Measuring Local-Area Racial Segregation for Medicare Hospital Admissions

JAMA Network Open

Ellesse-Roselee L. Akr., Deanna Chyn, Heather A. Carlos, Amber E. Barnato, Jonathan Skinner

Considerable racial segregation exists in U.S. hospitals which cannot be explained by where patients live. Using 2019 Medicare claims data linked to geographic data, we define a hospital’s market based on ZIP-code based driving time, and estimate the racial composition of all hospitalizations in that market. We then compare the racial composition of the hospital with the racial composition of its market. In our sample of 4.9 million hospital admissions, we find a considerable degree of sorting, with Black Medicare enrollees more likely admitted to some hospitals in their market, and less likely to be admitted to other hospitals nearby.  At a regional level, we observed the greatest degree of patient sorting in the New York, Chicago, and Detroit HRRs.

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The role of comorbidities,medications, and social determinants of health in understanding urban-rural outcome differences among patients with heart failure

The journal of Rural Health

Emily P. Zeitler, Joanna Joly, Christopher G. Leggett, Sandra L.Wong, A. JamesO’Malley, Sally A. Kraft, Matthew B. Mackwood, Sarah T. Jones,Jonathan S. Skinner

The role of comorbidities, medications, and social determinants of health in understanding urban-rural outcome differences among patients with heart failure.

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Public versus Private Care in the Military Health System: Evidence From Low Back Pain Patients

Military Medicine

Christopher G. Leggett, Rachel O. Schmidt, Jonathan Skinner, Jon D. Lurie, William Patrick Luan

Introduction There is a longstanding debate about whether health care is more efficiently provided by the public or private sector. The debate is particularly relevant to the Military Health System (MHS), which delivers care through a combination of …

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A Regional Analysis of Low Back Pain Treatments in the Military Health System

Spine Health Services Research

Jon D. Lurie, Christopher G. Leggett, Jonathan Skinner, Eugene Carragee, Andrea M. Austin, and William Patrick Luan

Low back pain (LBP) is a common, potentially disabling, condition with an estimated point prevalence of 12% and a lifetime prevalence of 40%.1 LBP is a particular concern for the Military Health System (MHS) and a leading cause of medical separation from service for soldiers.2,3 From 2010 to 2014, LBP was associated with over 6 million outpatient visits and 25,000 hospitalizations among active service members4; much more active-duty personnel might be seen informally and triaged back to training without recorded visits within the MHS.

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The role of comorbidities, medications, and social determinants of health in understanding urban-rural outcome differences among patients with heart failure

Journal of Rural Health

Zeitler EP, Joly J, Leggett CG, Wong SL, O'Malley AJ, Kraft SA, Mackwood MB, Jones ST, Skinner JS

There is now a 20% disparity in all-cause, excess deaths between urban and rural areas, much of which is driven by disparities in cardiovascular death. We sought to explain the sources of these disparities for Medicare beneficiaries with heart failure with reduced ejection fraction (HFrEF).

Among patients with HFrEF, living in a rural area is associated with an increased risk of death and return ER visits within 30 days of discharge from HF hospitalization. Differences in SDOH appear to partially explain mortality differences but the remaining gap may be the consequence of rural-urban differences in HF treatment.

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Receipt of Medications for Chronic Disease During the First 2 Years of the COVID-19 Pandemic Among Enrollees in Fee-for-Service Medicare

JAMA Network OPEN

Nancy E. Morden, Weiping Zhou, Ziad Obermeyer, Jonathan Skinner

During the first 2 years of the COVID-19 pandemic, inpatient and ambulatory care

declined dramatically. Little is known about prescription drug receipt during this period, particularly

for populations with chronic illness and with high risk of adverse COVID-19 outcomes and decreased

access to care.

