Hemoglobin A1c Testing and Amputation Rates in Black, Hispanic, and White Medicare Patients

Annals of Vascular Surgery
Suckow BD, Newhall KA, Bekelis K, Faerber AE, Gottlieb DJ, Skinner JS

Major (above-knee or below-knee) amputation is a complication of diabetes and is seen more common among black and Hispanic patients. While amputation rates have declined for patients with diabetes in the last decade, it remains unknown if these improvements have equitably extended across racial groups and if measures of diabetic care, such as hemoglobin A1c testing, are associated with these improvements. We set out to characterize secular changes in amputation rates among black, Hispanic, and white patients, and to determine associations between hemoglobin A1c testing and amputation risk.

Physician Practice Style Variation—Implications for Policy

JAMA Internal Medicine
Van Parys J and Skinner J

Practice style variation at the regional level has been well documented at different geographic levels, but there is much less research focusing on the role of individual physician variability in practice. Two studies have shown considerable variation in the practice styles of cardiologists who treat patients with acute myocardial infarction and obstetricians who perform cesarean-sections, but less is known about how the use of non-recommended or “low-value” care varies across physicians.

Long-Term Revisional or Contralateral Treatments After Carotid Revascularization in the Vascular Quality Initiative

Journal of Vascular Surgery
Svoboda RM, Newhall K, Sedrakyan A, Skinner J, Stone DH, Goodney PP

Significant work has detailed the risk of long-term stroke, myocardial infarction, and death in patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS). However, little is known about the relative rates of subsequent intervention following these procedures. We aimed to compare the rates of subsequent carotid artery intervention—either ipsilateral or contralateral—for patients undergoing CEA and CAS.

Primary Stroke Center Hospitalization for Elderly Patients With Stroke Implications for Case Fatality and Travel Times

JAMA Internal Medicine
Kimon Bekelis, MD; Nancy J. Marth, MS, MSN; Kendrew Wong, BS; Weiping Zhou, MS; John D. Birkmeyer, MD; Jonathan Skinner, PhD

Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care.

An analysis of patient-sharing physician networks and implantable cardioverter defibrillator therapy

Health Services and Outcomes Research Methodology
Moen EL, Austin AM, Bynum JP, Skinner JS, O’Malley AJ

The application of social network analysis to the organization of healthcare delivery is a relatively new area of research that may not be familiar to health services statisticians and other methodologists. We present a methodological introduction to social network analysis with a case study of physicians’ adherence to clinical guidelines regarding use of implantable cardioverter defibrillators (ICDs) for the prevention of sudden cardiac death. We focus on two hospital referral regions in Indiana, Gary and South Bend, characterized by different rates of evidence-based ICD use (86 and 66 %, respectively). Using Medicare Part B claims, we construct a network of physicians who care for cardiovascular disease patients based on patient-sharing relationships. Approaches for weighting physician dyads and aggregating physician dyads by hospital are discussed. Then, we obtain a set of weighted network statistics for the positions of hospitals in their referral region, global statistics for the physician network within each hospital, and of the network positions of individual physicians within hospitals, providing the mathematical specification and sociological intuition underlying each measure. We find that adjusting for network measures can reduce the observed differences between referral regions for evidence-based ICD therapy. This study supports previous reports on how variation in physician network structure relates to utilization of care, and motivates future work using physician network measures to examine variation in evidence-based medicine.

Consistency of Hemoglobin A1c Testing and Cardiovascular Outcomes in Medicare Patients With Diabetes

Journal of the American Heart Association
Goodney PP, Newhall KA, Bekelis K, Gottlieb D, Comi R, Chaudrain S, Faerber AE, Mackenzie TA, Skinner JS

Annual hemoglobin A1c testing is recommended for patients with diabetes mellitus. However, it is unknown how consistently patients with diabetes mellitus receive hemoglobin A1c testing over time, or whether testing consistency is associated with adverse cardiovascular outcomes.

Out-of-Pocket Medical Expenditures in the United States: Evidence from the Health and Retirement Study

Fiscal Studies
Sean Fahle, Kathleen McGarry, and Jonathan Skinner

We use data from the Health and Retirement Study (HRS) to document the distribution of out-of-pocket medical spending among individuals aged 55 and over in the US. The HRS data permit us to examine out-of-pocket spending close to the end of life and to analyse the components of spending in more detail than has been done in previous studies. We find that spending risk rises sharply at older ages and near the end of life. While the median individual spent $6,328 out-of-pocket in the last year of life, 5 per cent were reported to have spent over $62,040. Our results also indicate that out-of-pocket spending is highly concentrated, with the top 10 per cent of spenders accounting for 42 per cent of all spending, and very persistent, even over periods spanning many years. Finally, while certain categories of spending are very responsive to income and wealth, we do not find overall spending to be highly concentrated along these dimensions. Viewed within the international context, our results suggest that the fraction of households facing very high out-of-pocket spending is substantially greater in the US than in other developed countries.

The Past and Future of the Affordable Care Act

JAMA
Jonathan Skinner and Amitabh Chandra

President Barack Obama has provided a comprehensive assessment of the Affordable Care Act (ACA),1 which as he indicates is the most comprehensive health care reform since Medicare. In 1965, Medicare passed in the House with a 313-115 vote and in the Senate with a 68-21 vote. By contrast, the ACA barely reached the filibusterproof threshold of 60 votes in the Senate and passed the House with a 219-212 vote. As President Obama has chronicled, that the ACA passed at all, let alone survived multiple Supreme Court and Congressional challenges, is a political miracle.

Despite these compromises and partial setbacks, the primary goal of the ACA has been met: to expand the number of people with health insurance. With an estimated expansion in health insurance of 20 million individuals, President Obama is right to claim credit for the ACA. But counting up the number of individuals with insurance is not enough to assess if the ACA was a success. Perhaps the more important measures are whether the ACA improved health and saved money. For example, the 2008 Oregon Health Insurance Experiment, a randomized trial of Medicaid expansion, found that newly insured individuals used more hospital care, were given more prescription drugs, and received more preventive care than before receiving insurance. Individuals were less likely to be diagnosed with depression and experienced lessmedical debt, a leading source of bankruptcy. Although almost everyone reported being able to see a physician, hypertension and diabetes control did not change relative to the control group, overall medical spending increased by $1000 per person annually, and emergency department use increased by 40%.

These findings from Oregon, in contrast to claims that were made to justify the ACA,4 suggest both optimism and caution for the ACA’s primary goal of expanding insurance coverage and the related consequences. Even Medicaid—an insurance program that offers lower payment rates and narrower networks than commercial insurers andMedicare—is valuable but possibly less valuable than had been hoped. In other words, providing health insurance may not automatically result in an improvement in health when health care systems are fragmented and inefficient.

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The relationship of regional hemoglobin A1c testing and amputation rate among patients with diabetes

Vascular
Karina A Newhall, Kimon Bekelis, Bjoern D Suckow, Daniel J Gottlieb, Adrienne E Farber, Philip P Goodney, and Jonathan S Skinner

The risk of leg amputation among patients with diabetes has declined over the past decade, while use of preventative measures—such as hemoglobin A1c monitoring—has increased. However, the relationship between hemoglobin A1c testing and amputation risk remains unclear.

Use of Guideline-Directed Medications for Heart Failure Before Cardioverter-Defibrillator Implantation

Journal of the American College of Cardiology
Roth GA , Poole JE , Zaha R , Zhou W , Skinner JS , Morden NE

Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is recommended before primary prevention implantable cardioverter-defibrillator (ICD) placement. Adherence to this recommendation and associated outcomes are unknown.