Wendy E. Weller

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

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

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

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.

Alzheimer's disease under managed care : Implications from medicare utilization and expenditure patterns

BACKGROUND: Little information is available about the costs, utilization patterns, and the delivery system used by Medicare beneficiaries with chronic illnesses. This information will become increasingly important as more Medicare beneficiaries with chronic illness enroll in managed care plans and delivery systems must be developed to meet their needs.

Patterns of Expenditures and Use of Services Among Older Adults With Diabetes: Implications for the transition to capitated managed care

OBJECTIVE To examine health care use and expenditures among older adults with diabetes, investigate factors that are associated with higher expenditures, and describe the policy implications of caring for this population under managed care. RESEARCH DESIGN AND METHODS A cross-sectional analysis of expenditures for individuals with diabetes over age 65 years from a nationwide 5% random sample of Medicare beneficiaries was conducted during 1992. All components of medical care covered under Medicare were examined. Multivariate analysis was used to assess the contribution of age, race, sex, number of diabetic complications, and comorbidity (Charlson Index) on total expenditures. RESULTS On average, individuals with diabetes (n = 188,470) were 1.5 times (P < 0.0001) as expensive as all Medicare beneficiaries (n = 1,371,960). However, there were wide variations, with the most expensive 10% of beneficiaries with diabetes accounting for 56% of expenditures for individuals with diabetes and the least expensive 50% accounting for 4% Acute carehospitalizations accounted for the majority (60%) of total expenditures, whereas outpatient and physician services accounted for 7 and 33%, respectively. There were no differences in the number of complications for all older adults with diabetes compared with those with the highest expenditures. However, the average number of hospitalizations was 1.6 times (0.53 vs. 0.34; P < 0.0001) higher, and the average length of stay was 2 days longer, among older adults with diabetes (P < 0.0001). In the regression model, age and male sex (factors currently used to set payment rates for Medicare managed care enrollees), and number of diabetic complications, but not race, were positively related to expenditures, yet had minimal predictive power (R2 = 0.0006). The addition of the Charlson Index, also positively related to expenditures, was able to explain up to 20% of the variation in total expenditures (R2 = 0.196). CONCLUSIONS There are large variations in expenditures among older adults with diabetes. Because elderly beneficiaries with diabetes are more expensive than the average older adult, current Medicare capitation rates may be inadequate. To avoid selection bias and undertreatment of this vulnerable population under managed care, methods to construct fair payment rates and safeguard quality of care are desirable.

The costs of children with sickle cell anemia: Preparing for managed care

Purpose: To anticipate the clinical challenges and financial risks facing physicians and managed care organizations who care for children with chronic illnesses, such as sickle cell anemia (SCA), under capitated managed care arrangements. Patients and Methods: A cross-sectional study based on claims data from the Washington State Medicaid Program (WSMP) and the Federal Employees Health Benefits Program (FEP). Expenditure patterns were compared for children 18 years of age or younger for whom a claim with a diagnosis of SCA was submitted and paid in the State of Washington during fiscal year 1993 (FY1993) or by the FEP during FY1992 to expenditure patterns for all children. Results: Children with SCA had mean expenditures 8.8 times the mean expenditures for all children in WSMP. There was wide variation in the annual expenditures among children with SCA; the most expensive 10% of children accounted for 56% of total expenditures. Ninety-seven percent of the expenditures were concentrated in four broad categories: 72% for inpatient care, 11% for outpatient care, 11% for physician payments, and 3% for prescription drugs. Examination of expenditure and utilization patterns for children with sickle cell anemia enrolled in the FEP yielded similar results. Conclusions: Unless managed care organizations and capitated pediatricians receive payment rates that reflect the higher expected expenditures of caring for these children, access to and quality of care may suffer. Analyses of practice guidelines and utilization patterns suggest that newborn screening, regular access to specialty facilities, and comprehensive education programs are critical areas that are vulnerable to reductions under capitation.

Capitation for cardiologists: Accepting risk for coronary artery disease under managed care

Patients with chronic disease may be excluded from capitated managed care plans due to higher than average expected costs. In an attempt to remedy this inequity, one type of risk adjustment technique proposes to set separate capitation rates for certain chronic illnesses, including coronary artery disease (CAD). Cardiologists, who increasingly are requested to accept capitation, will benefit from understanding the impact of using clinical factors as opposed to using demographic factors to set capitation rates. Using a 5% national random sample of the 1992 Medicare population, we determined mean annual expenditures and variation in expenditures of individuals with CAD. We compared the use of 2 demographic factors currently used for capitation rate adjustment (age and gender) with 2 factors not currently used--3-digit International Classification of Disease (ICD-9) code (a measure for severity) and Charlson index (a measure for comorbidity). Mean annual expenditures for individuals with CAD were more than double mean annual expenditures for the general Medicare population (

Out-Of-Pocket Medical Spending For Care Of Chronic Conditions

6,944 vs

Preventable Hospitalization Among Elderly Medicare Beneficiaries With Type 2 Diabetes

3,247). Among individuals with CAD, mean expenditures of subgroups defined by both age and gender ranged from

Capitation, Managed Care, and Chronic Obstructive Pulmonary Disease

6,205 to