Care Fragmentation, Care Continuity, and Care Coordination-How They Differ and Why It Matters

This Viewpoint considers why fragmentation occurs and suggests a potential path forward for developing evidenced-based strategies that can reduce the occurrence of fragmentation and its associated harms.

Accountable Care Organization Attribution and Post-Acute Skilled Nursing Facility Outcomes for People Living With Dementia

OBJECTIVES

Under the Accountable Care Organization (ACO) model, reductions in healthcare spending have been achieved by targeting post-acute care, particularly in skilled nursing facilities (SNFs). People with Alzheimer disease and related dementias (ADRD) are frequently discharged to SNF for post-acute care and may be at particular risk for unintended consequences of SNF cost reduction efforts. We examined SNF length of stay (LOS) and outcomes among ACO-attributed and non-ACO-attributed ADRD patients.

DESIGN

Observational serial cross-sectional study.

SETTING AND PARTICIPANTS

Twenty percent national random sample of fee-for-service Medicare beneficiaries (2013-2017) to identify beneficiaries with a diagnosis of ADRD and with a hospitalization followed by SNF admission (n = 263,676).

METHODS

Our primary covariate of interest was ACO (n = 66,842) and non-ACO (n = 196,834) attribution. Hospital readmission and death were measured for 3 time periods (<30, 31-90, and 91-180 days) following hospital discharge. We used 2-stage least squares regression to predict LOS as a function of ACO attribution, and patient and facility characteristics.

RESULTS

ACO-attributed ADRD patients have shorter SNF LOS than their non-ACO counterparts (31.7 vs 32.8 days; P < .001). Hospital readmission rates for ACO vs non-ACO differed at ≤30 days (13.9% vs 14.6%; P < .001) but were similar at 31-90 days and 91-180 days. No significant difference was observed in mortality post-hospital discharge for ACO vs non-ACO at ≤30 days; however, slightly higher mortality was observed at 31-90 days (8.4% vs 8.8%; P = .002) and 91-180 days (7.6% vs 7.9%; P = .011). No significant association was found between LOS and readmission, with small effects on mortality favoring ACOs in fully adjusted models.

CONCLUSIONS AND IMPLICATIONS

Being an ACO-attributed patient is associated with shorter SNF LOS but is not associated with changes in readmission or mortality after controlling for other factors. Policies that shorten LOS may not have adverse effects on outcomes for people living with dementia.

Identification of Dementia in Medicare Claims Compared to Rigorous Clinical Assessments in African Americans

BACKGROUND

Evidence indicates the health care system disproportionately misses dementia in African American compared to White individuals. In preliminary data, we examined factors related to dementia identification by the health care system among African Americans.

METHODS

We leveraged linked Medicare fee-for-service claims and detailed annual cohort evaluations in African Americans from 4 cohorts at Rush Alzheimer's Disease Center.

RESULTS

Among 88 African Americans with cognitive impairment (mean = 10 years follow-up), Medicare claims identified dementia <2 years from cohort diagnosis in 55%; 27% were identified 2-9.9 years after cohort diagnosis, and in 18% there was either no claims diagnosis during the study period, or claims identified dementia 10+ years after cohort diagnosis. Claims identification of dementia was related to older age at cohort diagnosis (eg, <2 years between cohort and claims: mean = 82 years; 10+ years/no diagnosis: mean = 77 years, p = .04), lower Mini-Mental State Examination (MMSE) score (<2 years: mean = 24; 10+ years/no diagnosis: mean = 26, p = .04), more depressive symptoms (<2 years: mean = 2.1 symptoms; 10+ years/no diagnosis: mean = 1.2, p = .04), and more comorbidity (<2 years: mean = 5.6 comorbidities; 10+ years/no diagnosis, mean = 3.0, p = .02).

CONCLUSIONS

Among African Americans, preliminary data indicate the health care system most rapidly identifies dementia in older individuals, with worse cognitive and physical health. The health care system may miss opportunities for early support of African Americans with dementia, and caregivers.

Initiation of Disease-Modifying Antirheumatic Drugs in Older Medicare Beneficiaries With New Diagnosis of Late-Onset Rheumatoid Arthritis

OBJECTIVE

Older adults with rheumatoid arthritis (RA) account for up to one-third of the RA population and are less likely to receive optimal treatment. For the subgroup of older adults with late-onset RA (LORA), who experience more symptomatic and progressive disease, suboptimal treatment could be more consequential than the general population who age with RA. We evaluated use of disease-modifying antirheumatic drugs (DMARDs) in older adults with a new diagnosis of LORA.

METHODS

In this retrospective observational study, we identified adults 66 years of age or older with a new diagnosis of LORA using Medicare data from 2008 to 2017. Information on baseline patient characteristics and DMARD initiation during the first 12 months after LORA diagnosis were collected. We also assessed concomitant use of glucocorticoids (GCs).

RESULTS

We identified 33,373 older adults with new diagnosis of LORA. Average age at LORA diagnosis was 76.7 (SD 7.6); 75.4% were female, 76.9% were White, and 35.6% had low-income subsidy (LIS). Less than one-third were initiated on a DMARD (28.9%). In multivariable analyses, DMARD initiation was associated with younger age, fewer comorbidities, and absence of LIS status. Concomitant long-term (>3 months) GC use was higher among those on any DMARD (44.3%) compared with those without (15.2%).

CONCLUSIONS

DMARD initiation after new diagnosis of LORA is low despite current clinical practice guidelines recommending early aggressive initiation of treatment. Long-term GC use is common among those on any DMARDs, raising concern for suboptimal DMARD use. Further studies are needed to understand drivers of DMARD use in older adults.

Characteristics of Emergency Department Visits Among Older Adults With Dementia

This cross-sectional study examines emergency department use among older adults with Alzheimer disease and related dementias.

Federal Nursing Home Policies on Antipsychotics had Similar Impacts by Race and Ethnicity for Residents With Dementia

OBJECTIVES

Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups.

DESIGN

Retrospective, cross-sectional trends study.

SETTING AND PARTICIPANTS

National long-stay nursing home residents with dementia from 2011 to 2017.

METHODS

We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015).

RESULTS

Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = -0.8807, P = .0023) and the slope declined further after the Partnership (β = -0.6611, P < .0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P = .4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (β = -0.0428, P = .0312) and Hispanic residents (β = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = -0.086, P = .0275) and post-Five Star Rating (β = -0.0775, P < .0001) declined faster among Hispanic residents.

CONCLUSIONS AND IMPLICATIONS

We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives.

Factors Associated With Benzodiazepine and Antipsychotic Prescribing in Hospice: A Qualitative Study of Hospice Prescribers

OBJECTIVES

Benzodiazepine and antipsychotic medications are common components of the hospice toolkit and are routinely prescribed for behavioral symptom management at end of life. These medications have significant associated risks but, despite their frequent use, little is known about how clinicians weigh prescribing decisions for individuals in hospice. In this qualitative study, we examined the key factors that influence the decision to initiate a benzodiazepine and antipsychotic medication for management of behavioral symptoms at end of life.

DESIGN

A qualitative study using semi-structured interviews and descriptive qualitative analysis.

SETTING AND PARTICIPANTS

We conducted semi-structured interviews with prescribing hospice physicians and nurse practitioners working in hospice settings across the United States.

METHODS

Hospice clinicians were asked to describe factors that influence prescribing decisions to initiate benzodiazepine and antipsychotic medications for the management of behavioral symptoms. Data from audio-recorded sessions were transcribed, coded to identify relevant concepts, and reduced to determine major themes.

RESULTS

We completed 23 interviews with hospice physicians and nurse practitioners. On average, participants had worked in a hospice setting for a mean of 14.3 years (SD: 10.9); 39% had geriatrics training. Major themes related to benzodiazepine and antipsychotic prescribing were (1) caregiving factors strongly influence the use of medications, (2) patient and caregiver stigma and concerns regarding medication use limit prescribing, (3) medications are initiated to avoid hospitalization or transition to a higher level of care, and (4) nursing home hospice care brings unique challenges.

CONCLUSION AND IMPLICATIONS

Caregiver factors and the setting of hospice care strongly influence clinician decisions to initiate benzodiazepines and antipsychotics in hospice. Caregiver education about medication use at end of life and support in managing challenging behaviors may help promote optimal prescribing.

