Prehabilitation Utilization for Elective Lower Extremity Joint Replacement Among Older Medicare Beneficiaries

To compare clinical and economic outcomes of early insulin initiation with those of delayed initiation in older adults with type 2 diabetes mellitus (T2DM). Retrospective cohort study. Humana Medicare Advantage health insurance plan. Older (≥65) Medicare beneficiaries with T2DM. Subjects were grouped according to number of classes of oral antidiabetes drugs (OADs) they had taken before initiation of insulin: one (early insulin initiators), two, or three or more (delayed insulin initiators). One-year follow-up outcomes included change in glycosylated hemoglobin (HbA1c), percentage of older adults with HbA1c less than 8.0%, hypoglycemic events, and total healthcare costs. Overall, 14,669 individuals were included in the analysis. Baseline and 1-year follow-up HbA1c levels were available for 4,028 (27.5%) individuals. Insulin was initiated early in 32% and delayed in 20%. At follow-up, unadjusted reduction in HbA1c was 0.9±3.7% for the group with one OAD, 0.7±2.4% for those with two, and 0.5±3.6% for those with three or more. Early insulin initiation was associated with significantly greater reduction in HbA1c (0.4%; adjusted P<.001), 30% greater likelihood of achieving HbA1c less than 8.0% (adjusted odds ratio=1.30, 95% confidence interval=1.18-1.43), and no significant differences in total costs or hypoglycemia events (11.5% of early initiators vs 10.2% of delayed initiators; P=.32). This study suggests beneficial effects of early insulin initiation in older adults with T2DM who do not have adequate glycemic control, without increasing the risk of hypoglycemia or greater total direct healthcare costs.

To examine rates of adherence to continuous positive airway pressure (CPAP) therapy among a representative sample of older adult Medicare beneficiaries with obstructive sleep apnea (OSA), and to identify demographic and health-related factors associated with CPAP adherence. Using a 5% sample of Medicare claims data, we utilized Medicare policy and CPAP machine charges as a proxy for CPAP adherence. A cumulative logit model was used to identify demographic, medical, and psychiatric predictors of CPAP adherence status. Of beneficiaries who initiated CPAP (n = 3,229), 74.9% (n = 2,417) met the so-called "90-day Medicare adherence criteria," but only 58.8% of these individuals (n = 1,420) continued to use CPAP throughout the entire 13-month rent-to-own period. Anxiety, anemia, fibromyalgia, traumatic brain injury, and lower socioeconomic status (SES) were all associated with reduced CPAP adherence. These results provide the first national estimates of CPAP adherence among older adult Medicare beneficiaries in the United States. In addition, findings highlight the salience of medical and psychiatric comorbidity, as well as SES, as important markers of CPAP adherence among older adults in the United States. Future studies should seek to evaluate interventions to improve CPAP adherence among older adults of lower SES.

To investigate whether older Medicare beneficiaries enrolled in Medicare risk health maintenance organizations (HMOs) have different rates of disablement than fee-for-service (FFS) beneficiaries. Secondary analysis of annual functional status transitions using the Medicare Current Beneficiary Survey, 1991 to 1996. Telephone interviews. Forty-four thousand seven hundred and sixty-five person-years of annual functional status transitions for noninstitutionalized older Medicare beneficiaries who were either risk HMO enrollees or FFS beneficiaries with or without private supplementary insurance. Five multinomial logit models were estimated as single-state transition models, with five functional states, death, and censored as outcomes. The probability of being in a certain functional state the following year was specified as a function of individual risk factors and HMO versus FFS supplementary insurance status. Among functionally independent beneficiaries, the odds of becoming disabled in activities of daily living (ADLs) within a year were lower among FFS individuals with supplementary insurance (odds ratios (OR) = 0.67, P <.01) and HMO enrollees (OR = 0.58, P <.01). Among older people who were functionally impaired, neither HMO enrollment nor private supplementary insurance affected the risk of further functional decline or functional improvement. Supplementary insurance, but not HMO enrollment, was associated with lower mortality risk among beneficiaries with functional limitations (OR = 0.65, P <.05) or moderate ADL disability (OR = 0.72, P <.05). Medicare risk HMO enrollment and FFS private supplementary insurance convey similar benefits of slowing functional decline and extending life span for nonseverely disabled older people. That no association was found between adverse functional status outcomes and risk HMO enrollment has favorable implications regarding the quality of care of managed care plans.

