Quantifying the association of individual-level characteristics with disparities in kidney transplant waitlist addition among people with HIV

BACKGROUND

Over 45% of people with HIV (PWH) in the United States at least 50 years old and are at heightened risk of aging-related comorbidities including end-stage kidney disease (ESKD), for which kidney transplant is the optimal treatment. Among ESKD patients, PWH have lower likelihood of waitlisting, a requisite step in the transplant process, than individuals without HIV. It is unknown what proportion of the inequity by HIV status can be explained by demographics, medical characteristics, substance use history, and geography.

METHODS

The United States Renal Data System, a national database of all individuals ESKD, was used to create a cohort of people with and without HIV through Medicare claims linkage (2007-2017). The primary outcome was waitlisting. Inverse odds ratio weighting was conducted to assess what proportion of the disparity by HIV status could be explained by individual characteristics.

RESULTS

Six thousand two hundred and fifty PWH were significantly younger at ESKD diagnosis and more commonly Black with fewer comorbidities. PWH were more frequently characterized as using tobacco, alcohol and drugs. Positive HIV-status was associated with 57% lower likelihood of waitlisting [adjusted hazard ratio (aHR): 0.43, 95% confidence interval (CI): 0.46-0.48, P  < 0.001]. Controlling for demographics, medical characteristics, substance use and geography explained 39.8% of this observed disparity (aHR: 0.69, 95% CI: 0.59-0.79, P  < 0.001).

CONCLUSION

PWH were significantly less likely to be waitlisted, and 60.2% of that disparity remained unexplained. HIV characteristics such as CD4 + counts, viral loads, antiretroviral therapy adherence, as well as patient preferences and provider decision-making warrant further study.

Racial Disparities in Access to the Kidney Transplant Waitlist Among People with Human Immunodeficiency Virus

The epidemiology of human immunodeficiency virus (HIV) has shifted such that Black individuals disproportionately represent incident HIV diagnoses. While risk of end-stage kidney disease (ESKD) among people with HIV (PWH) has declined with effective antiretroviral therapies, a substantial racial disparity in ESKD burden exists with the greatest prevalence among Black PWH. Disparities in waitlisting for kidney transplantation, the optimal treatment for ESKD, exist for both PWH and Black individuals without HIV, but it is unknown whether these characteristics together exacerbate such disparities. Six hundred two thousand six ESKD patients were identified from the United States Renal Data System (January 1, 2007 to December 31, 2017), and HIV-status was determined through Medicare claims. Cox proportional hazards regression was used to determine waitlisting rates. Multiplicative interaction terms between HIV-status and race were examined. The 6250 PWH were significantly younger, more commonly Black, and less commonly female than those without HIV. HIV-status and race were independently associated with 50% and 12% lower likelihood of waitlisting, respectively [adjusted hazard ratio (aHR): 0.50, 95% confidence interval (CI): 0.36-0.69, p < 0.001; aHR: 0.88, 95% CI: 0.87-0.90, p < 0.001]. There was also a significant interaction present between HIV-status and Black race (aHR: 0.80, 95% CI: 0.66-0.98, p < 0.001) such that, while HIV-status and Black race were independently associated with decreased waitlisting, the interaction of Black race and HIV-status exacerbated those disparities. While limited by lack of HIV-specific data that may impact inferences with respect to race, additional studies are urgently needed to understand the interplay between HIV risk factors, HIV-stigma, and racism, and how intersectionality may exacerbate disparities in transplantation among PWH.

Social determinants of health and emergency department utilization in Alabama Children's Health Insurance Program

OBJECTIVES

Injuries are the leading cause of death among children and youth in the United States, representing a major concern to society and to the public and private health plans covering pediatric patients. Data from ALL Kids, Alabama's Children's Health Insurance Program, were used to evaluate the relationship between community-level social determinants of health (SDOH) and pediatric emergency department (ED) use and differences in these associations by age and race.

STUDY DESIGN

This was a retrospective, pooled cross-sectional analysis.

METHODS

We used ALL Kids data to identify ED visits (injury and all-cause) among children who were enrolled at any time from 2015 to 2017. Exploratory factor analysis was used to categorize SDOH from 18 selected Census tract-level variables. Multilevel Poisson regression models were used to evaluate the effects of community and individual factors and their interactions.

RESULTS

Census tract-level SDOH were grouped as low socioeconomic status (SES), urbanicity, and immigrant-density factors. Low SES and urbanicity factors were associated with ED visits (injury and all-cause). The low SES and urbanicity factors also moderated the association between race and ED visits (injury and all-cause).

CONCLUSIONS

The environment in which children live influences their ED use; however, the impact varies by age, race, and Census tract factors. Further studies should focus on specific community factors to better understand the relationship among SDOH, individual characteristics, and ED utilization.

Changes in Type 2 Diabetes Trends in Children and Adolescents During the COVID-19 Pandemic

CONTEXT

There is concern that the growing incidence of pediatric type 2 diabetes (T2D) may have been further exacerbated by the COVID-19 pandemic.

OBJECTIVE

To examine whether trends in new-onset pediatric T2D-inclusive of patients requiring hospitalization and patients managed as outpatients-were impacted during the COVID-19 pandemic, and to compare patient characteristics prior to and during COVID-19.

METHODS

A retrospective single-center medical record review was conducted in a hospital which cares for 90% of Alabama's pediatric T2D patients. Patients with new-onset T2D referred from March 2017 to March 2021 were included. Counts of patients presenting per month ("monthly rates") were computed. Linear regression models were estimated for the full sample and stratified by Medicaid and non-Medicaid insurance status. Patient characteristics prior to vs during COVID-19 were compared.

RESULTS

A total of 642 patients presented with new-onset T2D over this period. Monthly rates were 11.1 ± 3.8 prior to COVID-19 and 19.3 ± 7.8 during COVID-19 (P = .004). Monthly rates for Medicaid patients differed prior to and during COVID-19 (7.9 ± 3.4 vs 15.3 ± 6.6, P = .003) but not for non-Medicaid patients (3.3 ± 1.7 vs 4.0 ± 2.4, P = .33). Regression results showed significant increases in monthly rates during COVID-19 for the full sample (β= 5.93, P < .05) and for Medicaid enrollees (β= 5.42, P < .05) Hospitalization rate, severity of obesity, and hemoglobin A1c remained similar prior to and during COVID-19, though the proportion of male patients increased from 36.8% to 46.1% (P = .021).

CONCLUSIONS

A rise in new-onset T2D was observed among Alabama's youth during the COVID-19 pandemic, a burden that disproportionately affected Medicaid enrollees and males. Future research should explore the pathways through which the pandemic impacted pediatric T2D.

Characteristics and outcomes associated with two asthma quality of care measures

OBJECTIVE

We investigated asthma quality measures to understand patient characteristics associated with non-attainment of quality care and measure the association with asthma-related emergency department (ED) visits or inpatient hospitalizations (IPs).

METHODS

Using administrative data from ALL Kids, Alabama's Children's Health Insurance Program, from 2013 to 2019 we calculated non-attainment of the Medication Management for Asthma (MMA) and Asthma Medication Ratio (AMR) quality measures. Patient characteristics and asthma-related ED visits and IPs associated with non-attainment of the MMA and AMR measures were assessed using logit regression models and Marginal effects at the mean.

RESULTS

Among 2528 children with asthma, 53.2% failed to attain the MMA measure and 8.5% the AMR measure. Prior asthma-related ED visits or IP stays increased likelihood of non-attainment by 14.8 percentage points (95% CI 8.6-20.9) for MMA and 7.3 percentage points (95% CI 2.8-11.8) for AMR. Among 868 children (34.3%) with three years of continuous enrollment, AMR non-attainment was associated with a 6.1 percentage point increase in ED or IP utilization (95% CI 1.3-10.9), however MMA non-attainment was not associated with either outcome. Prior ED visit/IP stay was associated with a 17.2 percentage point (95% CI 8.3-26.1) increase in the likelihood of a subsequent ED visit/IP stay among those with non-attainment MMA and a 15.5 percentage point increase (95% CI 6.9-24.2) for non-attainment AMR.

