Andrea M. Austin

Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare

IMPORTANCE Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia. OBJECTIVE To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia. DESIGN, SETTING, AND PARTICIPANTS This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1 416 369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included. EXPOSURES Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patients total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles. MAIN OUTCOMES AND MEASURES Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician). RESULTS Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending,

Outcomes in Older Adults with Multimorbidity Associated with Predominant Provider of Care Specialty

22 004 vs

Association of Quality Improvement Registry Participation With Appropriate Follow-up After Vascular Procedures

24 371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P < .001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups. CONCLUSIONS AND RELEVANCE Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.

Executive function, episodic memory, and Medicare expenditures

To determine whether receiving the predominance of ambulatory visits from a primary care provider compared to a specialty provider is associated with better outcomes in older adults with multi morbidity.

Long-Term Implications Of A Short-Term Policy: Redacting Substance Abuse Data

Importance Ensuring that patients undergo surveillance imaging after surgery is a key quality metric after many vascular procedures. It is unclear whether hospital participation in a national quality improvement registry such as the Vascular Quality Initiative (VQI) achieves this goal. Objective To determine if hospital participation in the VQI registry is associated with increased rates of surveillance imaging after vascular procedures. Design, Setting, and Participants A quasi-experimental study used Medicare claims to study 2174 US hospitals in which 1 530 102 patients had undergone an endovascular abdominal aortic aneurysm repair (EVAR), 1 403 067 patients had undergone a lower extremity bypass (LEB) or peripheral vascular intervention (PVI), and 294 942 patients had undergone carotid endarterectomy (CEA) and carotid artery stenting (CAS) procedures between January 1, 2007, and December 31, 2012. For each hospital, VQI participation was assessed, and a difference-in-differences analysis was used to measure the change in follow-up surveillance for VQI hospitals compared with control (non-VQI) hospitals selected after propensity score matching. The data were analyzed between January and August of 2016. Main Outcomes and Measures The proportion of patients who had imaging-based follow-up (computed tomography, duplex ultrasonography, or ankle-brachial index) within 1 year after their vascular procedure. Results A total of 1 830 928 patients (947 139 women and 883 789 men; mean [SD] age, 75.8 [7.1] years) were identified across 2174 hospitals. Of 3 228 111 total vascular procedures, 1 403 067 patients (43.5%) underwent LEB or PVI, 1 530 102 patients (47.4%) underwent EVAR, and 294 942 patients (9.1%) underwent CEA or CAS. During the 6-year period, follow-up imaging rates varied between 50% and 53% after EVAR, between 52% and 58% after LEB or PVI, and between 74% and 78% after CEA or CAS. A total of 68 VQI participating hospitals were propensity-matched to 68 hospitals, and 279 446 patients were studied across these 136 hospitals. In difference-in-differences analyses, there was no significant improvement in follow-up imaging after joining VQI during year 1 (relative risk, 0.99; 95% CI, 0.97-1.01), year 2 (relative risk, 0.98; 95% CI, 0.95-1.01), or year 3 (relative risk, 0.99; 95% CI, 0.96-1.03). This association was consistent for patients undergoing EVAR, LEB or PVI, and CEA or CAS procedures. Conclusions and Relevance Hospital participation in the VQI registry by itself does not increase rates of surveillance imaging after vascular procedures, suggesting that other strategies are needed to achieve this quality metric.

Hospitalization and Survival of Medicare Patients Treated With Carboplatin Plus Paclitaxel or Pemetrexed for Metastatic, Nonsquamous, Non–Small Cell Lung Cancer

We examined the relationship between health care expenditures and cognition, focusing on differences across cognitive systems defined by global cognition, executive function, or episodic memory.

Regional variation in the intensity of prostate cancer care: A study of a large Medicare sample

From 2013 to 2017 the Centers for Medicare and Medicaid Services redacted Medicare claims that included diagnosis or procedure codes related to substance abuse. The redaction policy was in effect as the Affordable Care Act and the opioid epidemic changed the health care landscape. The policy substantially altered prevalence estimates of common chronic conditions that co-occur with substance abuse.

A prospective study of the natural history of urinary incontinence in women

Key Points Question Does the risk of hospitalization among elderly patients receiving chemotherapy for metastatic, nonsquamous, non–small cell lung cancer vary by chemotherapy regimen? Findings In a cohort study of 2182 propensity-matched Medicare beneficiaries with non–small cell lung cancer, the 30-day hospitalization risk was 5% lower for patients receiving carboplatin with pemetrexed (21%) than for those receiving carboplatin with paclitaxel (26%), a statistically significant difference. Meaning When multiple standard-of-care chemotherapy regimens are available in a specific treatment setting, measures of regimen-specific hospitalization risk may be relevant for treatment selection.

MP47-15 REGIONAL VARIATION IN THE DIAGNOSIS AND TREATMENT OF PROSTATE CANCER IN A MEDICARE POPULATION

Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, Department of Urology, Columbia University Medical Center, New York City, New York, USA lael.s.reinstatler@hitchcock.org

PD07-06 REGIONAL VARIATION IN THE SCREENING, BIOPSY, AND DIAGNOSIS OF PROSTATE CANCER IN A MEDICARE POPULATION

BACKGROUND Symptoms of urinary incontinence are commonly perceived to vary over time; yet, there is limited quantitative evidence regarding the natural history of urinary incontinence, especially over the long term. OBJECTIVE We sought to delineate the course of urinary incontinence symptoms over time, using 2 large cohorts of middle‐aged and older women, with data collected over 10 years. STUDY DESIGN We studied 9376 women from the Nurses’ Health Study, age 56–81 years at baseline, and 7491 women from the Nurses’ Health Study II, age 39–56 years, with incident urinary incontinence in 2002 through 2003. Urinary incontinence severity was measured by the Sandvik severity index. We tracked persistence, progression, remission, and improvement of symptoms over 10 years. We also examined risk factors for urinary incontinence progression using logistic regression models. RESULTS Among women age 39–56 years, 39% had slight, 45% had moderate, and 17% had severe urinary incontinence at onset. Among women age 56–81 years, 34% had slight, 45% had moderate, and 21% had severe urinary incontinence at onset. Across ages, most women reported persistence or progression of symptoms over follow‐up; few (3–11%) reported remission. However, younger women and women with less severe urinary incontinence at onset were more likely to report remission or improvement of symptoms. We found that increasing age was associated with higher odds of progression only among older women (age 75–81 vs 56–60 years; odds ratio, 1.84; 95% confidence interval, 1.51–2.25). Among all women, higher body mass index was strongly associated with progression (younger women: odds ratio, 2.37; 95% confidence interval, 2.00–2.81; body mass index ≥30 vs <25 kg/m2; older women: odds ratio, 1.93; 95% confidence interval, 1.62–2.22). Additionally, greater physical activity was associated with lower odds of progression to severe urinary incontinence (younger women: odds ratio, 0.86; 95% confidence interval, 0.71–1.03; highest vs lowest quartile of activity; older women: odds ratio, 0.68; 95% confidence interval, 0.59–0.80). CONCLUSION Most women with incident urinary incontinence continued to experience symptoms over 10 years; few had complete remission. Identification of risk factors for urinary incontinence progression, such as body mass index and physical activity, could be important for reducing symptoms over time.