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Validation of discharge diagnosis codes to identify serious infections among middle age and older adults.
Wiese AD, Griffin MR, Stein CM, Schaffner W, Greevy RA, Mitchel EF, Grijalva CG
(2018) BMJ Open 8: e020857
MeSH Terms: Aged, Aged, 80 and over, Algorithms, Clinical Coding, Female, Humans, Infection, International Classification of Diseases, Male, Medicaid, Medical Records, Middle Aged, Patient Discharge, Predictive Value of Tests, Reproducibility of Results, Retrospective Studies, Tennessee, United States
Show Abstract · Added July 27, 2018
OBJECTIVES - Hospitalisations for serious infections are common among middle age and older adults and frequently used as study outcomes. Yet, few studies have evaluated the performance of diagnosis codes to identify serious infections in this population. We sought to determine the positive predictive value (PPV) of diagnosis codes for identifying hospitalisations due to serious infections among middle age and older adults.
SETTING AND PARTICIPANTS - We identified hospitalisations for possible infection among adults >=50 years enrolled in the Tennessee Medicaid healthcare programme (2008-2012) using International Classifications of Diseases, Ninth Revision diagnosis codes for pneumonia, meningitis/encephalitis, bacteraemia/sepsis, cellulitis/soft-tissue infections, endocarditis, pyelonephritis and septic arthritis/osteomyelitis.
DESIGN - Medical records were systematically obtained from hospitals randomly selected from a stratified sampling framework based on geographical region and hospital discharge volume.
MEASURES - Two trained clinical reviewers used a standardised extraction form to abstract information from medical records. Predefined algorithms served as reference to adjudicate confirmed infection-specific hospitalisations. We calculated the PPV of diagnosis codes using confirmed hospitalisations as reference. Sensitivity analyses determined the robustness of the PPV to definitions that required radiological or microbiological confirmation. We also determined inter-rater reliability between reviewers.
RESULTS - The PPV of diagnosis codes for hospitalisations for infection (n=716) was 90.2% (95% CI 87.8% to 92.2%). The PPV was highest for pneumonia (96.5% (95% CI 93.9% to 98.0%)) and cellulitis (91.1% (95% CI 84.7% to 94.9%)), and lowest for meningitis/encephalitis (50.0% (95% CI 23.7% to 76.3%)). The adjudication reliability was excellent (92.7% agreement; first agreement coefficient: 0.91). The overall PPV was lower when requiring microbiological confirmation (45%) and when requiring radiological confirmation for pneumonia (79%).
CONCLUSIONS - Discharge diagnosis codes have a high PPV for identifying hospitalisations for common, serious infections among middle age and older adults. PPV estimates for rare infections were imprecise.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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18 MeSH Terms
Race- and Sex-related Differences in Nephrolithiasis Risk Among Blacks and Whites in the Southern Community Cohort Study.
Hsi RS, Kabagambe EK, Shu X, Han X, Miller NL, Lipworth L
(2018) Urology 118: 36-42
MeSH Terms: Adult, African Americans, Aged, Cohort Studies, Continental Population Groups, European Continental Ancestry Group, Female, Humans, Incidence, Kidney Calculi, Male, Medicaid, Medicare, Middle Aged, Proportional Hazards Models, Risk Assessment, Risk Factors, Sex Factors, Socioeconomic Factors, United States
Show Abstract · Added July 18, 2018
OBJECTIVE - To investigate race-sex associations with risk among whites and blacks in the southeastern United States. The relationship between race, sex, and kidney stone risk is poorly understood.
METHODS - Participants were 42,136 black and white adults enrolled in the Southern Community Cohort Study between 2002 and 2009, with no history of kidney stones and receiving Medicare or Medicaid services. Incident kidney stone diagnoses through December 2014 were determined via linkage with Centers for Medicare and Medicaid Services research files. Hazard ratios (HRs) for associations with race and sex were computed from multivariable Cox proportional hazards models adjusting for baseline characteristics, comorbid diseases, and dietary intakes.
