Trends in Mortality and Medical Spending in Patients Hospitalized for Community-Acquired Pneumonia: 1993–2005

Background: Community-acquired pneumonia (CAP) is the most common infectious cause of death in the United States. To understand the impact of efforts to improve quality and efficiency of care in CAP, we examined trends in mortality and costs among hospitalized CAP patients. Methods: Using the National Inpatient Sample from 1993–2005, we studied 569,524 CAP admissions. The primary outcome was mortality at discharge. We used logistic regression to evaluate the mortality trend, adjusting for age, gender, and comorbidities. To account for the impact of early discharge practices, we also compared daily mortality rates and performed a Cox proportional-hazards model. We used a generalized linear model to analyze trends in hospitalization costs, which were derived using cost-to-charge ratios. Results: Over time, length of stay (LOS) declined, while more patients were discharged to other facilities. The frequency of many comorbidities increased. Age/gender-adjusted mortality decreased from 8.9% to 4.1% (P < 0.001). In multivariable analysis, the mortality risk declined through 2005 (odds ratio, 0.50; 95% confidence interval [CI], 0.48–0.53), compared to reference year 1993. The daily mortality rates demonstrated that most of the mortality reduction occurred early during hospitalization. After adjusting for early discharge practices, the risk of mortality still declined through 2005 (hazard ratio, 0.74, 95% CI 0.70–0.78). Median hospitalization costs exhibited a modest reduction over time, mostly due to reduced LOS. Conclusions: Mortality among patients hospitalized for CAP has declined. Lower in-hospital mortality at a reduced cost suggests that pneumonia is a case of improved productivity in health care.Economic

Incidence and Mortality of Hip Fractures in the United States

Context: Understanding the incidence and subsequent mortality following hip fracture is essential to measuring population health and the value of improvements in health care. Objective: To examine trends in hip fracture incidence and resulting mortality over 20 years in the US Medicare population. Design, Setting, and Patients: Observational study using data from a 20% sample of Medicare claims from 1985-2005. In patients 65 years or older, we identified 786 717 hip fractures for analysis. Medication data were obtained from 109 805 respondents to the Medicare Current Beneficiary Survey between 1992 and 2005. Main Outcome Measures: Age- and sex-specific incidence of hip fracture and age- and risk-adjusted mortality rates. Results: Between 1986 and 2005, the annual mean number of hip fractures was 957.3 per 100 000 (95% confidence interval [CI], 921.7-992.9) for women and 414.4 per 100 000 (95% CI, 401.6-427.3) for men. The age-adjusted incidence of hip fracture increased from 1986 to 1995 and then steadily declined from 1995 to 2005. In women, incidence increased 9.0%, from 964.2 per 100 000 (95% CI, 958.3-970.1) in 1986 to 1050.9 (95% CI, 1045.2-1056.7) in 1995, with a subsequent decline of 24.5% to 793.5 (95% CI, 788.7-798.3) in 2005. In men, the increase in incidence from 1986 to 1995 was 16.4%, from 392.4 (95% CI, 387.8-397.0) to 456.6 (95% CI, 452.0-461.3), and the subsequent decrease to 2005 was 19.2%, to 369.0 (95% CI, 365.1-372.8). Age- and risk-adjusted mortality in women declined by 11.9%, 14.9%, and 8.8% for 30-, 180-, and 360-day mortality, respectively. For men, age- and risk-adjusted mortality decreased by 21.8%, 25.4%, and 20.0% for 30-, 180-, and 360-day mortality, respectively. Over time, patients with hip fracture have had an increase in all comorbidities recorded except paralysis. The incidence decrease is coincident with increased use of bisphosphonates. Conclusion: In the United States, hip fracture rates and subsequent mortality among persons 65 years and older are declining, and comorbidities among patients with hip fractures have increased. The number of hip fractures occurring in the United States and the resulting postsurgical outcome are a major public health concern. About 30% of people with a hip fracture will die in the following year,1- 3 and many more will experience significant functional loss.4- 7 The long-term consequences may be great as well. Some studies have shown excess long-term mortality even 10 years after an episode,8- 12 although other studies have only shown moderate increases in mortality.13- 17. Treating hip fractures is also very expensive. A typical patient with a hip fracture spends US $40 000 in the first year following hip fracture for direct medical costs and almost$5000 in subsequent years.1,18- 20 Despite recent literature indicating that the hip fracture incidence may be stabilizing or decreasing,21- 29 concern still exists that because of the aging of the population, the hip fracture incidence will increase worldwide unless additional steps are taken.7,19,20,22,30- 35. Understanding the incidence and postsurgical outcome of hip fractures is a vital first step in improving population health. Our primary objective was to assess trends in the age- and sex-specific incidence and subsequent age- and risk-adjusted mortality of hip fractures among elderly individuals in the United States, controlling for comorbid conditions. A secondary objective was to examine trends in pharmaceutical use because this may affect fracture incidence, mortality, or both

