A. Marshall McBean

Chronic Kidney Disease and the Risk for Cardiovascular Disease, Renal Replacement, and Death in the United States Medicare Population, 1998 to 1999

Knowledge of the excess risk posed by specific cardiovascular syndromes could help in the development of strategies to reduce premature mortality among patients with chronic kidney disease (CKD). The rates of atherosclerotic vascular disease, congestive heart failure, renal replacement therapy, and death were compared in a 5% sample of the United States Medicare population in 1998 and 1999 (n = 1,091,201). Patients were divided into the following groups: 1, no diabetes, no CKD (79.7%); 2, diabetes, no CKD (16.5%); 3, CKD, no diabetes (2.2%); and 4, both CKD and diabetes (1.6%). During the 2 yr of follow-up, the rates (per 100 patient-years) in the four groups were as follows: atherosclerotic vascular disease, 14.1, 25.3, 35.7, and 49.1; congestive heart failure, 8.6, 18.5, 30.7, and 52.3; renal replacement therapy, 0.04, 0.2, 1.6, and 3.4; and death, 5.5, 8.1, 17.7, and 19.9, respectively (P < 0.0001). With use of Cox regression, the corresponding adjusted hazards ratios were as follows: atherosclerotic vascular disease, 1, 1.30, 1.16, and 1.41 (P < 0.0001); congestive heart failure, 1, 1.44, 1.28, and 1.79 (P < 0.0001); renal replacement therapy, 1, 2.52, 23.1, and 38.9 (P < 0.0001); and death, 1, 1.21, 1.38, and 1.56 (P < 0.0001). On a relative basis, patients with CKD were at a much greater risk for the least frequent study outcome, renal replacement therapy. On an absolute basis, however, the high death rates of patients with CKD may reflect accelerated rates of atherosclerotic vascular disease and congestive heart failure.

Practice Patterns in Benign Prostatic Hyperplasia Surgical Therapy: The Dramatic Increase in Minimally Invasive Technologies

PURPOSE We describe the trends in transurethral prostatectomy and minimally invasive surgical treatments for benign prostate hyperplasia from 1999 through 2005 among elderly male Medicare beneficiaries. MATERIALS AND METHODS Benign prostatic hyperplasia surgeries were identified using the annual 100% Medicare carrier files which contain physician claims for services reimbursed under Medicare Part B. The annual age group specific procedure rates as well as the age adjusted rates by race and percent of each procedure performed in different clinical settings were calculated. RESULTS The total number of benign prostatic hyperplasia procedures increased 44% from 88,868 in 1999 to 127,786 in 2005. The minimally invasive surgical treatment procedure counts increased 529% from 11,582 to 72,887 and the rates increased 439% from 136 to 678 per 100,000 males during that period. The transurethral prostate resection rate decreased approximately 5% per year. By 2005 minimally invasive surgical treatment procedures accounted for 57% of total benign prostatic hyperplasia surgeries, while transurethral prostate resection accounted for only 39%. Almost all transurethral microwave thermotherapy, 86% of transurethral needle ablation and 54% of laser coagulation procedures were performed in office clinics, and 78% of laser vaporization procedures were performed in hospital outpatient clinics. Black beneficiaries were 17% less likely to receive minimally invasive surgical treatment than whites in 2005. CONCLUSIONS The increase of total benign prostatic hyperplasia procedure rate was driven by a marked increase in minimally invasive surgical treatment and a continuing decrease of transurethral prostate resection. Differences in the use of minimally invasive surgical treatment across age and racial groups persisted. This dramatic change in the pattern of benign prostatic hyperplasia surgical treatment may have a profound impact on health care expenditures and outcomes, and requires further investigation.

Hospice use before death: Variability across cancer diagnoses

Background: There is little information available about patterns of hospice use before death for patients with a diagnosis of cancer. Objective: To examine whether rates of hospice use before death are different for persons dying of specific cancers or vary across age, sex, or racial groups. Methods: Information about cause-specific hospice use received by elderly Medicare beneficiaries was obtained from Medicare hospice administrative (claims) data. Information regarding cause-specific numbers of deaths was obtained from the National Center for Health Statistics. Rates of hospice use were calculated using direct standardization adjusted for age, sex, and race. Length of stay in a hospice was calculated as the median number of days between entry into the hospice and death. Results: Rates of hospice use before death ranged from 42.0 hospice users per 100 deaths for breast cancer to 48.1 hospice users per 100 deaths for pancreatic cancer. Across all cancers, blacks received approximately 82% of the hospice use as nonblacks. Men entered hospices at almost the same rate as women (overall male-to-female ratio = 0.97). Median length of stay in a hospice ranged from 21 to 27 days. Conclusions: A great deal of consistency was observed regarding hospice-use rates across cancer diagnoses. This consistency is greater than might be expected given differences in prognosis across cancers. The results suggest that there may be greater than previously predicted consistency across end-stage cancer patients in the ability to determine prognosis or patient preferences for hospice services.

Explaining trends in hospitalizations for pneumonia and influenza in the elderly.