CONCLUSIONS

Patient characteristics associated with non-attainment of asthma quality measures presents actionable evidence to guide improvement efforts as non-attainment AMR increases the risk of subsequent ED visits and IP stays.

Older age of childhood type 1 diabetes onset is associated with islet autoantibody positivity >30 years later: the Pittsburgh Epidemiology of Diabetes Complications Study

AIMS

To examine the association between islet autoantibody positivity and clinical characteristics, residual β-cell function (C-peptide) and prevalence of complications in a childhood-onset (age <17 years), long-duration (≥32 years) type 1 diabetes cohort.

METHODS

Islet autoantibodies (glutamic acid decarboxylase, insulinoma-associated protein 2 and zinc transporter-8 antibodies) were measured in the serum of participants who attended the 2011-2013 Pittsburgh Epidemiology of Diabetes Complications study follow-up examination (n=177, mean age 51 years, diabetes duration 43 years).

RESULTS

Prevalences of islet autoantibodies were: glutamic acid decarboxylase, 32%; insulinoma-associated protein 2, 22%; and zinc transporter-8, 4%. Positivity for each islet autoantibody was associated with older age at diabetes onset (glutamic acid decarboxylase antibodies, P=0.03; insulinoma-associated protein 2 antibodies, P=0.001; zinc transporter-8 antibodies, P<0.0001). Older age at onset was also associated with an increasing number of autoantibodies (P = 0.001). Glutamic acid decarboxylase antibody positivity was also associated with lower HbA_1c (P = 0.02), insulinoma-associated protein 2 antibody positivity was associated with lower prevalence of severe hypoglycaemic episodes (P=0.02) and both distal and autonomic neuropathy (P=0.04 for both), and zinc transporter-8 antibody positivity was associated with higher total and LDL cholesterol (P=0.01). No association between autoantibody positivity and C-peptide was observed.

CONCLUSIONS

The strong association between islet autoantibody positivity and older age at type 1 diabetes onset supports the hypothesis of a less aggressive, and thus more persistent, immune process in those with older age at onset. This observation suggests that there may be long-term persistence of heterogeneity in the underlying autoimmune process.

Differential Impact of Hospital and Community Factors on Medicare Readmission Penalties

OBJECTIVE

To identify hospital/county characteristics and sources of regional heterogeneity associated with readmission penalties.

DATA SOURCES/STUDY SETTING

Acute care hospitals under the Hospital Readmissions Reduction Program from fiscal years 2013 to 2018 were linked to data from the Annual Hospital Association, Centers for Medicare and Medicaid Services, Medicare claims, Hospital Compare, Nursing Home Compare, Area Resource File, Health Inequity Project, and Long-term Care Focus. The final sample contained 3,156 hospitals in 1,504 counties.

DATA COLLECTION/EXTRACTION METHODS

Data sources were combined using Medicare hospital identifiers or Federal Information Processing Standard codes.

STUDY DESIGN

A two-level hierarchical model with correlated random effects, also known as the Mundlak correction, was employed with hospitals nested within counties.

PRINCIPAL FINDINGS

Over a third of the variation in readmission penalties was attributed to the county level. Patient sociodemographics and the surrounding access to and quality of care were significantly associated with penalties. Hospital measures of Medicare volume, percentage dual-eligible and Black patients, and patient experience were correlated with unobserved area-level factors that also impact penalties.

CONCLUSIONS

As the readmission risk adjustment does not include any community-level characteristics or geographic controls, the resulting endogeneity bias has the potential to disparately penalize certain hospitals.

Cardiovascular Health and Healthcare Utilization and Expenditures Among Medicare Beneficiaries: The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

Background

Better cardiovascular health is associated with lower cardiovascular disease risk.

Methods and Results

We determined the association between cardiovascular health and healthcare utilization and expenditures in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. We included 6262 participants ≥65 years with Medicare fee‐for‐service coverage for the year after their baseline study visit in 2003‐2007. Cardiovascular health at baseline was assessed using the American Heart Association's Life's Simple 7 (LS7) metric, which includes 7 factors: cigarette smoking, physical activity, diet, body mass index, blood pressure, cholesterol, and glucose. Healthcare utilization and expenditures were ascertained using Medicare claims in the year following baseline. Overall, 17.2%, 31.1%, 29.0%, 16.4% and 6.4% of participants had 0 to 1, 2, 3, 4, and 5 to 7 ideal LS7 factors, respectively. The multivariable‐adjusted relative risk (95% confidence interval [CI]) for having any inpatient and outpatient encounters comparing participants with 5 to 7 versus 0 to 1 ideal LS7 factors were 0.55 (0.39, 0.76) and 1.00 (0.98, 1.02), respectively. Among participants with 0 to 1 and 5 to 7 ideal LS7 factors, mean inpatient expenditures were $3995 and $1250, respectively, mean outpatient expenditures were $5166 and $2853, respectively, and mean total expenditures were $9147 and $4111, respectively. After multivariable adjustment, the mean (95% CI) cost difference comparing participants with 5 to 7 versus 0 to 1 ideal LS7 factors was −$2551 (−$3667, −$1435) for inpatient, −$2410 (−$3089, −$1731) for outpatient, and −$5016 (−$6577, −$3454) for total expenditures.

Conclusions

Better cardiovascular health is associated with lower risk for inpatient encounters and lower inpatient and outpatient healthcare expenditures.

An assessment of the CHIP/Medicaid quality measure for ADHD

OBJECTIVES

We analyzed a standard children's quality measure for attention-deficit/hyperactivity disorder (ADHD) using data from a single state to understand the characteristics of those meeting the measure, potential barriers to meeting the measure, and how meeting the measure affected outcomes.

STUDY DESIGN

Retrospective study using claims from Alabama's Children's Health Insurance Program from 1999 to 2012.

METHODS

We calculated the quality measure for ADHD care, as specified within CMS' Child Core Set and with an expanded denominator. We described the eligible population meeting the measure, assessed potential barriers, and measured the association with health expenditures using logit regressions and log-Poisson models.

RESULTS

Among those receiving ADHD medication, 11% of enrollees were eligible for annual measure calculation during our study period. Calculated as specified by CMS, 38% of enrollees met the measure. Using an expanded denominator of 7615 eligible medication episodes, 14% met all aspects of the measure. Primary reasons for failing to meet the measure were lacking medication coverage (64%) and lacking a follow-up visit within 30 days (62%). The rate of meeting the measure decreased with age and was lower for black enrollees. Health service utilization and costs were greater among children meeting the measure.

CONCLUSIONS

Too few children are eligible for inclusion, and systematic differences exist among those who meet the measure. The measure may be sensitive to arbitrary criteria while missing potentially relevant clinical care. Refinements to the measure should be considered to improve generalizability to all children with ADHD and improve clinical relevance. States must consider additional analyses to direct quality improvement.

Health Expenditure Concentration and Characteristics of High-Cost Enrollees in CHIP

Devising effective cost-containment strategies in public insurance programs requires understanding the distribution of health care spending and characteristics of high-cost enrollees. The aim was to characterize high-cost enrollees in a state’s public insurance program and determine whether expenditure inequality changes over time, or with changes in cost-sharing policies or program eligibility. We use 1999-2011 claims and enrollment data from the Alabama Children’s Health Insurance Program, ALL Kids. All children enrolled in ALL Kids were included in our study, including multiple years of enrollment (N = 1,031,600 enrollee-months). We examine the distribution of costs over time, whether this distribution changes after increases in cost sharing and expanded eligibility, patient characteristics that predict high-cost status, and examine health services used by high-cost children to identify what is preventable. The top 10% (1%) of enrollees account for about 65.5% (24.7%) of total program costs. Inpatient and outpatient costs are the largest components of costs incurred by high-cost utilizers. Non-urgent emergency department costs are a relatively small portion. Average expenditure increases over time, particularly after expanded eligibility, and the share of costs incurred by the top 10% and 1% increases slightly. Multivariable logistic regression results indicate that infants and older teens, Caucasian children, and those with chronic conditions are more likely to be high-cost utilizers. Increased cost sharing does not reduce cost concentration or average expenditure among high-cost utilizers. These findings suggest that identifying and targeting potentially preventable costs among high-cost utilizers are called for to help reduce costs in public insurance programs.