RESULTS - During 116,931 and 270,917 person-years of follow-up for whites and blacks, respectively, age-adjusted incidence rates (95% confidence interval [CI]) were 5.98 (4.73-7.23) and 4.50 (3.86-5.14) per 1000 person-years for white men and women, respectively, while corresponding rates among blacks were 2.19 (1.71-2.67) and 2.47 (2.19-2.75) per 1000 person-years. Risk was higher among whites compared to blacks (HR = 2.23, 95% CI 1.97-2.53). Male sex was significantly associated with risk among whites (HR = 1.45, 95% CI 1.20-1.75), but not among blacks (HR = 0.90, 95% CI 0.75-1.07). Formal tests of interaction by race and sex were statistically significant for all models (P = .01 for fully adjusted model).
CONCLUSION - The association of incident kidney stones with sex differs between whites and blacks. White men have the highest risk, while no difference in risk is observed between black men and women.
Copyright © 2018 Elsevier Inc. All rights reserved.
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Fludrocortisone Is Associated With a Higher Risk of All-Cause Hospitalizations Compared With Midodrine in Patients With Orthostatic Hypotension.
Grijalva CG, Biaggioni I, Griffin MR, Shibao CA
(2017) J Am Heart Assoc 6:
MeSH Terms: Adrenergic alpha-1 Receptor Agonists, Aged, Blood Pressure, Databases, Factual, Female, Fludrocortisone, Heart Failure, Hospitalization, Humans, Hypotension, Orthostatic, Incidence, Logistic Models, Male, Medicaid, Middle Aged, Midodrine, Multivariate Analysis, Prevalence, Propensity Score, Retrospective Studies, Risk Factors, Tennessee, Time Factors, Treatment Outcome, United States, Vasoconstrictor Agents
Show Abstract · Added July 27, 2018
BACKGROUND - Orthostatic hypotension causes ≈80 000 hospitalizations per year in the United States. Treatments for orthostatic hypotension include fludrocortisone, a mineralocorticoid analog that promotes sodium reabsorption; and midodrine, an α-1 adrenergic agonist that is a direct vasoconstrictor. Although both medications are used to treat orthostatic hypotension, few studies have compared their relative safety.
METHODS AND RESULTS - We compared incidence rates of hospitalizations for all causes, and for congestive heart failure between users of fludrocortisone and users of midodrine in a retrospective cohort study of Tennessee Medicaid adult enrollees (1995-2009). Adjusted incidence rate ratios were calculated using negative binomial regression models. Subgroup analyses based on history of congestive heart failure were conducted. We studied 1324 patients initiating fludrocortisone and 797 patients initiating midodrine. Compared with fludrocortisone users, midodrine users had higher prevalence of cardiovascular conditions. Incidence rates of all-cause hospitalizations for fludrocortisone and midodrine users were 1489 and 1330 per 1000 person-years, respectively (adjusted incidence-rate ratio 1.20, 95% confidence interval, 1.02-1.40). The respective rates of heart failure-related hospitalization were 76 and 84 per 1000 person-years (adjusted incidence-rate ratio: 1.33, 95% confidence interval, 0.79-2.56). Among patients with a history of congestive heart failure, the rates of all-cause hospitalization for fludrocortisone and midodrine were 2448 and 1820 per 1000 person-years (adjusted incidence-rate ratio: 1.42, 95% confidence interval, 1.07-1.90), and the respective rates of heart failure exacerbation-related hospitalizations were 297 and 263 per 1000 person-years (adjusted incidence-rate ratio: 1.48, 95% confidence interval, 0.69-3.16).
CONCLUSIONS - Compared with users of midodrine, users of fludrocortisone had higher rates of all-cause hospitalizations, especially among patients with congestive heart failure.
© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
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MeSH Terms
Comparative Safety of Sulfonylurea and Metformin Monotherapy on the Risk of Heart Failure: A Cohort Study.
Roumie CL, Min JY, D'Agostino McGowan L, Presley C, Grijalva CG, Hackstadt AJ, Hung AM, Greevy RA, Elasy T, Griffin MR
(2017) J Am Heart Assoc 6:
MeSH Terms: Aged, Biomarkers, Blood Glucose, Databases, Factual, Diabetes Mellitus, Female, Glycated Hemoglobin A, Heart Failure, Hospitalization, Humans, Hypoglycemic Agents, Male, Medicaid, Medicare, Metformin, Middle Aged, Retrospective Studies, Risk Assessment, Risk Factors, Sex Factors, Sulfonylurea Compounds, Time Factors, Treatment Outcome, United States, United States Department of Veterans Affairs, Veterans Health
Show Abstract · Added July 27, 2018
BACKGROUND - Medications that impact insulin sensitivity or cause weight gain may increase heart failure risk. Our aim was to compare heart failure and cardiovascular death outcomes among patients initiating sulfonylureas for diabetes mellitus treatment versus metformin.
