Association between broadband capacity and telehealth utilization among Medicare Fee-for-service beneficiaries during the COVID-19 pandemic.

BACKGROUND: Telehealth is a rapidly growing modality for expanding healthcare access, especially in the post-COVID-19 era. However, telehealth requires high-quality broadband, thus making broadband a social determinant of health. The objective of this study was to evaluate the association between broadband access and telehealth utilization across the United States during the COVID-19 pandemic. METHODS: Using a cross-sectional, ecological study design, we merged county-level data on broadband capacity (Microsoft's Rural Broadband Initiative), telehealth utilization among Medicare Fee-for-Service beneficiaries from January through September 2020 (CareJourney), and county-level socioeconomic characteristics (Area Health Resources Files). Multivariable linear regression was used to estimate the association between broadband capacity, county-level characteristics, and telehealth utilization. RESULTS: Among the 3107 counties, those with the greatest broadband availability (quintile 5) had 47% higher telehealth utilization compared to counties with the least broadband availability (quintile 1). In the adjusted model, a 1 standard deviation (SD) increase in broadband access was associated with a 1.54 percentage point (pp) increase in telehealth utilization (P < 0.001). Rural county designation (-1.96 pp; P < 0.001) and 1 SD increases in average Medicare beneficiary age (-1.34 pp; P = 0.001), number of nursing home beds per 1000 individuals (-0.38 pp; P = 0.002), and proportion of Native Americans/Pacific Islanders (-0.59 pp; P < 0.001) were associated with decreased telehealth utilization. CONCLUSION: The association between broadband access and telehealth utilization and the decreased telehealth utilization in rural areas highlight the importance of broadband access for healthcare access and the need to continue investing in broadband infrastructure to promote equitable healthcare access across populations.

A digital divide in the COVID-19 pandemic: information exchange among older Medicare beneficiaries and stakeholders during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic resulted in unprecedented challenges for older adults. Medicare enrollment was already an overwhelming process for a high fraction of older adults pre-pandemic. Therefore, the purpose of this qualitative study was to gain understanding from community organizations and stakeholders about their pre-pandemic and during-pandemic experiences while adapting to continue offering insurance advice to seniors, what resources are available to seniors, and what needs to be done to help seniors make higher quality insurance choices in the Medicare program. In addition, we wanted to explore how the COVID-19 pandemic may have changed the ways that these stakeholders interacted with Medicare beneficiaries. METHODS: We employed a qualitative strategy to gain a deep understanding of the challenges that these organizations may have faced while offering advice/counseling to older adults. We accomplished this by interviewing a group of 30 stakeholders from different states. RESULTS: Every stakeholder mentioned that some older adults have difficulty making Medicare decisions, and 16 stakeholders mentioned that their system is complex and/or overwhelming for older adults. Twenty-three stakeholders mentioned that Medicare beneficiaries are often confused about Medicare, and this is more noticeable among new enrollees. With the onset of the pandemic, 22 of these organizations mentioned that they had to move to a virtual model in order to assist beneficiaries, especially at the beginning of the pandemic. However, older adults seeking advice/meetings have a strong preference for in-person meetings even during the pandemic. Given that the majority of the beneficiaries that these stakeholders serve may not have access to technology, it was difficult for some of them to smoothly transition to a virtual environment. With Medicare counseling moving to virtual or telephone methods, stakeholders discussed that many beneficiaries had difficulty utilizing these options in a variety of ways. CONCLUSIONS: Findings from our interviews with stakeholders provided information regarding experiences providing Medicare counseling pre- and during-COVID-19 pandemic. Some of the barriers faced by older adults included a complex and overwhelming system, a strong preference for in-person meetings among beneficiaries, challenges with technology, and an increased risk of information overload and misinformation. While bias may exist within the study and sample, given that technology-savvy beneficiaries may not seek help from organizations our study participants work in, they show how the current Medicare system may impact vulnerable older adults who may need support with access to high-speed internet and digital literacy.

ICD-10 anaphylaxis algorithm and the estimate of vaccine-attributable anaphylaxis incidence in Medicare.

BACKGROUND: Anaphylaxis is a rare, serious allergic reaction. Its identification in large healthcare databases can help better characterize this risk. OBJECTIVE: To create an ICD-10 anaphylaxis algorithm, estimate its positive predictive values (PPVs) in a post-vaccination risk window, and estimate vaccination-attributable anaphylaxis rates in the Medicare Fee For Service (FFS) population. METHODS: An anaphylaxis algorithm with core and extended portions was constructed analyzing ICD-10 anaphylaxis claims data in Medicare FFS from 2015 to 2017. Cases of post-vaccination anaphylaxis among Medicare FFS beneficiaries were then identified from October 1, 2015 to February 28, 2019 utilizing vaccine relevant anaphylaxis ICD-10 codes. Information from medical records was used to determine true anaphylaxis cases based on the Brighton Collaboration's anaphylaxis case definition. PPVs were estimated for incident anaphylaxis and the subset of vaccine-attributable anaphylaxis within a 2-day post-vaccination risk window. Vaccine-attributable anaphylaxis rates in Medicare FFS were also estimated. RESULTS: The study recorded 66,572,128 vaccinations among 21,685,119 unique Medicare FFS beneficiaries. The algorithm identified a total of 190 suspected anaphylaxis cases within the 2-day post-vaccination window; of these 117 (62%) satisfied the core algorithm, and 73 (38%) additional cases satisfied the extended algorithm. The core algorithm's PPV was 66% (95% CI [56%, 76%]) for identifying incident anaphylaxis and 44% (95% CI [34%, 56%]) for vaccine-attributable anaphylaxis. The vaccine-attributable anaphylaxis incidence rate after any vaccination was 0.88 per million doses (95% CI [0.67, 1.16]). CONCLUSION: The ICD-10 claims algorithm for anaphylaxis allows the assessment of anaphylaxis risk in real-world data. The algorithm revealed vaccine-attributable anaphylaxis is rare among vaccinated Medicare FFS beneficiaries.