Measuring Underuse of Necessary Care Among Elderly Medicare Beneficiaries Using Inpatient and Outpatient Claims

Asch, Steven M.; Sloss, Elizabeth M.; Hogan, Christopher; Brook, Robert H.; Kravitz, Richard L.

doi:10.1001/jama.284.18.2325

Cited by 151 publications

(99 citation statements)

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“…Our results are consistent with those found by Asch et al 9 in their analysis of the underuse of necessary care in over 345,000 Medicare beneficiaries, which found that beneficiaries experienced underuse about two thirds of the time and that minorities and those living in poverty were especially at risk. Our study now expands the use of these underuse measures to include the impact of disability.…”

Section: Discussionsupporting

confidence: 93%

“…To measure the quality of care provided to these disability groups, we used a tool that was developed to measure disparities in health care using Medicare claims data, 9 because these data are linked to each MCBS participant's survey responses. This tool was developed using information from published research and expert opinion (Delphi method 6 represent avoidable outcomes, and 3 are measures of preventive care.…”

Section: Methodsmentioning

confidence: 99%

“…First, the outcome measures assessed have been limited to self-reported health maintenance items such as vaccinations, mammograms, and Pap smears and have not included other, more extensive, process measures of care that avoid recall bias. 8,9 Second, most of the population-based studies to date have been cross-sectional in nature. 10 In a cross-sectional analysis, the dynamic nature of disability is not measured.…”

mentioning

confidence: 99%

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A Longitudinal Evaluation of Persons With Disabilities: Does a Longitudinal Definition Help Define Who Receives Necessary Care?

Chan

Ciol

Shumway-Cook

et al. 2008

Archives of Physical Medicine and Rehabilitation

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Objective-To assess, using a longitudinal definition, the impact of disability on a broad range of objective health care quality indicators.Design-Longitudinal cohort study following up with patients over several years. The first 2 interviews, 1 year apart, were used to determine each patient's disability status in activities of daily living (ADLs). Assessment of the health care indicators commenced after the second interview and continued throughout the survey period (an additional 1-3y).Setting-National survey. (1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001) with no, increasing, decreasing, and stable ADL disability. Participants-Participants (N[H11005]29,074) of the Medicare Current Beneficiary Survey Interventions-Not applicable.Main Outcome Measure-The incidence of 5 avoidable outcomes, receipt of 3 preventive care measures, and adherence to 32 diagnostically based indicators assessing the quality of treatment for acute myocardial infarction [AMI], angina, breast cancer, cerebrovascular accident, transient ischemic attack, cholelithiasis, chronic obstructive pulmonary disease [COPD], congestive heart failure, depression, gastrointestinal bleeding, diabetes, and hypertension.Results-For most indicators, less than 75% of eligible patients received necessary care, regardless of disability status. For 5 indicators, less than 50% of patients received appropriate treatment. In a logistic regression analysis that controlled for patient age, sex, race, and income, disability status was a significant factor in 7 quality measures (AMI, breast cancer, COPD, diabetes, angina, pneumonia, annual visits).Conclusions-Using a longitudinal definition of disability and objective health quality indicators, we found that disability status can be an important factor in determining receipt of quality health care in a broad range of diagnostic categories. However, the impact of disability -1469, 10 Center Dr, MSC 1604, Bethesda, MD 20892-1604 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript status varies depending on the indicator measured. In this cohort of patients, the changing nature of a person's disability seems to have less impact than whether they ever have had any functional deficits. KeywordsDisability evaluation; Medicare; Rehabilitation Disability has been shown to be a risk factor for a variety of poor outcomes in health care. These adverse outcomes have been documented in several populations experiencing a wide variety of limitations including mobility limitation, communication limitation, as well as physical, sensory, and psychiatric disability. [1][2][3][4][5] In these studies, subjects with disabilities were at risk for receipt of fewer preventive measures, such as mammograms and Papanicolaou (Pap) smears, as well as decreased satisf...

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Section: Discussionsupporting

confidence: 93%

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

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A Longitudinal Evaluation of Persons With Disabilities: Does a Longitudinal Definition Help Define Who Receives Necessary Care?