The Great Recession of 2007-2009 and Public Insurance Coverage for Children in Alabama: Enrollment and Claims Data from 1999-2011

OBJECTIVES

This study examined the impact of the Great Recession of 2007-2009 on public health insurance enrollment and expenditures in Alabama. Our analysis was designed to provide a framework for other states to conduct similar analyses to better understand the relationship between macroeconomic conditions and public health insurance costs.

METHODS

We analyzed enrollment and claims data from Medicaid and the Children's Health Insurance Program (CHIP) in Alabama from 1999 through 2011. We examined the relationship between county-level unemployment rates and enrollment in Medicaid and CHIP, as well as total county-level expenditures in the two programs. We used linear regressions with county fixed effects to estimate the impact of unemployment changes on enrollment and expenditures after controlling for population and programmatic changes in eligibility and cost sharing.

RESULTS

A one-percentage-point increase in a county's unemployment rate was associated with a 4.3% increase in Medicaid enrollment, a 0.9% increase in CHIP enrollment, and an overall increase in public health insurance enrollment of 3.7%. Each percentage-point increase in unemployment was associated with a 6.2% increase in total public health insurance expenditures on children, with Medicaid spending rising by 7.5% and CHIP spending rising by 1.8%. In response to the 6.4 percentage-point increase in the state's unemployment rate during the Great Recession, combined enrollment of children in Alabama's public health insurance programs increased by 24% and total expenditures rose by 40%.

CONCLUSION

Recessions have a substantial impact on the number of children enrolled in CHIP and Medicaid, and a disproportionate impact on program spending. Programs should be aware of the likely magnitudes of the effects in their budget planning.

The effects of state-level expenditures for home- and community-based services on the risk of becoming a long-stay nursing home resident after hip fracture

SUMMARY

This study measures the effect of spending policies for long-term care services on the risk of becoming a long-stay nursing home resident after a hip fracture. Relative spending on community-based services may reduce the risk of long-term nursing home residence. Policies favoring alternative sources of care may provide opportunities for older adults to remain community-bound.

INTRODUCTION

This study aims to understand how long-term care policies affect outcomes by investigating the effect of state-level spending for home- and community-based services (HCBSs) on the likelihood of an individual's nursing home placement following hip fracture.

METHODS

This study uses data from the 5% sample of Medicare beneficiaries from 2005 to 2010 to identify incident hip fractures among dual-eligibility, community-dwelling adults aged at least 65 years. A multilevel generalized estimating equation (GEE) model estimated the association between an individual's risk of nursing home residence within 1 year and the percent of states' Medicaid long-term support service (LTSS) budget allocated to HCBS. Other covariates included expenditures for Title III services and individual demographic and health status characteristics.

RESULTS

States vary considerably in HCBS spending, ranging from 17.7 to 83.8% of the Medicaid LTSS budget in 2009. Hip fractures were observed from claims among 7778 beneficiaries; 34% were admitted to a nursing home and 25% died within 1 year. HCBS spending was associated with a decreased risk of nursing home residence by 0.17 percentage points (p 0.056).

CONCLUSIONS

Consistent with other studies, our findings suggest that state policies favoring an emphasis on HCBS may reduce nursing home residence among low-income older adults with hip fracture who are at high risk for institutionalization.

Preventive Dental Care and Long-Term Dental Outcomes among ALL Kids Enrollees

OBJECTIVE

To investigate whether early or regular preventive dental visit (PDV) reduces restorative or emergency dental care and costs for low-income children.

STUDY SETTING

Enrollees during 1998-2012 in the Alabama CHIP program, ALL Kids.

STUDY DESIGN

Retrospective cohort study using claims data for children continuously enrolled in ALL Kids for at least 4 years. Analyses are conducted separately for children 0-4 years, 4-9 years, and >9 years. For 0-4 years, the intervention of interest is whether they have at least one PDV before age 3. For the other two age groups, interventions of interest are if they have regular PDVs during each of the first 3 years, and if they have claims for a sealant in the first 3 years. Outcomes-namely restorative and emergency dental service and costs-are measured in the fourth year. To account for selection into PDV, a high-dimensional propensity scores approach is utilized.

DATA EXTRACTION

Claims data were obtained from ALL Kids.

PRINCIPAL FINDINGS

Only sealants are associated with a reduced likelihood of using restorative and emergency services and costs.

CONCLUSIONS

Whether PDVs without sealants actually reduce restorative/emergency pediatric dental services is questionable. Further research into benefits of PDV is needed.

Prevalence and incidence of clinically recognized cases of Type 1 diabetes in children and adolescents in Rwanda, Africa

AIMS

To determine prevalence and incidence estimates for clinically recognized cases of Type 1 diabetes from the Life For a Child Program (LFAC) with onset < 26 years in six representative districts, and the capital, of Rwanda.

METHODS

Cases were identified from the LFAC registry and visits to district hospitals. Denominators were calculated from district-level population surveys. Period prevalence data were collected from 1 August 2011 to 31 July 2012 and annual incidence rates were calculated, retrospectively, for 2004-2011. Ninety-five per cent confidence intervals (95% CI) were calculated using a Poisson distribution.

RESULTS

The prevalence of known Type 1 diabetes in seven districts in Rwanda for ages < 26 years was 16.4 [95% CI 14.6-18.4]/100 000 and for < 15 years was 4.8 [3.5-6.4]/100 000. Prevalence was higher in females (18.5 [15.8-21.4]/100 000) than males (14.1 [11.8-16.7]/100 000; P = 0.01) and rates increased with age. The annual incidence rate for those < 26 years was stable between 2007 and 2011 with a mean incidence over that time of 2.7 [2.0-3.7]/100 000 ( < 15 years = 1.2 [0.5-2.0]/100 000). Incidence rates were higher in females than males and peaked in males at ages 17 and 22 years and in females at age 18 years.

CONCLUSIONS

Our report of known Type 1 diabetes cases shows lower incidence and prevalence rates in Rwanda than previously reported in the USA and most African countries. Incidence of recognized cases has increased over time, but has recently stabilized. However, the likelihood of missed cases due to death before diagnosis and misdiagnosis is high and therefore more definitive studies are needed.

Trends in mortality and recurrent coronary heart disease events after an acute myocardial infarction among Medicare beneficiaries, 2001-2009

BACKGROUND

Few contemporary studies examine trends in recurrent coronary heart disease (CHD) events and mortality after acute myocardial infarction (AMI) and whether these trends vary by race or sex.

METHODS

We used data from the national 5% random sample of Medicare fee-for-service beneficiaries for 1999 to 2010. We included beneficiaries who experienced an AMI (International Classification of Disease [ICD] 9 410.xx, except 410.x2) between January 1, 2001, and December 31, 2009. Each beneficiary's first AMI was included as their index event. Outcomes included all-cause mortality, recurrent AMI, and recurrent CHD events during the 365days after discharge for the index AMI. To examine secular trends, we pooled calendar years into 3 periods (2001-2003, 2004-2006, and 2007-2009).

RESULTS

Among 48,688 beneficiaries with index AMIs from 2001 to 2009, we observed decreases in the age-adjusted rates for mortality (-3.8% for each 3-year period, 95% CI -6.1% to -1.6%, P trend = .001), recurrent AMI (-15.0%, 95% CI -18.6% to -11.2%, P trend < .001), and recurrent CHD events (-11.1%, 95% CI -14.0% to -8.0%, P trend < .001) in the 365days after the index AMI. In 2007 to 2009, blacks had excess risk relative to whites for mortality and recurrent AMI (black/white incidence rate ratio of 1.38 for mortality [95% CI 1.21-1.57] and 1.38 for recurrent AMI [95% CI 1.07-1.79]).

CONCLUSIONS

Despite overall favorable trends in lower mortality and recurrent events after AMI, efforts are needed to reduce racial disparities.