METHODS AND RESULTS - National Veterans Health Administration databases were linked to Medicare, Medicaid, and National Death Index data. Veterans aged ≥18 years who initiated metformin or sulfonylureas between 2001 and 2011 and whose creatinine was <1.4 (females) or 1.5 mg/dL (males) were included. Each metformin patient was propensity score-matched to a sulfonylurea initiator. The outcome was hospitalization for acute decompensated heart failure as the primary reason for admission or a cardiovascular death. There were 126 867 and 79 192 new users of metformin and sulfonylurea, respectively. Propensity score matching yielded 65 986 per group. Median age was 66 years, and 97% of patients were male; hemoglobin A 6.9% (6.3, 7.7); body mass index 30.7 kg/m (27.4, 34.6); and 6% had heart failure history. There were 1236 events (1184 heart failure hospitalizations and 52 cardiovascular deaths) among sulfonylurea initiators and 1078 events (1043 heart failure hospitalizations and 35 cardiovascular deaths) among metformin initiators. There were 12.4 versus 8.9 events per 1000 person-years of use (adjusted hazard ratio 1.32, 95%CI 1.21, 1.43). The rate difference was 4 heart failure hospitalizations or cardiovascular deaths per 1000 users of sulfonylureas versus metformin annually.
CONCLUSIONS - Predominantly male patients initiating treatment for diabetes mellitus with sulfonylurea had a higher risk of heart failure and cardiovascular death compared to similar patients initiating metformin.
© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
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Doing More for More: Unintended Consequences of Financial Incentives for Oncology Specialty Care.
O'Neil B, Graves AJ, Barocas DA, Chang SS, Penson DF, Resnick MJ
(2016) J Natl Cancer Inst 108:
MeSH Terms: Ambulatory Surgical Procedures, Fee-for-Service Plans, Female, Humans, Male, Medicaid, Medical Oncology, Medicare, Motivation, Patient Acceptance of Health Care, Physicians, United States, Urinary Bladder Neoplasms
Show Abstract · Added February 4, 2016
BACKGROUND - Specialty care remains a significant contributor to health care spending but largely unaddressed in novel payment models aimed at promoting value-based delivery. Bladder cancer, chiefly managed by subspecialists, is among the most costly. In 2005, Centers for Medicare and Medicaid Services (CMS) dramatically increased physician payment for office-based interventions for bladder cancer to shift care from higher cost facilities, but the impact is unknown. This study evaluated the effect of financial incentives on patterns of fee-for-service (FFS) bladder cancer care.
METHODS - Data from a 5% sample of Medicare beneficiaries from 2001-2013 were evaluated using interrupted time-series analysis with segmented regression. Primary outcomes were the effects of CMS fee modifications on utilization and site of service for procedures associated with the diagnosis and treatment of bladder cancer. Rates of related bladder cancer procedures that were not affected by the fee change were concurrent controls. Finally, the effect of payment changes on both diagnostic yield and need for redundant procedures were studied. All statistical tests were two-sided.
RESULTS - Utilization of clinic-based procedures increased by 644% (95% confidence interval [CI] = 584% to 704%) after the fee change, but without reciprocal decline in facility-based procedures. Procedures unaffected by the fee incentive remained unchanged throughout the study period. Diagnostic yield decreased by 17.0% (95% CI = 12.7% to 21.3%), and use of redundant office-based procedures increased by 76.0% (95% CI = 59% to 93%).
CONCLUSIONS - Financial incentives in bladder cancer care have unintended and costly consequences in the current FFS environment. The observed price sensitivity is likely to remain a major issue in novel payment models failing to incorporate procedure-based specialty physicians.
© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
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13 MeSH Terms
Opioid Analgesics and the Risk of Serious Infections Among Patients With Rheumatoid Arthritis: A Self-Controlled Case Series Study.