Hospice agency characteristics associated with benzodiazepine and antipsychotic prescribing

BACKGROUND

Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing.

METHODS

Cross-sectional analysis of hospice-enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics.

RESULTS

In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest-prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest-prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine- and antipsychotic- prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non-Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6-0.7, Hispanic RR 0.4, 95% CI 0.3-0.5; antipsychotic: non-Hispanic Black RR 0.7, 95% CI 0.6-0.8, Hispanic RR 0.4, 95% CI 0.3-0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine-prescribing quintile (RR 1.3, 95% CI 1.2-1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over-represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5-2.7) and antipsychotics (RR 2.7, 95% CI 2.6-2.8), as were for-profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3-2.4; antipsychotic: RR 2.3, 95% CI 2.2-2.4). Prescribing rates varied widely across Census regions.

CONCLUSIONS

Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients.

Accountable care organizations and use of surgery among patients with Alzheimer disease and related dementias

OBJECTIVE

To understand the effects of accountable care organizations (ACOs) on use of surgery in patients with Alzheimer disease and related dementias (ADRD).

STUDY DESIGN

Retrospective national cohort study of all Medicare beneficiaries identified in a 20% sample between 2010 and 2017. The primary exposure was participation in ACOs. The primary outcome was use of 1 of 6 common surgical procedures (aortic valve replacement [AVR], abdominal aortic aneurysm [AAA] repair, colectomy, carotid artery repair, major joint repair, and prostatectomy).

METHODS

Multivariable logistic regression models were fit using beneficiary-year as the unit of analysis to estimate the likelihood of undergoing each procedure among patients with ADRD and without ADRD, stratified by ACO participation. Additional models were fit to determine how the relationship between ACO participation and surgery was altered based on procedure urgency and the availability of minimally invasive technology.

RESULTS

Adjusted odds for use of surgery were lower among patients with ADRD compared with patients without ADRD for all procedures. ACO participation had varying impact on patients with ADRD, with higher odds of AVR and major joint surgery and lower odds of carotid artery repair. Availability of minimally invasive technology increased the likelihood of AVR and AAA repair among patients with ADRD; however, ACO participation reduced these effects. The effect of ACO participation on the likelihood of undergoing surgery did not vary by urgency of the procedure.

CONCLUSIONS

The likelihood of undergoing surgery is overall lower among patients with ADRD and may vary by ACO participation for specific procedures.

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

OBJECTIVES

More than two-thirds of assisted living (AL) residents have dementia or cognitive impairment and antipsychotics are commonly prescribed for behavioral disturbances. As AL communities are regulated by state-level policies, which vary significantly regarding the care for people with dementia, we examined how antipsychotic prescribing varied across states among AL residents with dementia.

DESIGN

This was an observational study using 20% sample of national Medicare data in 2017.

SETTING AND PARTICIPANTS

The study cohort included Medicare beneficiaries with dementia aged 65 years or older who resided in larger (≥25-bed) ALs in 2017.

METHODS

The study outcome was the percentage of eligible AL person-months in which antipsychotics were prescribed for each state. We used a random intercept linear regression model to shrink estimates toward the overall mean use of antipsychotics addressing unstable estimates due to small sample sizes in some states.

RESULTS

A total of 20,867 AL residents with dementia were included in the analysis, contributing to 194,718 person-months of observation. On average, AL residents with dementia were prescribed antipsychotics during 12.6% of their person-months. This rate varied significantly by state, with a low of 7.8% (95% CI 5.9%-10.3%) for Hawaii to a high of 20.5% (95% CI 16.4%-25.3%) for Wyoming.

CONCLUSIONS AND IMPLICATIONS

We observed significant state variation in the prescribing of antipsychotics among AL residents with dementia using national data. These variations may reflect differences in state regulations regarding the care for AL residents with dementia and suggest the need for further investigation to ensure high quality of care.

Predictors of Receipt of Comprehensive Medication Reviews in Older Adults

BACKGROUND

Polypharmacy is highly prevalent among older adults. This study's purpose was to provide nationally representative estimates of self-reported comprehensive medication review (CMR) receipt among older adults and describe factors associated with their receipt, as CMRs are available through the Medicare Part D program.

METHODS

This cross-sectional study used data from the National Poll on Healthy Aging (NPHA), a nationally representative online survey of community-dwelling adults aged 50-80, administered in December 2019. Participants included older adults aged 65-80 with any health insurance (n = 960). Outcomes were self-reported CMR receipt, awareness of CMR insurance coverage, and interest in a future CMR with a pharmacist. Sociodemographic and health-related variables were included. Descriptive statistics and multivariable logistic regression with NPHA population sampling weights were used.

RESULTS

Among older adults on 2 or more prescription medications, only 20.8% had received a CMR while 34.3% were interested in a future CMR. Among individuals who had not received a CMR, most (83.4%) were unaware their insurance might cover a CMR. Factors associated with higher odds of receiving a CMR included taking 5 or more prescription medications (adjusted odds ratio [AOR] = 2.6, 95% CI: 1.59-4.38) and reporting food insecurity (AOR = 2.9, 95% CI: 1.07-7.93). Having fair or poor self-reported physical health was associated with lower odds of receiving a CMR (AOR = 0.49, 95% CI: 0.25-0.97).

CONCLUSIONS

Most older adults on 2 or more prescription medications with health insurance had not received a CMR and many were interested in one. Targeted strategies to increase older adults' awareness and receipt of CMRs are warranted.

Mortality After Exposure to a Hurricane Among Older Adults Living With Dementia

This cohort study examines mortality after hurricane exposure in older adults living with Alzheimer disease and other related dementias.

Time to dementia diagnosis by race: A retrospective cohort study

BACKGROUND

Non-Hispanic Black individuals may be less likely to receive a diagnosis of dementia compared to non-Hispanic White individuals. These findings raise important questions regarding which factors may explain this observed association and any differences in the time to which disparities emerge following dementia onset.

METHODS

We conducted a retrospective cohort study using survey data from the 1995 to 2016 Health and Retirement Study linked with Medicare fee-for-service claims. Using the Hurd algorithm (a regression-based approach), we identified dementia onset among older adult respondents (age ≥65 years) from the Telephone Interview for Cognitive Status and proxy respondents. We determined date from dementia onset to diagnosis using Medicare data up to 3 years following onset using a list of established diagnosis codes. Cox Proportional Hazards modeling was used to examine the association between an individual's reported race and likelihood of diagnosis after accounting for sociodemographic characteristics, income, education, functional status, and healthcare use.

RESULTS

We identified 3435 older adults who experienced a new onset of dementia. Among them, 30.1% received a diagnosis within 36 months of onset. In unadjusted analyses, the difference in cumulative proportion diagnosed by race continued to increase across time following onset, p-value <0.001. 23.8% of non-Hispanic Black versus 31.4% of non-Hispanic White participants were diagnosed within 36 months of dementia onset, Hazard Ratio = 0.73 (95% CI: 0.61, 0.88). The association persisted after adjustment for functional status and healthcare use; however, these factors had less of an impact on the strength of the association than income and level of education.

CONCLUSION

Lower diagnosis rates of dementia among non-Hispanic Black individuals persists after adjustment for sociodemographic characteristics, functional status, and healthcare use. Further understanding of barriers to diagnosis that may be related to social determinants of health is needed to improve dementia-related outcomes among non-Hispanic Black Americans.

Variation in Benzodiazepine and Antipsychotic Prescribing Among Hospice Agencies

BACKGROUND

Benzodiazepines and antipsychotics are routinely prescribed for symptom management in hospice. There is minimal evidence to guide prescribing in this population, and little is known about how prescribing varies across hospice agencies.

OBJECTIVE

Examine patient- and hospice agency-level characteristics associated with incident prescribing of benzodiazepines and antipsychotics in hospice.

DESIGN

Retrospective cohort study of a 20% sample of Medicare beneficiaries newly enrolled in hospice.

PARTICIPANTS

Medicare hospice beneficiaries ≥ 65 years old between 2014 and 2016, restricted to those without benzodiazepine (N = 169,688) or antipsychotic (N = 190,441) prescription fills in the 6 months before hospice enrollment.