Adverse Selection in the Children's Health Insurance Program

This study investigates whether new enrollees in the Alabama Children’s Health Insurance Program have different claims experience from renewing enrollees who do not have a lapse in coverage and from continuing enrollees. The analysis compared health services utilization in the first month of enrollment for new enrollees (who had not been in the program for at least 12 months) with utilization among continuing enrollees. A second analysis compared first-month utilization of those who renew immediately with those who waited at least 2 months to renew. A 2-part model estimated the probability of usage and then the extent of usage conditional on any utilization. Claims data for 826 866 child-years over the period from 1999 to 2012 were used. New enrollees annually constituted a stable 40% share of participants. Among those enrolled in the program, 13.5% renewed on time and 86.5% of enrollees were late to renew their enrollment. In the multivariate 2-part models, controlling for age, gender, race, income eligibility category, and year, new enrollees had overall first-month claims experience that was nearly $29 less than continuing enrollees. This was driven by lower ambulatory use. Late renewals had overall first-month claims experience that was $10 less than immediate renewals. However, controlling for the presence of chronic health conditions, there was no statistically meaningful difference in the first-month claims experience of late and early renewals. Thus, differences in claims experience between new and continuing enrollees and between early and late renewals are small, with greater spending found among continuing and early renewing participants. Higher claims experience by early renewals is attributable to having chronic health conditions.

Enrollment, expenditures, and utilization after CHIP expansion: evidence from Alabama

OBJECTIVE

In October 2009, Alabama expanded eligibility in its Children's Health Insurance Program (CHIP), known as ALL Kids, from 200% to 300% of the federal poverty level (FPL). We examined the expenditures, utilization, and enrollment behavior of expansion enrollees relative to traditional enrollees (100-200% FPL) and assessed the impact of expansion on total program expenditures.

METHODS

We compared unadjusted mean person-month-level expenditures and utilization of expansion enrollees and various categories of existing enrollees and used a 2-part modeling strategy to examine differences after controlling for enrollee characteristics. We used probit models to examine adjusted differences in reenrollment behavior by eligibility category.

RESULTS

Expansion enrollees had higher total monthly expenditures ($10.33, P < .05) than traditional ALL Kids enrollees, including higher outpatient ($5.35, P < .001) and dental ($0.85, P < .01) expenditures but lower emergency department (-$1.34, P < .001) expenditures. Expansion enrollees had marginally lower utilization of emergency department services for low-severity conditions and higher utilization of physician outpatient visits. Expansion enrollees were 4.47 percentage points (P < .001) more likely to reenroll before their contract expiration date than traditional ALL Kids enrollees. As of October 2012, expansion enrollees accounted for approximately 20% of ALL Kids enrollment and expenditures.

CONCLUSIONS

The expansion population was characterized by moderately higher health expenditures and utilization, and more persistent enrollment relative to fee group enrollees who are subject to the same levels of cost sharing and annual premiums. Although states are prohibited from changing program eligibility until 2019, the costs associated with the expansion population will be important to future policy decisions.

Patterns and predictors of osteoporosis medication discontinuation and switching among Medicare beneficiaries

BACKGROUND

Low adherence to bisphosphonate therapy is associated with increased fracture risk. Factors associated with discontinuation of osteoporosis medications have not been studied in-depth. This study assessed medication discontinuation and switching patterns among Medicare beneficiaries who were new users of bisphosphonates and evaluated factors possibly associated with discontinuation.

METHODS

We identified patients initiating bisphosphonate treatment using a 5% random sample of Medicare beneficiaries with at least 24 months of traditional fee-for-service and part D drug coverage from 2006 through 2009. We classified medication status at the end of follow-up as: continued original bisphosphonate, discontinued without switching or restarting, restarted the same drug after a treatment gap (≥ 90 days), or switched to another anti-osteoporosis medication. We conducted logistic regression analyses to identify baseline characteristics associated with discontinuation and a case-crossover analysis to identify factors that precipitate discontinuation.

RESULTS

Of 21,452 new users followed respectively for 12 months, 44% continued their original therapy, 36% discontinued without switching or restarting, 8% restarted the same drug after a gap greater than 90 days, and 11% switched to another anti-osteoporosis medication. Factors assessed during the 12-month period before initiation were weakly associated with discontinuation. Several Factors measured during follow-up were associated with discontinuation, including more physician visits, hospitalization, having a dual-energy X-ray absorptiometry test, higher Charlson comorbidity index scores, higher out-of-pocket drug payments, and upper gastrointestinal problems. Patterns were similar for 4,738 new users followed for 30 months.

CONCLUSIONS

Among new bisphosphonates users, switching within and across drug classes and extended treatment gaps are common. Robust definitions and time-varying considerations should be considered to characterize medication discontinuation more accurately.

Trends in the utilization and outcomes of Medicare patients hospitalized for hip fracture, 2000-2008

OBJECTIVE

This study examines temporal trends in hip fracture related utilization and outcomes among elderly fee-for-service Medicare beneficiaries.

METHOD

The study uses claims data for a 5% sample of Medicare beneficiaries with an incident hip fracture hospitalization between 2000 and 2008. We present annual mean patient characteristics, health services utilization, and outcomes and use ordinary least squares regressions to examine adjusted trends in utilization and outcomes after controlling for changes in patient characteristics.

RESULTS

We observe a statistically significant temporal decline in inpatient acute days and a statistically significant increase in inpatient post-acute days following hip fractures. In models that control for patient characteristics, we observe statistically significant declines in 1-year hip fracture readmission and mortality rates. Rates of nursing home residence 1-year following fracture were unchanged and remain high.

DISCUSSION

Hip fractures remain highly debilitating events and pose significant challenges for the financing of public health insurance programs.

Characteristics of low-severity emergency department use among CHIP enrollees

OBJECTIVES

To describe patient characteristics among those utilizing the emergency department (ED) for low-severity conditions (ie, conditions potentially treatable or manageable in a primary care setting).

STUDY DESIGN

A pooled cross-sectional study of administrative claims for ED visits among enrollees in Alabama's Children's Health Insurance Program (CHIP), ALL Kids, from January 1, 1999, through December 31, 2010.

METHODS

Severity of visit was categorized based on primary diagnosis code using an established claims-based algorithm. Logistic regression was used to identify patient characteristics that predicted low-severity ED visits relative to high-severity visits.

RESULTS

Of a total of 141,709 qualifying ED visits, 97,961 (69%) were classified as low severity, 33,941 (24%) as intermediate severity, and 9807 (7%) as high severity. Based on absolute risk differences, we found that among children utilizing the ED, low-severity visits were more likely than high-severity visits among children who were noncompliant with recommended well-child care (1.2 percentage points, 95% confidence interval [CI], 0.4-1.9); children who were nonurban residents (urban vs isolated: 1.6 percentage points, 95% CI, 1.0-2.2; urban vs small rural: 1.1 percentage points, 95% CI, 0.5-1.7); children without chronic disease (10.3 percentage points, 95% CI, 9.9-10.7) and children whose ED visits were on Sunday versus weekdays (0.9 percentage point, 95% CI, 0.6-1.3), and on Saturday versus weekdays (1.2 percentage points; 95% CI, 0.8-1.6).

CONCLUSIONS

Our results suggest that improving access to primary care on weekends and in rural areas are potential ways to improve the efficient use of ED services.

Characterization and Remediation of Chlorinated Volatile Organic Contaminants in the Vadose Zone: An Overview of Issues and Approaches

Contamination of vadose-zone systems by chlorinated solvents is widespread, and poses significant potential risk to human health through impacts on groundwater quality and vapor intrusion. Soil vapor extraction (SVE) is the presumptive remedy for such contamination, and has been used successfully for innumerable sites. However, SVE operations typically exhibit reduced mass-removal effectiveness at some point due to the impact of poorly accessible contaminant mass and associated mass-transfer limitations. Assessment of SVE performance and closure is currently based on characterizing contaminant mass discharge associated with the vadose-zone source, and its impact on groundwater or vapor intrusion. These issues are addressed in this overview, with a focus on summarizing recent advances in our understanding of the transport, characterization, and remediation of chlorinated solvents in the vadose zone. The evolution of contaminant distribution over time and the associated impacts on remediation efficiency will be discussed, as will the potential impact of persistent sources on groundwater quality and vapor intrusion. In addition, alternative methods for site characterization and remediation will be addressed.