From 1987–99, influenza and pneumococcal vaccination rates among elderly Medicare beneficiaries increased by 300 percent and 500 percent, respectively. Despite these gains, annual rates of hospitalizations for pneumonia and influenza (P&I) have not decreased; rather, they have increased steadily. The authors investigate whether this paradoxical increase in hospitalization rates reflects an increasing burden of P&I or the effects of a changing healthcare environment. They find that from 1987–99, P&I hospitalizations per one thousand beneficiaries increased from 15.1 to 23.4. Of this increase, 23 percent was due to an aging Medicare population, 2.4 percent was due to increased rates of rehospitalization, and at most 5 percent was due to upcoding. There was no evidence that physicians were increasingly admitting patients with less complicated cases of P&I. The changing healthcare environment only partially explained the paradoxical increase in P&I hospitalizations. P&I appears to be an increasing burden to the elderly, despite increased vaccination rates.

The use of preventive health services among elderly uterine cancer survivors.

OBJECTIVE The purpose of the study was to determine whether women who survived uterine cancer received 4 recommended preventive services (mammography, colorectal cancer screening, influenza immunization, and bone density testing) at the same rates as women with no history of cancer. STUDY DESIGN We used the Surveillance, Epidemiology, and End Results-Medicare database to compare the rates among survivors aged 67 years or older with a matched group of women with no history of cancer. RESULTS Survivors were significantly more likely to have a mammogram (adjusted odds ratio [OR], 1.40; 95% confidence interval [CI], 1.30-1.50) or a colorectal cancer screening examination (adjusted OR, 1.11; 95% CI, 1.05-1.18). Influenza immunization and bone density testing rates were similar. The 28% of survivors seen by an obstetrician-gynecologist or gynecologic oncologist had the highest rates of use. CONCLUSION Efforts need to be made to increase the use of services by all women to achieve the target rates established by Healthy People 2010.

Physician visits, patient comorbidities, and mammography use among elderly colorectal cancer survivors

IntroductionOver a million Americans have survived colorectal cancer. This study examined physician visit patterns, patient comorbidities, and mammography use among colorectal cancer survivors based on the competing demands model.MethodsUsing Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data (2003 merge), study cohorts included female colorectal cancer patients who were diagnosed from 1973 through 1994 and had survived five or more years after the cancer diagnosis (n = 12,681), and a non-cancer comparison population who had no history of cancer and resided in the SEER areas during the study period.ResultsCancer survivors had a significant 6% higher mammography rate during 2000 to 2001 than matched women with no history of cancer (50 vs 47 per 100 persons, respectively). Among cancer survivors, there was a significant and positive association between the number of physician visits for evaluation and management (E&M) and mammography rates. More physician visits for E&M reduced the differences of mammography rates between those with and without additional comorbidities. Cancer survivors who visited gynecologists for E&M were 45% more likely to receive mammograms than those who visited only primary care physicians (multivariate adjusted rate ratio, 1.45; 95% CI, 1.38–1.53).ConclusionsElderly female colorectal cancer survivors were more likely to receive mammograms than matched women with no history of cancer.Implications for cancer survivorsPatients with multiple comorbidities might receive more mammograms by increasing the number of office visits for E&M and by visiting gynecologists. Primary care physicians should increase the priority for recommending mammograms among cancer survivors.

Unequal Use of New Technologies by Race: The Use of New Prostate Surgeries (Transurethral Needle Ablation, Transurethral Microwave Therapy and Laser) Among Elderly Medicare Beneficiaries

PURPOSE We compared the availability and use of transurethral microwave therapy, transurethral needle ablation, contact or noncontact laser therapy and transurethral resection of the prostate among elderly black and white Medicare beneficiaries. MATERIALS AND METHODS We examined 100% Medicare Inpatient, Outpatient, Carrier and Denominator files of men 65 years old or older who underwent these procedures in 1999 through 2001. White-to-black race rate ratios for each procedure were computed for the entire United States, as well as for a restricted set of counties in which procedures were available to black beneficiaries. RESULTS A total of 170,067 TURP, 16,953 TUMT, 5,353 TUNA and 12,134 Laser procedures were performed during 3 years. Nationally there was only a 3% difference in the age adjusted TURP rates between white and black men (6.13 and 5.94 per 1,000 person-years, respectively). However, the age adjusted rates for TUMT and TUNA among white men were about twice those among black men (0.63 vs 0.31 and 0.20 vs 0.10 per 1,000 person-years, respectively). Laser rates were 17% higher among white men than among black men (0.44 vs 0.38 per 1,000 person-years). Large geographic variation existed in the new procedure rates. Negative binomial regression analysis confirmed the national findings in those counties in which the procedures were available to black men. Adjusted white-to-black rate ratios were 1.96 (95% CI 1.70-2.25) for TUMT, 2.33 (95% CI 1.87-2.90) for TUNA and 1.36 (95% CI 1.16-1.59) for Laser. CONCLUSIONS After controlling for availability, elderly black Medicare beneficiaries were less likely to undergo the new BPH procedures than white beneficiaries, while the usage difference for TURP remained small.