MAIN MEASURES

The primary outcome was incident (i.e., new) prescribing of a benzodiazepine or antipsychotic. A series of multilevel Cox regression models with random intercepts for hospice agency were fit to examine the association of incident benzodiazepine and antipsychotic prescribing with patient and hospice agency characteristics.

KEY RESULTS

A total of 91,728 (54.1%) and 58,175 (30.5%) hospice beneficiaries were newly prescribed an incident benzodiazepine or antipsychotic. The prescribing rate of the hospice agency was the strongest predictor of incident prescribing: Compared to patients in bottom-quartile benzodiazepine-prescribing agencies, those in top-quartile agencies were 10.7 times more likely to be prescribed an incident benzodiazepine (adjusted hazard ratio [AHR] 10.7, 95% CI 10.1-11.3). For incident antipsychotic prescribing, patients in top-quartile agencies were 51.7 times more likely to receive an antipsychotic (AHR 51.7, 95% CI 44.3-60.4) compared to those in the bottom quartile. Results remained consistent accounting for comfort kit prescribing.

CONCLUSIONS

The pattern of benzodiazepine or antipsychotic prescribing of a hospice agency strongly predicts whether a hospice enrollee is prescribed these medications, exceeding every other patient-level factor. While the appropriate level of prescribing in hospice is unclear, this variation may reflect a strong local prescribing culture across individual hospice agencies.

Validation of Claims Algorithms to Identify Alzheimer's Disease and Related Dementias

BACKGROUND

Using billing data generated through health care delivery to identify individuals with dementia has become important in research. To inform tradeoffs between approaches, we tested the validity of different Medicare claims-based algorithms.

METHODS

We included 5 784 Medicare-enrolled, Health and Retirement Study participants aged older than 65 years in 2012 clinically assessed for cognitive status over multiple waves and determined performance characteristics of different claims-based algorithms.

RESULTS

Positive predictive value (PPV) of claims ranged from 53.8% to 70.3% and was highest using a revised algorithm and 1 year of observation. The tradeoff of greater PPV was lower sensitivity; sensitivity could be maximized using 3 years of observation. All algorithms had low sensitivity (31.3%-56.8%) and high specificity (92.3%-98.0%). Algorithm test performance varied by participant characteristics, including age and race.

CONCLUSION

Revised algorithms for dementia diagnosis using Medicare administrative data have reasonable accuracy for research purposes, but investigators should be cognizant of the tradeoffs in accuracy among the approaches they consider.

Identification of Dementia in Recent Medicare Claims Data, Compared With Rigorous Clinical Assessments

BACKGROUND

Medicare fee-for-service (FFS) claims data are increasingly leveraged for dementia research. Few studies address the validity of recent claim data to identify dementia, or carefully evaluate characteristics of those assigned the wrong diagnosis in claims.

METHODS

We used claims data from 2014 to 2018, linked to participants administered rigorous, annual dementia evaluations in 5 cohorts at the Rush Alzheimer's Disease Center. We compared prevalent dementia diagnosed through the 2016 cohort evaluation versus claims identification of dementia, applying the Bynum-standard algorithm.

RESULTS

Of 1 054 participants with Medicare Parts A and B FFS in a 3-year window surrounding their 2016 index date, 136 had prevalent dementia diagnosed during cohort evaluations; the claims algorithm yielded 217. Sensitivity of claims diagnosis was 79%, specificity 88%, positive predictive value 50%, negative predictive value 97%, and overall accuracy 87%. White participants were disproportionately represented among detected dementia cases (true positive) versus cases missed (false negative) by claims (90% vs 75%, respectively, p = .04). Dementia appeared more severe in detected than missed cases in claims (mean Mini-Mental State Exam = 15.4 vs 22.0, respectively, p < .001; 28% with no limitations in activities of daily living versus 45%, p = .046). By contrast, those with "over-diagnosis" of dementia in claims (false positive) had several worse health indicators than true negatives (eg, self-reported memory concerns = 51% vs 29%, respectively, p < .001; mild cognitive impairment in cohort evaluation = 72% vs 44%, p < .001; mean comorbidities = 7 vs 4, p < .001).

CONCLUSIONS

Recent Medicare claims perform reasonably well in identifying dementia; however, there are consistent differences in cases of dementia identified through claims than in rigorous cohort evaluations.

Trends in US Medicare Decedents’ Diagnosis of Dementia From 2004 to 2017

Question

To what degree did the diagnosis of Alzheimer disease and related dementias (ADRD) change at the end of life between 2004 and 2017?

Findings

Among 3 515 329 Medicare fee-for-service decedents, the percentage who received an ADRD diagnosis within 2 years of death increased from 34.7% in 2004 to 47.2% in 2017. The likelihood of receiving an ADRD diagnosis particularly increased in the inpatient, hospice, and home health settings; individual characteristics and service use were stable over time, while the intensity of end-of-life care declined on most measures.

Meaning

Dying with an ADRD diagnosis has become more common among older US decedents, potentially owing to increased awareness and temporal changes in billing.

Importance

Alzheimer disease and related dementias (ADRD) have received considerable attention among clinicians, researchers, and policy makers in recent years. Despite increased awareness, few studies have documented temporal changes in the documentation of ADRD diagnoses despite its new importance for risk adjustment for health plans in Medicare.

Objective

To assess trends in frequency of ADRD diagnosis in the last 2 years of life from 2004 to 2017, as well as any associated changes in billing practices, characteristics of the population with diagnosed ADRD, and intensity of end-of-life care.

Design, Setting, and Participants

This is a serial cross-sectional study of older adult decedents (67 years or older) from 2004 to 2017 using a 20% sample of fee-for-service Medicare decedents. An ADRD diagnosis within the last 2 years of life was identified using diagnosis codes from inpatient, professional service, home health, or hospice claims, requiring the standard claims algorithm that required at least 1 claim and a more stringent algorithm that required at least 2 claims. Trends in ADRD diagnosis among decedents were used to lessen influence of new diagnostic technologies for early stage disease. Demographic characteristics, selected comorbidities, place of death, and health service use at the end-of-life were also examined. Data were analyzed from July 9, 2020, to May 3, 2021.

Exposures

Calendar year 2004 to 2017.

Main Outcome and Measure

An ADRD diagnosis within 2 years of death.

Results

Among the included 3 515 329 Medicare fee-for-service decedents, when adjusted for age and sex, the percentage of older decedents with an ADRD diagnosis increased from 34.7% in 2004 to 47.2% in 2017. The trend was attenuated (25.2% to 39.2%) using a stringent ADRD definition. There was an inflection in the curve from 2011 to 2013, the time at which additional diagnoses were added to Medicare claims and the National Alzheimer Care Act was enacted. The ADRD diagnosis frequency increased considerably in inpatient (49.0% to 67.3%), hospice (12.2% to 42.0%), and home health (10.1% to 28.7%) claims. However, individual characteristics, number of visits, and hospitalizations were similar across the study period, and the intensity of end-of-life care declined on most measures.

Conclusions and Relevance

In this cross-sectional study, nearly half of older Medicare decedents had a diagnosis of ADRD at the time of death. From 2004 to 2017, the percentage of older adult decedents who received an ADRD diagnosis increased substantially prior to announcement of the addition of ADRD to Medicare risk adjustment strategies.

Small practice participation and performance in Medicare accountable care organizations

OBJECTIVES

Alternative payment models (APMs) encouraging provider collaboration may help small practices overcome the participation challenges that they face in APMs. We aimed to determine whether small practices in accountable care organizations (ACOs) reduced their beneficiaries' spending more than large practices in ACOs.

STUDY DESIGN

Retrospective cohort study of Medicare patients attributed to ACOs and non-ACOs.

METHODS

We conducted a modified difference-in-differences analysis that allowed us to compare large vs small practices before and after the Medicare Shared Savings Program (MSSP) ACO started, between 2010 and 2016. Our sample included Medicare fee-for-service beneficiaries with 12 months of Medicare Part A and Part B (unless death) who were attributed to small (≤ 15 providers) and large (> 15 providers) practices participating in ACOs and non-ACOs. The outcome was patient annual spending based on CMS' total per capita costs.