Wiese AD, Griffin MR, Stein CM, Mitchel EF, Grijalva CG
(2016) Arthritis Rheumatol 68: 323-31
MeSH Terms: Adult, Age Factors, Analgesics, Opioid, Antirheumatic Agents, Arthritis, Rheumatoid, Codeine, Cohort Studies, Delayed-Action Preparations, Dextropropoxyphene, Hospitalization, Humans, Hydrocodone, Immunosuppressive Agents, Incidence, Infection, Medicaid, Middle Aged, Morphine, Oxycodone, Retrospective Studies, Risk Factors, Tennessee, United States
Show Abstract · Added July 27, 2018
OBJECTIVE - Animal studies and in vitro human studies suggest that certain opioid analgesics impair crucial immune functions. This study was undertaken to determine whether opioid use is associated with increased risk of serious infection in patients with rheumatoid arthritis (RA).
METHODS - We conducted a self-controlled case series analysis on a retrospective cohort of 13,796 patients with RA enrolled in Tennessee Medicaid in 1995-2009. Within-person comparisons of the risk of hospitalization for serious infection during periods of opioid use versus non-use were performed using conditional Poisson regression. Fixed confounders were accounted for by design; time-varying confounders included age and use of disease-modifying antirheumatic drugs, glucocorticoids, and proton-pump inhibitors. In additional analyses, risks associated with new opioid use, use of opioids known to have immunosuppressive properties, use of long-acting opioids, and different opioid dosages were assessed. Sensitivity analyses were performed to account for potential protopathic bias and confounding by indication.
RESULTS - Among 1,790 patients with RA who had at least 1 hospitalization for serious infection, the adjusted incidence rate of serious infection was higher during periods of current opioid use compared to non-use, with an incidence rate ratio (IRR) of 1.39 (95% confidence interval [95% CI] 1.19-1.62). The incidence rate was also higher during periods of long-acting opioid use, immunosuppressive opioid use, and new opioid use compared to non-use (IRR 2.01 [95% CI 1.52-2.66], IRR 1.72 [95% CI 1.33-2.23], and IRR 2.38 [95% CI 1.65-3.42], respectively). Results of sensitivity analyses were consistent with the main findings.
CONCLUSION - In within-person comparisons of patients with RA, opioid use was associated with an increased risk of hospitalization for serious infection.
© 2016, American College of Rheumatology.
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Development of an algorithm to identify serious opioid toxicity in children.
Chung CP, Callahan ST, Cooper WO, Murray KT, Hall K, Dudley JA, Stein CM, Ray WA
(2015) BMC Res Notes 8: 293
MeSH Terms: Adolescent, Algorithms, Analgesics, Opioid, Child, Child, Preschool, Clinical Coding, Drug-Related Side Effects and Adverse Reactions, Female, Humans, Male, Medicaid, Predictive Value of Tests, Reproducibility of Results, Severity of Illness Index, Tennessee, United States
Show Abstract · Added February 4, 2016
BACKGROUND - The use of opioids is increasing in children; therefore, opioid toxicity could be a public health problem in this vulnerable population. However, we are not aware of a published algorithm to identify cases of opioid toxicity in children using administrative databases. We sought to develop an algorithm to identify them. After review of literature and de-identified computer profiles, a broad set of ICD-9 CM codes consistent with serious opioid toxicity was selected. Based on these codes, we identified 195 potential cases of opioid toxicity in children enrolled in Tennessee Medicaid. Medical records were independently reviewed by two physicians; episodes considered equivocal were reviewed by an adjudication committee. Cases were adjudicated as Group 1 (definite/probable), Group 2 (possible), or Group 3 (excluded).
RESULTS - Of the 195 potential cases, 168 (86.2%) had complete records for review and 85 were confirmed cases. The overall positive predictive value (PPV) for all codes was 50.6%. The PPV for codes indicating: unintentional opioid overdose (25/31) was 80.7%; intentional opioid overdose (15/30) was 50.0%, adverse events (33/58) was 56.9%, the presence of signs or symptoms compatible with opioid toxicity (12/47) was 25.5%, and no cases were confirmed in records from the two deaths. Of the confirmed cases, 65.8% were related to therapeutic opioid use.
CONCLUSION - For studies utilizing administrative claims to quantify incidence of opioid toxicity in children, our findings suggest that use of a broad set of screening codes coupled with medical record review is important to increase the completeness of case ascertainment.
