The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease.

Background: In 2014, the Affordable Care Act Medicaid Expansion (ME) increased Medicaid eligibility for adults with an income level up to 138% of the federal poverty level. In this study, we examined the impact of ME on mortality and amputation in patients with peripheral artery disease (PAD). Methods: The 100% MedPAR and Part-B Carrier files from 2011 to 2018 were queried to identify all fee-for-service Medicare beneficiaries with PAD using International Classification of Diseases codes. Our primary exposure was whether a state had adopted the ME on January 1, 2014. Our primary outcomes were the change in all-cause 1-year mortality and leg amputation. We used a state-level difference-in-differences (DID) analysis to compare the rates of the primary outcomes among patients who were in states (including the District of Columbia) who adopted ME (n = 25) versus those who were in states that did not (n = 26). We performed a subanalysis stratifying by sex, race, region, and dual-eligibility status. Results: Over the 8-year period, we studied 37,743,929 patients. The average unadjusted 1-year mortality decreased from 2011 to 2018 in both non-ME (9.5% to 8.7%, p < 0.001) and ME (9.1% to 8.3%, p < 0.001) states. The average unadjusted 1-year amputation rate did not improve in either the non-ME (0.86% to 0.87%, p = 0.17) or ME (0.69% to 0.69%, p = 0.65) states. Across the entire cohort, the DID model revealed that ME did not lead to a significant change in mortality (p = 0.15) or amputation (p = 0.34). Conclusion: Medicaid Expansion was not associated with reduced mortality or leg amputation in Medicare beneficiaries with PAD.

IV Diuresis in Alternative Treatment Settings for the Management of Heart Failure: Implications for Mortality, Hospitalizations and Cost.

BACKGROUND: Recent advances in heart failure (HF) care have sought to shift management from inpatient to outpatient and observation settings. We evaluated the association among HF treatment in the (1) inpatient; (2) observation; (3) emergency department (ED); and (4) outpatient settings with 30-day mortality, hospitalizations and cost. METHODS: Using 100% Medicare inpatient, outpatient and Part B files from 2011-2018, 1,534,708 unique patient encounters in which intravenous (IV) diuretics were received for a primary diagnosis of HF were identified. Encounters were sorted into mutually exclusive settings: (1) inpatient; (2) observation; (3) ED; or (4) outpatient IV diuretic clinic. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 30-day hospitalization and total 30-day costs. Multivariable logistic and linear regression were used to examine the association between treatment location and the primary and secondary outcomes. RESULTS: Patients treated in observation and outpatient settings had lower 30-day mortality rates (observation OR 0.67, 95% CI 0.66-0.69; P < 0.001; outpatient OR 0.53, 95% CI 0.51-0.55; P < 0.001) compared to those treated in inpatient settings. Observation and outpatient treatment were also associated with decreased 30-day total cost compared to inpatient treatment. Observation relative cost -$5528.77, 95% CI -$5613.63 to -$5443.92; outpatient relative cost -$7005.95; 95% CI -$7103.94 to -$6907.96). Patients treated in the emergency department and discharged had increased mortality rates (OR 1.15, 95% CI 1.13-1.17; P < 0.001) and increased rates of hospitalization (OR 1.72, 95% CI 1.70-1.73; P < 0.001) compared to patients treated as inpatients. CONCLUSIONS: Medicare beneficiaries who received IV diuresis for acute HF in the outpatient and observation settings had lower mortality rates and decreased costs of care compared to patients treated as inpatients. Outpatient and observation management of acute decompensated HF, when available, is a safe and cost-effective strategy in certain populations of patients with HF.

Factors associated with the quality of patients' surgical decisions for treatment of hip and knee osteoarthritis.

BACKGROUND: Shared decision making requires informing patients and ensuring that treatment decisions reflect their goals. It is not clear to what extent this happens for patients considering total joint replacement (TJR) for hip or knee osteoarthritis. STUDY DESIGN: We conducted a cross-sectional mail survey of osteoarthritis patients at 4 sites, who made a decision about TJR. The survey measured knowledge and goals, the decision making process, decision confidence, and decision regret. Decision quality was defined as the percentage of patients who had high knowledge scores and received treatments that matched their goals. Multivariable regression models examined factors associated with knowledge and decision quality. RESULTS: There were 382 patients who participated (78.6% response rate). Mean knowledge score was 61% (SD 20.7%). In multivariate linear regression, higher education, having TJR, and site were associated with higher knowledge. Many patients (73%) received treatments that matched their goals. Thirty-one percent of patients met our definition for high decision quality. Higher decision making process scores, higher quality of life scores, and site were associated with higher decision quality. Patients who had high decision quality had less regret (73.1% vs 58.5%, p = 0.007) and greater confidence (9.0 [SD 1.6] vs 8.2 [SD 2.3] out of 10, p < 0.001). CONCLUSIONS: A third of patients who recently made a decision about osteoarthritis treatment met both criteria for a high quality decision. Controlling for treatment, patients reporting more involvement in the decision making process, higher quality of life, and being seen at a site that uses decision aids were associated with higher decision quality.

Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation.