RESULTS

Patients attributed to small practices in ACOs had annual Medicare spending decreases of $269 (95% CI, $213-$325; P < .001) more than patients attributed to large practices in ACOs. Small ACO practices reduced spending more than large practices by $165 for physician services (95% CI, $140-$190; P < .001), $113 for hospital/acute care (95% CI, $65-162; P < .001), and $52 for other services (95% CI, $27-$77; P < .001). Small practices in ACOs spent $253 more on average at baseline than small practices in non-ACOs. ACOs with a higher proportion of small practices were more likely to receive shared savings payments.

CONCLUSIONS

Small practices in ACOs controlled costs more so than large practices. Small practice participation may generate higher savings for ACOs.

Provider Specialty and the Use of Disease-Modifying Antirheumatic Drugs for Rheumatoid Arthritis Among Older Adults in the 2005-2016 National Ambulatory Medical Care Survey

Objective

We compared disease‐modifying antirheumatic drug (DMARD) use for older adults with rheumatoid arthritis (RA)‐related ambulatory visits from rheumatologists and primary care providers (PCPs).

Methods

In this study of national sample office visits, we characterized ambulatory visits by older adults 65 years of age or older seen by rheumatologists or PCPs for diagnosis of RA using the 2005‐2016 National Ambulatory Medical Care Survey. We analyzed patterns and trends of DMARD use using descriptive statistics and multivariable analyses by provider specialty.

Results

We identified 518 observations representing 7,873,246 ambulatory RA visits by older adults over 12 years; 74% were with rheumatologists. Any DMARD use was recorded at 56% of rheumatologist and 30% of PCP visits. Among visits with any DMARD use, 20% of rheumatologist visits had two or more DMARDs compared with 6% of PCP visits. Over the 12‐year study period, there was no statistical difference in trend of any or conventional synthetic DMARD use at visits by provider specialty, adjusted for patient characteristics, non‐DMARD polypharmacy and multimorbidity. However, biologic DMARD use was more likely to incrementally increase with rheumatologist compared with PCP visits (P = 0.003).

Conclusion

DMARD use for older adults with RA remains low from both rheumatologists and PCPs, including biologic DMARDs, even though American College of Rheumatology guidelines recommend earlier and more aggressive treatment of RA. With predicted shortages in the rheumatology workforce and maldistribution of rheumatology providers, PCPs may play an increasingly important role in caring for older adults with RA. Further research is needed to understand to optimize appropriate use of DMARDs in older patients with RA.

Access to primary care and cognitive impairment: results from a national community study of aging Americans

BACKGROUND

Despite a growing burden of Alzheimer's Disease and related dementias (ADRD) in the US, the relationship between health care and cognitive impairment prevention is unclear. Primary care manages risk causing conditions and risk reducing behaviors for dementia, so we examine the association between individual and area-level access to primary care and cognitive impairment in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.

METHODS

REGARDS participants with a cognitive assessment and vascular measurements at their baseline visit were included in this cross-sectional analysis. Cognitive impairment was defined as a Six-Item Screener (SIS) score < 5. Primary care supply, primary care utilization and emergency department (ED) utilization were measured at the primary care service area (PCSA) level based on participant's address. Individual access to care was self-reported. Models were adjusted for confounding by demographics, socioeconomic status and behavioral risk factors.

RESULTS

Among 25,563 adults, living in a PCSA with low primary care supply was associated with 25% higher odds of cognitive impairment (OR 1.25 CI 1.07-1.45). Not having a regular source of medical care was associated with 14% higher odds of cognitive impairment (OR 1.14 CI 1.02-1.28), and living in a PCSA with high emergency department utilization was associated with 12% higher odds of cognitive impairment (OR 1.12 CI 1.02-1.23).

CONCLUSIONS

Our results are an important first step in understanding how health care may prevent cognitive impairment. They highlight the importance of primary care and suggest future work clarifying its role in preventing cognitive decline is imperative.

Disproportionate increases in schizophrenia diagnoses among Black nursing home residents with ADRD

BACKGROUND

Previous research demonstrated an increase in the reporting of schizophrenia diagnoses among nursing home (NH) residents after the Centers for Medicare & Medicaid Services National Partnership to Improve Dementia Care. Given known health and healthcare disparities among Black NH residents, we examined how race and Alzheimer's and related dementia (ADRD) status influenced the rate of schizophrenia diagnoses among NH residents following the partnership.

METHODS

We used a quasi-experimental difference-in-differences design to study the quarterly prevalence of schizophrenia among US long-stay NH residents aged 65 years and older, by Black race and ADRD status. Using 2011-2015 Minimum Data Set 3.0 assessments, our analysis controlled for age, sex, measures of function and frailty (activities of daily living [ADL] and Changes in Health, End-stage disease and Symptoms and Signs scores) and behavioral expressions.

RESULTS

There were over 1.2 million older long-stay NH residents, annually. Schizophrenia diagnoses were highest among residents with ADRD. Among residents without ADRD, Black residents had higher rates of schizophrenia diagnoses compared to their nonblack counterparts prior to the partnership. Following the partnership, Black residents with ADRD had a significant increase of 1.7% in schizophrenia as compared to nonblack residents with ADRD who had a decrease of 1.7% (p = 0.007).

CONCLUSIONS

Following the partnership, Black NH residents with ADRD were more likely to have a schizophrenia diagnosis documented on their MDS assessments, and schizophrenia rates increased for Black NH residents with ADRD only. Further work is needed to examine the impact of "colorblind" policies such as the partnership and to determine if schizophrenia diagnoses are appropriately applied in NH practice, particularly for black Americans with ADRD.

Resources, methods, and data infrastructure to promote research in dementia care, caregiving, and services

BACKGROUND

The National Institute on Aging, in conjunction with the Department of Health and Human Services as part of the National Alzheimer's Project Act, hosted a 2020 Dementia Care, Caregiving, and Services Research Summit Virtual Meeting Series on August 13, 2020. This article reflects three presentations related to Theme 6: Research Resources, Methods, and Data Infrastructure. Dr. Bynum discussed the challenges of identifying people for population- and healthcare-based research, including how definitions of dementia have changed over time, the opportunities and challenges inherent in the use of electronic data sources, and the need to fit data collection strategies to research goals and questions. Dr. Travison provided an overview on the growing use of embedded pragmatic clinical trials (ePCTs) and how to enhance their impact in dementia research. Dr. Wendler presented on the ethical considerations relevant to consent for dementia research, including assessment of decisional capacity and the role of decisional surrogates.

CONCLUSIONS

The availability of claims data, electronic health records, and other sources of "existing" data has made the use and development of ePCTs both easier and more appealing. Among other things, they offer advantages in terms of lower cost and generalizability to real-world settings. This is turn has necessitated the use of informatic and analytic approaches to account for some of the limitations and complexities of such data, including multilevel clustering and the need to link and jointly analyze data from the person with dementia and those of their care partner. As part of this process, it will be important to broaden the scope of who is assessed for decisional capacity, make those assessments more study specific, and assist surrogates in making decisions based on what the individual would have chosen for themselves if capacitated (i.e., substituted judgment).

Using Healthcare Data in Embedded Pragmatic Clinical Trials among People Living with Dementia and Their Caregivers: State of the Art

Embedded pragmatic clinical trials (ePCTs) are embedded in healthcare systems as well as their data environments. For people living with dementia (PLWD), settings of care can be different from the general population and involve additional people whose information is also important. The ePCT designs have the opportunity to leverage data that becomes available through the normal delivery of care. They may be particularly valuable in Alzheimer's disease and Alzheimer's disease-related dementia (AD/ADRD), given the complexity of case identification and the diversity of care settings. Grounded in the objectives of the Data and Technical Core of the newly established National Institute on Aging Imbedded Pragmatic Alzheimer's Disease and AD-Related Dementias Clinical Trials Collaboratory (IMPACT Collaboratory), this article summarizes the state of the art in using existing data sources (eg, Medicare claims, electronic health records) in AD/ADRD ePCTs and approaches to integrating them in real-world settings. J Am Geriatr Soc 68:S49-S54, 2020.

Association of US Nurse and Physician Occupation With Risk of Suicide

IMPORTANCE

Nurses are the largest component of the US health care workforce. Recent research suggests that nurses may be at high risk for suicide; however, few studies on this topic exist.