Phytosterols, red yeast rice, and lifestyle changes instead of statins: a randomized, double-blinded, placebo-controlled trial

BACKGROUND

Many patients who refuse or cannot tolerate statin drugs choose alternative therapies for lipid lowering.

OBJECTIVES

This study aimed to determine the lipid-lowering effects of phytosterol tablets and lifestyle change (LC) on top of red yeast rice (RYR) therapy in patients with a history of statin refusal or statin-associated myalgias.

DESIGN

A total of 187 participants (mean low-density lipoprotein cholesterol [LDL-C], 154 mg/dL) took RYR 1800 mg twice daily and were randomized to phytosterol tablets 900 mg twice daily or placebo. Participants were also randomized to a 12-week LC program or usual care (UC). Primary end point was change in LDL-C at 12, 24, and 52 weeks. Secondary end points were effect on other lipoproteins, high-sensitivity C-reactive protein, weight, and development of myalgia.

RESULTS

Phytosterols did not significantly improve LDL-C at weeks 12 (P = .54), 24 (P = .67), or 52 (P = .76) compared with placebo. Compared with the UC group, the LC group had greater reductions in LDL-C at weeks 12 (-51 vs -42 mg/dL, P = .006) and 24 (-48 vs -40 mg/dL, P = .034) and was 2.3 times more likely to achieve an LDL-C <100 mg/dL (P = .004). The LC group lost more weight for 1 year (-2.3 vs -0.3 kg, P < .001). All participants took RYR and had significant decreases in LDL-C, total cholesterol, triglycerides, high-sensitivity C-reactive protein, and an increase in high-density lipoprotein cholesterol for 1 year when compared with baseline (P < .001). Four participants stopped supplements because of myalgia.

CONCLUSIONS

The addition of phytosterol tablets to RYR did not result in further lowering of LDL-C levels. Participants in an LC program lost significantly more weight and were more likely to achieve an LDL-C <100 mg/dL compared with UC.

Co-payments and the use of emergency department services in the children's health insurance program

Research suggests that more than half of all emergency department (ED) visits in the United States are for nonurgent conditions, leading to billions of dollars in potentially avoidable spending annually. In this study, we examine the effects of co-payment changes on ED utilization among children enrolled in ALL Kids, Alabama's Children's Health Insurance Program We separately model the effect of the 2003 co-payment increases on the monthly probability of any ED visit, and visits within three severity categories, using linear probability models that control for beneficiary characteristics and time trends that are allowed to vary in the pre- and postperiods. We observe a small decline in the probability of ED visits 1 year after the co-payment increase. However, low-severity visits, which we hypothesize to be more price sensitive, show no significant evidence of a decline. Our study suggests that the modest co-payment changes were not effective in improving the efficiency of ED utilization.

Effectiveness of preventive dental visits in reducing nonpreventive dental visits and expenditures

BACKGROUND AND OBJECTIVE

Although preventive dental visits are considered important for maintaining pediatric oral health, there is relatively little research showing that they reduce subsequent nonpreventive dental visits or costs. At least 1 study seemed to find that early preventive dental care is associated with more restorative and emergency visits. Previous studies are limited by their inability to account for unmeasurable factors that may lead children to "select" into using both more preventive and nonpreventive dental care. We used econometric techniques that minimize selection bias to assess the effectiveness of preventive dental care in reducing subsequent nonpreventive dental service utilization among children.

METHODS

Using data from Alabama's Children's Health Insurance Program (CHIP), 1998-2010., a cohort study of children's dental service utilization was conducted. Outcomes were 1-year lagged nonpreventive dental care and expenditures, and overall dental and medical expenditures. Children who were continuously enrolled for at least 3 years were included. Separate models were estimated for children aged <8 years (n = 14 972) and those aged ≥8 years (n = 21 833).

RESULTS

More preventive visits were associated with fewer subsequent nonpreventive dental visits and lower nonpreventive dental expenditures for both groups. However, more preventive visits did not reduce overall dental or medical (inclusive of dental) expenditures.

CONCLUSIONS

Preventive dental visits can reduce subsequent nonpreventive visits and expenditures for children continuously enrolled in CHIP. However, they may not reduce overall program costs. Effective empirical research in this area must continue to address unobserved confounders and selection issues.

Favorable selection, risk adjustment, and the Medicare Advantage program

OBJECTIVES

To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees.

DATA

From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures.

STUDY DESIGN

Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA. Similar regression analysis of the costliness of those switching into (out of) MA in the 6 months prior to enrollment (after disenrollment) relative to nonswitchers in the same county over the same period.

FINDINGS

Payment generosity and more sophisticated risk adjustment were associated with substantial increases in MA enrollment and decreases in disenrollment. Claims experience of those newly switching into MA was not affected by any of the policy reforms, but disenrollment became increasingly concentrated among high-cost beneficiaries.

CONCLUSIONS

Enrollment is very sensitive to payment levels. The use of more sophisticated risk adjustment did not alter favorable selection into MA, but it did affect the costliness of disenrollees.

Characterizing the transition from paediatric to adult care among emerging adults with Type 1 diabetes

AIMS

The goals of the study were to describe the transition of youth with Type 1 diabetes from paediatric to adult healthcare services, examine the link of this transition with self care and glycaemic control, and distinguish youth who received medical treatment from different physicians in terms of demographic and parent relationship variables.

METHODS

Youth with Type 1 diabetes (n = 118) were enrolled in a prospective study that examined the transition from the paediatric to adult healthcare systems and were evaluated during their senior year of high school (time 1) and 1 year later (time 2). Data on self care, glycaemic control and parent relationship were collected.

RESULTS

The majority of youth saw a paediatric endocrinologist at both assessments (n = 64); others saw an adult care physician at both assessments (n = 26) or transitioned from a paediatric endocrinologist to an adult care physician (n = 19). Nine youth saw no physician between time 1 and time 2. There were group differences in demographic and parent relationship variables and self-care behaviour and glycaemic control related to the transition of care. Youth who remained in the paediatric healthcare system had the best self care and did not experience declines in glycaemic control over time.

CONCLUSIONS

Early transition from the paediatric healthcare system to the adult healthcare system is associated with psychosocial variables and worse glycaemic control. Future research should identify factors that determine optimal timing and strategies to avoid deterioration of care and control during this transition.

A close examination of healthcare expenditures related to fractures

This study evaluated reasons for healthcare expenditures both before and after the occurrence of fractures among Medicare beneficiaries. In a previous study we examined healthcare expenditures in the 6 months before and after fractures. The difference-"incremental" expenditures-provides one estimate of the potentially avoidable costs associated with fractures. We constructed a second estimate of the cost burden-"attributable" expenditures-using only those costs recorded in claims with fracture diagnosis codes. Attributable expenditures accounted for only 24% to 60% of incremental expenditures, depending on the fracture site. We examined health care expenditures between 1999 and 2005 among Medicare beneficiaries who experienced fractures (cases) and among beneficiaries who did not experience fractures (controls), matched to cases on age, race, and sex. We also examined healthcare expenditures for cases and controls for 24 months prior to the fracture index date. When expenditures associated with diagnoses for aftercare, joint pain, and osteoporosis, other musculoskeletal diagnoses, pneumonia, and pressure ulcers were included, the proportion of incremental costs directly attributable to fracture care rose to 72% to 88%. Expenditures prior to fracture were higher for cases than controls, and the rate of increase accelerated over the 12 months prior to the hip fracture. Our findings confirm that the original incremental cost analysis constituted a satisfactory method for estimating avoidable costs associated with fractures. We also conclude that those with fractures had much higher and growing healthcare expenditures in the 12 months prior to the event, compared with age-, race-, and sex-matched controls. This suggests that patterns of healthcare services utilization may provide a means to improve fracture prediction rules.

Measuring prevention more broadly: an empirical assessment of CHIPRA core measures

OBJECTIVE

To assess limitations of using select Children's Health Insurance Program Reauthorization Act (CHIPRA) core claims-based measures in capturing the preventive services that may occur in the clinical setting.