Complications and Mortality Following CRT-D Versus ICD Implants in Older Medicare Beneficiaries With Heart Failure

BackgroundDiabetes self-management education (DSME) has significant clinical benefits on diabetic glycemic control and reduction in the onset of complications. However, the economic benefits of DSME in older Medicare beneficiaries are not well known. The objective of this study is to examine the effect of DSME on different types of costs in older Medicare beneficiaries with diabetes.MethodsThis was a pooled cross-sectional study using the Medicare Current Beneficiary Survey (MCBS). The use of DSME was reported by survey respondents. Economic outcomes included total medical costs, total diabetes-related medical costs, total prescription costs, and total anti-diabetic prescription costs were measured based on Medicare claims and prescription drug events data from the perspective of the Medicare system. All costs were adjusted to 2012 U.S. dollars using the Consumer Price Index (CPI). Generalized linear models, with a log link and gamma distribution, were used to examine the effect of DSME on different costs.ResultsA total of 3,003 older Medicare beneficiaries with diabetes were included, among whom 35.50% (n = 1,066) had DSME. Individuals who did not have DSME had significantly higher total prescription costs than those who had DSME ($4,398.19 vs. $3,966.82, P =.0134). After adjusting for covariates, compared to those who did not have DSME, those who had DSME had 16.36% (95% CI: 9.69% to 22.54%) lower total medical costs and 12.83% (95% CI: 6.41% to 18.80%) lower total prescription costs.ConclusionThis study found that DSME is associated with significantly lower spending in total medical and prescription costs for older Medicare beneficiaries. Given the economic benefits associated with DSME, different healthcare providers should further promote and increase the awareness of DSME to ensure sustained activities, enrollment, and patient retention in older Medicare beneficiaries with diabetes.

BackgroundThe burden of spinal pain can be aggravated by the hazards of opioid analgesics, which are still widely prescribed for spinal pain despite evidence-based clinical guidelines that identify non-pharmacological therapies as the preferred first-line approach. Previous studies have found that chiropractic care is associated with decreased use of opioids, but have not focused on older Medicare beneficiaries, a vulnerable population with high rates of co-morbidity and polypharmacy. The purpose of this investigation was to evaluate the association between chiropractic utilization and use of prescription opioids among older adults with spinal pain.MethodsWe conducted a retrospective observational study in which we examined a nationally representative multi-year sample of Medicare claims data, 2012–2016. The study sample included 55,949 Medicare beneficiaries diagnosed with spinal pain, of whom 9,356 were recipients of chiropractic care and 46,593 were non-recipients. We measured the adjusted risk of filling a prescription for an opioid analgesic for up to 365 days following diagnosis of spinal pain. Using Cox proportional hazards modeling and inverse weighted propensity scoring to account for selection bias, we compared recipients of both primary care and chiropractic to recipients of primary care alone regarding the risk of filling a prescription.ResultsThe adjusted risk of filling an opioid prescription within 365 days of initial visit was 56% lower among recipients of chiropractic care as compared to non-recipients (hazard ratio 0.44; 95% confidence interval 0.40–0.49).ConclusionsAmong older Medicare beneficiaries with spinal pain, use of chiropractic care is associated with significantly lower risk of filling an opioid prescription.

