Jeffrey O. Tom

Geographic variation in cardiovascular procedure use among medicare fee-for-service vs medicare advantage beneficiaries

IMPORTANCE Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures. OBJECTIVE To compare regional cardiovascular procedure rates between Medicare Advantage and Medicare FFS beneficiaries. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of Medicare beneficiaries older than 65 years between 2003-2007 comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery across 32 hospital referral regions in 12 states. MAIN OUTCOMES AND MEASURES Rates of coronary angiography, PCI, and CABG surgery. RESULTS We evaluated a total of 878,339 Medicare Advantage patients and 5,013,650 Medicare FFS patients. Compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates per 1000 person-years for angiography (16.5 [95% CI, 14.8-18.2] vs 25.9 [95% CI, 24.0-27.9]; P < .001) and PCI (6.8 [95% CI, 6.0-7.6] vs 9.8 [95% CI, 9.0-10.6]; P < .001) but similar rates for CABG surgery (3.1 [95% CI, 2.8-3.5] vs 3.4 [95% CI, 3.1-3.7]; P = .33). There were no significant differences between Medicare Advantage and Medicare FFS patients in the rates per 1000 person-years of urgent angiography (3.9 [95% CI, 3.6-4.2] vs 4.3 [95% CI, 4.0-4.6]; P = .24) or PCI (2.4 [95% CI, 2.2-2.7] vs 2.7 [95% CI, 2.5-2.9]; P = .16). Procedure rates varied widely across hospital referral regions among Medicare Advantage and Medicare FFS patients. For angiography, the rates per 1000 person-years ranged from 9.8 to 40.6 for Medicare Advantage beneficiaries and from 15.7 to 44.3 for Medicare FFS beneficiaries. For PCI, the rates ranged from 3.5 to 16.8 for Medicare Advantage and from 4.7 to 16.1 for Medicare FFS. The rates for CABG surgery ranged from 1.5 to 6.1 for Medicare Advantage and from 2.5 to 6.0 for Medicare FFS. Across regions, we found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography (Spearman r = 0.19, P = .29) and modest correlations for PCI (Spearman r = 0.33, P = .06) and CABG surgery (Spearman r = 0.35, P = .05). Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates. CONCLUSIONS AND RELEVANCE Although Medicare beneficiaries enrolled in capitated Medicare Advantage programs had lower angiography and PCI procedure rates than those enrolled in Medicare FFS, the degree of geographic variation in procedure rates was substantial among Medicare Advantage beneficiaries and was similar in magnitude to that observed among Medicare FFS beneficiaries.

Personal health record use for children and health care utilization: propensity score-matched cohort analysis

OBJECTIVES To examine the association between caregiver personal health record (PHR) use and health care utilization by pediatric patients. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective observational cohort study of 2286 pediatric members aged six months to 2.5 years of Kaiser Permanente Hawaii and Northwest Regions in 2007-2011, using propensity score matching methods and t and chi-square tests to examine associations between PHR use and health care utilization. We used ANOVA to examine utilization across quartiles of PHR use. MAIN OUTCOME MEASURES Outpatient clinic visits, telephone encounters, and emergency department visits. RESULTS PHR-registered children, compared with propensity score-matched nonregistered children, had 21% (95% CI, 14-28; P < .0001) more outpatient clinic visits and 26% (95% CI, 16-37; P < .0001) more telephone encounters. Utilization differences were more pronounced with nonprimary care providers than with primary care providers. Outpatient clinic visits and telephone encounters increased among the quartile with the highest PHR use; no utilization differences occurred in the 3 lowest-use quartiles. CONCLUSIONS PHR use by caregivers was associated with statistically significant increases in outpatient clinic visits and telephone encounters among pediatric patients.

Improving Adherence to Cardiovascular Therapies: An Economic Evaluation of a Randomized Pragmatic Trial☆

OBJECTIVE Preplanned economic analysis of a pragmatic trial using electronic-medical-record-linked interactive voice recognition (IVR) reminders for enhancing adherence to cardiovascular medications (i.e., statins, angiotensin-converting enzyme inhibitors [ACEIs], and angiotensin receptor blockers [ARBs]). METHODS Three groups, usual care (UC), IVR, and IVR plus educational materials (IVR+), with 21,752 suboptimally adherent patients underwent follow-up for 9.6 months on average. Costs to implement and deliver the intervention (from a payer perspective) were tracked during the trial. Medical care costs and outcomes were ascertained using electronic medical records. RESULTS Per-patient intervention costs ranged from

Comparative Effectiveness of Statin Therapy in Chronic Kidney Disease and Acute Myocardial Infarction: A Retrospective Cohort Study

9 to

C-B4-03: Promoting Adherence to Improve Effectiveness of Cardiovascular Disease Therapies (PATIENT): Implementing a Medication Adherence Intervention Using Health Information Technology

17 for IVR and from

Identifying and Reducing Barriers to Improve Lipid Screening in Youth

36 to

Use of select dietary supplements among individuals with diabetes or atherosclerotic cardiovascular disease

47 for IVR+. For ACEI/ARB, the incremental cost-effectiveness ratio for each percent adherence increase was about 3 times higher with IVR+ than with IVR (

PS2-11: Impact of a Health Information Technology (HIT) Based Intervention to Improve Adherence to Cardiovascular Disease Medications: Early Results from the PATIENT Trial

6 and

Improving adherence to cardiovascular disease medications with information technology.

16 for IVR and IVR+, respectively). For statins, the incremental cost-effectiveness ratio for each percent adherence increase was about 7 times higher with IVR+ than with IVR (

Personal Health Record Use and Association with Immunizations and Well-Child Care Visits Recommendations

6 and