METHODS

We use claims data from ALL Kids, the Alabama Children's Health Insurance Program (CHIP), to calculate each of four quality measures under two alternative definitions: (1) the formal claims-based guidelines outlined in the CMS Technical Specifications, and (2) a broader definition of appropriate claims for identifying preventive service use. Additionally, we examine the extent to which these two claims-based approaches to measuring quality differ in assessments of disparities in quality of care across subgroups of children.

RESULTS

Statistically significant differences in rates were identified when comparing the two definitions for calculating each quality measure. Measure differences ranged from a 1.9 percentage point change for measure #13 (receiving preventive dental services) to a 25.5 percentage point change for measure #12 (adolescent well-care visit). We were able to identify subgroups based upon family income, rural location, and chronic disease status with differences in quality within the core measures. However, some identified disparities were sensitive to the approach used to calculate the quality measure.

CONCLUSIONS

Differences in CHIP design and structure, across states and over time, may limit the usefulness of select claims-based core measures for detecting disparities accurately. Additional guidance and research may be necessary before reporting of the measures becomes mandatory.

Evaluating comorbidity scores based on health service expenditures

OBJECTIVE

To describe the performance of Charlson Comorbidity Index (CCI) specifications among Medicare beneficiaries and subgroups.

DATA SOURCES

Medicare data for beneficiaries covered by Parts A and B and not Medicare Advantage throughout 2007.

STUDY DESIGN

We evaluated several CCI specifications, particularly a model using expenditures related to Charlson categories, to predict 1 year mortality.

DATA COLLECTION/EXTRACTION METHODS

Data were obtained from the Chronic Condition Data Warehouse.

PRINCIPAL FINDINGS

The use of Charlson related expenditures did not result in improved mortality prediction. CCI models perform less well in population subgroups with higher underlying mortality risks based on age and chronic conditions.

CONCLUSIONS

Relatively simple models provide quite adequate discrimination compared to more sophisticated models. Our proposed and more sophisticated model, which added in expenditure information, did not perform as well as much more easily executed methods.

Weekend hospitalization and mortality: a critical review

Numerous studies have documented a positive association between weekend hospitalization and mortality. Some researchers have argued that these associations are causal and arise from weekend reductions in hospital staffing. Others have suggested that the observed correlations reflect differences in the unobservable characteristics of weekend versus weekday patients. The existing literature has provided only limited evidence of the specific pathways through which weekend hospitalization might affect health outcomes. This article outlines the limitations of the existing research and highlights the need for in-depth condition-specific studies that acknowledge the potential threat posed by selection bias.

Did copayment changes reduce health service utilization among CHIP enrollees? Evidence from Alabama

OBJECTIVE

To explore whether health care utilization changed among enrollees in Alabama's CHIP program, ALL Kids, following copayment increases at the beginning of fiscal year 2004.

DATA SOURCES

Data on all ALL Kids enrollees over 1999-2009 are obtained from claims files and the state's administrative database.

STUDY DESIGN

We use pooled month-level data for all enrollees and conduct covariate-adjusted segmented regression models. Health services considered are inpatient care, emergency department (ED) visits, brand-name prescription drugs, generic prescription drugs, physician office visits and outpatient-services, ambulance services, allergy treatments, and non-preventive dental services. Physician well-visits, preventive dental services, and service use by Native-Americans--which saw no copayment increases--serve as counterfactuals.

PRINCIPAL FINDINGS

There are significant declines in utilization for inpatient care, physician visits, brand-name medications, and ED visits following the copayment increases. By and large, utilization did not decline, or declined only temporarily, for those services and for those enrollees that who not subject to increased copayments.

CONCLUSIONS

Copayment increases reduced utilization of many health services among ALL Kids enrollees. Concerns remain regarding the long-term health consequences to low-income children of copayment-induced reductions in health care utilization.

The impact of CHIP coverage on children with asthma in Alabama

This study evaluates the impact of coverage in ALL Kids, the Alabama Child Health Insurance Program (CHIP), by examining asthma-related utilization and outcomes among children continuously enrolled for 3 years (N = 1954)with persistent asthma at enrollment. Outcomes and costs were compared for the first, second, and third years of enrollment using repeated measures analysis of variance and controlling for age, gender, and year fixed-effects. Compared with subsequent years, first year enrollment utilization was higher for asthma-related hospitalizations (6% vs 2% vs 2%; P < .0001) and emergency visits (10% vs 3% vs 2%; P < .0001). Also decreasing were asthma-related outpatient visits (1.46 vs 1.12 vs 0.94; P < .0001), quick-relief prescriptions (2.6 vs 2.2 vs 2.1; P < .0001), and long-term control prescriptions (5.8 vs 5.2 vs 4.4; P < .0001). As a result, significant declines in the mean costs per child were observed. Ongoing ALL Kids coverage is associated with improved disease-management and lower costs for persistent asthma.

Continuity of insurance coverage and ambulatory care-sensitive hospitalizations/ED visits: evidence from the children's health insurance program

OBJECTIVE

To assess the effects of continuity of insurance coverage on treatment of ambulatory-care sensitive conditions (ACSC).

STUDY POPULATION

42,382 children enrolled in ALL Kids (Alabama Children's Health Insurance Program) for 3 or more years.

METHODS

We model annual hospitalizations and ED visits for six ACSCs identified by the AHRQ - bacterial pneumonia, dehydration, perforated appendix, urinary tract infection, gastroenteritis, and severe ear, nose and throat infection.

RESULTS

In unadjusted models, we find lower risk of ACSC hospitalizations and ED visits in the second and third years of continuous enrollment. Risk of hospitalization in year 3 was significantly lower for pneumonia (OR 0.608, 95% CI: 0.421-0.878) and gastroenteritis (OR 0.549, 95% CI: 0.404-0.746). These beneficial effects of duration of coverage disappear after controlling for age, year and other enrollee characteristics.

CONCLUSIONS

Hospitalizations and ED visits for ACSCs are rare and do not decrease with additional years of coverage.

Clinical and demographic factors associated with fractures among older Americans

Medicare claims data were used to investigate associations between history of previous fractures, chronic conditions, and demographic characteristics and occurrence of fractures at six anatomic sites. The study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.

INTRODUCTION

This study investigates the associations of a history of fracture, comorbid chronic conditions, and demographic characteristics with incident fractures among Medicare beneficiaries. The majority of fracture incidence studies have focused on the hip and on white females. This study examines a greater variety of fracture sites and more population subgroups than prior studies.

METHODS

We used Medicare claims data to examine the incidence of fracture at six anatomic sites in a random 5% sample of Medicare beneficiaries during the time period 2000 through 2005.

RESULTS

For each type of incident fracture, women had a higher rate than men, and there was a positive association with age and an inverse association with income. Whites had a higher rate than nonwhites. Rates were lowest among African-Americans for all sites except ankle and tibia/fibula, which were lowest among Asian-Americans. Rates of hip and spine fracture were highest in the South, and fractures of other sites were highest in the Northeast. Fall-related conditions and depressive illnesses were associated with each type of incident fracture, conditions treated with glucocorticoids with hip and spine fractures and diabetes with ankle and humerus fractures. Histories of hip and spine fractures were associated positively with each site of incident fracture except ankle; histories of nonhip, nonspine fractures were associated with most types of incident fracture.

CONCLUSIONS

This study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.

Characterizing sudden death and dead-in-bed syndrome in Type 1 diabetes: analysis from two childhood-onset Type 1 diabetes registries

AIMS

Type 1 diabetes mellitus increases the risk for sudden unexplained death, generating concern that diabetes processes and/or treatments underlie these deaths. Young (< 50 years) and otherwise healthy patients who are found dead in bed have been classified as experiencing 'dead-in-bed' syndrome.

METHODS

We thus identified all unwitnessed deaths in two related registries (the Children's Hospital of Pittsburgh and Allegheny County) yielding 1319 persons with childhood-onset (age < 18 years) Type 1 diabetes diagnosed between 1965 and 1979. Cause of death was determined by a Mortality Classification Committee (MCC) of at least two physician epidemiologists, based on the death certificate and additional records surrounding the death.