Long-term acute care (LTAC) hospitals provide extended complex post-acute care to more than 120 000 Medicare beneficiaries annually, with the goal of helping patients to regain independence and recover. Because little is known about patients' long-term outcomes, we sought to examine the clinical course after LTAC admission. Nationally representative 5-year cohort study using 5% Medicare data from 2009 to 2013. LTAC hospitals. Hospitalized Medicare fee-for-service beneficiaries 65 years of age or older who were transferred to an LTAC hospital. Mortality, recovery (defined as achieving 60 consecutive days alive without inpatient care), time spent in an inpatient facility following LTAC hospital admission, receipt of an artificial life-prolonging procedure (feeding tube, tracheostomy, hemodialysis), and palliative care physician consultation. Of 14 072 hospitalized older adults transferred to an LTAC hospital, median survival was 8.3 months, and 1- and 5-year survival rates were 45% and 18%, respectively. Following LTAC admission, 53% never achieved a 60-day recovery. The median time of their remaining life a patient spent as an inpatient after LTAC admission was 65.6% (interquartile range = 21.4%-100%). More than one-third (36.9%) died in an inpatient setting, never returning home after the LTAC admission. During the preceding hospitalization and index LTAC admission, 30.9% received an artificial life-prolonging procedure, and 1% had a palliative care physician consultation. Hospitalized older adults transferred to LTAC hospitals have poor survival, spend most of their remaining life as an inpatient, and frequently undergo life-prolonging procedures. This prognostic understanding is essential to inform goals of care discussions and prioritize healthcare needs for hospitalized older adults admitted to LTAC hospitals. Given the exceedingly low rates of palliative care consultations, future research is needed to examine unmet palliative care needs in this population. J Am Geriatr Soc 67:2282-2288, 2019.

To examine the effect of untreated obstructive sleep apnea (OSA) on health care utilization (HCU) and costs among a nationally representative sample of Medicare beneficiaries. Our data source was a random 5% sample of Medicare administrative claims data for years 2006-2013. OSA was operationalized as (1) receipt of one or more International Classification of Disease, Version 9, Clinical Modification diagnostic codes for OSA in combination with (2) initiation of OSA treatment with either continuous positive airway pressure or oral appliance (OA) therapy. First, HCU and costs were assessed during the 12 months prior to treatment initiation. Next, these HCU and costs were compared between beneficiaries with OSA and matched control patients without sleep-disordered breathing using generalized linear models. The final sample (n = 287,191) included 10,317 beneficiaries with OSA and 276,874 control patients. In fully adjusted models, during the year prior to OSA diagnosis and relative to matched control patients, beneficiaries with OSA demonstrated increased HCU and higher mean total annual costs ($19,566, 95% confidence interval [CI] $13,239, $25,894) as well as higher mean annual costs across all individual points of service. Inpatient care was associated with the highest incremental costs (ie, greater than control patients; $15,482, 95% CI $8,521, $22,443) and prescriptions were associated with the lowest incremental costs (ie, greater than control patients; $431, 95% CI $339, $522). In this randomly selected and nationally representative sample of Medicare beneficiaries and relative to matched control patients, individuals with untreated OSA demonstrated increased HCU and costs across all points of service.

Geographic disparities in health and health care are increasingly well-documented, as are financial barriers to accessing care. Still, less is known about whether Medicare beneficiaries differ in their ability to pay for care by rurality. Using data from the 2016 Medicare Current Beneficiary Survey (n = 12,688 U.S. community-dwelling beneficiaries), we analyzed rural-urban differences in rates of collection agency contact for unpaid medical bills using chi-square tests and multivariable logistic regression for the full sample and by age (65+ and <65). Nearly 10% of Medicare beneficiaries had been contacted by a collection agency for medical debt in the previous year, with higher percentages among rural beneficiaries (8% for urban vs 10% for rural micropolitan and 11% for rural noncore, p < .05). This difference attenuated after adjusting for educational attainment and income, suggesting that attention to socio-economic status among rural Medicare beneficiaries would help to address financial barriers to care and decrease medical debt.

Access to prescription drugs is a critical issue for adults 65 and older, almost 90% of whom take at least one medication to manage their health. About one in four Medicare beneficiaries has difficulty affording prescription drugs, resulting in delayed and unfilled prescriptions, and the cost burden is higher among non-Hispanic Black and Latino/a adults. We used nationally representative data to evaluate how differences in socioeconomic resources, access to care, health care need, and the use of cost-saving strategies contributed to long-standing racial and ethnic inequalities in prescription cost burden among older Medicare beneficiaries. We used logistic regressions and the Karlson-Holm-Breen decomposition method to quantify the degrees to which each factor accounted for the heightened cost burden among non-Hispanic Black and Latino/a beneficiaries compared to non-Hispanic White beneficiaries. Non-Hispanic White beneficiaries had lower odds of cost burden and higher odds of engaging in cost-saving strategies compared to marginalized groups. Even after controlling for socioeconomic, insurance, and health characteristics, non-Hispanic Black beneficiaries were more likely to experience prescription drug cost burden, and Hispanic or Latino/a beneficiaries were less likely to use cost-saving strategies compared to non-Hispanic White beneficiaries. Socioeconomic inequalities accounted for a large share of the greater cost burden experienced by older non-Hispanic Black and Hispanic/Latino adults. Notably, Hispanic/Latino beneficiaries' lower use of cost-saving strategies was a significant driver of their greater cost burden. Our study highlights how Medicare, a near-universal insurance system for older Americans, still reproduces systemic inequities and threatens the health and financial well-being of many.