OBJECTIVES

To estimate the national incidence of suicide among nurses and examine characteristics of nurse suicides compared with physicians and the general population.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used US data from 159 372 suicides reported in the National Violent Death Reporting System from 2007 to 2018. With the use of workforce denominators, sex-specific suicide incidence estimates were generated among nurses, physicians, and the general population (age, ≥30 years). Associations between clinician type and method of suicide and results of toxicology examination at death were calculated, adjusted for sociodemographic characteristics. Statistical analysis was performed from October 16, 2020, to January 10, 2021.

EXPOSURE

Occupation as a nurse or physician.

MAIN OUTCOME AND MEASURES

Suicide incidence and characteristics associated with suicides.

RESULTS

A total of 2374 suicides among nurses (1912 women [80.5%]; mean [SD] age, 52.8 [11.8] years), 857 suicides among physicians (723 men [84.4%]; mean [SD] age, 59.8 [15.3] years), and 156 141 suicides in the general population (121 483 men [77.8%]; mean [SD] age, 53.1 [14.7] years) were identified. Overall, suicide was more common among nurses compared with the general population (sex-adjusted incidence in 2017-2018, 23.8 per 100 000 vs 20.1 per 100 000; relative risk, 1.18 [95% CI, 1.03-1.36]). Among women in 2017-2018, the suicide incidence among nurses was 17.1 per 100 000 (506 among 2 966 048) vs 8.6 per 100 000 (8879 among 103 731 387) in the general female population (relative risk, 1.99 [95% CI, 1.82-2.18]). In absolute terms, being a female nurse was associated with an additional 8.5 suicides per 100 000 (95% CI, 7.0-10.0 per 100 000) compared with the general population of women. By sex, physician suicide rates were not statistically different from the general population other than among female physicians in 2011-2012 (11.7 per 100 000 [95% CI, 6.6-16.8 per 100 000] female physicians vs 7.5 per 100 000 [95% CI, 7.2-7.7 per 100 000] general population; P = .04). In terms of the characteristics of suicides, clinicians were more likely to use poisoning than the general population; for example, 24.9% (95% CI, 23.5%-26.4%) of nurses used poisoning compared with 16.8% (95% CI, 16.6%-17.0%) of the general suicide population. The presence of antidepressants, benzodiazepines, barbiturates, and opiates was more common among clinician suicides than suicides in the general population.

CONCLUSION AND RELEVANCE

This study suggests that, in the US, the risk of suicide compared with the general population was significantly greater for nurses but not for physicians. Further research is needed to assess whether interventions would be associated with benefit in reducing suicide risk among nurses.

Trends in antipsychotic prescribing among long-term care residents receiving hospice care

IMPORTANCE

The Centers for Medicare & Medicaid Services' (CMS) National Partnership to Improve Dementia Care in Nursing Homes ("CMS National Partnership") focuses on reducing antipsychotic prescribing to long-term care residents. Hospice enrollment is not an exclusionary condition for the antipsychotic quality measure reported by CMS. It is unclear how prescribing in hospice may have been impacted by the initiative.

OBJECTIVE

Estimate the association of the CMS National Partnership with trends in antipsychotic prescribing among long-term care residents in hospice.

DESIGN

Interrupted time-series analysis of a 100% Minimum Data Set sample with linked hospice claims from 2011 to 2017.

SETTING

Long-term care nursing facilities.

PARTICIPANTS

Older adults ≥65 residing in long-term care (n = 3,741,379) and limited to those enrolled in hospice (n = 821,610).

MAIN OUTCOME

Quarterly prevalence of antipsychotic and other psychotropic (antianxiety, hypnotic, antidepressant) use among long-term care residents; overall and among residents with dementia, stratified by hospice enrollment.

RESULTS

From 2011 to 2017, parallel declines in antipsychotic prescribing were observed among long-term care residents enrolled and not enrolled in hospice (hospice: decline from 26.8% to 18.7%; non-hospice: decline from 23.0% to 14.4%). Following the 2012 CMS National Partnership, quarterly rates of antipsychotic prescribing declined significantly for both residents enrolled and not enrolled in hospice care. Declines in antipsychotic prescribing were greater for residents with dementia, with similar rates among residents enrolled and not enrolled in hospice. Among residents with dementia enrolled in hospice, use of other psychotropic medication classes including antianxiety, antidepressant, and hypnotic use remained relatively stable over time.

CONCLUSIONS AND RELEVANCE

Declines in antipsychotic prescribing during the CMS National Partnership occurred among long-term care residents in hospice, where use may be deemed clinically appropriate. Nursing homes are an important location for the provision of dementia end-of-life care and the drivers of potentially unintended reductions in antipsychotic use merits further investigation.

Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US

IMPORTANCE

Community-dwelling older adults with dementia have a high prevalence of psychotropic and opioid use. In these patients, central nervous system (CNS)-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death.

OBJECTIVE

To determine the extent of CNS-active polypharmacy among community-dwelling older adults with dementia in the US.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of all community-dwelling older adults with dementia (identified by International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes; N = 1 159 968) and traditional Medicare coverage from 2015 to 2017. Medication exposure was estimated using prescription fills between October 1, 2017, and December 31, 2018.

EXPOSURES

Part D coverage during the observation year (January 1-December 31, 2018).

MAIN OUTCOMES AND MEASURES

The primary outcome was the prevalence of CNS-active polypharmacy in 2018, defined as exposure to 3 or more medications for longer than 30 days consecutively from the following classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, and opioids. Among those who met the criterion for polypharmacy, duration of exposure, number of distinct medications and classes prescribed, common class combinations, and the most commonly used CNS-active medications also were determined.

RESULTS

The study included 1 159 968 older adults with dementia (median age, 83.0 years [interquartile range {IQR}, 77.0-88.6 years]; 65.2% were female), of whom 13.9% (n = 161 412) met the criterion for CNS-active polypharmacy (32 139 610 polypharmacy-days of exposure). Those with CNS-active polypharmacy had a median age of 79.4 years (IQR, 74.0-85.5 years) and 71.2% were female. Among those who met the criterion for CNS-active polypharmacy, the median number of polypharmacy-days was 193 (IQR, 88-315 polypharmacy-days). Of those with CNS-active polypharmacy, 57.8% were exposed for longer than 180 days and 6.8% for 365 days; 29.4% were exposed to 5 or more medications and 5.2% were exposed to 5 or more medication classes. Ninety-two percent of polypharmacy-days included an antidepressant, 47.1% included an antipsychotic, and 40.7% included a benzodiazepine. The most common medication class combination included an antidepressant, an antiepileptic, and an antipsychotic (12.9% of polypharmacy-days). Gabapentin was the most common medication and was associated with 33.0% of polypharmacy-days.

CONCLUSIONS AND RELEVANCE

In this cross-sectional analysis of Medicare claims data, 13.9% of older adults with dementia in 2018 filled prescriptions consistent with CNS-active polypharmacy. The lack of information on prescribing indications limits judgments about clinical appropriateness of medication combinations for individual patients.

Prevalence of psychotropic and opioid prescribing among hospice beneficiaries in the United States, 2014-2016

BACKGROUND/OBJECTIVES

Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes.

DESIGN

Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016.

SETTING

Beneficiaries enrolled in the Medicare hospice benefit.

PARTICIPANTS

Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022).

MAIN OUTCOME

Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing.

RESULTS

70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics.

CONCLUSIONS

Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.

The Effect of Healthcare Provider Availability on Spine Spending

BACKGROUND

Spine conditions are costly and a major cause of disability. A growing body of evidence suggests that healthcare utilization and spending are driven by provider availability, which varies geographically and is a topic of healthcare policy debate.

OBJECTIVE

To estimate the effect of provider availability on spine spending.

DESIGN

Retrospective cohort study using relocation as a natural experiment.

PARTICIPANTS

Fee-for-service Medicare beneficiaries over age 65 who relocated to a new hospital referral region between 2010 and 2014.

MAIN MEASURES

We used generalized linear models to evaluate how changes in per-beneficiary availability of three types of healthcare providers (primary care physicians, spine surgeons, and chiropractors) affected annual per-beneficiary spine spending. We evaluated increases and decreases in provider availability separately. To account for the relative sizes of the provider workforces, we also calculated estimates of the effects of changes in national workforce size on changes in national spine spending.

