Inpatient-outpatient transitions for patients with resident primary care physicians: access and readmission.

BACKGROUND: Transition from hospitalization to postdischarge care is a vulnerable period for patients. How the experience of this transition differs for patients with resident primary care physicians is unknown. METHODS: In a single, large academic primary care practice, we examined an inception cohort of consecutive hospitalizations and postdischarge visits of hospitalized patients with resident or faculty primary care physicians between 2008 and 2013. We compared patient demographics, readmission risk, and access to outpatient care between resident and faculty primary care physicians by using generalized estimating equations to account for repeated hospitalizations. RESULTS: We documented 8161 hospitalizations among patients with resident primary care physicians and 20,844 hospitalizations among patients with faculty primary care physicians. Hospitalized patients with resident primary care physicians were generally younger, more likely to be on Medicaid, and more likely to be African American (P < .001). Patients with resident primary care physicians were less likely to be seen within 7 and 30 days of discharge (adjusted relative risk, 0.83; 95% confidence interval [CI], 0.81-0.93 at 7 days; adjusted relative risk, 0.88; 95% CI, 0.85-0.92 at 30 days) and had an increased risk of readmission within 30 days (adjusted odds ratio, 1.25; 95% CI, 1.13-1.37). They also were considerably less likely to see their own provider at first follow-up (relative risk, 0.55; 95% CI, 0.52-0.59). CONCLUSIONS: Hospitalized patients with resident primary care physicians had lower rates of timely postdischarge follow-up, higher rates of readmission, and a lower likelihood of seeing their own provider than did patients with faculty primary care physicians. These findings highlight the challenges facing academic centers for patients with resident primary care physicians.

Skeletal-related events and mortality among older men with advanced prostate cancer.

OBJECTIVE: Skeletal-related events (SREs) are defined as a cluster of events including clinical diagnoses and treatment. Using claims data, the burden of SREs as a group has been reported among patients with cancer. We investigate the mortality impact of subcomponents of SREs, a topic that has received limited attention among older men. MATERIALS AND METHODS: We analyzed prostate cancer (PCa) and all-cause mortality among men diagnosed with metastatic PCa from 2000 to 2007 using Surveillance, Epidemiology, and End Results data linked with 1999-2009 Medicare data. We created three measures of pathological fracture (PF), spinal cord compression (SCC), and bone surgery (BS) that differed in the use of claims-based bone metastasis information. We reported covariate-adjusted hazard ratios (HRs) using the full sample and a propensity score-matched sample (PSMS). RESULTS: Application of inclusion/exclusion criteria resulted in 7062 men in the full sample (1776 in the PSMS). PCa-specific (all-cause mortality) was 54% (80%) at a median follow-up of 609days. SRE prevalence ranged from 9.7% to 17.1% across the measures. In a PCa mortality model, the HR associated with an SRE ranged from 1.07 (0.98-1.16) to 1.31 (1.18-1.45). The HRs for SCC and PF were statistically significant and positively associated with PCa-specific mortality. The results for BS depended on the measure. Results for SCC and BS, but not for PF, were preserved using a PSMS. CONCLUSIONS: The relationship between SREs and mortality among older men with metastatic PCa was driven by SCC and depended on the definition used to measure SREs.

The characteristics and impact of a hospitalist-staffed post-discharge clinic.

