Foster Gesten

Time to Treatment and Mortality during Mandated Emergency Care for Sepsis

BACKGROUND In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. METHODS We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3‐hour bundle of care for patients with sepsis (i.e., blood cultures, broad‐spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3‐hour bundle and risk‐adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid. RESULTS Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3‐hour bundle completed within 3 hours. The median time to completion of the 3‐hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3‐hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk‐adjusted in‐hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21). CONCLUSIONS More rapid completion of a 3‐hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk‐adjusted in‐hospital mortality. (Funded by the National Institutes of Health and others.)

Underuse of Hospice Care by Medicaid-Insured Patients With Stage IV Lung Cancer in New York and California

PURPOSE Medicare patients with advanced cancer have low rates of hospice use. We sought to evaluate hospice use among patients in Medicaid, which insures younger and indigent patients, relative to those in Medicare. PATIENTS AND METHODS Using linked patient-level data from California (CA) and New York (NY) state cancer registries, state Medicaid programs, NY Medicare, and CA Surveillance, Epidemiology, and End Results-Medicare data, we identified 4,797 CA Medicaid patients and 4,001 NY Medicaid patients ages 21 to 64 years, as well as 27,416 CA Medicare patients and 16,496 NY Medicare patients ages ≥ 65 years who were diagnosed with stage IV lung cancer between 2002 and 2006. We evaluated hospice use, timing of enrollment, and location of death (inpatient hospice; long-term care facility or skilled nursing facility; acute care facility; home with hospice; or home without hospice). We used multiple logistic regressions to evaluate clinical and sociodemographic factors associated with hospice use. RESULTS Although 53% (CA) and 44% (NY) of Medicare patients ages ≥ 65 years used hospice, fewer than one third of Medicaid-insured patients ages 21 to 64 years enrolled in hospice after a diagnosis of stage IV lung cancer (CA, 32%; NY, 24%). A minority of Medicaid patient deaths (CA, 19%; NY, 14%) occurred at home with hospice. Most Medicaid patient deaths were either in acute-care facilities (CA, 28%; NY, 36%) or at home without hospice (CA, 39%; NY, 41%). Patient race/ethnicity was not associated with hospice use among Medicaid patients. CONCLUSION Given low rates of hospice use among Medicaid enrollees and considerable evidence of suffering at the end of life, opportunities to improve palliative care delivery should be prioritized.

Application of a Framework to Assess the Usefulness of Alternative Sepsis Criteria

The current definition of sepsis is life-threatening, acute organ dysfunction secondary to a dysregulated host response to infection. Criteria to operationalize this definition can be judged by six domains of usefulness (reliability, content, construct and criterion validity, measurement burden, and timeliness). The relative importance of these six domains depends on the intended purpose for the criteria (clinical care, basic and clinical research, surveillance, or quality improvement [QI] and audit). For example, criteria for clinical care should have high content and construct validity, timeliness, and low measurement burden to facilitate prompt care. Criteria for surveillance or QI/audit place greater emphasis on reliability across individuals and sites and lower emphasis on timeliness. Criteria for clinical trials require timeliness to ensure prompt enrollment and reasonable reliability but can tolerate high measurement burden. Basic research also tolerates high measurement burden and may not need stability over time. In an illustrative case study, we compared examples of criteria designed for clinical care, surveillance and QI/audit among 396,241 patients admitted to 12 academic and community hospitals in an integrated health system. Case rates differed four-fold and mortality three-fold. Predictably, clinical care criteria, which emphasized timeliness and low burden and therefore used vital signs and routine laboratory tests, had the greater case identification with lowest mortality. QI/audit criteria, which emphasized reliability and criterion validity, used discharge information and had the lowest case identification with highest mortality. Using this framework to identify the purpose and apply domains of usefulness can help with the evaluation of existing sepsis diagnostic criteria and provide a roadmap for future work.

Asthma in medicaid managed care enrollees residing in New York City: Results from a post-world trade center disaster survey

The collapse of the World Trade Center on September 11, 2001, released a substantial amount of respiratory irritants into the air. To assess the asthma status of Medicaid managed care enrollees who may have been exposed, the New York State Department of Health, Office of Managed Care, conducted a mail survey among enrollees residing in New York City. All enrollees, aged 5–56 with persistent asthma before September 11, 2001, were surveyed during summer 2002. Administrative health service utilization data from the Medicaid Encounter Data System were used to validate and supplement survey responses. A total of 3.664 enrollees responded. Multivariate logistic regression models were developed to examine factors associated with self-reported worsened asthma post September 11, 2001, and with emergency department/inpatient hospitalizations related to asthma from September 11, 2001, through December 31, 2001. Forty-five percent of survey respondents reported worsened asthma post 9/11. Respondents who reported worsened asthma were significantly more likely to have utilized health services for asthma than those who reported stable or improved asthma. Residence in both lower Manhattan (adjusted OR=2.28) and Western Brooklyn (adjusted OR=2.40) were associated with self-reported worsened asthma. However, only residents of Western Brooklyn had an elevated odds ratio for emergency department/inpatient hospitalizations with diagnoses of asthma post 9/11 (adjusted OR=1.52). Worsened asthma was reported by a significant proportion of this low-income, largely minority population and was associated with the location of residence. Results from this study provide guidance to health care organizations in the development of plans to ensure the health of people with asthma during disaster situations.

