Donald Carmichael

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,

Exnovation of Low Value Care: A Decade of Prostate-Specific Antigen Screening Practices: Change in PSA Screening Practices

22 004 vs

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

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.

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

To examine prostate‐specific antigen (PSA) screening practice change in subgroups of men defined in guidelines and in various regions and to identify factors associated with change in screening practices.

PD07-06 REGIONAL VARIATION IN THE SCREENING, BIOPSY, AND DIAGNOSIS 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

PD40-01 ARE THERE REGIONAL TENDENCIES TOWARD CONTROVERSIAL SCREENING PRACTICES? A STUDY OF PROSTATE AND BREAST CANCER SCREENING IN A MEDICARE POPULATION

assess, whether preoperative CAPRA risk-score is an independent predictor of BSF and MSF. The model was quantified using the receiver operating characteristic-derived area under the curve RESULTS: Overall, 38.3 (n1⁄46584), 45.3 (n1⁄47806) and 16.4% (n1⁄42825) were stratified as preoperative LR, IR and HR CAPRA, respectively. Within LR patients, 14.8% (n1⁄4976) upgraded to IR or HR CAPRA-S at RP, respectively. Similarly, within IR patients, 11.7% were upgraded to HR CAPRA-S at RP (n1⁄4912). The 5-yr BSF of CAPRA-S HR patients at RP that had preoperative LR profiles was 95.8% (95% CI 95.1-96.5%), relative to 90.6% (95% CI 89.2-92.0%) of those with preoperative IR/HR profiles (p <0.001). Similarly, 5-yr MSF of HR patients at RP with preoperative LR vs IR/HR profiles was 99.7% (95% CI 99.6-99.9) vs. 98.8 (95% CI 98.3-99.4%) (p1⁄40.001). In MVAs assessing BSF and MSF, preoperative CAPRA risk-score was an independent predictor and increased the accuracy compared to CAPRA-S risk-score at RP alone. (AUC 76.8 vs. 78.8% and 82.6 vs. 84.4%). CONCLUSIONS: In postoperative CAPRA-S risk-scores, the additional consideration of clinically derived, preoperative CAPRA risk scores show a significant influence on BSF and MSF. Specifically, BSF and MSF is lower in postoperative CAPRA-S HR patients, who had low preoperative CAPRA risk-scores. These results warrant attention when using existing nomograms and genetic markers developed for the prediction of adverse pathologic outcomes. Finally, our results strongly suggest that postoperative CAPRA-S should be combined with preoperative CAPRA risk-score whenever applicable.

Second fractures among older adults in the year following hip, shoulder, or wrist fracture

and Ovarian (PLCO) Cancer Screening trial for high-grade prostate cancer. With a follow up of 314,033 person-years and 1,612 high-grade cancers detected, we performed age-adjusted competing-risks regression analysis to evaluate the interaction between time varying suspicious DRE and serum PSA. RESULTS: 10-yr cumulative incidence of high-grade cancer was 5.8% (95% C.I. 5.5-6.1). Higher risk was seen among those with suspicious vs. non-suspicious DRE. There was a statistically significant interaction between PSA and DRE, with a smaller increase in relative risk for DRE with higher PSA (p1⁄40.01). However, increases in absolute risk were small and clinically irrelevant for PSA < 2 (2.2% vs 1.1% risk of high grade cancer at 10 years), but of clinical importance for PSA 310 (37.5% vs 19.5%). Increases in risk were of equivocal clinical relevance for PSA 2-3 (9.0% vs 6.0%). CONCLUSIONS: DRE demonstrated increasingly prognostic utility when PSA >3, limited utility when PSA <2, and some benefit in the setting of equivocal PSA 2-3. These findings provide support for the NCCN guideline recommendation to restrict DRE to men with higher PSA, as a follow-up test to improve specificity rather than as a primary screening modality to improve sensitivity. Further research is warranted on the value of DRE in men with PSA 2-3.

High-Cost Dual Eligibles’ Service Use Demonstrates The Need For Supportive And Palliative Models Of Care

and Cochran’s and Mantel-Haenszel Chi-square test were used to analyze the relationship between all the features and PPI incidence and severity, respectively. A Kaplan-Meier curve was created to clarify recovery of incontinence after prostatectomy. Cox regression analysis was performed in the analysis of influence factors of PPI recovery. Nomograms were formulated based on the results of multivariate analysis and by using the package of rms in R version 2.14.1. RESULTS: All 364 patients had complete data and the medium follow-up time was 17 months. The total immediate incontinence rate was 61.8%. The incontinence rate was 10.4% at the 12th month after the surgery. Risk factors related to PPI incidence included smoking, hypertension, preoperative incontinence, preoperative dysuresia and chief surgeon. Risk factors related to PPI severity included age, preoperative PSA, neutrophil-to-lymphocyte ratio, postoperative urinary stricture and Gleason score. Risk factors related to PPI recovery included age, BMI, diabetes, hernia, biopsy approaches, prostate volume, preoperative incontinence, preoperative dysuresia, preoperative PSA, postoperative urinary stricture and PPI severity. Age, BMI and PPI severity were independent predictor of PPI recovery. CONCLUSIONS: Incontinence is a very common complication after radical prostatectomy, which adversely affects patients’ quality of life. According to the nomograms developed by this study, now it is possible to predict the incidence of PPI and PPI recovery probabilities, which offers a strong evidence to the establishment of personalized prostate cancer management.