Stearns, Sally C.

AbstractRationaleExisting literature describing differences in survival following percutaneous coronary intervention (PCI) by patient sex, race‐ethnicity and the role of socioeconomic characteristics (SEC) is limited.Aims and ObjectivesEvaluate differences in 1‐year survival after PCI by sex and race‐ethnicity, and explore the contribution of SEC to observed differences.MethodsUsing a 20% sample of Medicare claims data for beneficiaries aged 65+, we identified fee‐for‐service patients who received PCI from 2007 to 2015. We performed logistic regression to assess how sex and race‐ethnicity relate to procedural indication, inpatient versus outpatient setting, and 1‐year mortality. We evaluated whether these relationships are moderated by sequentially controlling for factors including age, comorbidities, presence of acute myocardial infarction (AMI), county SEC, medical resource availability and inpatient versus outpatient procedural status.ResultsWe identified 300,491 PCI procedures, of which 94,863 (31.6%) were outpatient. There was a significant transition to outpatient PCI during the study period, especially for men compared with women and White patients compared with Black patients. Black patients were 3.50 percentage points (p < 0.001) and women were 3.41 percentage points (p < 0.001) more likely than White and male patients to undergo PCI at the time of AMI, which typically occurs in the inpatient setting. Controlling for age and calendar year, Black patients were 2.87 percentage points more likely than non‐Hispanic White patients to die within 1 year after PCI. After controlling for Black–White differences in comorbidities, the differences in 1‐year mortality decreased to 0.95 percentage points, which then became nonsignificant when further controlling for county resources and state of residence.ConclusionWomen were more likely to experience PCI in the setting of AMI and had less transition to outpatient care during the period. Black patients experienced higher 1‐year mortality following PCI, which is explained by differences in baseline comorbidities, county medical resources, and state of residence.

AbstractAimTo examine the impact of socioeconomic status (SES) and postacute care (PAC) locations on the association between hospital safety‐net status and 30‐day postdischarge outcomes (readmission, hospice use, or death).MethodMedicare Current Beneficiary Survey (MCBS) participants during 2006–2011 who were Medicare Fee‐for‐Service beneficiaries aged 65.5 years or older were included. The associations between hospital safety‐net status and 30‐day post‐discharge outcomes were evaluated by comparing the models with and without PAC and SES adjustments. Safety‐net hospital status was defined as being in the top 20% of hospitals ranked by hospital‐level percent of total Medicare patient days. SES was measured using individual‐level SES (dual eligibility, income, and education) and the Area Deprivation Index (ADI).ResultsThis study identified 13,173 index hospitalizations for 6,825 patients; 1,428 hospitalizations (11.8%) were in safety‐net hospitals. The average unadjusted 30‐day hospital readmission rate was 22.6% in safety‐net hospitals versus 18.8% in nonsafety‐net hospitals. Regardless of whether patient SES status was controlled or not, safety‐net hospitals had higher estimated probabilities of 30‐day readmission (ranging from 0.217 to 0.222 vs. 0.184 to 0.189), and lower probabilities for having neither readmission nor hospice/death (0.750–0.763 vs. 0.780–0.785); for models additionally adjusted for PAC types, safety‐net patients had lower rates of hospice use or death (0.019–0.027 vs. 0.030–0.031).ConclusionsThe results suggested that safety‐net hospitals had lower hospice/death rates but higher readmission rates relative to outcomes at nonsafety‐net hospitals. Readmission rate differences were similar regardless of patients' SES status. However, the rate of hospice referral or death rate was related to SES, which suggested that the outcomes were affected by SES and PAC types.

AbstractObjectivesTo assess and compare the associations between socioeconomic status (SES) measures from two sources (claims vs. survey data) and the type of post‐acute care (PAC) locations following hospital discharge.MethodsThis observational study included Medicare Fee‐for‐Service (FFS) beneficiaries age 65.5 years or older who participated in the Medicare Current Beneficiary Survey (MCBS) and were hospitalized in 2006–2011. Multiple data sets were used including: Area Deprivation Index; Medicare Cost Reports, Provider of Services files, and Area Health Resource File. Multinomial regression models estimated associations between beneficiary's SES and PAC type. SES measures came from surveys (income and education) and administrative records (dual enrollment and area deprivation). PAC types included home with self‐care, home health agency, skilled nursing facility (SNF), or inpatient rehabilitation facility.ResultsLow income and dual enrollment were associated with higher SNF use while living in a deprived area was associated with lower SNF use and higher use of home with self‐care. Dual enrollment and area deprivation were associated with the largest differences.ConclusionsIf policies to modify payment based on SES are considered, administrative measures (dual enrollment and area deprivation) rather than survey measures (education and income) may be sufficient.