KEY RESULTS

The association between provider availability and spending was generally stronger among beneficiaries who experienced a decrease (versus an increase) in availability. Of the three provider groups, spine surgeon availability was most strongly associated with spending. Among beneficiaries who experienced a decrease in availability, a decrease in one spine surgeon per 10,000 beneficiaries was associated with a decrease of $36.97 (95% CI: $12.51, $61.42) in annual spending per beneficiary, versus a decrease of $1.41 (95% CI: $0.73, $2.09) for a decrease in primary care physician availability. However, changes in the national workforce size of primary care physicians were associated with the largest changes in national spine spending.

CONCLUSIONS

Provider availability affects individual spine spending, with substantial changes observed at the national level. The effect depends on provider type and whether availability increases or decreases. Policymakers should consider how changes in the size of the physician workforce affect healthcare spending.

Financial Presentation of Alzheimer Disease and Related Dementias

IMPORTANCE

Alzheimer disease and related dementias (ADRD), currently incurable neurodegenerative diseases, can threaten patients' financial status owing to memory deficits and changes in risk perception. Deteriorating financial capabilities are among the earliest signs of cognitive decline, but the frequency and extent of adverse financial events before and after diagnosis have not been characterized.

OBJECTIVES

To describe the financial presentation of ADRD using administrative credit data.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective secondary data analysis of consumer credit report outcomes from 1999 to 2018 linked to Medicare claims data included 81 364 Medicare beneficiaries living in single-person households.

EXPOSURES

Occurrence of adverse financial events in those with vs without ADRD diagnosis and time of adverse financial event from ADRD diagnosis.

MAIN OUTCOMES AND MEASURES

Missed payments on credit accounts (30 or more days late) and subprime credit scores.

RESULTS

Overall, 54 062 (17 890 [33.1%] men; mean [SD] age, 74 [7.3] years) were never diagnosed with ADRD during the sample period and 27 302 had ADRD for at least 1 quarter of observation (8573 [31.4%] men; mean [SD] age, 79.4 [7.5] years). Single Medicare beneficiaries diagnosed with ADRD were more likely to miss payments on credit accounts as early as 6 years prior to diagnosis compared with demographically similar beneficiaries without ADRD (7.7% vs 7.3%; absolute difference, 0.4 percentage points [pp]; 95% CI, 0.07-0.70:) and to develop subprime credit scores 2.5 years prior to diagnosis (8.5% vs 8.1%; absolute difference, 0.38 pp; 95% CI, 0.04-0.72). By the quarter after diagnosis, patients with ADRD remained more likely to miss payments than similar beneficiaries who did not develop ADRD (7.9% vs 6.9%; absolute difference, 1.0 pp; 95% CI, 0.67-1.40) and more likely to have subprime credit scores than those without ADRD (8.2% vs 7.5%; absolute difference, 0.70 pp; 95% CI, 0.34-1.1). Adverse financial events were more common among patients with ADRD in lower-education census tracts. The patterns of adverse events associated with ADRD were unique compared with other medical conditions (eg, glaucoma, hip fracture).

CONCLUSIONS AND RELEVANCE

Alzheimer disease and related dementias were associated with adverse financial events years prior to clinical diagnosis that become more prevalent after diagnosis and were most common in lower-education census tracts.

Association of Continuity of Care With Outcomes in US Veterans With Inflammatory Bowel Disease

IMPORTANCE

Health care fragmentation is associated with inefficiency and worse outcomes. Continuity of care (COC) models were developed to address fragmentation.

OBJECTIVE

To examine COC and selected outcomes in US veterans with inflammatory bowel disease (IBD).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Veterans Health Administration (VHA) Corporate Data Warehouse to identify veterans with IBD who received care in the VHA health care system between January 1, 2002, and December 31, 2014. Included patients were veterans with IBD who had a primary care physician and at least 4 outpatient visits with key physicians (gastroenterologist, primary care physician, and surgeon) within the first year after an index IBD encounter. Data were analyzed from November 2018 to May 2020.

EXPOSURES

Care continuity was measured with the Bice-Boxerman COC index to define care density and dispersion within year 1 after the initial presentation.

MAIN OUTCOMES AND MEASURES

A Cox proportional hazards regression model was used to quantify the association between a low level of COC in year 1 (defined as ≤0.25 on a 0 to 1 scale) and subsequent IBD-related outcomes in years 2 and 3 (outpatient flare, hospitalization, and surgical intervention).

RESULTS

Among the 20 079 veterans with IBD who met the inclusion criteria, 18 632 were men (92.8%) and the median (interquartile range [IQR]) age was 59 (48-66) years. In the first year of follow-up, substantial variation in the dispersion of care was observed (median [IQR] COC, 0.24 [0.13-0.46]). In a Cox proportional hazards regression model, a low level of COC was associated with a higher likelihood of outpatient flares that required corticosteroids (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.01-1.22), hospitalizations (aHR, 1.25; 95% CI, 1.06-1.47), and surgical interventions (aHR, 1.72; 95% CI, 1.43-2.07).

CONCLUSIONS AND RELEVANCE

Results of this cohort study showed a wide variation in dispersion of IBD care and an association between a lower level of COC and active IBD and worse outcomes. The findings suggest that investigating the barriers to COC in integrated systems that have invested in care coordination is key to not only better understanding COC but also identifying opportunities to improve care fragmentation.

Prevalence of Psychotropic and Opioid Prescription Fills Among Community-Dwelling Older Adults With Dementia in the US

This pharmacoepidemiology study uses Medicare data to estimate US prescription fills for antidepressants, anxiolytics, antipsychotics, opioids, and antiepileptics among community-dwelling older adults with dementia in 2014-2015, and identifies the most commonly prescribed medications.

Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014

OBJECTIVE

The Centers for Medicare and Medicaid Services' National Partnership to Improve Dementia Care in Nursing Homes focuses on but is not limited to long-term care (LTC) residents with dementia; the potential impact on residents with other diagnoses is unclear. We sought to determine whether resident subpopulations experienced changes in antipsychotic and mood stabilizer prescribing.

DESIGN

Repeated cross-sectional analysis of a 20% Medicare sample, 2011-2014.

SETTING AND PARTICIPANT

Fee-for-service Medicare beneficiaries with Part D coverage in LTC (n = 562,485) and a secondary analysis limited to persons with depression or bipolar disorder (n = 139,071).

METHODS

Main outcome was quarterly predicted probability of treatment with an antipsychotic or mood stabilizer.

RESULTS

From 2011 to 2014, the adjusted predicted probability (APP) of antipsychotic treatment fell from 0.120 [95% confidence interval (CI) 0.119-0.121] to 0.100 (95% CI 0.099-0.101; P < .001). Use decreased for all age, sex, and racial/ethnic groups; the decline was larger for persons with dementia (P < .001). The APP of mood stabilizer use grew from 0.140 (95% CI 0.139-0.141) to 0.185 (95% CI 0.184-0.186), growth slightly larger among persons without dementia (P < .001). Among persons with depression or bipolar disorder, the APP of antipsychotic treatment increased from 0.081 (95% CI 0.079-0.082) to 0.087 (95% CI 0.085-0.088; P < .001); APP of mood stabilizer treatment grew more, from 0.193 (95% CI 0.190-0.196) to 0.251 (0.248-0.253; P < .001). Quetiapine was the most commonly prescribed antipsychotic. The most widely prescribed mood stabilizer was gabapentin, prescribed to 70.5% of those who received a mood stabilizer by the end of 2014.

CONCLUSIONS AND IMPLICATIONS

The likelihood of antipsychotic and mood stabilizer treatment did not decline for residents with depression or bipolar disorder, for whom such prescribing may be appropriate but who were not excluded from the Partnership's antipsychotic quality measure. Growth in mood stabilizer use was widespread, and largely driven by growth in gabapentin prescribing.

The Development of a Crosswalk for Functional Measures in Postacute Medicare Claims

OBJECTIVE

Although Medicare assessment files will include Standardized Patient Assessment Data Elements from 2016 forward, lack of uniformity of functional data prior to 2016 impedes longitudinal research. The purpose of this study was to create crosswalks for postacute care assessment measures and the basic mobility and daily activities scales of the Activity Measure for Post-Acute Care (AM-PAC) and to test their accuracy and validity in development and validation datasets.

