officer at Leavitt Partners, in Washington, and an adjunct assistant professor at the Dartmouth Institute, Geisel School of Medicine, in Hanover, New Hampshire
| | - Mark McClellan
- Mark McClellan is director of the Duke-Margolis Center for Health Policy, Duke University, in Washington, D.C., and the Robert J. Margolis Professor of Business, Medicine, and Policy at Duke University in Durham, North Carolina
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Kaufman BG, O'Brien EC, Stearns SC, Matsouaka RA, Holmes GM, Weinberger M, Schwamm LH, Smith EE, Fonarow GC, Xian Y, Taylor DH. Medicare Shared Savings ACOs and Hospice Care for Ischemic Stroke Patients. J Am Geriatr Soc 2019; 67:1402-1409. [DOI: 10.1111/jgs.15852] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Brystana G. Kaufman
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- Duke Margolis Center for Health Policy Durham North Carolina
| | - Emily C. O'Brien
- Department of Population Health SciencesDuke University Durham North Carolina
| | - Sally C. Stearns
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- The Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Roland A. Matsouaka
- Duke Clinical Research Institute Durham North Carolina
- Department of Biostatistics and BioinformaticsDuke University Durham North Carolina
| | - G. Mark Holmes
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- The Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Morris Weinberger
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General HospitalHarvard Medical School Boston Massachusetts
| | - Eric E. Smith
- Department of Neurology, Cumming School of MedicineUniversity of Calgary Calgary Canada
| | - Gregg C. Fonarow
- Division of CardiologyDavid Geffen School of Medicine at UCLA Los Angeles California
| | - Ying Xian
- Duke Clinical Research Institute Durham North Carolina
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Kaufman BG, Klemish D, Kassner CT, Reiter JP, Li F, Harker M, O'Brien EC, Taylor DH, Bhavsar NA. Predicting Length of Hospice Stay: An Application of Quantile Regression. J Palliat Med 2018; 21:1131-1136. [PMID: 29762075 DOI: 10.1089/jpm.2018.0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Use of the Medicare hospice benefit has been associated with high-quality care at the end of life, and hospice length of use in particular has been used as a proxy for appropriate timing of hospice enrollment. Quantile regression has been underutilized as an alternative tool to model distributional changes in hospice length of use and hospice payments outside of the mean. OBJECTIVE To test for heterogeneity in the relationship between patient characteristics and hospice outcomes across the distribution of hospice days. SETTING Medicare Beneficiary Summary File and survey data (2014) for hospice beneficiaries in North and South Carolina with common terminal diagnoses. MEASUREMENTS Distributional shifts associated with patient characteristics were evaluated at the 25th and 75th percentiles of hospice days and hospice payments using quantile regressions and compared to the mean shift estimated by ordinary least squares (OLS) regression. PRINCIPAL FINDINGS Significant (p < 0.001) heterogeneity in the marginal effects on hospice days and costs was observed, with patient characteristics associated with generally larger shifts in the 75th percentile than the 25th percentile. Mean effects estimated by OLS regression overestimate the magnitude of the median marginal effects for all patient characteristics except for race. Results for hospice payments in 2014 were similar. CONCLUSIONS Methodological decisions can have a meaningful impact in the evaluation of factors influencing hospice length of use or cost.
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Affiliation(s)
- Brystana G Kaufman
- 1 Department of Health Policy and Management, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
| | - David Klemish
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | | | - Jerome P Reiter
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | - Fan Li
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | - Matthew Harker
- 5 Margolis Center for Health Policy , Duke University, Durham, North Carolina
| | - Emily C O'Brien
- 2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
| | - Donald H Taylor
- 6 Sanford School of Public Policy , Duke University, Durham, North Carolina
| | - Nrupen A Bhavsar
- 2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
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Kaufman BG, Kim S, Pieper K, Allen LA, Gersh BJ, Naccarelli GV, Ezekowitz MD, Fonarow GC, Mahaffey KW, Singer DE, Chan PS, Freeman JV, Ansell J, Kowey PR, Rieffel JA, Piccini J, Peterson E, O'Brien EC. Disease understanding in patients newly diagnosed with atrial fibrillation. Heart 2018; 104:494-501. [PMID: 28790169 PMCID: PMC5861387 DOI: 10.1136/heartjnl-2017-311800] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/07/2017] [Accepted: 07/12/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To describe self-reported disease understanding for newly diagnosed patients with atrial fibrillation (AF) and assess (1) how disease understanding changes over the first 6 months after diagnosis and (2) the relationship between patient understanding of therapies at baseline and treatment receipt at 6 months among treatment-naïve patients. METHODS We analysed survey data from SATELLITE (Survey of Patient Knowledge and Personal Priorities for Treatment), a substudy of patients with new-onset AF enrolled in the national Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT) II registry across 56 US sites. Patients were surveyed at the baseline and 6-month follow-up clinic visits using Likert scales. RESULTS Among 1004 baseline survey responses, patients' confidence in their understanding of rhythm control, ablation, anticoagulation and cardioversion was suboptimal, with 'high' understanding ranging from 8.5% for left atrial appendage closure to 71.3% for rhythm therapy. Of medical history and demographic factors, education level was the strongest predictor of reporting 'high' disease understanding. Among the 786 patients with 6-month survey data, significant increases in the proportion reporting high understanding were observed (p<0.05) only for warfarin and direct oral anticoagulants (DOACs). With the exception of ablation, high understanding for a given therapeutic option was not associated with increased use of that therapy at 6 months. CONCLUSIONS About half of patients with new-onset AF understood the benefits of oral anticoagulant at the time of diagnosis and understanding improved over the first 6 months. However, understanding of AF treatment remains suboptimal at 6 months. Our results suggest a need for ongoing patient education. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov. Identifier: NCT01701817.