To determine whether area-level Medicare physician fees for mastectomy and breast conserving surgery were associated with treatment received by Medicare beneficiaries with localized breast cancer and to compare these results with an earlier analysis conducted using small areas (three-digit zip codes) as the unit of observation. Medicare claims and physician survey data for a national sample of elderly (aged 67 or older) Medicare beneficiaries with localized breast cancer treated in 1994 (unweighted n = 1,787). Multinomial logistic regression analysis was used to estimate a model of treatment received as a function of Medicare fees, controlling for other area economic factors, patient demographic and clinical characteristics, physician experience, and region. In 1994, average Medicare fees (adjusted for the effects of modifiers and procedure mix) for mastectomy (MST) and breast conserving surgery (BCS) were 904 dollars and 305 dollars, respectively. Holding other fees and factors fixed, a 10 percent increase in the BCS fee increased the odds of breast conserving surgery with radiation therapy relative to mastectomy to 1.34 (p = 0.02), while a 10 percent decrease in the MST fee increased the odds of breast conserving surgery with radiation therapy to 1.86 (p < 0.01). Among older women with localized breast cancer, financial incentives appear to influence the use of mastectomy and breast conserving surgery with radiation therapy. This finding is consistent with the hypothesis that physicians are responsive to financial incentives when the alternative procedures have clinically equivalent outcomes and the patient's clinical condition does not dominate the treatment choice. We also find that the fee effects derived from this analysis of individual data with more precise measurement of both diagnosis and treatment are qualitatively similar to the results of the small-area analysis. This suggests that the earlier study was not severely affected by ecological bias or other data limitations inherent in Medicare claims data.

Inequalities in Treatment Utilization Among Older Medicare Beneficiaries with Newly Diagnosed Acute Myeloid Leukemia Who Are Ineligible for Induction Therapy

BackgroundDespite the rising number of older adults with medical encounters for opioid misuse, dependence, and poisoning, little is known about patterns of prescription opioid dose and their association with risk for opioid-related adverse events (ORAEs) in older patients. The study aims to compare trajectories of prescribed opioid doses in 6 months preceding an incident ORAE for cases and a matched control group of older patients with chronic noncancer pain (CNCP).Methods and findingsWe conducted a nested case–control study within a cohort of older (≥65 years) patients diagnosed with CNCP who were new users of prescription opioids, assembled using a 5% national random sample of Medicare beneficiaries from 2011 to 2018. From the cohort with a mean follow-up of 2.3 years, we identified 3,103 incident ORAE cases with ≥1 opioid prescription in 6 months preceding the event, and 3,103 controls matched on sex, age, and time since opioid initiation. Key exposure was trajectories of prescribed opioid morphine milligram equivalent (MME) daily dosage over 6 months before the incident ORAE or matched controls. Among the cases and controls, 2,192 (70.6%) were women, and the mean (SD) age was 77.1 (7.1) years. Four prescribed opioid trajectories before the incident ORAE diagnosis or matched date emerged: gradual dose discontinuation (from ≤3 to 0 daily MME, 1,456 [23.5%]), gradual dose increase (from 0 to >3 daily MME, 1,878 [30.3%]), consistent low dose (between 3 and 5 daily MME, 1,510 [24.3%]), and consistent moderate dose (>20 daily MME, 1,362 [22.0%]). Few older patients (<5%) were prescribed a mean daily dose of ≥90 daily MME during 6 months before diagnosis or matched date. Patients with gradual dose discontinuation versus those with a consistent low dose, moderate dose, and increase dose were more likely to be younger (65 to 74 years), Midwest US residents, and receiving no low-income subsidy. Compared to patients with gradual dose discontinuation, those with gradual dose increase (adjusted odds ratio [aOR] = 3.4; 95% confidence interval (CI) 2.8 to 4.0; P < 0.001), consistent low dose (aOR = 3.8; 95% CI 3.2 to 4.6; P < 0.001), and consistent moderate dose (aOR = 8.5; 95% CI 6.8 to 10.7; P < 0.001) had a higher risk of ORAE, after adjustment for covariates. Our main findings remained robust in the sensitivity analysis using a cohort study with inverse probability of treatment weighting analyses. Major limitations include the limited generalizability of the study findings and lack of information on illicit opioid use, which prevents understanding the clinical dose threshold level that increases the risk of ORAE in older adults.ConclusionsIn this sample of older patients who are Medicare beneficiaries, 4 prescription opioid dose trajectories were identified, with most prescribed doses below 90 daily MME within 6 months before ORAE or matched date. An increased risk for ORAE was observed among older patients with a gradual increase in dose or among those with a consistent low-to-moderate dose of prescribed opioids when compared to patients with opioid dose discontinuation. Whether older patients are susceptible to low opioid doses warrants further investigations.