METHODS

This cross-sectional study is a secondary analysis of AM-PAC, the Inpatient Rehabilitation Facility Patient Assessment Instrument, the Minimum Data Set, and the Outcome and Assessment Information Set data from 300 adults receiving rehabilitation recruited from 6 health care networks in 1 metropolitan area. Rasch analysis was used to co-calibrate items from the 3 measures onto the AM-PAC metric and to create look-up tables to create estimated AM-PAC (eAM-PAC) scores. Mean scores and correlation and agreement between actual and estimated scores were examined in the development dataset. Scores were estimated in a cohort of Medicare beneficiaries with hip, humerus and radius fractures. Correlations between eAM-PAC and Functional Independence Measure motor scores were examined. Differences in mean eAM-PAC scores were evaluated across groups of known differences (age, fracture type, dementia).

RESULTS

Strong correlations were found between actual and eAM-PAC scores in the development dataset. Moderate to strong correlations were found between the eAM-PAC basic mobility and Functional Independence Measure motor scores in the validation dataset. Differences in basic mobility scores across known groups were statistically significant and appeared to be clinically important. Differences between mean daily activities scores were statistically significant but appeared not to be clinically important.

CONCLUSION

Although further testing is warranted, the basic mobility crosswalk appears to provide valid scores for aggregate analysis of Medicare postacute care data.

IMPACT

This study reports on a method to take data from different Medicare administrative data sources and estimate scores on 1 scale. This approach was applied separately for data related to basic mobility and to daily activities. This may allow researchers to overcome challenges with using Medicare administrative data from different sources.

Modeling peer effect modification by network strength: The diffusion of implantable cardioverter defibrillators in the US hospital network

We develop methodology that allows peer effects (also referred to as social influence and contagion) to be modified by the structural importance of the focal actor's position in the network. The methodology is first developed for a single peer effect and then extended to simultaneously model multiple peer-effects and their modifications by the structural importance of the focal actor. This work is motivated by the diffusion of implantable cardioverter defibrillators (ICDs) in patients with congestive heart failure across a cardiovascular disease patient-sharing network of United States hospitals. We apply the general methodology to estimate peer effects for the adoption of capability to implant ICDs, the number of ICD implants performed by hospitals that are capable, and the number of patients referred to other hospitals by noncapable hospitals. Applying our novel methodology to study ICD diffusion across hospitals, we find evidence that exposure to ICD-capable peer hospitals is strongly associated with the chance a hospital becomes ICD-capable and that the direction and magnitude of the association is extensively modified by the strength of that hospital's position in the network, even after controlling for effects of geography. Therefore, interhospital networks, rather than geography per se, may explain key patterns of regional variations in healthcare utilization.

Patterns of stereotactic body radiation therapy: The influence of lung cancer treatment on prostate cancer treatment

INTRODUCTION

Technology availability and prior experience with novel cancer treatments may partially drive their use. We sought to examine this issue in the context of stereotactic body radiation therapy (SBRT) by studying how its use for an established indication (lung cancer) impacts its use for an emerging indication (prostate cancer).

METHODS

Using SEER-Medicare from 2007 to 2011, we developed prostate cancer-specific physician-hospital networks. Our primary dependent variable was SBRT use for prostate cancer and our primary independent variable was SBRT use for lung cancer, both at the network level. To assess the influence of SBRT availability and experiential use, we generated predicted probabilities of SBRT use for prostate cancer stratified by a network's use of lung cancer SBRT, adjusting for network characteristics. To assess intensity of use, we examined the correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT within a network.

RESULTS

We identified 316 networks that served 41,034 prostate cancer and 83,433 lung cancer patients. A network was significantly more likely to use SBRT for prostate cancer if that network used SBRT for lung cancer (e.g., in 2011, odds ratio [OR] 12.7; 95% confidence interval [CI] 3.9-41.8). The Pearson's correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT in a network was 0.34, which was not statistically significant (P = 0.12).

CONCLUSIONS

SBRT availability and experiential use for lung cancer influences its use for prostate cancer, but intensity of use for one does not relate to intensity of use for the other.

The Development and Validation of Prostate Cancer-specific Physician-Hospital Networks

OBJECTIVE

To develop prostate cancer-specific physician-hospital networks to define hospital-based units that more accurately group hospitals, providers, and the patients they serve.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare, we identified men diagnosed with localized prostate cancer between 2007 and 2011. We created physician-hospital networks by assigning each patient to a physician and each physician to a hospital based on treatment patterns. We assessed content validity by examining characteristics of hospitals anchoring the physician-hospital networks and of the patients associated with these hospitals.

RESULTS

We identified 42,963 patients associated with 344 physician-hospital networks. Networks anchored by a teaching hospital (compared to a nonteaching hospital) had higher median numbers of prostate cancer patients (117 [interquartile range {71-189} vs 82 {50-126}]) and treating physicians (7 [4-11] vs 4 [3-6]) (both P <0.001). On average, patients traveled farther to networks anchored by a teaching hospital (49 miles [standard deviation] [207] vs 41 [183]; P <.001). Hospitals known as high-volume centers for robotic prostatectomies, proton-beam therapy, and active surveillance had network rates for these procedures well above the mean. Hospitals known as safety net providers served higher proportions of minorities.

CONCLUSION

We empirically developed prostate-cancer specific physician-hospital networks that exhibit content validity and are relevant from a clinical and policy perspective. They have the potential to become targets for policy interventions focused on improving the delivery of prostate cancer care.

Measuring racial segregation in health system networks using the dissimilarity index

Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care).

Access to chiropractic care and the cost of spine conditions among older adults

OBJECTIVES

Chiropractic care is a service that operates outside of the conventional medical system and is reimbursed by Medicare. Our objective was to examine the extent to which accessibility of chiropractic care affects spending on medical spine care among Medicare beneficiaries.

STUDY DESIGN

Retrospective cohort study that used beneficiary relocation as a quasi-experiment.

METHODS

We used a combination of national data on provider location and Medicare claims to perform a quasi-experimental study to examine the effect of chiropractic care accessibility on healthcare spending. We identified 84,679 older adults enrolled in Medicare with a spine condition who relocated once between 2010 and 2014. For each year, we measured accessibility using the variable-distance enhanced 2-step floating catchment area method. Using data for the years before and after relocation, we estimated the effect of moving to an area of lower or higher chiropractic accessibility on spine-related spending adjusted for access to medical physicians.

RESULTS

There are approximately 45,000 active chiropractors in the United States, and local accessibility varies considerably. A negative dose-response relationship was observed for spine-related spending on medical evaluation and management as well as diagnostic imaging and testing (mean differences, $20 and $40, respectively, among those exposed to increasingly higher chiropractic accessibility; P <.05 for both). Associations with other types of spine-related spending were not significant.

CONCLUSIONS

Among older adults, access to chiropractic care may reduce medical spending on services for spine conditions.

Association Between Care Management and Outcomes Among Patients With Complex Needs in Medicare Accountable Care Organizations

IMPORTANCE

People with complex needs account for a disproportionate amount of Medicare spending, partially because of fragmented care delivered across multiple practitioners and settings. Accountable care organization (ACO) contracts give practitioners incentives to improve care coordination to the extent that coordination initiatives reduce total spending or improve quality.

OBJECTIVE

To assess the association between ACO-reported care management and coordination activities and quality, utilization, spending, and health care system interactions in older adults with complex needs.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, survey information on care management and coordination processes from 244 Medicare Shared Savings Program ACOs in the 2017-2018 National Survey of ACOs (of 351 Medicare ACO respondents; response rate, 69%) conducted from July 20, 2017, to February 15, 2018, was linked to 2016 Medicare administrative claims data. Medicare beneficiaries 66 years or older who were defined as having complex needs because of frailty or 2 or more chronic conditions associated with high costs and clinical need were included.

EXPOSURES

Beneficiary attribution to ACO reporting comprehensive (top tertile) care management and coordination activities.

MAIN OUTCOMES AND MEASURES

All-cause prevention quality indicator admissions, 30-day all-cause readmissions, acute care and critical access hospital admissions, evaluation and management visits in ambulatory settings, inpatient days, emergency department visits, total spending, post-acute care spending, health care contact days, and continuity of care (from Medicare claims).

