Browsing by Subject "Health services research, policy, and administration"

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    A decrease in physician reimbursement for hormone therapy in prostate cancer and patterns of utilization.
    (2011-05) Elliott, Sean Patrick, MD.
    Background Use of androgen suppression therapy (AST) in prostate cancer increased more than three-fold from 1991–1999. The 2003 Medicare Modernization Act reduced reimbursements for AST by 64% between 2004 and 2005, but the effect of this large reduction on use of AST is unknown. Methods A cohort of 72 818 men diagnosed with prostate cancer in 1992-2005 was identified from the Surveillance, Epidemiology, and End Results database. From Medicare claims data, indicated AST was defined as 3 months or more of AST in the first year in men with metastatic disease (n = 8030). Non-indicated AST was defined as AST given without other therapies such as radical prostatectomy or radiation in men with low risk disease ( n = 64 788). The unadjusted annual proportion of men receiving AST was plotted against the median Medicare AST reimbursement. A multivariate model was used to estimate the odds of AST use in men with low risk and metastatic disease, with the predictor of interest being the calendar year of the payment change. Covariates in the model included age in 5 year categories, clinical tumor stage (T1-4), WHO grade (1-3, unknown), Charlson comormidity (0,1,2,≥3), race, education, income, and tumor registry site, all as categorical variables. The models included variations in the definition of AST use (≥1, ≥3 and ≥6 months of AST). All statistical tests were two-sided. Results AST use in the low risk group peaked at 10.2% in 2003, then declined to 7.1% in 2004 and 6.1% in 2005. After adjusting for tumor and demographic covariates, the odds of receiving non-indicated primary AST decreased statistically significantly in 2004 (odds ratio (OR) = 0.70, 95% confidence interval (CI) = 0.61 to 0.80) and 2005 (OR = 0.61, 95% CI = 0.53 to 0.71) compared with 2003. AST use in the metastatic disease group was stable at 60% during the payment change, and the adjusted odds ratio (OR) of receiving AST in this group was unchanged in 2004-5. Conclusions In this example of hormone therapy for prostate cancer, decreased physician reimbursement was associated with a reduction in overtreatment without a reduction in needed services.
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    Five year rehospitalization outcomes in a cohort of acute ischemic stroke patients: medicare linkage study.
    (2011-05) Lakshminarayan, Kamakshi
    Background To track mortality and rehospitalizations over 5 years post-stroke in a stroke cohort and compare long-term risks of major complications to a matched non-stroke cohort. Methods A cohort design with a matched non-stroke comparison cohort was used. The stroke cohort (SC) was a validated database of acute ischemic stroke patients, 65 years or older, hospitalized across 19 Minnesota hospitals in the year 2000. The non-stroke cohort (NSC) was constructed by matching stroke cohort members on age, race and sex, to the year 2000 General Medicare Population. Both cohorts were tracked across 5 years of Medicare claims data to identify dates and causes of rehospitalization and death dates. Kaplan-Meier survival curves estimated cumulative incidence rates. Cox regression models were used to calculate adjusted hazard ratios (HR) and confidence intervals (CI). Results Event rates and adjusted HR were: Mortality: 1 year SC=24%, NSC=4%; 5 years SC=49%, NSC= 24%; HR: 4.9 (95% CI 4.0-6.1). Overall rehospitalization rates: 1 year SC=49%, NSC=20%; 5 years SC=83%; NSC=63%; HR: 2.6 (95% CI 2.2-3.0). Cause specific 5-year rehospitalization rates were significantly higher in SC versus NSC for recurrent ischemic stroke, heart failure, cardiac events, any vascular events pneumonia and hip fractures. The excess risk of mortality and iii rehospitalizations in the SC persisted beyond the initial aftermath of the acute stroke (i.e. beyond 30 days post-stroke) and persisted even after 1 year post-stroke. Conclusions The high rates of acute care readmissions in stroke survivors indcate a need for trials to prevent long-term post-stroke complications.
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    Safety of intravenous recombinant tissue plasminogen activator for treatment of acute ischemic stroke: the Minnesota experience.
    (2011-08) Manyara, Warren
    Background and Purpose Intravenous recombinant tissue plasminogen activator (IV rt-PA) has been shown to reduce the likelihood of disability and death following an acute ischemic stroke by placebo-controlled, randomized clinical trials. We evaluated the safety of this treatment in routine clinical practice by analyzing frequencies and predictors of poor outcomes in patients treated within hospitals in Minnesota. Methods In a retrospective observational cohort study of 576 acute ischemic stroke patients treated with IV rt-PA from January 2008 to June 2010, we reviewed data from 21 hospitals contributing information on stroke admissions to the Minnesota Stroke Registry. We applied multivariate logistic regression to determine association of demographic characteristics, cardiovascular risk factors and stroke severity with symptomatic intracranial hemorrhage, serious systemic hemorrhage and inpatient death. Results Acute ischemic stroke patients administered IV rt-PA were slightly older than non-thrombolytic treatment patients and had significantly higher frequencies of atrial fibrillation, diabetes mellitus and medical history of previous stroke. 4.6% of IV rt-PA patients were diagnosed with symptomatic intracranial hemorrhage (sICH), 1.1% incurred systemic hemorrhage and 7.3% died during their hospitalization. In comparison, 4.7% of patients not treated with any rt-PA died in the hospital. After adjustment for demographic and clinical factors, significant predictors of sICH were National Institutes of Health Stroke Scale (NIHSS) Score OR: 1.14 (1.06 – 1.22), diabetes mellitus OR: 9.97 (1.32 – 75.21), dyslipidemia OR: 6.42 (1.35 – 30.51), hypertension OR: 5.57 (1.11 – 27.98) and medical history of a previous stroke OR: 5.32 (1.03 – 27.62). Higher NIHSS scores were associated with a greater risk of inpatient death. Intravenous thrombolysis 3 – 4.5 hours after stroke symptoms did not increase the risk for sICH or inpatient death when compared with IV rt-PA administration within 3 hours. Patients aged 80 years and older did not incur significantly different inpatient outcomes. Conclusions When compared to the frequencies of poor outcomes reported in clinical trials and previous observational studies, inpatient IV rt-PA clinical outcomes in Minnesota suggest this is a safe treatment. NIHSS Score, diabetes mellitus, dyslipidemia, hypertension and previous stroke are possible risk factors for post-thrombolytic cerebral hemorrhage.