Incidence and mortality of hip fractures in the United States

CONTEXT: Understanding the incidence and subsequent mortality following hip fracture is essential to measuring population health and the value of improvements in health care. OBJECTIVE: To examine trends in hip fracture incidence and resulting mortality over 20 years in the US Medicare population. DESIGN, SETTING, AND PATIENTS: Observational study using data from a 20% sample of Medicare claims from 1985-2005. In patients 65 years or older, we identified 786,717 hip fractures for analysis. Medication data were obtained from 109,805 respondents to the Medicare Current Beneficiary Survey between 1992 and 2005. MAIN OUTCOME MEASURES: Age- and sex-specific incidence of hip fracture and age- and risk-adjusted mortality rates. RESULTS: Between 1986 and 2005, the annual mean number of hip fractures was 957.3 per 100,000 (95% confidence interval [CI], 921.7-992.9) for women and 414.4 per 100,000 (95% CI, 401.6-427.3) for men. The age-adjusted incidence of hip fracture increased from 1986 to 1995 and then steadily declined from 1995 to 2005. In women, incidence increased 9.0%, from 964.2 per 100,000 (95% CI, 958.3-970.1) in 1986 to 1050.9 (95% CI, 1045.2-1056.7) in 1995, with a subsequent decline of 24.5% to 793.5 (95% CI, 788.7-798.3) in 2005. In men, the increase in incidence from 1986 to 1995 was 16.4%, from 392.4 (95% CI, 387.8-397.0) to 456.6 (95% CI, 452.0-461.3), and the subsequent decrease to 2005 was 19.2%, to 369.0 (95% CI, 365.1-372.8). Age- and risk-adjusted mortality in women declined by 11.9%, 14.9%, and 8.8% for 30-, 180-, and 360-day mortality, respectively. For men, age- and risk-adjusted mortality decreased by 21.8%, 25.4%, and 20.0% for 30-, 180-, and 360-day mortality, respectively. Over time, patients with hip fracture have had an increase in all comorbidities recorded except paralysis. The incidence decrease is coincident with increased use of bisphosphonates. CONCLUSION: In the United States, hip fracture rates and subsequent mortality among persons 65 years and older are declining, and comorbidities among patients with hip fractures have increased

Trends in Stroke Rates, Risk, and Outcomes in the United States, 1988 to 2008

BackgroundStroke is a major cause of morbidity and mortality. We describe trends in the incidence, outcomes, and risk factors for stroke in the US Medicare population from 1988 to 2008.MethodsWe analyzed data from a 20% sample of hospitalized Medicare beneficiaries with a principal discharge diagnosis of ischemic (n = 918,124) or hemorrhagic stroke (n = 133,218). Stroke risk factors were determined from the National Health and Nutrition Examination Survey (years 1988-1994, 2001-2008) and medication uptake from the Medicare Current Beneficiary Survey (years 1992-2008). Primary outcomes were stroke incidence and 30-day mortality after stroke hospitalization.ResultsIschemic stroke incidence decreased from 927 per 100,000 in 1988 to 545 per 100,000 in 2008, and hemorrhagic stroke decreased from 112 per 100,000 to 94 per 100,000. Risk-adjusted 30-day mortality decreased from 15.9% in 1988 to 12.7% in 2008 for ischemic stroke and from 44.7% to 39.3% for hemorrhagic stroke. Although observed stroke rates decreased, the Framingham stroke model actually predicted increased stroke risk (mean stroke score 8.3% in 1988-1994, 8.8% in 2005-2008). Statin use in the general population increased (4.0% in 1992, 41.4% in 2008), as did antihypertensive use (53.0% in 1992, 73.5% in 2008).ConclusionsIncident strokes in the Medicare population aged ≥65 years decreased by approximately 40% over the last 2 decades, a decline greater than expected on the basis of the population's stroke risk factors. Case fatality from stroke also declined. Although causality cannot be proven, declining stroke rates paralleled increased use of statins and antihypertensive medications

