Gerard F. Anderson

Noncardiac Comorbidity Increases Preventable Hospitalizations and Mortality Among Medicare Beneficiaries With Chronic Heart Failure

OBJECTIVES We studied the impact of noncardiac comorbidity on potentially preventable hospitalizations and mortality in elderly patients with chronic heart failure (CHF). BACKGROUND Chronic HF disproportionately affects older individuals, who typically have extensive comorbidity. However, little is known about how noncardiac comorbidity complicates care in these patients. METHODS This was a cross-sectional study of 122,630 individuals age >/=65 years with CHF identified through a 5% random sample of all U.S. Medicare beneficiaries. We assessed the relationship of the 20 most common noncardiac comorbidities to one-year potentially preventable hospitalizations and total mortality. Preventable hospitalizations were determined by admissions for ambulatory care sensitive conditions using predefined criteria. RESULTS Sixty-five percent of the sample had at least one hospitalization, of which 50% were potentially preventable. Exacerbations of CHF accounted for 55% of potentially preventable hospitalizations. Nearly 40% of patients with CHF had >/=5 noncardiac comorbidities, and this group accounted for 81% of the total inpatient hospital days experienced by all CHF patients. The risk of hospitalization and potentially preventable hospitalization strongly increased with the number of chronic conditions (both p < 0.0001). After controlling for demographic factors and other diagnoses, comorbidities that were associated consistently with notably higher risks for CHF-preventable and all-cause preventable hospitalizations, and mortality, included chronic obstructive pulmonary disease/bronchiectasis, renal failure, diabetes, depression, and other lower respiratory diseases (all p < 0.01). CONCLUSIONS Noncardiac comorbidities are highly prevalent in older patients with CHF and strongly associate with adverse clinical outcomes. Cardiologists and other providers routinely caring for older patients with CHF may improve outcomes in this high-risk population by better recognizing non-CHF conditions, which may complicate traditional CHF management strategies.

The Relation between Funding by the National Institutes of Health and the Burden of Disease

BACKGROUND The Institute of Medicine has proposed that the amount of disease-specific research funding provided by the National Institutes of Health (NIH) be systematically and consistently compared with the burden of disease for society. METHODS We performed a cross-sectional study comparing estimates of disease-specific funding in 1996 with data on six measures of the burden of disease. The measures were total mortality, years of life lost, and number of hospital days in 1994 and incidence, prevalence, and disability-adjusted life-years (one disability-adjusted life-year is defined as the loss of one year of healthy life to disease) in 1990. With the use of these measures as explanatory variables in a regression analysis, predicted funding was calculated and compared with actual funding. RESULTS There was no relation between the amount of NIH funding and the incidence, prevalence, or number of hospital days attributed to each condition or disease (P=0.82, P=0.23, and P=0.21, respectively). The numbers of deaths (r=0.40, P=0.03) and years of life lost (r=0.42, P=0.02) were weakly associated with funding, whereas the number of disability-adjusted life-years was strongly predictive of funding (r=0.62, P<0.001). When the latter three measures were used to predict expected funding, the conclusions about the appropriateness of funding for some diseases varied according to the measure used. However, the acquired immunodeficiency syndrome, breast cancer, diabetes mellitus, and dementia all received relatively generous funding, regardless of which measure was used as the basis for calculating support. Research on chronic obstructive pulmonary disease, perinatal conditions, and peptic ulcer was relatively underfunded. CONCLUSIONS The amount of NIH funding for research on a disease is associated with the burden of the disease; however, different measures of the burden of disease may yield different conclusions about the appropriateness of disease-specific funding levels.

The Growing Burden of Chronic Disease in America

a In 2000, approximately 125 million Americans (45% of the population) had chronic conditions and 61 million (21% of the population) had multiple chronic conditions. The number of people with chronic conditions is projected to increase steadily for the next 30 years. While current health care financing and delivery systems are designed primarily to treat acute conditions, 78% of health spending is devoted to people with chronic conditions. Quality medical care for people with chronic conditions requires a new orientation toward prevention of chronic disease and provision of ongoing care and care manage- ment to maintain their health status and functioning. Specific focus should be applied to people with multiple chronic conditions.

Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care

ObjectiveIntensive care units (ICUs) account for an increasing percentage of hospital admissions and resource consumption. Adverse events are common in ICU patients and contribute to high mortality rates and costs. Although evidence demonstrates reduced complications and mortality when intensivists manage ICU patients, a dramatic national shortage of these specialists precludes most hospitals from implementing an around-the-clock, on-site intensivist care model. Alternate strategies are needed to bring expertise and proactive, continuous care to the critically ill. We evaluated the feasibility of using telemedicine as a means of achieving 24-hr intensivist oversight and improved clinical outcomes. DesignObservational time series triple cohort study. SettingA ten-bed surgical ICU in an academic-affiliated community hospital. PatientsAll patients whose entire ICU stay occurred within the study periods. InterventionsA 16-wk program of continuous intensivist oversight was instituted in a surgical ICU, where before the intervention, intensivist consultation was available but there were no on-site intensivists. Intensivists provided management during the intervention using remote monitoring methodologies (video conferencing and computer-based data transmission) to obtain clinical information and to communicate with on-site personnel. To assess the benefit of the remote management program, clinical and economic performance during the intervention were compared with two 16-wk periods within the year before the intervention. Measurements and Main ResultsICU and hospital mortality (observed and Acute Physiology and Chronic Health Evaluation III, severity-adjusted), ICU complications, ICU and hospital length-of-stay, and ICU and hospital costs were measured during the 3 study periods. Severity-adjusted ICU mortality decreased during the intervention period by 68% and 46%, compared with baseline periods one and two, respectively. Severity-adjusted hospital mortality decreased by 33% and 30%, and the incidence of ICU complications was decreased by 44% and 50%. ICU length of stay decreased by 34% and 30%, and ICU costs decreased by 33% and 36%, respectively. The cost savings were associated with a lower incidence of complications. ConclusionsTechnology-enabled remote care can be used to provide continuous ICU patient management and to achieve improved clinical and economic outcomes. This intervention’s success suggests that remote care programs may provide a means of improving quality of care and reducing costs when on-site intensivist coverage is not available.