BACKGROUND: Limited primary care access and care discontinuities hamper care for patients following hospital discharge. As the proportion of inpatient care delivered by hospitalists continues to increase, hybrid models that incorporate hospitalists in post-discharge care may ameliorate this problem. METHODS: We established a post-discharge clinic staffed by hospitalists in a large academic urban primary care practice in October 2009. We compared visits of recently hospitalized patients seen in the post-discharge clinic with post-discharge visits elsewhere in the practice, including patient demographics, health care utilization, and duration from discharge, using generalized estimating equations to account for repeated hospitalizations. RESULTS: Patients seen in the post-discharge clinic and elsewhere in the practice were generally similar, although patients seen in the post-discharge clinic were particularly likely to be black and receive primary care from residents. Relative to other patients seen following discharge, patients in the post-discharge clinic were seen 8.45 ± 0.43 days earlier (P <.001). Among all 10,845 discharges of Healthcare Associates patients between 2009 and 2011, patients were 40% more likely to be seen within a week of discharge when the post-discharge clinic was open than when it was closed (adjusted odds ratio 1.41; 95% confidence interval, 1.25-1.57). CONCLUSION: In this primary care practice, a hospitalist-staffed post-discharge clinic was associated with substantially shorter time to first post-hospitalization visit and with improvement in the overall likelihood of an early visit among all hospitalized patients. It was particularly used by black patients and those seen by residents, in whom access tends to be most fragmented, and may represent a novel approach to the problem of post-discharge care.

Lenalidomide performance in the real world: patterns of use and effectiveness in a Medicare population with myelodysplastic syndromes.

BACKGROUND: Lenalidomide is approved for the treatment of anemia with transfusion dependence (TD) in patients with lower-risk myelodysplastic syndrome (MDS) with 5q deletion (del5q-MDS), but its "real-life" use and effect on transfusion needs are unclear. In the current study, the authors examined its use in the Medicare population. METHODS: Patients with MDS who were enrolled in Medicare Parts A, B, and D were identified using International Classification of Diseases 9-Clinical Modification (ICD-9) codes from 100% Medicare claims from 2006 through 2008. Patients were followed until the end of the study or death. Claims were used to determine time to initiation of lenalidomide, daily dose, duration, and other MDS therapies. Transfusion status was defined each week based on transfusion use in rolling 8-week period: TD, required transfusions during 2 weeks, separated by ≥ 3 weeks; transfusion user (TU), 1 transfusion; and transfusion independence (TI), no transfusions. RESULTS: A total of 753 of 23,855 patients (3.2%) received lenalidomide, including 31% of 470 patients with del5q-MDS. At the time of lenalidomide initiation, 33% of patients were TD, 31% were TU, and 36% were TI. The median time to lenalidomide initiation was shorter for patients with del5q-MDS than for other lower-risk patients (8 weeks vs 20 weeks; P < .01). The percentage of patients with del5q-MDS receiving lenalidomide increased over time. Lenalidomide initiation was found to be negatively associated with older age and baseline diabetes, stroke, and renal disease. During the observation period, 44% of TU/TD patients (53% of the patients with del5q-MDS) achieved reductions in transfusion use; among TD patients receiving ≥ 3 cycles, 77% reduced their transfusion use and 40% achieved TI. CONCLUSIONS: To the authors' knowledge, the current study is the first report of lenalidomide use in a large Medicare-enrolled population with MDS. Reductions in transfusion rates were overall consistent with data from clinical trials. Response rates were higher when ≥ 3 lenalidomide cycles were received.

Prevalence of thyrotoxicosis, antithyroid medication use, and complications among pregnant women in the United States.

BACKGROUND: Population-based estimates of the prevalence of thyrotoxicosis (TTX), the frequency of antithyroid drug (ATD) use, and risk of adverse events in pregnant women and their infants are lacking. Therefore, our objective was to obtain epidemiologic estimates of these parameters within a large population-based sample of pregnant women with TTX. METHODS: A retrospective claims analysis was performed from the MarketScan Commercial Claims and Encounters health insurance database for the period 2005-2009. Women aged 15-44 years, enrolled for at least 2 years, and who had a pregnancy during the study period were included. Diagnosis of TTX was based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes using narrow (TTX-1=ICD 242.0) and broad (TTX-2=ICD 242.0 or 242.9) definitions. ATD use was based on prescriptions filled for propylthiouracil (PTU) or methimazole (MMI). Adverse events in mothers and infants were determined from the ICD-9-CM diagnosis codes recorded on submitted claims. RESULTS: The database contained 904,497 eligible women. The average yearly prevalence per 1000 pregnant women was 2.46 for TTX-1 and 5.88 for TTX-2. Thirty-nine percent used ATD at any time during the study period. Compared to women without a TTX diagnosis, there was more than a twofold increase for liver disease among women with TTX (odds ratio [OR]=2.08, p<0.001) and a 13% increased risk for congenital anomalies (OR=1.13, p=0.014), but no association was observed with ATD use. The rates of congenital defects (per 1000 infants) associated with ATD use were 55.6 for MMI, 72.1 for PTU, and 65.8 for untreated women with TTX, compared to 58.8 among women without TTX. CONCLUSIONS: There was some indication of an elevated risk of liver disease and congenital anomalies in women with TTX, but the risk did not appear to be related to the ATD use. There seems to be a higher pregnancy termination rate for women with TTX on MMI, which likely reflects elective pregnancy terminations.