Trends in stroke rates, risk, and outcomes in the United States, 1988 to 2008

BACKGROUND: Stroke is a major cause of morbidity and mortality. We describe trends in the incidence, outcomes, and risk factors for stroke in the US Medicare population from 1988 to 2008. METHODS: We analyzed data from a 20% sample of hospitalized Medicare beneficiaries with a principal discharge diagnosis of ischemic (n = 918,124) or hemorrhagic stroke (n = 133,218). Stroke risk factors were determined from the National Health and Nutrition Examination Survey (years 1988-1994, 2001-2008) and medication uptake from the Medicare Current Beneficiary Survey (years 1992-2008). Primary outcomes were stroke incidence and 30-day mortality after stroke hospitalization. RESULTS: Ischemic stroke incidence decreased from 927 per 100,000 in 1988 to 545 per 100,000 in 2008, and hemorrhagic stroke decreased from 112 per 100,000 to 94 per 100,000. Risk-adjusted 30-day mortality decreased from 15.9% in 1988 to 12.7% in 2008 for ischemic stroke and from 44.7% to 39.3% for hemorrhagic stroke. Although observed stroke rates decreased, the Framingham stroke model actually predicted increased stroke risk (mean stroke score 8.3% in 1988-1994, 8.8% in 2005-2008). Statin use in the general population increased (4.0% in 1992, 41.4% in 2008), as did antihypertensive use (53.0% in 1992, 73.5% in 2008). CONCLUSIONS: Incident strokes in the Medicare population aged \u3e/=65 years decreased by approximately 40% over the last 2 decades, a decline greater than expected on the basis of the population\u27s stroke risk factors. Case fatality from stroke also declined. Although causality cannot be proven, declining stroke rates paralleled increased use of statins and antihypertensive medications

The effect of direct cognitive assessment in the Medicare annual wellness visit on dementia diagnosis rates

Objective: To evaluate the relationship between direct cognitive assessment introduced with the Medicare Annual Wellness Visit (AWV) and new diagnoses of dementia, and to determine if effects vary by race. Data Sources: Medicare Limited Data Set 5% sample claims 2003-2014 and the HRSA Area Health Resources Files. Study Design: Instrumental Variable approach estimating the relationship between AWV utilization and new diagnoses of dementia using county-level Welcome to Medicare Visit rates as an instrument. Data Collection/Extraction Methods: Three hundred twenty-four thousand three hundred and eighty-five fee-for-service Medicare beneficiaries without dementia when the AWV was introduced in 2011. Principal Findings: Annual Wellness Visit utilization was associated with an increased probability of new dementia diagnosis with effects varying by racial group (categorized as white, black, Hispanic/Latino, or Asian based on Social Security Administration data). Hazard ratios (95% confidence intervals) for new dementia diagnosis within 6 months of AWV utilization were as follows: 2.34 (2.13, 2.58) white, 2.22 (1.71, 2.89) black, 4.82 (2.94, 7.89) Asian, and 6.14 (3.70, 10.19) Hispanic (P <.001 for each). Our findings show that estimates that do not control for selection underestimate the effect of AWV on new diagnoses. Conclusions: Dementia diagnosis rates increased with AWV implementation with heterogenous effects by race and ethnicity. Current recommendations by the United States Preventive Services Task Force state that the evidence is insufficient to recommend for or against screening for cognitive impairment in older adults. © 2021 Health Research and Educational Trust12 month embargo; first published: 22 January 2021This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]