RESULTS

Of the 329 participants who had died, the Mortality Classification Committee has so far reviewed and assigned a final cause of death to 255 (78%). Nineteen (8%) of these were sudden unexplained deaths (13 male) and seven met dead-in-bed criteria. The Mortality Classification Committee adjudicated cause of death in the seven dead-in-bed persons as: diabetic coma (n =4), unknown (n=2) and cardiomyopathy (n=1, found on autopsy). The three dead-in-bed individuals who participated in a clinical study had higher HbA(1c) , lower BMI and higher daily insulin dose compared with both those dying from other causes and those surviving.

CONCLUSIONS

Sudden unexplained death in Type 1 diabetes seems to be increased 10-fold and associated with male sex, while dead-in-bed individuals have a high HbA(1c) and insulin dose and low BMI. Although sample size is too small for definitive conclusions, these results suggest specific sex and metabolic factors predispose to sudden unexplained death and dead-in-bed death.

Medical liability and health care reform

We examine the impact of the Affordable Care Act (ACA) on medical liability and the controversy over whether federal medical reform including a damages cap could make a useful contribution to health care reform. By providing guaranteed access to health care insurance at community rates, the ACA could reduce the problem of under-compensation resulting from damages caps. However, it may also exacerbate the problem of under-claiming in the malpractice system, thereby reducing incentives to invest in loss prevention activities. Shifting losses from liability insurers to health insurers could further undermine the already weak deterrent effect of the medical liability system. Republicans in Congress and physician groups both pushed for the adoption of a federal damages cap as part of health care reform. Physician support for damages caps could be explained by concerns about the insurance cycle and the consequent instability of the market. Our own study presented here suggests that there is greater insurance market stability in states with caps on non-economic damages. Republicans in Congress argued that the enactment of damages caps would reduce aggregate health care costs. The Congressional Budget Office included savings from reduced health care utilization in its estimates of cost savings that would result from the enactment of a federal damages cap. But notwithstanding recent opinions offered by the CBO, it is not clear that caps will significantly reduce health care costs or that any savings will be passed on to consumers. The ACA included funding for state level demonstration projects for promising reforms such as offer and disclosure and health courts, but at this time the benefits of these reforms are also uncertain. There is a need for further studies on these issues.

Is withholding osteoporosis medication after fracture sometimes rational? A comparison of the risk for second fracture versus death

INTRODUCTION

Undertreatment of osteoporosis is common, even for high-risk patients. Among the reasons for undertreatment may be a clinician's perception of a lack of treatment benefit, particularly in light of patients' expected future mortality. Among US Medicare beneficiaries, we evaluated the risk for second fracture versus death in the 5 years following a hip, clinical vertebral, and wrist/forearm fracture.

METHODS

Using data from 1999 to 2006 for a random 5% sample of US Medicare beneficiaries, we identified individuals who experienced an incident hip, clinical vertebral, or wrist/forearm fracture in 2000 or 2001. We evaluated the risk for a second incident fracture versus death in the following 5 years. Results were stratified by age, gender, race/ethnicity, and medical comorbidities. In light of the competing mortality risk, and assuming 30% efficacy of an osteoporosis medication to prevent a second fracture, we calculated the number of individuals needed to treat (NNT) for 5 years after first fracture to prevent 1 additional subsequent fracture.

RESULTS

We identified 18,853, 12,751, and 7635 persons with an incident hip, clinical vertebral, and wrist/forearm fracture, respectively. Although the 5-year risk of death usually exceeded the risk for second fracture across age, gender, racial groups, and primary fracture type (median ratio of death to second fracture=1.4, interquartile range 0.9, 2.0), the 5-year risk for second fracture was high, varying from a low of 13% to a high of 43%. Across demographic groups, the NNT to prevent a second fracture was low, ranging from 8 to 46.

CONCLUSION

Among older persons with hip, clinical vertebral, or wrist/forearm fracture, although the risk for death was usually greater than the risk for a second fracture, both were high. The relatively low NNT to prevent 1 additional subsequent fracture fell within a range generally considered acceptable for secondary prevention strategies.

Health services utilization after fractures: evidence from Medicare

BACKGROUND

Osteoporosis-related fractures impose a large and growing societal burden, including adverse health effects and direct medical costs. Postfracture utilization of health care services represents an alternative measure of the resource costs associated with these fractures.

METHODS

We use a 5% random sample of Medicare claims data to construct annual cohorts (2000-2004) of beneficiaries diagnosed with incident fractures at one of seven sites--clinical vertebral, hip pelvis, femur, tibia/fibula, humerus, and distal radius/ulna. We use person-specific changes in health services utilization (eg, inpatient acute/postacute days, home health visits, physical, and occupational therapy) before/after fractures and probabilities of entry into (long-term) nursing home residency to estimate the utilization burden associated with fractures.

RESULTS

Relative to the prior 6-month period, rates of acute hospitalization are between 19.5 (distal radius/ulna) and 72.4 (hip) percentage points higher in the 6 months after fractures. Average acute inpatient days are 1.9 (distal radius/ulna) to 8.7 (hip) higher in the postfracture period. Fractures are associated with large increases in all forms of postacute care, including postacute hospitalizations (13.1-71.5 percentage points), postacute inpatient days (6.1-31.4), home health care hours (3.4-8.4), and hours of physical (5.2-23.6) and occupational (4.3-14.0) therapy. Among patients who were community dwelling at the time of the initial fracture, 0.9%-1.1% (2.4%-4.0%) were living in a nursing home 6 months (1 year) after the fracture.

CONCLUSIONS

Fractures are associated with significant increases in health services utilization relative to prefracture levels. Additional research is needed to assess the determinants and effectiveness of alternative forms of fracture care.

"Pathologic" fractures: should these be included in epidemiologic studies of osteoporotic fractures?

Pathologic fractures are often excluded in epidemiologic studies of osteoporosis. Using Medicare administrative data, we identified persons with vertebral and hip fractures. Among these, 48% (vertebral) and 3% (hip) of the fractures were coded as pathologic. Only 25% and 66% of persons with these pathologic fractures had evidence for malignancy.

INTRODUCTION

Analyses of osteoporosis-related fractures that use administrative data often exclude pathologic fractures (ICD-9 733.1x) due to concern that these are caused by cancer. We examined "pathologic" fractures of the vertebrae and hip to evaluate their contribution to fracture incidence and assessed the evidence for a malignancy.

METHODS

We studied US Medicare beneficiaries age > or =65 with new fractures identified using ICD-9 diagnosis codes 733.13 (pathologic vert), 805.0, 805.2, 805.4, 805.8 (nonpathologic vert); and 733.14 (pathologic hip), 820.0, 820.2, 820.8 (nonpathologic hip). We further examined the proportion of cases with a diagnosis of a malignancy proximate to the fracture.

RESULTS

We identified 44,120 individuals with a vertebral fracture and 60,354 with a hip fracture. Approximately 48% of vertebral fractures and 3% of hip fractures were coded as pathologic. For only approximately 25% of persons with a "pathologic" vertebral fracture ICD-9 code, but 66% of persons with a "pathologic" hip fracture, there was evidence of a possible cancer diagnosis.

CONCLUSION

Among US Medicare beneficiaries, one fourth of pathologic vertebral fracture and two thirds of pathologic hip fracture cases had evidence for a malignancy. Particularly for vertebral fractures, excluding persons with pathologic fractures in epidemiologic analyses that utilize administrative claims data substantially underestimates the burden of fractures due to osteoporosis.

The geographic availability and associated utilization of dual-energy X-ray absorptiometry (DXA) testing among older persons in the United States

Using national Medicare data from 1999-2006, we evaluated the relationship between travel distance and receipt of dual-energy X-ray absorptiometry (DXA). After adjusting for potentially confounding factors, travel distance was strongly associated with DXA testing. Rural residents were most strongly dependent on the availability of DXAs performed in physician offices.

INTRODUCTION

Medicare reimbursement for DXAs performed in non-facility settings (e.g., physician offices) decreased in 2007. With declining reimbursement, some DXA providers may cease providing this service, which would increase travel distance for some people. The impact of travel distance on access to DXA is unclear.