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The Diffusion of Health Care Fraud: A Network Analysis

Social Science & Medicine

A. James O’Malley, Thomas A. Bubolz, Jonathan S. Skinner

Many studies have examined the diffusion of health care innovations but less is known about the diffusion of health care fraud. In this paper, we consider the diffusion of potentially fraudulent Medicare home health care billing in the United States during 2002-16, with a focus on the 21 hospital referral regions (HRRs) covered by local Department of Justice anti-fraud “strike force” offices. We hypothesize that patient-sharing across home health care agencies provides a mechanism for the rapid diffusion of fraudulent strategies; we measure such activity using a novel bipartite mixture (or BMIX) network index. First, we find a remarkable increase in home health care activity between 2002 and 2009 in some but not all regions; average billing per Medicare enrollees in McAllen TX and Miami increased by $2,127 and $2,422 compared to a $289 increase in other HRRs not targeted by the Department of Justice. Second, we establish that the HRR-level BMIX (but not other network measures) was a strong predictor of above-average home care expenditures across HRRs. Third, within HRRs, agencies sharing more patients with other agencies were predicted to increase spending the following year. Finally, the initial 2002 BMIX index was a strong predictor of subsequent changes in HRR-level home health billing during 2002-9. These results highlight the importance of bipartite network structure in diffusion and in infection models more generally.

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Association Between Opening a Palliative Care Unit and Hospital Care for Patients with Serious Illness

Journal of Palliative Medicine

Meredith A. MacMartin, Olivia A. Sacks, Andrea M. Austin,Gouri Chakraborti,Elizabeth A. Stedina,Jonathan S. Skinner, Amber E. Barnato

Palliative care units (PCUs) are devoted to intensive management of symptoms and other palliative care needs. We examined the association between opening a PCU and acute care processes at a single U.S. academic medical center.

We retrospectively compared acute care processes for seriously ill patients admitted before and after the opening of a PCU at a single academic medical center. Outcomes included rates of change in code status to do-not-resuscitate (DNR) and comfort measures only (CMO) status, and time to DNR and CMO. We calculated unadjusted and adjusted rates and used logistic regression to assess interaction between care period and palliative care consultation.

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What explains different rates of nursing home admissions? Comparing the United States to Denmark and the Netherlands

The Journal of the Economics of Ageing

Judith Bom, Pieter Bakx, Eddy van Doorslaer, Mette Gørtz, Jonathan Skinner

The share of older adults residing in a nursing home is much higher in the Netherlands and Denmark than in the US, while in the US, perhaps surprisingly, individuals are much more likely to be admitted to a nursing home. We explore reasons for the higher US admission rates and aim to understand to what extent these differences are due to (i) differences in the composition of the population aged 65+ or (ii) differences in LTC system features.

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A Regional Analysis of Low Back Pain Treatments in the Military Health System

Spine (Phila Pa 1976)

Lurie JD, Leggett CG, Skinner J, Carragee E, Austin AM, Luan WP.

To compare rates of utilization of 5 LBP treatments (physical therapy, manual therapy, behavioral therapies, opioid and benzodiazepine prescription) across catchment areas and assess their association with resolution of LBP.

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Benefits and harms of oral anticoagulants for atrial fibrillation in nursing home residents with advanced dementia

Journal of the American Geriatrics Society

Gregory M. Ouellet, John R. O'Leary, Christopher G. Leggett, Jonathan Skinner, Mary E. Tinetti, Andrew B. Cohen

Although the potential benefits of anticoagulation for AF diminish as individuals with dementia develop more profound cognitive and functional loss, guidelines currently provide little guidance about when to consider discontinuation. This study provides valuable information to clinicians and surrogate decision-makers as they discuss whether to continue anticoagulation in patients with advanced dementia, who have high dementia-related mortality and for whom the primary goal is most frequently comfort.

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The association between beta-blockers and outcomes in patients with heart failure and concurrent Alzheimer's disease and related dementias

Journal of the American Geriatrics

Lauren Gilstrap, Andrew Cohen, Gregory M. Ouellet, Parag Goyal, Barbara Gladders, Danette Flint, Jonathan Skinner

Background Contemporary patients with heart failure with reduced ejection fraction
(HFrEF) are older and have a higher prevalence of cognitive impairment than those
studied in trials. The risk/benefit trade-off of routine beta-blocker (BB) use in patients …

Geographical Variation in Health Spending Across the US Among Privately Insured Individuals and Enrollees in Medicaid and Medicare

JAMA Network

Zack Cooper, Olivia Stiegman, Chima D. Ndumele, Becky Staiger, Jonathan Skinner

Little is known about small-area variations in health care spending and utilization across the 3 major funders of health care in the US: Medicare, Medicaid, and private insurers.

