Bruce Vogel

Cost, utilization, and policy of provision of assistive technology devices to veterans poststroke by Medicare and VA.

Background:The increase in provision of assistive technology devices (ATDs) has spurred controversy over Medicare policy aimed at reducing cost-policy that forces social isolation and conflicts with legislation, facilitating participation for individuals with disabilities. In contrast, Department of Veterans Affairs (VA) policy does not limit provision of AT to “in home” use only but rather, states “all enrolled and some non-enrolled veterans are eligible for all needed prosthetics.” Objectives:Examine ATD provision policy by comparing 2 systems, Medicare and VA. Empirically analyze differences in ATDs provided, cost, and duplication in provision. Research Design:Retrospective study of VA databases, including VA Medicare data. Subjects:A population based study of 12,0461 veterans post-stroke. Measures:Frequency of provision of ATDs by Health Care Common Procedural Code, purchase price, and capped rental payments. Results:Of the poststroke veteran cohort, 39% received no AT, 56% received AT from the VA only, 1% received AT from Medicare only, and 3% received AT from both the VA and Medicare. Most ATDs were for activities of daily living, followed by walkers/canes/crutches. In specific ATD comparisons, VA costs were substantially lower than Medicare for purchased items and slightly lower than Medicare for capped rental payments. Conclusion:VA provides a broader variety of ATDs at a lesser cost than Medicare. Analyses of policy differences between VA and Medicare suggest VA policy is driven by veteran need whereas Medicare policy is driven at least in part, by containing costs that have skyrocketed as a result of fraudulent claims.

Effect of prophylaxis on fungal infection and costs for high‐risk liver transplant recipients

We sought to determine whether the prophylactic use of amphotericin B products (conventional amphotericin B and liposomal amphotericin B) reduces the incidence of fungal infections in high‐risk liver transplant recipients, and if so, whether this lowers the cost of care. The study sample comprised 232 adult orthotopic liver transplants performed from 1994 to 2005 at a single center for patients classified as being at high risk for fungal infections. High‐risk patients who received transplants with a prophylaxis regimen of amphotericin B (n = 58 transplants) were compared with high‐risk patients who received no prophylaxis (n = 174 transplants). Fungal infections occurred in 3 transplants (5.17%) of those who received amphotericin B and 28 transplants (16.09%) in those without prophylaxis (P = 0.0432). Regression models were used to analyze fungal infection and costs for the 232 high‐risk transplants. Failure to offer prophylaxis conferred a 4‐fold greater risk of fungal infection (P = 0.046) compared with those who received amphotericin B. A fungal infection in a high‐risk recipient increased mean costs by 46.48%. The indirect effect of prophylaxis (operating through infection reduction) is estimated to reduce overall costs in high‐risk patients by 8.73%. Liver Transpl 13: 1743–1750, 2007.

Distribution and Cost of Wheelchairs and Scooters Provided by Veterans Health Administration

During fiscal years 2000 and 2001, the Veterans Health Administration provided veterans with more than 131,000 wheelchairs and scooters at a cost of

The use and misuse of thrombolytic therapy within the veterans health administration

109 million. This national study is the first to investigate Veterans Health Administration costs in providing wheelchairs and scooters and to compare regional prescription patterns. With a retrospective design, we used descriptive methods to analyze fiscal years 2000 and 2001 National Prosthetics Patient Database data (cleaned data set of 113,724 records). Wheelchairs were categorized by function, weight, and adjustability options for meeting individual needs (e.g., axle position, camber, position of wheels, tilt, and recline options). Results displayed a cost distribution that was negatively skewed by low-cost accessories coded as wheelchairs. Of the standard manual wheelchairs, 3.5% could be considered beyond the customary cost. Regionally, 71% to 86% of all wheelchairs provided were manual wheelchairs, 5% to 11% were power wheelchairs, and 5% to 20% were scooters. The considerable variation found in the types of wheelchairs and scooters provided across Veterans Integrated Service Networks may indicate a need for evidence-based prescription guidelines and clinician training in wheeled-mobility technologies.

Demographic and Clinical Variation in Veterans Health Administration Provision of Assistive Technology Devices to Veterans Poststroke

Background:Within the Veterans Health Administration (VHA), approximately 6000 veterans are hospitalized with acute ischemic stroke annually. We examined the use and misuse of thrombolytic therapy with tissue plasminogen activator (tPA) in a national sample of veterans who were admitted to a VHA Medical Center (VAMC) with acute ischemic stroke. Methods:Medical record reviews were conducted on 5000 acute stroke patients who were admitted to a VAMC in 2007. Patients were defined as eligible to receive tPA if they arrived at the hospital within 3 hours of stroke symptom onset and had no contraindications to tPA. We compared eligible patients who received tPA to those who did not and examined the distribution of eligible patients across the 129 VAMCs included in this study. Results:Among the 3931 ischemic stroke patients, 174 (4.4%) were eligible for tPA. Among the 135 patients who arrived within 2 hours of symptom onset which allowed adequate time for testing and evaluation, 19 (14.1%) received tPA. An additional 11 patients received tPA but did not meet eligibility criteria. Eligible patients receiving tPA were similar to eligible patients not receiving tPA in terms of clinical conditions and time to brain imaging. Among the 30 patients that received tPA, 5 (16.6%) received the wrong dose. Among the 85 VAMCs that received ≥1 eligible patient, on average 2.3 patients were eligible for tPA annually. Conclusions:Relatively few eligible veterans receive thrombolysis across the VHA system. Strategies to improve thrombolysis delivery will have to account for the low annual volume of eligible stroke patients cared for at individual VAMCs.