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16 MeSH Terms
Prevalence and characteristics of medication sharing behavior in a pediatric Medicaid population with asthma.
Valet RS, Gebretsadik T, Minton PA, Woodward KB, Wu AC, Hartert TV, Larkin EK
(2015) Ann Allergy Asthma Immunol 114: 151-3
MeSH Terms: Anti-Asthmatic Agents, Asthma, Child, Child, Preschool, Data Collection, Female, Humans, Male, Medicaid, Prescription Drug Misuse, Prevalence, United States
Added January 20, 2015
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12 MeSH Terms
The effect of health insurance status on the treatment and outcomes of patients with colorectal cancer.
Parikh AA, Robinson J, Zaydfudim VM, Penson D, Whiteside MA
(2014) J Surg Oncol 110: 227-32
MeSH Terms: African Continental Ancestry Group, Aged, Aged, 80 and over, Colorectal Neoplasms, Combined Modality Therapy, European Continental Ancestry Group, Female, Humans, Insurance, Health, Lymph Node Excision, Lymphatic Metastasis, Male, Medicaid, Medicare, Middle Aged, Multivariate Analysis, Neoplasm Staging, Outcome Assessment (Health Care), Proportional Hazards Models, Registries, Time-to-Treatment, United States, United States Department of Veterans Affairs, Veterans
Show Abstract · Added June 26, 2014
BACKGROUND AND OBJECTIVES - Uninsured and underinsured cancer patients often have delayed diagnosis and inferior outcomes. As healthcare reform proceeds in the US, this disparity may gain increasing importance. Our objective was to investigate the impact of health insurance status on the presentation, treatment, and survival among colorectal cancer (CRC) patients.
METHODS - A total of 10,692 patients diagnosed with CRC between 2004 and 2008 identified from the Tennessee Cancer Registry were stratified into five groups: Private, Medicare, Military, Medicaid, and uninsured. Multivariable regression models were constructed to test the association of insurance with receipt of recommended adjuvant therapy and overall survival (OS).
RESULTS - Uninsured and Medicaid patients were more often African American (AA) and presented with higher stage tumors (P < 0.001). Medicare patients were less likely to receive recommended adjuvant therapy (OR 0.54). Lack of insurance, Medicaid, and failure to receive recommended adjuvant therapy were independently associated with worse OS.
CONCLUSIONS - Although uninsured and Medicaid patients receive recommended adjuvant therapy comparable to other patients, they present with later stage disease and have a worse OS. Future studies are needed to better explain these disparities especially in the light of changing healthcare climate in the US.
© 2014 Wiley Periodicals, Inc.
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24 MeSH Terms
Medicaid and marketplace eligibility changes will occur often in all states; policy options can ease impact.
Sommers BD, Graves JA, Swartz K, Rosenbaum S
(2014) Health Aff (Millwood) 33: 700-7
MeSH Terms: Adult, Eligibility Determination, Health Insurance Exchanges, Health Policy, Humans, Income, Insurance Coverage, Medicaid, Middle Aged, Patient Protection and Affordable Care Act, State Government, United States, Young Adult
Show Abstract · Added February 19, 2015
Under the Affordable Care Act (ACA), changes in income and family circumstances are likely to produce frequent transitions in eligibility for Medicaid and health insurance Marketplace coverage for low- and middle-income adults. We provide state-by-state estimates of potential eligibility changes ("churning") if all states expanded Medicaid under health reform, and we identify predictors of rates of churning within states. Combining longitudinal survey data with state-specific weighting and small-area estimation techniques, we found that eligibility changes occurred frequently in all fifty states. Higher-income states and states that had more generous Medicaid eligibility criteria for nonelderly adults before the ACA experienced more churning, although the differences were small. Even in states with the least churning, we estimated that more than 40 percent of adults likely to enroll in Medicaid or subsidized Marketplace coverage would experience a change in eligibility within twelve months. Policy options for states to reduce the frequency and impact of coverage changes include adopting twelve-month continuous eligibility for adults in Medicaid, creating a Basic Health Program, using Medicaid funds to subsidize Marketplace coverage for low-income adults, and encouraging the same health insurers to offer plans in Medicaid and the Marketplaces.
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13 MeSH Terms