To measure regional health spending and utilization across Medicare, Medicaid, and the privately insured; to observe whether there are regions that are simultaneously low spending for all 3 payers; and to determine what factors are correlated with regional spending and utilization by payer.

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Improving Efficiency in Medical Diagnosis

JAMA

Leila Agha, Jonathan Skinner, David Chan

The US health care system experiences wide variation in diagnosis rates forcommonconditions,muchof which is drivenby differences indiagnostic practice rather than byunderlyingpatient health.1 Diagnosis-related errors are common, and a report from 2014 estimated that 12 million patientsmayexperienceanoutpatient diagnostic error each year.2 To improve health outcomes and reduce unnecessaryspending,theUShealthsystemshouldmove toward greater efficiency in medical diagnosis.

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The Federal Health Authority, a Federal Reserve System for Health Care COVID-19 Has Exposed a Need for Change

JAMA Health Forum

James N. Weinstein, William B. Weeks, Jonathan S. Skinner

In 1907, a financial collapse led to a major US national recession, a 17%decline in industrial output,1 and creation of the Federal Reserve system in 1913 to “provide a means by which periodic panics which shake the American Republic and do it enormous injury shall be stopped.”2 The current COVID-19 pandemic shares many of the same causes as the Panic of 1907: lack of a coordinated federal response, lax state-level regulations, and absence of clear strategies to respond and recover from the initial outbreak. Therefore, we propose a new entity paralleling the Federal Reserve —the Federal Health Authority (FHA)—to anticipate health shocks, coordinate future responses, and address longer-term problems in the nation’s health and health care. Just as the Federal Reserve is tasked with sustainably maximizing the nation’s financial health, the FHAwould be tasked with doing the same for the nation’s health.

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Geographic Variation in Apical Support Procedures for Pelvic Organ Prolapse

Obstet Gynecol

Kristen A. Gerjevic, Helen Newton, Christopher Leggett, Jonathan Skinner, Elisabeth Erekson, Kris Strohbehn

To measure geographic variation in rates of apical support procedures for the treatment of pelvic organ prolapse (POP) among female Medicare beneficiaries.

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Advance Care Planning and Treatment Intensity Before Death Among Black, Hispanic, and White Patients Hospitalized with COVID-19

Journal General Internal Medicine

Amber E. Barnato, Gregory R. Johnson, John D. Birkmeyer, Jonathan S. Skinner, Alistair James O’Malley, Nancy J. O. Birkmeyer

Black and Hispanic people aremore likely to contract COVID-19, require hospitalization, and die thanWhite people due to differences in exposures, comorbidity risk, and healthcare access.

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Trends in Mortality Rates Among Medicare Enrollees With Alzheimer Disease and Related Dementias Before and During the Early Phase of the COVID-19 Pandemic

JAMA Neurology

Lauren Gilstrap, Weiping Zhou, Marcella Alsan, Anoop Nanda, Jonathan S. Skinner

Mortality rates from March through December 2020 were compared with those from March through December 2019. Excess mortality was calculated by comparing mortality rates in 2020 with rates in 2019 for specific, predetermined groups. Means were compared using t tests, and 95% CIs were estimated using the delta method.

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Complications and Mortality Following CRT-D Versus ICD Implants in Older Medicare Beneficiaries With Heart Failure

J A C C : Heart Failure

Emily P. Zeitler, Andrea M. Austin, Christopher G. Leggett, Lauren Gilstrap, Daniel J. Friedman, Jonathan S. Skinner, Sana M. Al-Khatib

Heart failure (HF) remains a fast-growing cardiovascular disease affecting the Medicare population in large numbers (1,2). Increasingly, HF is managed as a chronic disease, in part because of the incremental improvements achieved with medical and device-based therapies. Despite the large proportion of older patients with HF, clinical trials designed to assess HF interventions rarely include an adequate number of older patients...

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