BACKGROUND: A high quality decision requires that patients who meet clinical criteria for surgery are informed about the options (including non-surgical alternatives) and receive treatments that match their goals. The aim of this study was to evaluate the psychometric properties and clinical sensibility of a patient self report instrument, to measure the quality of decisions about total joint replacement for knee or hip osteoarthritis. METHODS: The performance of the Hip/Knee Osteoarthritis Decision Quality Instrument (HK-DQI) was evaluated in two samples: (1) a cross-sectional mail survey with 489 patients and 77 providers (study 1); and (2) a randomized controlled trial of a patient decision aid with 138 osteoarthritis patients considering total joint replacement (study 2). The HK-DQI results in two scores. Knowledge items are summed to create a total knowledge score, and a set of goals and concerns are used in a logistic regression model to develop a concordance score. The concordance score measures the proportion of patients whose treatment matched their goals. Hypotheses related to acceptability, feasibility, reliability and validity of the knowledge and concordance scores were examined. RESULTS: In study 1, the HK-DQI was completed by 382 patients (79%) and 45 providers (58%), and in study 2 by 127 patients (92%), with low rates of missing data. The DQI-knowledge score was reproducible (ICC = 0.81) and demonstrated discriminant validity (68% decision aid vs. 54% control, and 78% providers vs. 61% patients) and content validity. The concordance score demonstrated predictive validity, as patients whose treatments were concordant with their goals had more confidence and less regret with their decision compared to those who did not. CONCLUSIONS: The HK-DQI is feasible and acceptable to patients. It can be used to assess whether patients with osteoarthritis are making informed decisions about surgery that are concordant with their goals.

Utility of quantitative computerized pain drawings in a sample of spinal stenosis patients.

OBJECTIVE: To evaluate the utility of quantitative computerized pain drawings (CPDs) in a sample of spine patients before and after surgery. DESIGN: Analysis of changes in quantified CPDs, the Oswestry Disability Index (ODI), the Short Form-36 Health Survey Questionnaire (SF-36), and numerical ratings of pain intensity before and after surgery. SETTING: Private clinic in large metropolitan area. Patients. Forty-six patients with spinal stenosis. Interventions. Surgery for the relief of pain due to spinal stenosis. OUTCOME MEASURES: A total points (TP) score was calculated from the CPD that reflected the total number of pixels filled by the patient, and the percentage of total pain area indicated as aching, stabbing, numbness, pins and needles, burning, and other, were each calculated separately. CPD scores, ODI score, Physical Components Summary (PCS) and Mental Components Summary scores of the SF-36, and pain intensity ratings (0-10 scale) were all recorded before and after surgical intervention. Results. After surgery, patients showed significant improvements in the extent of shaded pain area of the CPD, pain intensity ratings, ODI, and SF-36 PCS scores (paired t-test, P < or = 0.01). Changes in TP scores calculated from the CPDs were significantly correlated (P < or = 0.05) with changes in ODI scores (r = 0.34) and pain intensity ratings (r = 0.37). Changes in the percentage of total pain area covered by specific qualities of pain were not significant. CONCLUSIONS: Results from the present study provide initial support for the use of automated quantified data collected from CPDs to evaluate treatment interventions and to serve the clinician as a record of changes in spatial location, radiation or extent of pain, and the sensory quality of pain when evaluating individual patient needs.

Validation of a preparation for decision making scale.

OBJECTIVE: The Preparation for Decision Making (PrepDM) scale was developed to evaluate decision processes relating to the preparation of patients for decision making and dialoguing with their practitioners. The objective of this study was to evaluate the scale's psychometric properties. METHODS: From July 2005 to March 2006, after viewing a decision aid prescribed during routine clinical care, patients completed a questionnaire including: demographic information, treatment intention, decisional conflict, decision aid acceptability, and the PrepDM scale. RESULTS: Four hundred orthopaedic patients completed the questionnaire. The PrepDM scale showed significant correlation with the informed (r=-0.21, p<0.01) and support (r=-0.13, p=0.01) subscales (DCS); and discriminated significantly between patients who did and did not find the decision aid helpful (p<0.0001). Alpha coefficients for internal consistency ranged from 0.92 to 0.96. The scale is strongly unidimensional (principal components analysis) and Item Response Theory analyses demonstrated that all ten scale items function very well. CONCLUSION: The psychometric properties of the PrepDM scale are very good. PRACTICE IMPLICATIONS: The scale could allow more comprehensive evaluation of interventions designed to prepare patients for shared-decision making encounters regarding complex health care decisions.

Can women with early-stage breast cancer make an informed decision for mastectomy?

PURPOSE: The purpose of this study was to measure the degree to which informed women chose mastectomy, and to reveal their reasons for this choice. PATIENTS AND METHODS: This was a prospective cohort study of patients radiographically and pathologically eligible for either mastectomy or breast-conserving surgery (BCS; n = 125). Participants completed questionnaires at three time points: baseline, after viewing a decision aid, and after a surgical consultation. Questionnaires assessed clinical history, preference for participation in decision making, information comprehension, values, decisional conflict, and preferred treatment. RESULTS: Of 125 participants, 44 (35%) chose mastectomy. Most understood that BCS and mastectomy offer an equivalent survival benefit (98%) and that BCS has a slightly higher local recurrence risk (63%); most accurately identified the magnitude of ipsilateral local recurrence risk (91%). Values assigned to three treatment attributes/outcomes ("remove breast for peace of mind," "avoid radiation," and "keep breast") clearly discriminated between patients choosing mastectomy or BCS. High decisional conflict scores improved after both the decision aid and surgical consultation. CONCLUSION: Although conventional wisdom may view BCS as the preferred treatment, a notable proportion of well informed women choose mastectomy. Whereas prior studies have linked objective factors to treatment choice, this study reveals subjective preferences that underlie decision making. The systematic use of a decision aid before the surgical consultation may help women make informed, values-based decisions, while clearly reducing decisional conflict.