Jennifer R. Frytak

Bouncing Back: Patterns and Predictors of Complicated Transitions 30 Days After Hospitalization for Acute Ischemic Stroke

OBJECTIVES: To identify predictors of complicated transitions within 30 days after discharge from hospitalization for acute stroke.

A claims database analysis of persistence with alendronate therapy and fracture risk in post-menopausal women with osteoporosis.

ABSTRACT Objective: To explore the relationship between persistence with alendronate therapy and fracture rates in women with postmenopausal osteoporosis. Research design and methods: Claims data from a large US health plan database were used to examine persistence with therapy in postmenopausal women followed for 24 months. Persistence was defined as the time (in days) from the date of first fill to the run-out date of the last prescription with no lapses > 30 days after completion of the previous refill. A persistent cohort (length of persistence ≥ 182 days) and a non-persistent cohort (length of persistence < 182 days) were defined. The number of patients with a fracture claim in each cohort was determined. Cox-proportional hazards regression (HR) analysis was used to determine significant differences in fracture rates between the two cohorts. Results: 4769 patients were followed for 24 months. Patients in the persistent cohort were significantly more likely to receive a treatment (vs. prevention) dose of alendronate ( p = 0.03) and to be older than 65 years ( p = 0.04). There was a trend toward more fractures in the non-persistent (4.9%) than in the persistent cohort (3.9%; p = 0.09). When controlled for other significant factors (including age and previous fractures) patients in the persistent cohort were 26% less likely to have a fracture diagnosis claim during the study period than those in the non-persistent cohort (HR = 0.74; 95% CI, 0.549–0.996; p = 0.045). Prescription fill data are an indirect measure of medication-taking behavior. The use of claims data to estimate persistence and identify fracture events prohibits the establishment of causality between these two variables. Conclusion: Study results demonstrated that non-persistence with therapy, along with previous fracture and increasing age, was associated with a greater risk of fracture.

Rehospitalization and survival for stroke patients in managed care and traditional Medicare plans.

Background:Stroke affects more than 500,000 older persons each year in the United States, but no studies have compared older stroke patients in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) after recent changes in FFS reimbursement. Objectives:We sought to compare utilization and outcomes after stroke in Medicare HMO and FFS. Design:We reviewed administrative data in 11 regions from Medicare and a large national health plan. Subjects:We studied Medicare beneficiaries 65 years and older discharged with ischemic stroke during 1998–2000, ie, 4816 HMO patients and a random sample of 4187 FFS patients from 422 hospitals. Measures:We measured survival, rehospitalization, length of stay, discharge destination, and warfarin use. Results:Overall, HMO patients were younger, male, non-Caucasian, and had fewer comorbid conditions. When compared with FFS patients, HMO patients were more likely to be rehospitalized within 30 days for a primary diagnosis of ischemic stroke (Adjusted Hazard Ratio = 1.45, 95% Confidence Interval [CI] 1.14–1.83) or ill-defined conditions (eg, rehabilitation services) (2.87, 95% CI 1.85–4.46) and less likely to be rehospitalized for fluid and electrolyte disorders (0.54, 95% CI 0.34–0.87) or circulatory/respiratory problems (0.77, 95% CI 0.60–0.98). There were no consistent differences in 30-day mortality or in 1-year rehospitalization or mortality for 30-day survivors. HMO patients also were much less likely to be discharged to rehabilitation facilities, slightly less likely to be discharged to skilled nursing facilities and to have a shorter length of stay, and did not differ in the use of home care services or warfarin use when compared with FFS patients. Conclusions:Traditional measures of quality such as 30-day rehospitalization may not be valid when comparing HMO and FFS patients if differences might reflect an alternative service mix. Utilization of postacute care for FFS patients appears similar to HMO patients except for discharge to rehabilitation facilities.

Socioeconomic Status and Health over the Life Course

On average, individuals of lower socioeconomic status (SES)—based on education, income, or occupation—have worse health than their higher SES counterparts (Adler, Boyce, Chesney, Folkman, & Syme, 1993; Antonovsky, 1967; Feinstein, 1993; Feldman, Makuc, Kleinman, & Cornoni-Huntley, 1989; House, Kessler, & Herzog, 1990; Kitagawa & Hauser, 1973; Marmot, Shipley, & Rose, 1984; Pappas, Queen, Hadden, & Fisher, 1993; Preston & Taubman, 1994; Townsend & Davidson, 1982). This relationship is best depicted as a gradient in health with a fairly linear trend in better health associated with increasing levels of SES, rather than a threshold effect. Furthermore, this relationship is stratified by age; lower SES individuals begin to experience health problems shortly after adolescence, while higher SES individuals experience little health decline until around retirement age (House et al, 1990, 1994). This life course patterning of SES and health is intriguing since it suggests substantial variation in the ability of each group to sustain good health over the life course.

