Association between diagnosis code expansion and changes in 30-day risk-adjusted outcomes for cardiovascular diseases

BACKGROUND In January 2011, Centers for Medicare and Medicaid Services expanded the number of inpatient diagnosis codes from 9 to 25, which may influence comorbidity counts and risk-adjusted outcome rates for studies spanning January 2011. This study examines the association between (1) limiting versus not limiting diagnosis codes after 2011, (2) using inpatient-only versus inpatient and outpatient data, and (3) using logistic regression versus the Centers for Medicare and Medicaid Services risk-standardized methodology and changes in risk-adjusted outcomes. METHODS AND RESULTS Using 100% Medicare inpatient and outpatient files between January 2009 and December 2013, we created 2 cohorts of fee-for-service beneficiaries aged ≥65 years. The acute myocardial infarction cohort and the heart failure cohort had 578 728 and 1 595 069 hospitalizations, respectively. We calculate comorbidities using (1) inpatient-only limited diagnoses, (2) inpatient-only unlimited diagnoses, (3) inpatient and outpatient limited diagnoses, and (4) inpatient and outpatient unlimited diagnoses. Across both cohorts

Political environment and mortality rates in the United States, 2001-19: Population based cross sectional analysis

OBJECTIVE: To assess recent trends in age adjusted mortality rates (AAMRs) in the United States based on county level presidential voting patterns. DESIGN: Cross sectional study. SETTING: USA, 2001-19. PARTICIPANTS: 99.8% of the US population. MAIN OUTCOME MEASURES: AAMR per 100 000 population and average annual percentage change (APC). METHODS: The Centers for Disease Control and Prevention WONDER database was linked to county level data on US presidential elections. County political environment was classified as either Democratic or Republican for the four years that followed a November presidential election. Additional sensitivity analyses analyzed AAMR trends for counties that voted only for one party throughout the study, and county level gubernatorial election results and state level AAMR trends. Joinpoint analysis was used to assess for an inflection point in APC trends. RESULTS: The study period covered five presidential elections from 2000 to 2019. From 2001 to 2019, the AAMR per 100 000 population decreased by 22% in Democratic counties, from 850.3 to 664.0 (average APC -1.4%, 95% confidence interval -1.5% to -1.2%), but by only 11% in Republican counties, from 867.0 to 771.1 (average APC -0.7%, -0.9% to -0.5%). The gap in AAMR between Democratic and Republican counties therefore widened from 16.7 (95% confidence interval 16.6 to 16.8) to 107.1 (106.5 to 107.7). Statistically significant inflection points in APC occurred for Democratic counties between periods 2001-09 (APC -2.1%, -2.3% to -1.9%) and 2009-19 (APC -0.8%, -1.0% to -0.6%). For Republican counties between 2001 and 2008 the APC was -1.4% (-1.8% to -1.0%), slowing to near zero between 2008 and 2019 (APC -0.2%, -0.4% to 0.0%). Male and female residents of Democratic counties experienced both lower AAMR and twice the relative decrease in AAMR than did those in Republican counties. Black Americans experienced largely similar improvement in AAMR in both Democratic and Republican counties. However, the AAMR gap between white residents in Democratic versus Republican counties increased fourfold, from 24.7 (95% confidence interval 24.6 to 24.8) to 101.3 (101.0 to 101.6). Rural Republican counties experienced the highest AAMR and the least improvement. All trends were similar when comparing counties that did not switch political environment throughout the period and when gubernatorial election results were used. The greatest contributors to the widening AAMR gap between Republican and Democratic counties were heart disease (difference in AAMRs 27.6), cancer (17.3), and chronic lower respiratory tract diseases (8.3), followed by unintentional injuries (3.3) and suicide (3.0). CONCLUSION: The mortality gap in Republican voting counties compared with Democratic voting counties has grown over time, especially for white populations, and that gap began to widen after 2008

Medicare eligibility and healthcare access, affordability, and financial strain for low- and higher-income adults in the United States: A regression discontinuity analysis.

BackgroundUS policymakers are debating whether to expand the Medicare program by lowering the age of eligibility. The goal of this study was to determine the association of Medicare eligibility and enrollment with healthcare access, affordability, and financial strain from medical bills in a contemporary population of low- and higher-income adults in the US.Methods and findingsWe used cross-sectional data from the National Health Interview Survey (2019) to examine the association of Medicare eligibility and enrollment with outcomes by income status using a local randomization-based regression discontinuity approach. After weighting to account for survey sampling, the low-income group consisted of 1,660,188 adults age 64 years and 1,488,875 adults age 66 years, with similar baseline characteristics, including distribution of sex (59.2% versus 59.7% female) and education (10.8% versus 12.5% with bachelor's degree or higher). The higher-income group consisted of 2,110,995 adults age 64 years and 2,167,676 adults age 66 years, with similar distribution of baseline characteristics, including sex (40.0% versus 49.4% female) and education (41.0% versus 41.6%). The share of adults age 64 versus 66 years enrolled in Medicare differed within low-income (27.6% versus 87.8%, p ConclusionsMedicare eligibility and enrollment at age 65 years were associated with improvements in healthcare access, affordability, and financial strain in low-income adults and, to a lesser extent, in higher-income adults. Our findings provide evidence that lowering the age of eligibility for Medicare may improve health inequities in the US