Nina R. Joyce

The rise of concurrent care for veterans with advanced cancer at the end of life.

Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the “terrible choice” between receipt of hospice services or disease‐modifying chemotherapy/radiation therapy. For this report, the authors characterized the VAs provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy.

Prevalence and impact of Clostridium difficile infection in elderly residents of long-term care facilities, 2011: A nationwide study.

Abstract The elderly population is particularly vulnerable to Clostridium difficile infection (CDI), but the epidemiology of CDI in long-term care facilities (LTCFs) is unknown. We performed a retrospective cohort study and used US 2011 LTCF resident data from the Minimum Data Set 3.0 linked to Medicare claims. We extracted CDI cases based on International Classification of Diseases-9 coding, and compared residents with the diagnosis of CDI to those who did not have a CDI diagnosis during their LTCF stay. We estimated CDI prevalence rates and calculated 3-month mortality rates. The study population consisted of 2,190,613 admissions (median age 82 years; interquartile range 76–88; female to male ratio 2:1; >80% whites), 45,500 of whom had a CDI diagnosis. The nationwide CDI prevalence rate was 1.85 per 100 LTCF admissions (95% confidence interval [CI] 1.83–1.87). The CDI rate was lower in the South (1.54%; 95% CI 1.51–1.57) and higher in the Northeast (2.29%; 95% CI 2.25–2.33). Older age, white race, presence of a feeding tube, unhealed pressure ulcers, end-stage renal disease, cirrhosis, bowel incontinence, prior tracheostomy, chemotherapy, and chronic obstructive pulmonary disease were independently related to “high risk” for CDI. Residents with a CDI diagnosis were more likely to be admitted to an acute care hospital (40% vs 31%, Pu200a<u200a0.001) and less likely to be discharged to the community (46% vs 54%, Pu200a<u200a0.001) than those not reported with CDI during stay. Importantly, CDI was associated with higher mortality (24.7% vs 18.1%, Pu200a=u200a0.001). CDI is common among the elderly residents of LTCFs and is associated with significant increase in 3-month mortality. The prevalence is higher in the Northeast and risk stratification can be used in CDI prevention policies.

Passive Enrollment Of Dual-Eligible Beneficiaries Into Medicare And Medicaid Managed Care Has Not Met Expectations

The Centers for Medicare and Medicaid Services Financial Alignment Initiative represents the largest effort to date to move beneficiaries who are eligible for both Medicare and Medicaid-known as dual eligibles-into a coordinated care model by the use of passive (automatic) enrollment. Thirteen states are testing integrated payment and delivery demonstration programs in which an estimated 1.3xa0million dual eligibles are qualified to participate. As of Octoberxa02016, passive enrollment had brought over 300,000 dual eligibles into nine capitated programs in eight states. However, program participation levels remained relatively low. Across the eight states, only 26.7xa0percent of dual eligibles who were qualified to participate were enrolled, ranging from 5.3xa0percent for the two New York programs together to 62.4xa0percent in Ohio. Although the exact causes of the high rates of opting out and disenrolling that we observed among passively enrolled dual eligibles are unknown, experience to date suggests that administrative challenges were combined with demand- and supply-side barriers to enrollment. These early findings draw into question whether passive enrollment can encourage dual eligibles to participate in integrated care models.

Patterns and predictors of medication adherence to lipid-lowering therapy in children aged 8 to 20 years

BACKGROUNDnThe American Academy of Pediatrics recommends lipid-lowering therapy (LLT) for children at high risk of cardiovascular disease. However, the use of LLT in children is rare, and rates of nonadherence are unknown.nnnOBJECTIVEnTo identify patterns of use and predictors of nonadherence to LLT in children aged 8 to 20 years and the subgroup with dyslipidemia.nnnMETHODSnCommercially insured patients with a new dispensing for an LLT were included. Nonadherence was defined as a gap of >90xa0days between the last dispensing plus the medication days supply and the next dispensing or censoring. Descriptive statistics characterize the patterns of LLT adherence and class-specific drug switching. Kaplan-Meier curves and multivariable Cox proportional hazard models identified time to, and predictors of, nonadherence for the cohort and the dyslipidemia subgroup.nnnRESULTSnOf the 8710 patients meeting inclusion criteria, 87% were nonadherent. Statins were the most common index prescription, and patients with an index statin dispensing were more likely to have multiple comorbidities and other prescription drug use. In multivariable analyses, nonadherence was inversely associated with dyslipidemia (hazard ratio [HR]xa0= 0.61, 95% confidence interval [CI]xa0= 0.57-0.65), chronic kidney disease (HRxa0= 0.69, 95% CIxa0= 0.54-0.88), higher outpatient (HRxa0= 0.87, 95% CIxa0= 0.77-0.98), and inpatient (HRxa0= 0.83, 95% CIxa0= 0.70-0.97) use. When limited to patients with dyslipidemia, nonadherence was related to age (HRxa0= 1.21, 95% CIxa0= 1.07-1.38) and obesity (HRxa0= 1.23, 95% CIxa0= 1.02-1.49).nnnCONCLUSIONSnDespite recommendations to begin continuous treatment early for high-risk children, nonadherence to LLT is frequent in this population, with modestly higher adherence in children with dyslipidemia.