Do Commercial Managed Care Members Rate Their Health Plans Differently than Medicaid Managed Care Members

OBJECTIVE To determine if members of commercial managed care and Medicaid managed care rate the experience with their health plans differently. DATA SOURCES Data from both commercial and Medicaid Consumer Assessment of Health Plan Surveys (CAHPS) in New York State. STUDY DESIGN Regression models were used to determine the effect of population (commercial or Medicaid) on a members rating of their health plan, controlling for health status, age, gender, education, race/ethnicity, number of office visits, and place of residence. DATA COLLECTION Managed care plans are required to submit to the New York State Department of Health (NYSDOH) results of the annual commercial CAHPS survey. The NYSDOH conducted a survey of Medicaid enrollees using Medicaid CAHPS. PRINCIPAL FINDINGS Medicaid managed care members in excellent or very good health rate their health plan higher than commercial members in excellent or very good health. There is no difference in health plan rating for commercial and Medicaid members in good, fair, or poor health. Older, less educated, black, and Hispanic members who live outside New York City are more likely to rate their managed care plan higher. CONCLUSIONS Medicaid members rating of their health care equals or exceeds ratings by commercial members.

Improving Adolescent Preventive Services Through State, Managed Care, and Community Partnerships

PURPOSE To develop and evaluate a multipronged, guideline-based initiative to improve quality of adolescent preventive care. METHODS Activities included: (a) academic institution-based grand rounds and insurance company-sponsored community rounds continuing education sessions on preventive care for primary care clinicians, (b) academic detailing during chart review visits to practices by nurse reviewers, to encourage adolescent-specific confidentiality policies and use of screener or trigger questionnaires during well visits, and (c) partnerships with community corporate leaders to promote awareness of quality preventive services. Interventions were evaluated by comparing 2000 and 2001 chart reviews for rates of tobacco use, substance use, and human immunodeficiency virus (HIV) prevention screening and counseling. RESULTS A total of 285 clinicians attended continuing education (CE) sessions and 96 offices received detailing visits. Improvements in adolescent preventive health services delivery were noted in both commercial and Medicaid populations. We found the following when comparing 2001 results with those from 2000: Tobacco use screening or counseling increased from 42.5% to 45.5% for the commercial population and from 32.0% to 43.5% for the Medicaid population; substance use screening increased from 42.5% to 44.0% for the commercial population and from 32.0% to 43.5% for the Medicaid population. HIV counseling increased from 26.5% to 35.5% for the commercial population, and from 28.0% to 40.0% for the Medicaid population (all Medicaid and HIV differences are significant at p <.05). CONCLUSIONS These activities have been successful in improving adolescent preventive services for Medicaid populations in New York. Academic detailing can assist health plans in promoting preventive care improvements by primary care clinicians. Further measurement is needed to assess the effect on commercially insured populations.

High Intensity of End-of-Life Care Among Adolescent and Young Adult Cancer Patients in the New York State Medicaid Program.

Background:Little is known about the care that adolescent and young adult (AYA) cancer patients receive at the end of life (EOL). Objective:To evaluate use of intensive measures and hospice and location of death of AYA cancer patients insured by Medicaid in New York State. Design:Using linked patient-level data from the New York State Cancer Registry and state Medicaid program, we identified 705 Medicaid patients who were diagnosed with cancer between the ages of 15 and 29 in the years 2004–2011, who subsequently died, and who were continuously enrolled in Medicaid in the last 60 days of life. We evaluated use of intensive EOL measures (chemotherapy within 14 d of death; intensive care unit care, >1 emergency room visit, and hospitalizations in the last 30 d of life), hospice use, and location of death (inpatient hospice, long-term care facility, acute care facility, home with hospice, home without hospice). Results:75% of AYA Medicaid decedents used at least 1 aspect of intensive EOL care. 38% received chemotherapy in the last 2 weeks of life; 21% received intensive care unit care, 44% had >1 emergency room visit, and 64% were hospitalized in the last month of life. Only 23% used hospice. 65% of patients died in acute care settings, including the inpatient hospital or emergency room. Conclusions:Given the high rates of intensive measures and low utilization of hospice at the EOL among AYA Medicaid enrollees, opportunities to maximize the quality of EOL care in this high-risk group should be prioritized.