Impact of venous thromboembolism on mortality of elderly Medicare patients with stage III colon cancer.

BACKGROUND: The improvement in survival rates for patients with colon cancer has shifted the focus from examining cancer-specific mortality to exploring all-cause mortality. Adverse events such as venous thromboembolism (VTE) affect overall survival times and the net clinical benefit of cancer management strategies. METHODS: This retrospective study used Surveillance, Epidemiology and End Results (SEER) Medicare data to examine VTE incidence and mortality rates for elderly patients with stage III colon cancer who were diagnosed in 2004 or 2005 and followed through 2007. The impact of VTE on mortality was estimated using multivariable Cox proportional hazards regression. RESULTS: In all, 20.7% of 4,985 elderly patients with stage III colon cancer had clinically diagnosed VTE following diagnosis. All-cause mortality risk was higher for patients with a VTE diagnosis (hazard ratio [HR]: 1.15, 95% confidence interval [CI]: 1.04-1.27), greater comorbidity burden, more advanced tumor depth and nodal involvement within stage III, advanced age, and male sex; the risk was lower for patients treated with chemotherapy. VTE was associated with higher mortality hazards (HR: 1.41, 95% CI: 1.21-1.64) for patients treated with adjuvant chemotherapy but not for untreated patients. CONCLUSIONS: A new diagnosis of VTE significantly reduced survival rates for elderly patients with stage III colon cancer and further reduced survival rates for patients treated with chemotherapy. Improved prevention and management of VTE for elderly patients with stage III colon cancer who are at risk for VTE is warranted, particularly for patients treated with chemotherapy.

Patient and physician characteristics associated with erythropoiesis-stimulating agent use in patients with myelodysplastic syndromes.

Patient and physician characteristics associated with use of erythropoiesis-stimulating agents in myelodysplastic syndrome patients have not yet been described. Myelodysplastic syndrome patients diagnosed from 2001 to 2005 were identified from the Surveillance Epidemiology and End Results-Medicare database. Multivariate regressions examined the association between patient and physician characteristics and the probability of receiving any erythropoiesis-stimulating agents, and of receiving therapeutic-length (≥ 8 week) treatment episodes. Among the 6,588 myelodysplastic syndrome patients studied, 65% received erythropoiesis-stimulating agents. Use of erythropoiesis-stimulating agents was lower for blacks compared to whites (OR 0.78; 95% CI:0.61-0.99), single persons compared to married (OR 0.77; 95% CI:0.62-0.97), Medicaid recipients (OR 0.66; 95% CI:0.55-0.79), and those living in census tracts with lower educational attainment. Patients who did not consult a hematology-oncology specialist were less likely to receive erythropoiesis-stimulating agents. Specialist access, financial resources and mobility are key determinants of receipt of erythropoiesis-stimulating agents among myelodysplastic syndrome patients.

Erythropoiesis-stimulating agents are not associated with increased risk of thrombosis in patients with myelodysplastic syndromes.