30-day survival and rehospitalization for stroke patients according to physician specialty.

Background and Purpose: Stroke patients appear to have improved outcomes when cared for by neurologists, but the mechanism by which improved outcome is achieved is unclear. This study compares 30-day cause-specif ic rehospitalization, 30-day mortality, and specific processes of care for patients treated by a neurologist only, a generalist only, a neurologist and a generalist (i.e., collaborative care), or by another specialist during the index hospitalization.Methods: This study uses Cox regression to analyze claims and enrollment data from 44,099 Medicare beneficiaries 65 years of age and older and discharged with acute ischemic stroke from 1998 to 2000 in 11 US metropolitan regions. Results: Patients seen by neurologists had more severe strokes than patients seen by generalists, though patients seen by generalists had more comorbidities. Patients seen by neurologists (alone or collaboratively) had a 10 and 16% lower risk of 30-day mortality, respectively. Patients seen by a neurologist only had a 12% lower risk of rehospitalization for infections and aspiration pneumonitis. In contrast, patients seen by neurologists had a higher risk of rehospitalization for atherosclerotic (cardiovascular and non-acute cerebrovascular) disease. Patients seen by neurologists were more likely to be discharged to inpatient rehabilitation, had longer lengths of stay, and were more likely to receive warfarin after discharge. Conclusions: Results support the hypothesis that neurologists improve outcomes specifically by reducing the potential for aspiration (through increased swallowing evaluations) or by improving functioning (through use of rehabilitation therapy). Future studies should continue to examine the mechanisms by which neurologists may achieve better outcomes in stroke care.

The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs.

OBJECTIVES: To examine 1‐year mortality and healthcare payments of stroke patients experiencing zero, one and two or more bounce‐backs within 30 days of discharge.

Bouncing-Back: Rehospitalization in Patients with Complicated Transitions in the First Thirty Days After Hospital Discharge for Acute Stroke

SUMMARY Background: “Bounce-backs” (movements from a less intensive to a more intensive care setting) soon after hospital discharge are common, but reasons for bouncing-back remain unknown. Objective: To examine how the primary diagnosis for first rehospitalization relates to thirty-day bounce-back number and initial discharge destination in acute stroke. Population: Administrative data from 5,250 Medicare beneficiaries > 65 years discharged with acute ischemic stroke in 1998–2000 to a rehabilitation center, skilled nursing facility or home with home health care and with at least one thirty day rehospitalization. Analysis: Probability of thirty-day bounce-back was calculated using multivariate models. Results: Infections and aspiration pneumonitis were the most common reasons for rehospitalization, regardless of initial discharge site. Conclusions: Efforts addressing aspirations and infections, the preventable complications of immobility, will be critical in decreasing acute stroke bounce-backs.

Estimation of economic costs associated with transfusion dependence in adults with MDS

ABSTRACT Objective: To examine the economic burden of myelodysplastic syndromes (MDS) and the incremental cost of transfusion dependence. Research design and methods: Adults with evidence of MDS were identified between 05/01/2000 and 09/30/2003 from a longitudinal, retrospective claims database for a large, geographically diverse US health plan and their medical histories were followed for at least 6 months. Patients were classified as transfusion-dependent (MDS-TD) or transfusion-independent (MDS-TI). Main outcome measures: Variables were categorized as demographic, health status, utilization, or cost. Utilization (inpatient hospitalizations, outpatient facility visits, emergency department visits, and physician office visits) is reported as the mean and median numbers of each specified encounter per subject. Costs were measured as the sum of patient and plan liability. All variables were analyzed descriptively, and appropriate statistical tests were used to compare the MDS-TD and MDS-TI cohorts. Pharmacy, medical, and total health care costs, adjusted for demographics and comorbidity, were estimated using gamma regression with a log link. Results: The MDS-TI cohort consisted of 2864 patients, and the MDS-TD cohort comprised 336 patients. Mean age for the entire study sample was 70.2 years. The MDS-TI cohort tended to receive most of its medical care at physicians’ offices, whereas the MDS-TD cohort received nearly as much medical care at outpatient facilities (e.g., infusion clinics, hospital outpatient clinics) as it did in physicians’ offices. The MDS-TD cohort had significantly higher mean annual costs: pharmacy,

The complexity of medication regimens and test ordering for patients with diabetes from 1995 to 2003

4457 vs.

Predictors of Hospice Utilization among Acute Stroke Patients who Died within Thirty Days

2926; medical,