Variations in use and timing of hospice and palliative care: Differences across health care payers and cancer type.

132 Background: Cancer societies recommend cancer patients receive palliative care soon after diagnosis of illness and hospice for at least 3 days before death. While studies suggest receipt of hospice in the last 3 days of life is increasing for patients, the timing of first hospice and first palliative care is currently unknown. It is also not known whether fee-for-service versus capitated healthcare systems differ in their provision of supportive care. We evaluated the timing and frequency of palliative care and hospice use across the Department of Veterans Affairs (VA) and Medicare for dually-eligible Veterans, to understand variations in the use and timing of these services across healthcare systems for the same patient population.nnnMETHODSnA retrospective evaluation of all VA and Medicare administrative data for the population of Veterans aged 65 or older who died with advanced cancer in 2012.nnnRESULTSnThe majority of Veterans received supportive care before death: 67% received hospice and 69% received palliative care. On average, patients had 2 encounters with palliative care before death. Patients with melanoma were most likely to receive palliative care (82%); patients with hematologic malignancies were least likely to receive palliative care (58%). Veterans received VA-based hospice on average 35 days before death (SD = 42), while Veterans receiving Medicare-based hospice did so an average of 25 days before death (SD = 24). However, across both systems, 50% of Veterans were receiving hospice 16 days before death. There were substantial variations in timing of hospice enrollment by cancer type. Of Veterans receiving VA- or Medicare-based hospice, 22% cycled in and out of hospice, meaning they dis-enrolled and re-enrolled in such care. 16% of patients were discharged from hospice before death, with VA more likely to discharge Veterans before death compared with Medicare.nnnCONCLUSIONSnThere are large variations in healthcare system approaches to timing and use of hospice and palliative care, as well variations by cancer type. VA provides hospice to patients earlier in the disease trajectory, while Medicare is more likely to have patients die while enrolled in hospice.

The alternative quality contract: Impact on service use and spending for children with ADHD

In 2009, Blue Cross-Blue Shield of Massachusetts (BCBSMA) implemented the alternative quality contract (AQC), which pays provider organizations a global payment for all services used by enrollees. BCBSMA claims for 2006-2011 were used to compare youths enrolled in provider organizations participating in the AQC (7,407 person-years [PYs]) with those not participating (45,398 PYs). Difference-in-differences models estimated changes in mental health and substance abuse treatment service utilization and spending attributable to the AQC. The AQC was associated with small increases in the probability of any outpatient visits and in the probability and number of medication management visits among children with attention-deficit hyperactivity disorder (ADHD). Spending did not change, and there was no evidence of reductions in service utilization or spending for children with ADHD in the first three years of AQC implementation.

Statin Use and the Risk of Type 2 Diabetes Mellitus in Children and Adolescents

OBJECTIVEnThere is increasing evidence of an association between statin use and type 2 diabetes mellitus (T2DM) in adults, yet this relationship has never been studied in children or adolescents and may have important implications for assessing risks and benefits of treatment in this population. We estimated the association between statin use and the risk of T2DM in children with and without a dyslipidemia diagnosis.nnnMETHODSnPropensity scores were used to match new users of statins with a minimum 50 percent of days covered (PDC) in the first year of use to up to 10 nonusers. Analyses were stratified by a dyslipidemia diagnosis based on recent evidence suggesting a potentially protective effect of familial hypercholesterolemia on T2DM. In sensitivity analyses, we varied this period of exclusion and PDC. Cox proportional hazard models compared the hazard of the outcome between the exposed and unexposed patients.nnnRESULTSnA total of 21,243,305 patients met the eligibility criteria, 2085 (0.01%) of whom met the exposure definition and 1046 (50%) of whom had a dyslipidemia diagnosis. Statin use was associated with an increased risk of T2DM in children without dyslipidemia (hazard ratio 1.96, 95% confidence interval 1.20-3.22), but not in children with dyslipidemia (hazard ratio 1.11, 95% confidence interval 0.65-1.90). The results were consistent across variations in the exclusion period and PDC.nnnCONCLUSIONSnStatin use was associated with an increased likelihood of developing T2DM in children without dyslipidemia. Physicians and patients need to weigh the possible risk of T2DM against the long-term benefits of statin therapy at a young age.