Background: Atrial fibrillation (AF) is associated with increased risk of hospitalization. However, little is known about the impact of AF on non-inpatient healthcare utilization or about sex or race differences in AF-related utilization. We examined rates of inpatient and outpatient utilization by AF status in the Atherosclerosis Risk in Communities (ARIC) study. Methods and Results: ARIC cohort participants with incident AF enrolled in fee-for-service Medicare, Parts A and B, for at least 12 continuous months between 1991 and 2009 were matched on age, sex, race and center to up to three participants without AF. Healthcare utilization was ascertained from inpatient and outpatient Medicare claims and classified based on primary ICD-9 code. The analysis included 944 AF and 2,761 non-AF participants. The average number of days hospitalized per year was 13.1 (95% confidence interval [CI]: 11.5-15.0) and 2.8 (95% CI: 2.5-3.1) for those with and without AF, respectively. The corresponding number of outpatient claims per year was 53.2 (95% CI: 50.4-56.1) and 23.0 (95% CI: 22.2-23.8) for those with and without AF, respectively (Table). Most utilization in AF patients was attributable to non-AF conditions, particularly other-cardiovascular disease (CVD)-related reasons; the adjusted rate ratio for days hospitalized per year for other-CVD-related reasons was 4.76 (95% CI: 3.51 - 6.44) for those with compared to those without AF. There was suggestive evidence that sex modified the association between AF and inpatient utilization, with AF related to greater utilization in women than men. The association between AF and healthcare utilization was similar in whites and blacks. Conclusions: This study highlights the considerably greater healthcare utilization (inpatient and outpatient) among those with AF; the differential in utilization due to other-CVD-related reasons was substantial. In addition to recommended heart rate or rhythm treatment, accompanying cardiovascular comorbidities should be evaluated and managed.

AbstractBackgroundObservational analyses comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) among elderly or frail patients are likely biased by treatment selection. PCI is typically chosen for frail patients, while CABG is more common for patients with good recovery potential.HypothesisWe hypothesized that skilled nursing facility (SNF) use after revascularization is a measure of relative frailty associated with outcomes following coronary revascularization.MethodsWe used a 20 percent sample of Medicare beneficiaries aged 65 years or older who received inpatient PCI or CABG between 2007–2014. Key explanatory variables were the revascularization strategy and SNF use after revascularization. We used Cox regression to evaluate death and repeat revascularization within one year and logistic regression to evaluate SNF use and 30‐day readmissions/death.ResultsCABG patients were 25.1 percentage points [95% confidence interval: 24.7, 25.5] more likely to use SNF following revascularization than inpatient PCI patients. SNF use was associated with a higher death rate (hazard ratio (HR): 3.19 [3.02, 3.37]) and a 16.2 percentage point (15.5, 16.9) increase in 30‐day readmissions/death. Among patients with SNF use, CABG was associated with a decrease in 30‐day readmissions/death compared to PCI.ConclusionsWhile CABG was associated with higher rates of SNF use and 30‐day readmission/death overall, CABG was associated with significantly lower rates of 30‐day readmissions/death among patients with SNF use. The findings suggest that caution is needed in treatment selection for patients at high‐risk for SNF use and that selection of inpatient PCI over CABG may be associated with frailty and worse outcomes for some patients.

OBJECTIVES Administrative records such as Medicare fee‐for‐service (FFS) claims provide accurate information on services paid for by Medicare. However, the increasing availability of electronic health records means many researchers may be inclined to rely on data coded in hospital information systems rather than claims. The current quality and accuracy of hospital reports on the use of post‐acute care (PAC) services are not known. DESIGN This study examined differences in the PAC use between hospital discharge status recorded on Medicare Provider and Analysis Review inpatient hospital records and claims for PAC services. SETTING In addition to assessments of the three types of Medicare‐reimbursed PAC (home health agency [HHA], skilled nursing facility [SNF], and inpatient rehabilitation facility [IRF]), the analysis also considered home without PAC services as a default discharge location. PARTICIPANTS The analysis was conducted using data for FFS beneficiaries who participated in the Medicare Current Beneficiary Survey and had one or more inpatient hospitalizations from 2006 to 2011. MEASUREMENTS This study measured discrepancies between hospital‐reported discharges to PAC and PAC use based on Medicare claims. RESULTS The study found that, on average, 27.9% of hospital reports of discharging to Medicare‐covered PAC services were not substantiated by Medicare PAC claims. Among all the discharge pathways, discharging to HHAs had the highest discrepancy rate (29.6%), followed by IRFs (14.7%) and SNFs (13.8%). CONCLUSION The study results call for cautions about the extent to which the reported discharge locations on hospital claims may differ from actual PAC services used. Assuming that Medicare FFS claims were complete and accurate, researchers using the discharge status reported on Medicare hospital claims should be aware of possible measurement errors when using hospital‐reported discharge locations. J Am Geriatr Soc 68:847–851, 2020

Background Atrial fibrillation ( AF ) is associated with increased risk of hospitalization. Little is known about the impact of AF on utilization of noninpatient health care or about sex or race differences in AF ‐related utilization. We examined rates of inpatient and outpatient utilization by AF status in the Atherosclerosis Risk in Communities study. Methods and Results Participants with incident AF enrolled in fee‐for‐service Medicare for at least 12 continuous months between 1991 and 2009 (n=932) were matched on age, sex, race and field center with up to 3 participants without AF (n=2729). Healthcare utilization was ascertained from Medicare claims and classified by primary International Classification of Diseases, ninth revision code. The average annual numbers of days hospitalized were 13.2 (95% CI 11.6 to 15.0) and 2.8 (95% CI 2.5 to 3.1) for those with and without AF , respectively. The corresponding numbers of annual outpatient claims were 53.3 (95% CI 50.5 to 56.3) and 22.9 (95% CI 22.1 to 23.8) for those with and without AF , respectively. Most utilization among AF patients was attributable to non‐ AF conditions. The adjusted rate ratio for annual days hospitalized for other cardiovascular disease–related reasons was 4.58 (95% CI : 3.41 to 6.16) for those with AF versus those without AF . The association between AF and healthcare utilization was similar among men and women and among white and black participants. Conclusions Participants with AF had considerably greater healthcare utilization, and the difference in utilization for other cardiovascular disease –related reasons was substantial. In addition to rate or rhythm treatment, AF management should focus on the accompanying cardiovascular comorbidities.