METHODS

Using national Medicare data, we identified claims for DXA to evaluate trends in the number and locations of DXAs performed. Travel distance was the distance from beneficiaries' residence and the nearest DXA provider. Binomial regression evaluated the relationship between travel distance and receipt of DXA.

RESULTS

In 2006, 2.9 million DXAs were performed, a 103% increase since 1999. In 2005-2006, 8.0% of persons were tested at non-facility sites versus 4.2% at facility sites. The remainder (88%) had no DXA. Persons traveling 5-9, 10-24, 25-39, and 40-54, and > or = 55 miles were less likely to receive DXA (adjusted risk ratios = 0.92, 0.79, 0.43, 0.32, and 0.26, respectively, < 5 miles referent). Rural residents were more dependent than urban residents on the availability of DXA from non-facility providers.

CONCLUSION

Approximately two-thirds of DXAs in 2005-2006 were performed in non-facility settings (e.g., physician offices). Rural residents would have preferentially reduced access to DXA if there were fewer non-facility sites.

Red yeast rice for dyslipidemia in statin-intolerant patients: a randomized trial

BACKGROUND

Red yeast rice is an herbal supplement that decreases low-density lipoprotein (LDL) cholesterol level.

OBJECTIVE

To evaluate the effectiveness and tolerability of red yeast rice and therapeutic lifestyle change to treat dyslipidemia in patients who cannot tolerate statin therapy.

DESIGN

Randomized, controlled trial.

SETTING

Community-based cardiology practice.

PATIENTS

62 patients with dyslipidemia and history of discontinuation of statin therapy due to myalgias.

INTERVENTION

Patients were assigned by random allocation software to receive red yeast rice, 1800 mg (31 patients), or placebo (31 patients) twice daily for 24 weeks. All patients were concomitantly enrolled in a 12-week therapeutic lifestyle change program.

MEASUREMENTS

Primary outcome was LDL cholesterol level, measured at baseline, week 12, and week 24. Secondary outcomes included total cholesterol, high-density lipoprotein (HDL) cholesterol, triglyceride, liver enzyme, and creatinine phosphokinase (CPK) levels; weight; and Brief Pain Inventory score.

RESULTS

In the red yeast rice group, LDL cholesterol decreased by 1.11 mmol/L (43 mg/dL) from baseline at week 12 and by 0.90 mmol/L (35 mg/dL) at week 24. In the placebo group, LDL cholesterol decreased by 0.28 mmol/L (11 mg/dL) at week 12 and by 0.39 mmol/L (15 mg/dL) at week 24. Low-density lipoprotein cholesterol level was significantly lower in the red yeast rice group than in the placebo group at both weeks 12 (P < 0.001) and 24 (P = 0.011). Significant treatment effects were also observed for total cholesterol level at weeks 12 (P < 0.001) and 24 (P = 0.016). Levels of HDL cholesterol, triglyceride, liver enzyme, or CPK; weight loss; and pain severity scores did not significantly differ between groups at either week 12 or week 24.

LIMITATION

The study was small, was single-site, was of short duration, and focused on laboratory measures.

CONCLUSION

Red yeast rice and therapeutic lifestyle change decrease LDL cholesterol level without increasing CPK or pain levels and may be a treatment option for dyslipidemic patients who cannot tolerate statin therapy.

Regional variation in the denial of reimbursement for bone mineral density testing among US Medicare beneficiaries

Although the Bone Mass Measurement Act outlines the indications for central dual-energy X-ray absorptiometry (DXA) testing for US Medicare beneficiaries, the specifics regarding the appropriate ICD-9 codes to use for covered indications have not been specified by Medicare and are sometimes ambiguous. We describe the extent to which DXA reimbursement was denied by gender and age of beneficiary, ICD-9 code submitted, time since previous DXA, whether the scan was performed in the physician's office and local Medicare carrier. Using Medicare administrative claims data from 1999 to 2005, we studied a 5% national sample of beneficiaries age > or =65 yr with part A+B coverage who were not health maintenance organization enrollees. We identified central DXA claims and evaluated the relationship between the factors listed above and reimbursement for central DXA (CPT code 76075). Multivariable logistic regression was used to evaluate the independent relationship between DXA reimbursement, ICD-9 diagnosis code, and Medicare carrier. For persons who had no DXA in 1999 or 2000 and who had 1 in 2001 or 2002, the proportion of DXA claims denied was 5.3% for women and 9.1% for men. For repeat DXAs performed within 23 mo, the proportion denied was approximately 19% and did not differ by sex. Reimbursement varied by more than 6-fold according to the ICD-9 diagnosis code submitted. For repeat DXAs performed at <23 mo, the proportion of claims denied ranged from 2% to 43%, depending on Medicare carrier. Denial of Medicare reimbursement for DXA varies significantly by sex, time since previous DXA, ICD-9 diagnosis code submitted, place of service (office vs facility), and local Medicare carrier. Greater guidance and transparency in coding policies are needed to ensure that DXA as a covered service is reimbursed for Medicare beneficiaries with the appropriate indications.

Simvastatin vs therapeutic lifestyle changes and supplements: randomized primary prevention trial

OBJECTIVE

To compare the lipid-lowering effects of an alternative regimen (lifestyle changes, red yeast rice, and fish oil) with a standard dose of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin).

PATIENTS AND METHODS

This randomized trial enrolled 74 patients with hypercholesterolemia who met Adult Treatment Panel III criteria for primary prevention using statin therapy. All participants were randomized to an alternative treatment group (AG) or to receive simvastatin (40 mg/d) in this open-label trial conducted between April 1, 2006, and June 30, 2006. The alternative treatment included therapeutic lifestyle changes, ingestion of red yeast rice, and fish oil supplements for 12 weeks. The simvastatin group received medication and traditional counseling. The primary outcome measure was the percentage change in low-density lipoprotein cholesterol (LDL-C). Secondary measures were changes in other lipoproteins and weight loss.

RESULTS

There was a statistically significant reduction in LDL-C levels in both the AG (-42.4%+/-15%) (P<.001) and the simvastatin group (-39.6%+/-20%) (P<.001). No significant differences were noted between groups. The AG also demonstrated significant reductions in triglycerides (-29% vs -9.3%; 95% confidence interval, -61 to -11.7; P=.003) and weight (-5.5% vs -0.4%; 95% confidence interval, -5.5 to -3.4; P<.001) compared with the simvastatin group.

CONCLUSION

Lifestyle changes combined with ingestion of red yeast rice and fish oil reduced LDL-C in proportions similar to standard therapy with simvastatin. Pending confirmation in larger trials, this multifactorial, alternative approach to lipid lowering has promise for a subset of patients unwilling or unable to take statins.

Changes in glycaemic control and risk of coronary artery disease in type 1 diabetes mellitus: findings from the Pittsburgh Epidemiology of Diabetes Complications Study (EDC)

AIMS/HYPOTHESIS

To complete a comparative analysis of studies that have examined the relationship between glycaemia and cardiovascular disease (CVD)/coronary artery disease (CAD) and perform a prospective analysis of the effect of change in glycosylated Hb level on CAD risk in the Pittsburgh Epidemiology of Diabetes Complications Study (EDC) of childhood-onset type 1 diabetes mellitus (n = 469) over 16 years of two yearly follow-up.

METHODS

Measured values for HbA(1) and HbA(1c) from the EDC were converted to the DCCT-standard HbA(1c) for change analyses and the change in HbA(1c) was calculated (final HbA(1c) minus baseline HbA(1c)). CAD was defined as EDC-diagnosed angina, myocardial infarction, ischaemia, revascularisation or fatal CAD after medical record review.

RESULTS

The comparative analysis suggested that glycaemia may have a stronger effect on CAD in patients without, than in those with, albuminuria. In EDC, the change in HbA(1c) differed significantly between CAD cases (+0.62 +/- 1.8%) and non-cases (-0.09 +/- 1.9%) and was an independent predictor of CAD.

CONCLUSIONS/INTERPRETATION

Discrepant study results regarding the relationship of glycaemia with CVD/CAD may, in part, be related to the prevalence of renal disease. Measures of HbA(1c) change over time show a stronger association with CAD than baseline values.