Effects of the Medicare Modernization Act on Spending for Outpatient Surgery

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/145408/1/hesr12807_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145408/2/hesr12807-sup-0001-AppendixSA1.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145408/3/hesr12807.pd

Resurrecting immortal‐time bias in the study of readmissions

ObjectiveTo compare readmission rates as measured by the Centers for Medicare and Medicaid Services and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) methods.Data Sources20 percent sample of national Medicare data for patients undergoing cystectomy, colectomy, abdominal aortic aneurysm (AAA) repair, and total knee arthroplasty (TKA) between 2010 and 2014.Study DesignRetrospective cohort study comparing 30‐day readmission rates.Data Collection/Extraction MethodsPatients undergoing cystectomy, colectomy, abdominal aortic aneurysm repair, and total knee arthroplasty between 2010 and 2014 were identified.Principal FindingsCystectomy had the highest and total knee arthroplasty had the lowest readmission rate. The NSQIP measure reported significantly lower rates for all procedures compared to the CMS measure, which reflects an immortal‐time bias.ConclusionsWe found significantly different readmission rates across all surgical procedures when comparing CMS and NSQIP measures. Longer length of stay exacerbated these differences. Uniform outcome measures are needed to eliminate ambiguity and synergize research and policy efforts.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154628/1/hesr13252-sup-0001-Authormatrix.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154628/2/hesr13252.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154628/3/hesr13252_am.pd

Value‐based payment models and management of newly diagnosed prostate cancer

Abstract Objective To examine the effect of urologist participation in value‐based payment models on the initial management of men with newly diagnosed prostate cancer. Methods Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow‐up, were assigned to their primary urologist, each of whom was then aligned to a value‐based payment model (the merit‐based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed‐effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non‐cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price‐standardized prostate cancer spending in the 12 months after diagnosis. Results Treatment did not vary by payment model, both overall (MIPS—67% [95% CI 66%–68%], ACOs without risk—66% [95% CI 66%–68%], ACOs with risk—66% [95% CI 64%–68%]). Similarly, treatment did not vary among men with very high risk of non‐cancer mortality by payment model (MIPS—52% [95% CI 50%–55%], ACOs without risk—52% [95% CI 50%–55%], ACOs with risk—51% [95% CI 45%–56%]). Adjusted spending was similar across payment models (MIPS—$16,501 [95$16,222–$16,780], ACOs without risk—$16,140 [95% CI $15,852–$16,429], ACOs with risk—$16,117 [95$15,585–$16,649]). Conclusions How urologists participate in value‐based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease

Longitudinal patterns of urinary incontinence and associated predictors in women with type 1 diabetes

AIMS: Urinary incontinence (UI) in women is a dynamic condition with numerous risk factors yet most studies have focused on examining its prevalence at a single time. The objective of this study was to describe the long-term time course of UI in women with type 1 diabetes (T1D). METHODS: Longitudinal data in women with T1D were collected from 568 women in the Epidemiology of Diabetes Interventions and Complications (EDIC) study, the observational follow-up of the Diabetes Control and Complications Trial (DCCT) cohort. Over a 12-year period, participants annually responded to whether they had experienced UI in the past year. RESULTS: We identified four categories of UI in this population over time: 205 (36.1%) women never reported UI (no UI), 70 (12.3%) reported it one or two consecutive years only (isolated UI), 247 (43.5%) periodically changed status between UI and no UI (intermittent UI), and 46 (8.1%) reported UI continuously after the first report (persistent UI). Compared to women reporting no/isolated UI, women displaying the intermittent phenotype were significantly more likely to be obese (OR: 1.86, 95% CI 1.15, 3.00) and report prior hysterectomy (OR: 2.57, 95% CI: 1.39, 4.77); whereas women with persistent UI were significantly more likely to have abnormal autonomic function (OR: 2.36, 95% CI: 1.16-4.80). CONCLUSIONS: UI is a dynamic condition in women with T1D. Varying risk factors observed for the different phenotypes of UI suggest distinctive pathophysiological mechanisms. These findings have the potential to be used to guide individualized interventions for UI in women with diabetes

Health care delivery system contributions to management of newly diagnosed prostate cancer

Abstract Background Despite clinical guidelines advocating for use of conservative management in specific clinical scenarios for men with prostate cancer, there continues to be tremendous variation in its uptake. This variation may be amplified among men with competing health risks, for whom treatment decisions are not straightforward. The degree to which characteristics of the health care delivery system explain this variation remains unclear. Methods Using national Medicare data, men with newly diagnosed prostate cancer between 2014 and 2019 were identified. Hierarchical logistic regression models were used to assess the association between use of treatment and health care delivery system determinants operating at the practice level, which included measures of financial incentives (i.e., radiation vault ownership), practice organization (i.e., single specialty vs. multispecialty groups), and the health care market (i.e., competition). Variance was partitioned to estimate the relative influence of patient and practice characteristics on the variation in use of treatment within strata of noncancer mortality risk groups. Results Among 62,507 men with newly diagnosed prostate cancer, the largest variation in the use of treatment between practices was observed for men with high and very high‐risk of noncancer mortality (range of practice‐level rates of treatment for high: 57%–71% and very high: 41%–61%). Addition of health care delivery system determinants measured at the practice level explained 13% and 15% of the variation in use of treatment among men with low and intermediate risk of noncancer mortality in 10 years, respectively. Conversely, these characteristics explained a larger share of the variation in use of treatment among men with high and very high‐risk of noncancer mortality (26% and 40%, respectively). Conclusions Variation among urology practices in use of treatment was highest for men with high and very high‐risk noncancer mortality. Practice characteristics explained a large share of this variation

The immediate effects of private equity acquisition of urology practices on the management of newly diagnosed prostate cancer

Abstract Introduction Some worry that physician practices acquired by private equity may increase the use of services to maximize revenue. We assessed the effects of private equity acquisition on spending, use of treatment, and diagnostic testing in men with prostate cancer. Methods We used a 20% sample of national Medicare claims to perform a retrospective cohort study of men with prostate cancer diagnosed from 2014 through 2019. The primary outcome was prostate cancer spending in the first 12 months after diagnosis. Secondary outcomes included the use of treatment and a composite measure of diagnostic testing (e.g., imaging, genomics) in the first 12 months after diagnosis. Multilevel modeling was used to adjust for differences in patient and market characteristics. The effect of practice acquisition on each outcome was assessed using a difference‐in‐differences design. Results There were 409 and 4021 men with prostate cancer managed by urologists in acquired and nonacquired practices, respectively. After acquisition, prostate cancer spending was comparable between acquired and nonacquired practices (difference‐in‐differences estimate $1182, p = 0.36). Acquisition did not affect the use of treatment (difference‐in‐differences estimate 3.7%, p = 0.30) or the use of diagnostic testing in men who were treated (difference‐in‐differences −5.5%, p = 0.12) and those managed conservatively (difference‐in‐differences −2.0%, p = 0.82). Conclusions In the year following acquisition of urology practices, private equity did not increase prostate cancer spending, the use of treatment or diagnostic testing in men with prostate cancer. Future work should evaluate the effects of private equity acquisition on practice patterns and quality over a longer time horizon

Adherence and out‐of‐pocket costs among Medicare beneficiaries who are prescribed oral targeted therapies for advanced prostate cancer

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163634/3/cncr33176.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163634/2/cncr33176-sup-0001-FigS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163634/1/cncr33176_am.pd