BACKGROUND: There are limited reports of thrombosis among myelodysplastic syndrome patients exposed to erythropoiesis stimulating agents. It is not clear whether erythropoiesis stimulating agents are associated with an increased risk of thrombosis in myelodysplastic syndromes, as they are among patients with solid tumors. DESIGN AND METHODS: The association between use of erythropoiesis stimulating agent and transient thrombosis risk in patients with myelodysplastic syndromes was assessed in a case-crossover study nested within a cohort of incident myelodysplastic syndrome patients. Using the US Surveillance, Epidemiology, and End Results Medicare-linked database, cases with an incident diagnosis of deep vein thrombosis were identified. Using conditional logistical regression, the odds of exposure to erythropoiesis stimulating agents in the 12 weeks prior to the incident deep vein thrombosis (hazard period) was compared to the exposure odds in a prior 12-week comparison period. RESULTS: Within the cohort of eligibles with myelodysplastic syndromes (n = 5,673) there were 212 incident cases of deep vein thrombosis events. Mean age was 76.2 (standard deviation = ± 8.6) years. Use of erythropoiesis stimulating agents was not associated with deep vein thrombosis in the crude nor the adjusted models (OR = 1.21, 95% CI: 0.60, 2.43). Central venous catheter placement (OR = 6.47, 95% CI: 2.37, 17.62) and red blood cell transfusion (OR = 4.60, 95% CI: 2.29, 9.23) were associated with deep vein thrombosis. CONCLUSIONS: Despite the link between use of erythropoiesis stimulating agents and thrombosis among patients with solid tumors, this study provides evidence that their safety profile may be different among patients with myelodysplastic syndromes.

The total economic burden of overactive bladder in the United States: a disease-specific approach.

OBJECTIVE: To employ results from a recent US population-based survey to calculate disease-specific total costs of overactive bladder (OAB). STUDY DESIGN: Disease-specific total cost-of-illness method using population prevalence estimates. METHODS: Cases were identified as community-dwelling adults reporting the presence of urinary urgency or urgency urinary incontinence. Two OAB classifications were used based on Likert scale responses of OAB symptoms: "often" (base case) or "sometimes" (alternative). The study estimates disease-specific total costs of OAB from the societal perspective and using an average costing method. A population-based survey, a claims data analysis, and the published literature provided the prevalence and resource utilization data. RESULTS: The prevalence of OAB as defined in the base case (alternative) was 18.6% (28.7%) in the adult US population, accounting for 42.2 million (65.1 million) community-dwelling adults. The disease-specific total cost of OAB is estimated at $24.9 billion for the base case and $36.5 billion for the alternative case. Total direct costs were $22.3 billion in the base case and $33.5 billion in the alternative case. Costs were higher among adults younger than 65 years of age, compared with adults 65 years or older. This relative cost burden was lower for the base case compared with the alternative case in the full sample, with a larger gap among men. CONCLUSION: The total cost of OAB among community-dwelling adults is significant and varies with demographic groups. Future research is needed to determine whether the differential cost burden is robust to alternate cost-of-illness estimation methods.

Asthma-related medication use among children in the United States.

BACKGROUND: Asthma is one of the most common chronic conditions in children and has a major impact on health care use and quality of life. The Best Pharmaceuticals for Children Act mandates the federal government to sponsor pediatric studies of drugs approved for use in the United States but lacking evaluation in the pediatric population and lacking interest of commercial sponsors. As input into the drug selection and prioritization process, information is needed on the percentage of children who receive asthma-related medications. OBJECTIVE: To estimate the percentage of children who receive asthma-related medications. METHODS: Retrospective analysis of outpatient medical and drug claims from members of commercial health care insurance plans enrolled any time from January 1, 2004, through December 31, 2005. The study population included 4,259,103 children throughout the United States aged birth through 17 years. RESULTS: Fifteen percent of all children were dispensed an asthma-related medication. Among 218,943 children with an asthma diagnosis, 188,286 (86%) had a dispensed asthma-related medication at any time during the 2-year study period. Among children without any asthma diagnoses, 398,880 (10%) had a dispensed medication. Fifty-nine percent of children with an asthma diagnosis were dispensed an anti-inflammatory medication within 90 days after a claim with a diagnosis of asthma. CONCLUSIONS: Asthma-related medications are dispensed to a large percentage of the pediatric population, including many who do not have claims with asthma diagnoses listed. Data on the pharmacokinetics and safety of these drugs in children are largely unknown and difficult to obtain. Clinical studies that use new tools and approaches are needed to resolve this information gap.