Participation of Older Patients With Prostate Cancer in Medicare Eligible Trials

OBJECTIVES To examine variation in provision of assistive technology (AT) devices and the extent to which such variation may be explained by patient characteristics or Veterans Health Administration (VHA) administrative region. DESIGN Retrospective population-based study. SETTING VHA. PARTICIPANTS Veterans poststroke in fiscal years 2001 and 2002 (N=12,046). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Provision of 8 categories of AT devices. RESULTS There was considerable regional variation in provision of AT. For example, differences across administrative regions in the VHA ranged from 5.1 to 28.1 standard manual wheelchairs per 100 veterans poststroke. Using logistic regression, with only demographic variables as predictors of standard manual wheelchair provision, the c statistic was .62, and the pseudo R(2) was 2.5%. Adding disease severity increased the c statistic to .67 and the pseudo R(2) to 6.2%, and adding Veteran Integrated Network System further increased the c statistic to .72 and pseudo R(2) to 9.8%. CONCLUSIONS Our research showed significant variation in the provision of AT devices to veterans poststroke, and it showed that patient characteristics accounted for only 6.2% of the variation. VHA administrative region and disability severity accounted for equivalent amounts of the variation. Our findings suggest the need for improvements in the process for providing AT and/or provider education concerning device provision.

Advanced topics in evidence-based urologic oncology: Economic analysis

PURPOSE On June 7, 2000 President Clinton issued an executive memorandum directing Medicare payment for routine patient care in qualifying clinical trials. We estimated the proportion of older patients with prostate cancer who were examined as part of a qualifying clinical trial, and the association between participation and patient characteristics. MATERIALS AND METHODS We performed an observational study using the Surveillance, Epidemiology and End Results Medicare database to determine participation in qualifying clinical trials in a sample of 37,216 men 66 years old or older who were enrolled in Medicare and diagnosed with prostate cancer between September 2000 and December 2002. RESULTS Within 3 years of diagnosis 211 men (0.567%) received routine patient care in a qualifying clinical trial. These participants were more likely to be younger than 70 years (OR 1.687, 95% CI 1.27-2.24) and less likely to be less educated and reside in low income, metropolitan neighborhoods. White men were more likely to participate in clinical trials than nonwhite men but this association was not statistically significant (OR 1.426, CI 0.97-2.09). Participation varied significantly by registry site (0% to 1.2%) but not by tumor grade or stage, or prostate specific antigen status. CONCLUSIONS Few older patients with prostate cancer participated in qualifying trials between 2000 and 2002. Those who participated were not representative of the general population of older patients with prostate cancer. Greater efforts are required to expand trial enrollment and decrease disparities in research participation.

The Effects of Reinsurance in Financing Children's Health Care

Urologists, regardless of whether they practice in the community or in an academic institution, make decisions not only about their individual patients but also about hospital and health care policy by providing input to various committees that influence the adoption of new diagnostic and therapeutic technology. In an era of increasing awareness of healthcare costs, economic analyses that consider not only the potential benefit and harm of a given intervention but also the costs of the intervention, are increasingly important. This review article introduces a framework to critically appraise an economic analysis for its validity, impact, and applicability to patient care using an example from the urologic literature.

Visits to Primary Care and Emergency Department Reliance for Foster Youth: Impact of Medicaid Managed Care

This paper examines the effects of reinsurance on the financial performance of health plans serving enrollees in a State Childrens Health Insurance Program (SCHIP). We demonstrate that simple reinsurance policies can reduce substantially the variation in the financial performance of plans with different case mixes, even when the plans bear the cost of the reinsurance and are not fully insured against large expenditures on individual enrollees.

Variation in outpatient emergency department utilization in Texas Medicaid: a state-level framework for finding “superutilizers”

OBJECTIVE To examine the rate of access to primary and preventive care and emergency department (ED) reliance for foster youth as well as the impact of a transition from fee-for-service (FFS) Medicaid to managed care (MC) on this access. METHODS Secondary administrative data were obtained from Medicaid programs in one state that transitioned foster youth from an FFS to an MC (Texas) and another state, comparable in population size and racial/ethnic diversity, which continuously enrolled foster youth in an FFS system (Florida). Eligible participants were foster youth (aged 0-18 years) enrolled in these states between 2006 and 2010 (n = 126,714). A Puhani approach to difference-in-difference was used to identify the effect of transition after adjusting for race/ethnicity, gender, and health status. Data were used to calculate access to primary and preventive care as well as ED reliance. ED reliance was operationalized as the number of ED visits relative to the number of total ambulatory visits; high ED reliance was defined as ≥33%. RESULTS The transition to MC was associated with a 6% to 13% increase in access to primary care. Preventive care visits were 10% to 13% higher among foster youth in MC compared to those in FFS. ED reliance declined for the intervention group but to a lesser extent than did the control group, yielding a positive mean percentage change. CONCLUSIONS Foster youth access to care may benefit from a Medicaid MC delivery system, particularly as the plans used are designed with the unique needs of this vulnerable population.