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Affiliation(s)
| | - Sunghee Kim
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Karen Pieper
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | | | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, California, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, School of Medicine, Stanford, California, USA
| | - Daniel E Singer
- Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul S Chan
- Department of Cardiovascular Research, St. Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - James V Freeman
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jack Ansell
- Hofstra Northwell School of Medicine, New York, New York, USA
| | - Peter R Kowey
- Jefferson Medical College, Philadelphia, Pennsylvania, USA
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | | | | | - Eric Peterson
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina, USA
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Kaufman BG, Spivack BS, Stearns SC, Song PH, O'Brien EC. Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review. Med Care Res Rev 2017; 76:255-290. [PMID: 29231131 DOI: 10.1177/1077558717745916] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.
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Affiliation(s)
- Brystana G Kaufman
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,2 Duke Clinical Research Institute, Durham, NC, USA
| | - B Steven Spivack
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sally C Stearns
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula H Song
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kaufman BG, Kim S, Pieper K, Ezekowitz MD, Fonarow GC, Naccarelli GV, Mahaffey KW, Ansell J, Berger PB, Reiffel JA, Chan PS, Singer DE, Allen LA, Freeman JV, Kowey PR, Gersh B, Piccini JP, Peterson ED, O’Brien EC. Abstract 057: Understanding of Treatment Strategies Among Patients Newly Diagnosed With Atrial Fibrillation: Findings From SATELITTE. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Patient understanding of available therapies for atrial fibrillation (AF) is foundational to shared medical decision making and long term medication adherence. Yet, there is a paucity of data regarding the extent to which patients newly diagnosed with AF in routine community practice understand their options.
Hypotheses:
1) Understanding of warfarin, novel oral anticoagulants (NOAC), rhythm control therapy, cardioversion and radio frequency ablation changes little from baseline to 6 months and 2) treatment rates at 6 months are associated with patient understanding of therapies at baseline.
Methods:
We analyzed survey data from SATELLITE, a substudy of new-onset AF patients enrolled at 56 US sites participating in the ORBIT-AF registry. Patients were surveyed at the baseline and 6 month follow up clinic visit using Likert scales. Agreement between time points was assessed with the McNemar test, and the relationship between understanding and treatment was assessed only for the subset not on treatment at baseline.
Results:
Of 1000 patients enrolled in SATELLITE, 506 had 6-month survey data (data collection is continuing). Among these, the median age was 69.0 years (IQR 63.0 - 76.0) and 93.7% (474 of 506) were white. There was evidence of improvement in the self-reported understanding of warfarin and NOACs from baseline to 6 months, but not for rhythm control, ablation or cardioversion. The proportion reporting high understanding improved significantly for warfarin (p<.0001) and NOACs (p<.0001) from 47% (223 of 474) and 51% (245 of 481) at baseline to 60% (284 of 474) and 69% (332 of 481) at 6 months respectively (Figure 1). Patients with high understanding of the benefits of ablation (p=0.0005) and options for ablation (p=0.0093) at baseline were more likely to have this therapy at the 6 month follow up (N=590), but improved understanding was not associated with increased use of warfarin/NOACs (N=83) or rhythm control (N=444).