Underserved older adults face increased risk for certain chronic conditions and multimorbidity, yet research on healthcare spending and utilization in these groups is limited. For example, there is a glaring absence of research on sexual and gender minority (SGM) Medicare beneficiaries. To address this gap, this study uses linked data from Aging with Pride: National Health, Aging and Sexuality/Gender Study (NHAS) and CMS Chronic Conditions Warehouse data (n = 902) to examine chronic conditions, healthcare spending and utilization among a diverse sample of SGM older adult Medicare beneficiaries. Chronic condition complexity was identified using the Medicare Chronic Conditions/Other Chronic Conditions files. Additional explanatory variables included adverse experiences, psychological and social resources, health-related indicators, socioeconomic factors, and background characteristics. The Cost and Use file was used to calculate four outcome variables: total Medicare spending, spending on physician services, high-cost beneficiary status, and healthcare utilization. A series of linear and logistic regressions were used to estimate the association between explanatory and outcome variables. SGM older adult participants with the greatest severity and complexity of chronic conditions had significantly higher total Medicare spending, spending on physician services, and were more likely to be a high-cost beneficiary and higher use of healthcare services compared to those who were comparatively healthy. We also find strong evidence linking higher Medicare spending to disability and dual eligibility, highlighting an urgent need for research given SGM older adults' increased risk for disabling chronic conditions, yet at times lower healthcare utilization. Higher day-to-day discrimination was associated with greater likelihood of chronic condition complexity and lower Medicare spending. Understanding the relationship between chronic health conditions and healthcare cost and utilization is a critical step in developing responsive health services and effective interventions to promote healthy aging in our increasingly diverse yet often underserved communities.

Objective Comorbid depression among patients with diabetes is associated with an increased disease burden, healthcare utilization and adverse outcomes. However, little is known about how comorbid depression in older adults with diabetes affects diabetes treatment success. This study investigates the association between comorbid depression, diabetes-related self-care behaviors and blood glucose control among older Medicare beneficiaries with type 2 diabetes. Methods This pooled cross-sectional study used the Medicare Current Beneficiary Survey (MCBS) data for years 2006, 2008 and 2010. Depression was categorized into mild/episodic and moderate/severe. We defined levels of treatment success based on gradients of blood glucose control: all the time to little/none of the time. We used ordered-logit regression models for analyses. Key findings Among the study population of older Medicare beneficiaries with diabetes (n = 2418), 6.2% had episodic/mild depression and 7.9% had moderate/severe depression. Low frequency of performing self-check for blood glucose or sores on feet was not associated with either mild/episodic depression (OR = 0.92; 95% CI, 0.64 to 1.33)/(OR = 0.98; CI, 0.69 to 1.39) or moderate/severe depression (OR = 1.18; 95% CI, 0.83 to 1.66)/(OR = 0.98; 95% CI, 0.7 to 1.4) respectively. Patients with mild/episodic depression were more likely to reach blood glucose control little/none of the time, as compared to those with no comorbid depression (OR = 1.62; 95% CI, 1.17 to 2.26). Conclusions Comorbid mild/episodic depression is associated with low treatment success among older Medicare beneficiaries with diabetes; however, neither levels of comorbid depression are associated with regularity in performing self-care behavior.