Background: Despite cardiac rehabilitation (CR) being shown to improve health outcomes among patients with heart disease, its use has been suboptimal. In response, the Million Hearts Cardiac Rehabilitation Collaborative developed a road map to improve CR use, including increasing participation rates to ≥70% by 2022. This observational study provides current estimates to measure progress and identifies the populations and regions most at risk for CR service underutilization. Methods and Results: We identified Medicare fee-for-service beneficiaries who were CR eligible in 2016, and assessed CR participation (≥1 CR session attended), timely initiation (participation within 21 days of event), and completion (≥36 sessions attended) through 2017. Measures were assessed overall, by beneficiary characteristics and geography, and by primary CR-qualifying event type (acute myocardial infarction hospitalization; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant). Among 366 103 CR-eligible beneficiaries, 89 327 (24.4%) participated in CR, of whom 24.3% initiated within 21 days and 26.9% completed CR. Eligibility was highest in the East South Central Census Division (14.8 per 1000). Participation decreased with increasing age, was lower among women (18.9%) compared with men (28.6%; adjusted prevalence ratio: 0.91 [95% CI, 0.90–0.93]) was lower among Hispanics (13.2%) and non-Hispanic blacks (13.6%) compared with non-Hispanic whites (25.8%; adjusted prevalence ratio: 0.63 [0.61–0.66] and 0.70 [0.67–0.72], respectively), and varied by hospital referral region and Census Division (range: 18.6% [East South Central] to 39.1% [West North Central]) and by qualifying event type (range: 7.1% [acute myocardial infarction without procedure] to 55.3% [coronary artery bypass surgery only]). Timely initiation varied by geography and qualifying event type; completion varied by geography. Conclusions: Only 1 in 4 CR-eligible Medicare beneficiaries participated in CR and marked disparities were observed. Reinforcement of current effective strategies and development of new strategies will be critical to address the noted disparities and achieve the 70% participation goal.

IMPORTANCE A physician's prior experience caring for a patient may be associated with patient outcomes and care patterns during and after hospitalization.OBJECTIVE To examine differences in the use of health care resources and outcomes among hospitalized patients cared for by hospitalists, their own primary care physicians (PCPs), or other generalists. DESIGN, SETTING, AND PARTICIPANTSThis retrospective study analyzed admissions for the 20 most common medical diagnoses among elderly fee-for-service Medicare patients from January 1 through December 31, 2013. Patients had at least 1 previous encounter with an outpatient clinician within the 365 days before admission, and diagnoses were restricted to the 20 most common diagnosis related groups. Data were collected from Medicare Parts A and B claims data, and outcomes were analyzed from January 1, 2013, through January 31, 2014.EXPOSURES Physician types included hospitalists, PCPs (ie, the physicians who provided a plurality of ambulatory visits in the year preceding admission), or generalists (not the patients' PCPs). MAIN OUTCOMES AND MEASURESNumber of in-hospital specialist consultations, length of stay, discharge site, all-cause 7-and 30-day readmission rates, and 30-day mortality.RESULTS A total of 560 651 admissions were analyzed (41.9% men and 59.1% women; mean [SD] age, 80 [8] years). Patients' physicians were hospitalists in 59.7% of admissions; PCPs, in 14.2%; and other generalists, in 26.1%. Primary care physicians used consultations 3% more (relative risk, 1.03; 95% CI, 1.02-1.05) and other generalists used consultations 6% more (relative risk, 1.06; 95% CI, 1.05-1.07) than hospitalists. Lengths of stay were 12% longer among patients cared for by PCPs (adjusted incidence rate ratio, 1.12; 95% CI, 1.11-1.13) and 6% longer among those cared for by other generalists (adjusted incidence rate ratio, 1.06; 95% CI, 1.05-1.07) compared with patients cared for by hospitalists. However, PCPs were more likely to discharge patients home (adjusted odds ratio [AOR], 1.14; 95% CI, 1.11-1.17), whereas other generalists were less likely to do so (AOR, 0.94; 95% CI, 0.92-0.96). Relative to hospitalists, patients cared for by PCPs had similar readmission rates at 7 days (AOR, 0.98; 95% CI, 0.96-1.01) and 30 days (AOR, 1.02; 95% CI, 0.99-1.04), whereas other generalists' readmission rates were greater than hospitalists' rates at 7 (AOR, 1.05; 95% CI, 1.02-1.07) and 30 (AOR, 1.04; 95% CI, 1.03-1.06) days. Patients cared for by PCPs had lower 30-day mortality than patients of hospitalists (AOR, 0.94; 95% CI, 0.91-0.97), whereas the mortality rate of patients of other generalists was higher (AOR, 1.09; 95% CI, 1.07-1.12). CONCLUSIONS AND RELEVANCE A PCP's prior experience with a patient may be associated with inpatient use of resources and patient outcomes. Patients cared for by their own PCP had slightly longer lengths of stay and were more likely to be discharged home but also were less likely to die within 30 days compared with those cared for by hospitalists or other genera...