RESULTS

Among 1 402 582 Medicare beneficiaries with complex conditions, the mean (SD) age was 78 (8.0) years and 55.1% were female. Compared with beneficiaries assigned to ACOs in the bottom tertile of care management and coordination activities, those assigned to ACOs in the top tertile had identical median prevention quality indicator admissions and 30-day all-cause readmissions (0 per beneficiary across all tertiles), hospitalization and emergency department visits (1.0 per beneficiary in bottom and top tertiles), evaluation and management visits in ambulatory settings (14.0 per beneficiary [interquartile range (IQR), 8.0-21.0] in both tertiles), longer median inpatient days (11.0 [IQR, 4.0-33.0] vs 10.0 [IQR, 4.0-32.0]), higher median annual spending ($14 350 [IQR, $4876-$36 119] vs $14 229 [IQR, $4805-$36 268]), lower median health care contact days (28.0 [IQR, 17.0-44.0] vs 29.0 [IQR, 18.0-45.0]), and lower continuity-of-care index (0.12 [IQR, 0.08-0.20] vs 0.13 [IQR, 0.08-0.21]). Accounting for within-patient correlation, quality, utilization, and spending outcomes among patients with complex needs attributed to ACOs were not statistically different comparing the top vs bottom tertile of care management and coordination activities.

CONCLUSIONS AND RELEVANCE

The ACO self-reports of care management and coordination capacity were not associated with differences in spending or measured outcomes for patients with complex needs. Future efforts to care for patients with complex needs should assess whether strategies found to be effective in other settings are being used, and if so, why they fail to meet expectations.

Geographic variation in spatial accessibility of U.S. healthcare providers

BACKGROUND

Growing physician maldistribution and population demographic shifts have contributed to large geographic variation in healthcare access and the emergence of advanced practice providers as contributors to the healthcare workforce. Current estimates of geographic accessibility of physicians and advanced practice providers rely on outdated "provider per capita" estimates that have shortcomings.

PURPOSE

To apply state of the art methods to estimate spatial accessibility of physician and non-physician clinician groups and to examine factors associated with higher accessibility.

METHODS

We used a combination of provider location, medical claims, and U.S. Census data to perform a national study of health provider accessibility. The National Plan and Provider Enumeration System was used along with Medicare claims to identify providers actively caring for patients in 2014 including: primary care physicians (i.e., internal medicine and family medicine), specialists, nurse practitioners, and chiropractors. For each U.S. ZIP code tabulation area, we estimated provider accessibility using the Variable-distance Enhanced 2 step Floating Catchment Area method and performed a Getis-Ord Gi* analysis for each provider group. Generalized linear models were used to examine associations between population characteristics and provider accessibility.

RESULTS

National spatial patterns of the provider groups differed considerably. Accessibility of internal medicine most resembled specialists with high accessibility in urban locales, whereas relative higher accessibility of family medicine physicians was concentrated in the upper Midwest. In our adjusted analyses independent factors associated with higher accessibility were very similar between internal medicine physicians and specialists-presence of a medical school in the county was associated with approximately 70% higher accessibility and higher accessibility was associated with urban locales. Nurse practitioners were similar to family medicine physicians with both having higher accessibility in rural locales.

CONCLUSIONS

The Variable-distance Enhanced 2 step Floating Catchment Area method is a viable approach to measure spatial accessibility at the national scale.

Patterns of Opioid Use in the 12 Months Following Geriatric Fragility Fractures: A Population-Based Cohort Study

OBJECTIVES

Fractures of the hip, distal radius, and proximal humerus are common in the Medicare population. This study's objective was to characterize patterns and duration of opioid use, including regional variations in use, after both surgical and nonoperative management.

DESIGN

Population-based cohort study.

SETTING AND PARTICIPANTS

A cohort of opioid-naïve community-dwelling US Medicare beneficiaries who survived a hip, distal radius, or proximal humerus fracture between January 1, 2007 and December 31, 2010. Cohort members were required to be opioid-naïve for 4 months prior to fracture.

MEASURES

We analyzed the proportion of patients with an active opioid prescription in each month following the index fracture, and report continued fills at 12 months postfracture. We also compared opioid prescription use in fractures treated surgically and nonsurgically and characterized state-level variation in opioid prescription use at 3 months postfracture.

RESULTS

There were 91,749 patients included in the cohort. Hip fracture patients had the highest rate of opioid use at 12 months (6.4%), followed by proximal humerus (5.7%), and distal radius (3.7%). Patients who underwent surgical fixation of proximal humerus and wrist fractures had higher rates of opioid use in each of the first 12 postoperative months compared with those managed nonoperatively. There was significant variation of opioid use at the state level, ranging from 7.6% to 18.2% of fracture patients filling opioid prescriptions 3 months after the index fracture.

CONCLUSIONS/IMPLICATIONS

Opioid-naïve patients sustaining fragility fractures of the hip, proximal humerus, or distal radius are at risk to remain on opioid medications 12 months after their index injury, and surgical management of proximal humerus and distal radius fractures increases opioid use in the 12 months after the index fracture. There is significant state-level variation in opiate consumption after index fracture in nonvertebral geriatric fragility fractures. Opportunity exists for targeted quality improvement efforts to reduce the variation in opioid use following common geriatric fragility fractures.

AGS Report on Engagement Related to the NIH Inclusion Across the Lifespan Policy

After passage of the 21st Century Cures Act, the National Institutes of Health held a workshop in 2017 to consider expanding its inclusion policy to encompass individuals of all ages. American Geriatrics Society (AGS) leaders and members participated in the workshop and formal feedback period. AGS advocacy clearly impacted the resulting workshop report and Inclusion Across the Lifespan policy that eliminates upper-age limits for research participation unless risk justified and changes the language used to describe older adults and other vulnerable groups. AGS recommendations that were not specifically stated in the updated policy were to encourage active recruitment of older adults, add standard measures of function and/or frailty, and change review criteria to ensure the health status of a study population mirrors typical clinical populations. The updated inclusion policy ultimately offers academic geriatrics programs the opportunities to expand knowledge about health in aging and to continue to provide leadership for research and advocacy efforts on behalf of older adults. J Am Geriatr Soc 67:211-217, 2019.

Predictors of Advance Care Planning in Older Women: The Nurses' Health Study

BACKGROUND/OBJECTIVES

Relatively little is known regarding predictors of advance care planning (ACP) in former nurses. We aimed to evaluate potential predictors of ACP documentation and discussion.

DESIGN

Cross-sectional study, 2012-2014.

SETTING

Nurses' Health Study.

PARTICIPANTS

A total of 60,917 community-dwelling female nurses aged 66 to 93 years living across the United States.

MEASUREMENTS

Based on self-reports, participants were categorized as having (1) only ACP documentation, (2) ACP documentation and a recent ACP discussion with a healthcare provider, or (3) neither. Multivariable log-binomial models were used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) of the two separate ACP categories vs those with neither. We evaluated various demographic, health, and social factors.

RESULTS

The large majority (84%) reported ACP documentation; 35% reported a recent ACP discussion. Demographic factors such as age and race were associated with both ACP categories. In multivariable analyses, race was most strongly associated: compared with whites, African Americans were 27% less likely (PR = 0.73; 95% CI = 0.69-0.78) to report ACP documentation alone and 41% (PR = 0.59; 95% CI = 0.54-0.66) less likely to report documentation with discussion. Additionally, health/healthcare-related characteristics were more strongly associated with ACP documentation plus discussion. Women with functional limitations (PR = 1.15; 95% CI = 1.10-1.20), women who were recently hospitalized (PR: 1.10; 95% CI = 1.08-1.12) or women who had seen a physician for health symptoms (PR = 1.43; 95% CI = 1.35-1.52) or screening (PR = 1.40; 95% CI = 1.32-1.49) were more likely to report having both ACP documentation and discussion. Social factors showed limited relationships with ACP documentation only; for documentation plus discussion, being widowed and living alone was associated with higher prevalence (PR = 1.21; 95% CI = 1.19-1.24) and having little emotional support was associated with lower prevalence (PR = 0.84; 95% CI = 0.81-0.86).

CONCLUSIONS

Among older nurses, most of whom reported having documented ACP, 35% reported recent patient-clinician ACP discussions, indicating a major participatory gap in an element critical to ACP effectiveness. Even in nurses, African Americans reported less ACP documentation or discussion. J Am Geriatr Soc 67:292-301, 2019.