Impact of an educational intervention for secondary prevention of myocardial infarction on Medicaid drug use and cost.

OBJECTIVES: The objectives of this drug utilization review program were (1) to increase beta-blocker prescribing to fee-for-service post-acute myocardial infarction (AMI) Medicaid patients; (2) to improve compliance among patients who were prescribed beta-blockers post-AMI; and (3) to evaluate the economic implications of increased beta-blocker prescribing. STUDY DESIGN: Pre-post nonequivalent group design. PATIENTS AND METHODS: The intervention targeted physicians of Pennsylvania Medicaid recipients who had an AMI between November 1, 1998, and November 1, 1999. Educational materials were sent to the physicians of post-AMI patients not receiving beta-blockers. Preintervention and postintervention rates of beta-blocker prescribing in the Medicaid program within 7 and 30 days of discharge after an AMI hospitalization were compared. Similarly, pre- and postintervention compliance rates were compared for AMI patients who were prescribed beta-blockers. Cost savings and number of avoided deaths also were calculated. RESULTS: There was a 5.5%, to 6.9% increase in beta-blocker prescribing after the intervention, depending on the follow-up period. Postintervention AMI patients were 16% more likely to be prescribed a beta-blocker. There was an 8.3% increase in patient compliance with beta-blocker therapy from preintervention to postintervention. In the first 2 years of the intervention, the estimated cost savings to the Pennsylvania Medicaid program ranged from 71,970 dollars to 76,678 dollars, respectively. An estimated 3 deaths were avoided. CONCLUSIONS: The intervention resulted in increased appropriate prescribing and compliance with beta-blockers among post-AMI patients. There also were estimated cost savings to Pennsylvania Medicaid as a result of reduced hospitalization, and fewer deaths.

Evaluation of a physician-focused educational intervention on medicaid children with asthma.

BACKGROUND: The 1990 Omnibus Budget Reconciliation Act mandated drug utilization review in response to inappropriate drug use. In the Pennsylvania Medicaid program, pediatric asthma is associated with high healthcare utilization and cost. OBJECTIVE: To determine the effects of a physician-focused educational intervention on asthma drug use and healthcare utilization. METHODS: Pre- and postintervention comparison design was used in children 5-18 years of age who were enrolled in the Pennsylvania Medicaid fee-for-service program from July 1, 1998, to March 31, 1999 (preintervention), and July 1, 1999, to March 31, 2000 (postintervention). The intervention packet included patients' drug profiles, medical history, monograph with national asthma management guidelines, and patient education materials to physicians. Main outcome measures are changes in asthma drug utilization among high-users of short-acting beta(2)-agonists (SAB). RESULTS: The intervention focused on 2 asthma drug use criteria: (1) high-use of quick-relief medication and (2) use of salmeterol without the availability of a quick-relief medication. The intervention reduced quick-relief medication use by 26% among patients with higher use without significant changes in long-term control drugs. In addition, 82% of the recipients evaluated had a positive change in salmeterol utilization as either having an SAB inhaler added after the intervention or salmeterol discontinued after the intervention. There was no significant change in asthma-related emergency department visits or hospitalizations. CONCLUSIONS: Although the physician responders agreed on the usefulness of the educational materials, the results suggest that the intervention had limited success in improving the pharmacologic management and no effect on the health outcomes. We believe that mailed educational materials to physicians can be effective to change prescribing behavior; however, a more multifaceted intervention may be necessary to improve health outcomes.