Initiation of Adjuvant Hormone Therapy by Medicaid Insured Women With Nonmetastatic Breast Cancer

Hormone therapy is the mainstay of adjuvant treatment for hormone receptor positive (HR-positive) nonmetastatic breast cancer. We evaluated adjuvant hormone therapy (AHT) initiation among Medicaid-insured women aged 21-64 years with stage I-III HR-positive breast cancer. We used multivariable logistic regression to identify independent predictors of AHT initiation. Within 1 year of diagnosis, 68% (1049/1538) initiated AHT; by 18 months, 80% (1168/1461) initiated AHT. In multivariable analysis, women less likely to initiate AHT had more comorbidity (≥ 2 vs none: adjusted odds ratio (AOR) = 0.55; 95% CI = 0.32 to 0.97), more advanced disease (stage III vs I: AOR = 0.27; 95% CI = 0.18 to 0.39), and no radiation after breast conserving surgery (AOR = 0.15; 95% CI = 0.10 to 0.22). Race, age, and history of mental health disorders were not independently associated with initiation of AHT. Among initiators of AHT, 58% (604/1049) were adherent to treatment for the year after initiation. Despite comprehensive prescription coverage, only 39% (604/1538) received optimal AHT including prompt initiation and adherence for the year after treatment. Partnerships between Medicaid programs and cancer registries may help identify at-risk women and facilitate the implementation of quality improvement strategies.

Cancer Disparities in the Context of Medicaid Insurance: A Comparison of Survival for Acute Myeloid Leukemia and Hodgkin's Lymphoma by Medicaid Enrollment

BACKGROUND Because poverty is difficult to measure, its association with outcomes for serious illnesses such as hematologic cancers remains largely uncharacterized. Using Medicaid enrollment as a proxy for poverty, we aimed to assess potential disparities in survival after a diagnosis of acute myeloid leukemia (AML) or Hodgkins lymphoma (HL) in a nonelderly population. METHODS We used records from the New York (NY) and California (CA) state cancer registries linked to Medicaid enrollment records for these states to identify Medicaid enrolled and nonenrolled patients aged 21-64 years with incident diagnoses of AML or HL in 2002-2006. We compared overall survival for the two groups using Kaplan-Meier curves and Cox proportional hazards analyses adjusted for sociodemographic and clinical factors. RESULTS For HL, the adjusted risk for death for Medicaid enrolled compared with nonenrolled patients was 1.98 (95% confidence interval [CI], 1.47-2.68) in NY and 1.89 (95% CI, 1.43-2.49) in CA. In contrast, for AML, Medicaid enrollment had no effect on survival (adjusted hazard ratio, 1.00; 95% CI, 0.84-1.19 in NY and hazard ratio, 1.02; 95% CI, 0.89-1.16 in CA). These results persisted despite adjusting for race/ethnicity and other factors. CONCLUSIONS Poverty does not affect survival for AML patients but does appear to be associated with survival for HL patients, who, in contrast to AML patients, require complex outpatient treatment. Challenges for the poor in adhering to treatment regimens for HL could explain this disparity and merit further study.

Risk-adjusted primary cesarean delivery rates for managed care plans in New York State, 1998.

Objective: To demonstrate the effect of risk adjustment methodologies compared to crude rates in evaluating the rate of primary cesarean deliveries in managed care plans, after accounting for known demographic and clinical factors. Risk adjustment allows for a more accurate comparison of primary cesarean delivery rates among plans, eliminating potential confounding factors that could influence rates. Methods: Data was collected from managed care plans as part of their 1998 Quality Assurance Reporting Requirements (QARR). Medicaid and commercial populations were matched to New York State Department of Health Vital Statistics birth file to produce a crude measure of cesarean deliveries per plan. Logistic regression models were then used to adjust for maternal education, age, race/ethnicity, obstetrical history, preexisting comorbid conditions, obstetrical conditions, and pregnancy-related conditions to produce adjusted rates. Results: For Medicaid, the crude analysis showed four plans that were significantly lower than the statewide Medicaid managed care rate of 9.5 per 100 live births. One plan was significantly higher. The risk-adjusted results showed one plan being significantly lower than the statewide average and none being higher. For the commercial population, seven plans were significantly lower than the average of 16.3 and four plans were higher. After risk-adjusting, three plans were significantly lower and three plans were significantly higher than the statewide average. Conclusions: Risk-adjustment of primary cesarean delivery rates allows for a more accurate comparison among managed care plans. It is hoped that the generation and publication of more accurate rates will facilitate the acceptance and use of this information by clinicians in managed care plans to focus on improving health outcomes.