BACKGROUND: Differences among hospitals in the use of inpatient consultation may contribute to variation in outcomes and costs for hospitalized patients, but basic epidemiologic data on consultations nationally are lacking. OBJECTIVE: The purpose of the study was to identify physician, hospital, and geographic factors that explain variation in rates of inpatient consultation. The primary outcome measured was number of consultations conducted during the hospitalization, summarized at the hospital level as the number of consultations per 1,000 Medicare admissions, or Bconsultation density.K EY RESULTS: Consultations occurred 2.6 times per admission on average. Among non-critical access hospitals, use of consultation varied 3.6-fold across quintiles of hospitals (933 versus 3,390 consultations per 1,000 admissions, lowest versus highest quintiles, p<0.001). Sicker patients received greater intensity of consultation (rate ratio [RR] 1.18, 95 % CI 1.17-1.18 for patients admitted to ICU; and RR 1.19, 95 % CI 1.18-1.20 for patients who died). However, even after controlling for patient-level factors, hospital characteristics also predicted differences in rates of consultation. For example, hospital size (large versus small, RR 1.31, 95 % CI 1.25-1.37), rural location (rural versus urban, RR 0.78, CI 95 % 0.76-0.80), ownership status (public versus not-for-profit, RR 0.94, 95 % CI 0.91-0.97), and geographic quadrant (Northeast versus West, RR 1.17, 95 % CI 1.12-1.21) all influenced the intensity of consultation use. CONCLUSIONS: Hospitals exhibit marked variation in the number of consultations per admission in ways not fully explained by patient characteristics. Hospital Bconsultation density^may constitute an important focus for monitoring resource use for hospitals or health systems.

Background: Medication adherence is associated with lower health care utilization and savings in specific patient populations; however, few empirical estimates exist at the population level. Objective: The main objective of this study was to apply a data-driven approach to obtain population-level estimates of the impact of medication nonadherence among Medicare beneficiaries with chronic conditions. Research Design: Medicare fee-for-service (FFS) claims data were used to calculate the prevalence of medication nonadherence among individuals with diabetes, heart failure, hypertension, and hyperlipidemia. Per person estimates of avoidable health care utilization and spending associated with medication adherence, adjusted for healthy adherer effects, from prior literature were applied to the number of nonadherent Medicare beneficiaries. Subjects: A 20% random sample of community-dwelling, continuously enrolled Medicare FFS beneficiaries aged 65 years or older with Part D (N=14,657,735) in 2013. Measures: Avoidable health care costs and hospital use from medication nonadherence. Results: Medication nonadherence for diabetes, heart failure, hyperlipidemia, and hypertension resulted in billions of Medicare FFS expenditures, millions in hospital days, and thousands of emergency department visits that could have been avoided. If the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, with over 100,000 emergency department visits and 7 million inpatient hospital days that could be averted. Conclusion: Medication nonadherence places a large resource burden on the Medicare FFS program. Study results provide actionable information for policymakers considering programs to manage chronic conditions. Caution should be used in summing estimates across disease groups, assuming all nonadherent beneficiaries could become adherent, and applying estimates beyond the Medicare FFS population.

BackgroundUtilization of cardiac services varies across regions and hospitals, yet little is known regarding variation in the intensity of outpatient cardiac care across cardiology physician practices or the association with clinical endpoints, an area of potential importance to promote efficient care.Methods and ResultsWe included 7 160 732 Medicare beneficiaries who received services from 5635 cardiology practices in 2012. Beneficiaries were assigned to practices providing the plurality of office visits, and practices were ranked and assigned to quartiles using the ratio of observed to predicted annual payments per beneficiary for common cardiac services (outpatient intensity index). The median (interquartile range) outpatient intensity index was 1.00 (0.81–1.24). Mean payments for beneficiaries attributed to practices in the highest (Q4) and lowest (Q1) quartile of outpatient intensity were: all cardiac payments (Q4 $1272 vs Q1 $581; ratio, 2.2); cardiac catheterization (Q4 $215 vs Q1 $64; ratio, 3.4); myocardial perfusion imaging (Q4 $253 vs Q1 $83; ratio, 3.0); and electrophysiology device procedures (Q4 $353 vs Q1 $142; ratio, 2.5). The adjusted odds ratios (95% CI) for 1 incremental quartile of outpatient intensity for each outcome was: cardiac surgical/procedural hospitalization (1.09 [1.09, 1.10]); cardiac medical hospitalization (1.00 [0.99, 1.00]); noncardiac hospitalization (0.99 [0.99, 0.99]); and death at 1 year (1.00 [0.99, 1.00]).ConclusionSubstantial variation in the intensity of outpatient care exists at the cardiology practice level, and higher intensity is not associated with reduced mortality or hospitalizations. Outpatient cardiac care is a potentially important target for efforts to improve efficiency in the Medicare population.