Hospital Readmissions in the Medicare Population

In order to examine the proportion of Medicare expenditures attributable to repeated admissions to the hospital, we assessed the frequency with which 270,266 randomly selected Medicare beneficiaries were readmitted after hospital discharge between 1974 and 1977. Twenty-two per cent of Medicare hospitalizations were followed by a readmission within 60 days of discharge. Medicare spent over

National Outcomes of Cataract Extraction: Increased Risk of Retinal Complications Associated with Nd.-YAG Laser Capsulotomy

2.5 billion per year (24 per cent of Medicare inpatient expenditures) on such readmissions between 1974 and 1977. Analogous expenditures in 1984 could approach

The relationship between a dementia diagnosis, chronic illness, medicare expenditures, and hospital use

8 billion. Even a small decrease in the readmission rate could result in substantial savings for the Medicare program. The recently enacted prospective-payment legislation, however, creates economic incentives that could increase readmission rates. Attempts by professional review organizations or others to develop hospital readmission profiles will need to control for patient and hospital characteristics that are correlated with the likelihood of readmission. Further study of such characteristics could help identify high-risk patient groups for whom increased outpatient supports might prove cost effective.

Chronic medical illness, depression, and use of acute medical services among Medicare beneficiaries.

PURPOSE The authors studied 57,103 randomly selected Medicare beneficiaries who underwent extracapsular cataract extraction in 1986 or 1987 to determine the possible association between performance of neodymium (Nd):YAG laser capsulotomy and the risk of subsequent retinal break or detachment. METHODS Cases of cataract surgery were identified from Medicare claims submitted in 1986 and 1987 and were followed through the end of 1988. Episodes of cataract surgery, posterior capsulotomy, and retinal complications were ascertained based on procedure and diagnosis codes listed in physician bills and hospital discharge records. Lifetable and Coxs proportional hazards models were used to analyze the risk of retinal detachment or break in patients undergoing and not undergoing capsulotomy during the period of observation. RESULTS Of the 57,103 persons identified as having undergone extracapsular cataract extraction in 1986 or 1987, 13,709 subsequently underwent Nd:YAG laser capsulotomy between 1986 and 1988. A total of 337 persons had aphakic or pseudophakic retinal detachments between 1986 and 1988 and an additional 194 underwent repair of a retinal break. Proportional hazards modeling shows a 3.9-fold increase in the risk of retinal break or detachment among those who underwent capsulotomy (95% confidence interval: 2.89 to 5.25). Younger patient age, male sex, and white race also were associated with increased risk of retinal complications after extracapsular cataract extraction. CONCLUSION The authors conclude that there is a statistically significant increase in the risk of retinal detachment or break in those patients who undergo capsulotomy after cataract extraction. Therefore, capsulotomy should be deferred until the patients impairment caused by capsular opacification warrants the increased risk of retinal complications associated with performance of capsulotomy.

Uncertain demand, the structure of hospital costs, and the cost of empty hospital beds

Objectives: To determine whether dementia increases medical expenditures, the probability of hospitalization, and potentially preventable hospitalization, controlling for variables including age and comorbidity.

Comorbidity and the Use of Primary Care and Specialist Care in the Elderly

Background:This study assessed the relation of comorbid depressive syndrome with utilization of emergency department services and preventable inpatient hospitalizations among elderly individuals with chronic medical conditions. Research Design:A cross-sectional study. Setting:Individuals greater than or equal to 65 years of age living in the United States with Medicare part A and B fee-for-service coverage in 1999. Subjects:A 5% random sample of elderly Medicare recipients (N = 1,238,895) of whom 60,382 (4.9%) met criteria for a depressive syndrome. Measurements:Medicare beneficiaries were stratified based on the presence of at least 1 of the following medical conditions: coronary artery disease, diabetes mellitus, congestive heart failure, hypertension, prostate cancer, breast cancer, lung cancer, or colon cancer. For each stratum, we compared the odds of emergency department visits, all-cause hospitalization, and hospitalization for ambulatory care sensitive conditions (ACSC), conditions for which timely and effective medical care could decrease risk of hospitalization, for beneficiaries with and without a depressive syndrome. Results:Compared with those without a depressive syndrome, beneficiaries with a depressive syndrome were more likely to be older, white, and female (P <0.001). For each of the 8 chronic medical conditions, elderly beneficiaries with a depressive syndrome were at least twice as likely to use emergency department services (range of adjusted odds ratios, 2.12–3.16; P <0.001); medical inpatient hospital services (range of adjusted odds ratios, 2.59–3.71; P <0.001); and medical inpatient hospital services associated with an ACSC (range of adjusted odds ratios, 1.72–2.68; P <0.001) as compared with those without a depressive syndrome. Conclusions:For elderly individuals with at least 1 chronic medical condition, the presence of a depressive syndrome increased the odds of acute medical service use, suggesting that improvements in clinical management, access to mental health services, and coordination of medical and mental health services could reduce utilization.