Variation in the 12-Month Treatment Trajectories of Children and Adolescents After a Diagnosis of Depression

Importance Depression during childhood and adolescence is heterogeneous. Treatment patterns are often examined in aggregate, yet there is substantial variability across individual treatment trajectories. Understanding this variability can help identify treatment gaps among youths with depression. Objective To characterize heterogeneity in 12-month trajectories of psychotherapy and antidepressant treatment in youths with depression. Design, Setting, and Participants This is a longitudinal-cohort study of youths 18 years or younger with a new diagnosis of depression and at least 12 months of follow-up following diagnosis, as determined from commercial insurance claims filed from 2007 to 2014. Latent class models were fit to summary measures of psychotherapy and antidepressant use in the 12 months following the index diagnosis. We examined variation in baseline health, health care utilization, and health outcomes across classes with similar patterns of psychotherapy and antidepressant use. Data analysis took place between June 2016 and March 2017. Main Outcomes and Measures Psychotherapy and antidepressant use. Results The cohort included 84 909 individuals with a mean (SD) age at index diagnosis of 15.0 (2.6) years, of whom 49 995 (59%) were female. Attention-deficit/hyperactivity disorder (nu2009=u200914 625; 17%) and anxiety (nu2009=u200912 358; 15%) were the most common comorbid diagnoses. During the assessment period, 59 023 individuals (70%) received psychotherapy at any point, and 33 997 individuals (40%) were dispensed antidepressants at any point. Eight classes with distinct treatment trajectories were identified, which we classified into 4 broad groups: 3 classes that received dual therapy (nu2009=u200918 710; 22%), 2 classes that received antidepressant monotherapy (nu2009=u200915 287; 18%), 2 classes that received psychotherapy monotherapy (nu2009=u200940 313; 48%) and 1 class that received no treatment (nu2009=u200910 599; 13%). The most common class received psychotherapy monotherapy (nu2009=u200935 243; 42%) and had the lowest incidence of attempted suicide (0.8 per 100 person-years [PY]) and inpatient hospitalization (3.5 per 100 PY) during the assessment period and postassessment period (0.5 per 100 PY and 1.3 per 100 PY, respectively). The group receiving dual therapy had the highest incidence of attempted suicide during the assessment period (4.7-7.1 per 100 PY, depending on the class) and postassessment period (1.5-1.7 per 100 PY). Conclusions and Relevance In our sample, 13% of youths received no treatment, and 18% received antidepressants without concomitant psychotherapy. Summary measures of treatment can mask informative patterns of psychotherapy and antidepressant use. Latent class analysis can be used to identify subgroups of individuals with similar treatment trajectories and help identify treatment gaps under current practice patterns.

The Impact of Dementia Special Care Units on Quality of Care: An Instrumental Variables Analysis

OBJECTIVEnTo compare the quality of care following admission to a nursing home (NH) with and without a dementia special care unit (SCU) for residents with dementia.nnnDATA SOURCES/STUDY SETTINGnNational resident-level minimum dataset assessments (MDS) 2005-2010 merged with Medicare claims and provider-level data from the Online Survey, Certification, and Reporting database.nnnSTUDY DESIGNnWe employ an instrumental variable approach to address the endogeneity of selection into an SCU facility controlling for a range of individual-level covariates. We use differential distance to a nursing home with and without an SCU as our instrument.nnnDATA COLLECTION/EXTRACTION METHODSnMinimum dataset assessments performed at NH admission and every quarter thereafter.nnnPRINCIPAL FINDINGSnAdmission to a facility with an SCU led to a reduction in inappropriate antipsychotics (-9.7 percent), physical restraints (-9.6 percent), pressure ulcers (-3.3 percent), feeding tubes (-8.3 percent), and hospitalizations (-14.7 percent). We found no impact on the use of indwelling urinary catheters. Results held in sensitivity analyses that accounted for the share of SCU beds and the facilities overall quality.nnnCONCLUSIONSnFacilities with an SCU provide better quality of care as measured by several validated quality indicators. Given the aging population, policies to promote the expansion and use of dementia SCUs may be warranted.

Effect of Clostridium difficile Prevalence in Hospitals and Nursing Homes on Risk of Infection

To assess the effect of facility Clostridium difficile infection (CDI) prevalence on risk of healthcare facility (HFC) acquired CDI.