Conclusions:
Patients with new-onset AF had improved self-reported understanding of some treatment options over the first 6-months from diagnosis; however, factors other than patient understanding may influence AF treatments received at 6 months. Patient understanding of AF treatments remains suboptimal at 6 months, and our results suggest a need for ongoing patient education.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Paul S Chan
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
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Affiliation(s)
- Brystana G. Kaufman
- Brystana G. Kaufman ( ) is a doctoral student in the Department of Health Policy and Management and a graduate research assistant with the North Carolina Rural Health Research Program at the Cecil G. Sheps Center for Health Services Research, both at the University of North Carolina at Chapel Hill
| | - Kristin L. Reiter
- Kristin L. Reiter is an associate professor in the Department of Health Policy and Management and a research fellow in the North Carolina Rural Health Research Program at the Sheps Center, both at UNC-Chapel Hill
| | - George H. Pink
- George H. Pink is the Humana Distinguished Professor in the Department of Health Policy and Management and a senior research fellow in the North Carolina Rural Health Research Program at the Sheps Center, both at UNC-Chapel Hill
| | - George M. Holmes
- George M. Holmes is an associate professor in the Department of Health Policy and Management and director of the North Carolina Rural Health Research Program at the Sheps Center, both at UNC-Chapel Hill
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Holmes GM, Kaufman BG, Pink GH. Predicting Financial Distress and Closure in Rural Hospitals. J Rural Health 2016; 33:239-249. [DOI: 10.1111/jrh.12187] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/08/2016] [Accepted: 05/05/2016] [Indexed: 12/31/2022]
Affiliation(s)
- George M. Holmes
- North Carolina Rural Health Research and Policy Analysis Center, Cecil G. Sheps Center for Health Services Research; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- Department of Health Policy and Management; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Brystana G. Kaufman
- North Carolina Rural Health Research and Policy Analysis Center, Cecil G. Sheps Center for Health Services Research; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- Department of Health Policy and Management; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - George H. Pink
- North Carolina Rural Health Research and Policy Analysis Center, Cecil G. Sheps Center for Health Services Research; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- Department of Health Policy and Management; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
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Kaufman BG, Sueta CA, Chen C, Windham BG, Stearns SC. Are Trends in Hospitalization Prior to Hospice Use Associated With Hospice Episode Characteristics? Am J Hosp Palliat Care 2016; 34:860-868. [PMID: 27418598 DOI: 10.1177/1049909116659049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study expands current knowledge of factors associated with initiation of hospice care by examining prehospice patterns of medical care leading to Medicare hospice use and the relationships to hospice episode characteristics. Data from the Atherosclerosis Risk in Communities (ARIC) study cohort offer the ability to control for measures that are not available in Medicare claims data, including marital status, nursing home residency, and education. For 1248 ARIC participants who used hospice (2006-2012), participant level trends in the number of hospital days per 30-day period over the year prior to hospice initiation were generated using a fixed-effects model. Logistic regression was used to estimate the associations between increasing hospital use over the year prior to hospice enrollment with key patient characteristics (diagnosis, age, and comorbidity) and episode characteristics (short hospice stay ending in death, long hospice stay, and live discharge). Participants with severe comorbidity (measured as a Charlson comorbidity index score greater than 5) had higher odds of increasing hospital use prior to hospice (odds ratio [OR] = 3.28, confidence interval [CI] = 2.25-4.78). Increasing hospital use did not vary by diagnosis but was associated with reduced odds of a live hospice discharge (OR = 0.55, CI = 0.34-0.88) or long stay in hospice (OR = 0.44, CI = 0.24-0.79) and increased odds of a short stay in hospice (OR = 1.92, CI = 1.36-2.71). The evidence that care patterns prior to hospice use are associated with hospice outcomes could facilitate development of interventions to improve timely hospice referral.
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Affiliation(s)
- Brystana G Kaufman
- 1 Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carla A Sueta
- 2 Division of Cardiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cathy Chen
- 3 University of Mississippi Medical Center, Jackson, MS, USA
| | - B Gwen Windham
- 3 University of Mississippi Medical Center, Jackson, MS, USA
| | - Sally C Stearns
- 1 Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kaufman BG, Thomas SR, Randolph RK, Perry JR, Thompson KW, Holmes GM, Pink GH. The Rising Rate of Rural Hospital Closures. J Rural Health 2015; 32:35-43. [DOI: 10.1111/jrh.12128] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Brystana G. Kaufman
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill North Carolina
| | - Sharita R. Thomas
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill North Carolina
| | - Randy K. Randolph
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill North Carolina
| | - Julie R. Perry
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill North Carolina
| | - Kristie W. Thompson
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill North Carolina
| | - George M. Holmes
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill North Carolina
- Department of Health Policy and Management, Gillings School of Global Public Health; University of North Carolina; Chapel Hill North Carolina
| | - George H. Pink
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research; University of North Carolina; Chapel Hill North Carolina
- Department of Health Policy and Management, Gillings School of Global Public Health; University of North Carolina; Chapel Hill North Carolina
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