Chan

Ciol

Shumway-Cook

et al. 2008

Archives of Physical Medicine and Rehabilitation

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“…While our study is the first to address preventable hospitalizations in elderly type 2 diabetic patients with comorbidities, several reports have identified inadequacies in primary care for older adults with diabetes and comorbid illnesses. Asch et al (32) estimated that only 36% of patients with diabetes receive an HbA 1c or fructosamine assessment every 6 months and only 43% receive eye exams every year. In addition, Weiner et al (33) found that 45% of elderly Medicare beneficiaries received no cholesterol screening.…”

Section: Niefeld and Associatesmentioning

confidence: 99%

Preventable Hospitalization Among Elderly Medicare Beneficiaries With Type 2 Diabetes

Niefeld

Braunstein

et al. 2003

Diabetes Care

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OBJECTIVE -To examine the impact of comorbid conditions on preventable hospitalizations among Medicare beneficiaries aged Ն65 years with type 2 diabetes.RESEARCH DESIGN AND METHODS -Data were drawn from the 1999 Medicare Standard Analytic Files, a 5% nationally representative random sample of Medicare beneficiaries. The analysis sample included 193,556 Medicare beneficiaries aged Ն65 years with type 2 diabetes (ICD-9-CM codes 250.xx) who were enrolled in fee-for-service Medicare. Preventable hospitalization was assessed by measuring ambulatory care-sensitive conditions, an accepted measure of hospitalizations that could have been prevented with appropriate outpatient care. Multivariable analyses controlled for demographics; mortality; renal, ophthalmic, or neurological manifestations of diabetes; type of physician providing the outpatient care; and per capita community-level indicators of income and hospital beds.RESULTS -Ninety-six percent of beneficiaries in the sample had a comorbidity, and 46% had five or more comorbidities. Among beneficiaries with type 2 diabetes, cardiovascular-related comorbidities were common and accounted for increased odds of preventable hospitalization, controlling for other factors. The likelihood of a preventable hospitalization increased in the presence of a claim for comorbid congestive heart failure, cardiomyopathy, coronary atherosclerosis, hypertension, or cardiac dysrythmias. Noncardiovascular comorbidities associated with a greater likelihood of preventable hospitalization included chronic obstructive pulmonary disease, asthma and lower respiratory disorders, Alzheimer's disease/dementia, personality/anxiety disorders, depression, and osteoporosis. Our data suggest that nearly 7% of all hospitalizations could be avoided.CONCLUSIONS -These findings support the need for improved outpatient care strategies to reduce the impact of comorbidity on unnecessary hospitalization in patients aged Ն65 years with type 2 diabetes. Diabetes Care 26:1344 -1349, 2003T ype 2 diabetes is a major cause of morbidity and mortality. Diabetes complicates the diagnosis and treatment of other medical disorders, particularly in an elderly population already burdened by extensive comorbidity (1). For instance, both diabetes and older age can mask the typical manifestations of cardiac ischemia (2-4). Elderly patients with diabetes have more extensive atherosclerosis (5), experience worse clinical outcomes after revascularization (6 -11), and are two to four times more likely to die from cardiovascular disease (CVD) than elderly patients without diabetes (12-15). Appropriate management of subjects with type 2 diabetes and other comorbidities may differ substantially from the management of those without comorbidities (16 -18). Individuals with diabetes and concomitant comorbidities are at an increased risk of using greater resources by requiring more hospitalizations, longer hospital stays, and more expensive services (12,19 -21).Despite knowledge regarding interactions between diabetes and specific comor...

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“…Actually, these consequences influence patients" satisfaction and acceptance of the available care and services. Our results may also shed light on the issue of low care consumption by underserved populations (Auvray et al, 2001;Asch, 2000) -including the under-use of the clinics designed for them (a fact that professionals and researchers often underscore; for example, Klein et al, 2000). Based on a quantitative survey conducted at free clinics, we show that people experiencing humiliation run a higher risk of forgoing care and drugs than people experiencing settling-in (Chauvin & Parizot, 2003).…”

Section: Discussionmentioning

confidence: 62%

The moral career of poor patients in free clinics

Parizot

Chauvin

Paugam

2005

Social Science & Medicine

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AcknowledgementsThis research was supported by the INSERM Avenir programme, the Institut de l"Humanitaire and Médecins du Monde. Isabelle Parizot and Serge Paugam used the NGO data from an earlier analysis. Our thanks go to Jean-Marie Firdion and Julien Damon for helpful comments and suggestions with this. We also would like to thank the staff at the clinics and all the patients who answered our questions. 3 The Moral Career of Poor Patients in Free Clinics AbstractThis paper explores the lived experiences and the identity processes attached to attendance at free clinics. It draws on a qualitative study of 94 patients and 37 professionals that were interviewed at four free clinics in France. Since these facilities are for the poor and for people without health coverage, attendance reflects a medical experience as well as an experience of assistance, both of which have an impact on healthcare utilisation. Nevertheless, the meaning attached to the recourse to free clinics and the patients" lived experiences change over time and depend on interactions with clinic staff. This study proposes a typology of care recourse modes (occasional, regular and inconsistent attendance) crossed with different types of lived experiences. Occasional attendance and distant patient-professionals relationships, often due to the humiliation that some people feel when they have to ask for social assistance, characterise the first times people have recourse to care. Patients commit to regular followups only when they have come to terms with their position in the medical and assistance system, doing so by rationalising and adjusting their identity. When discussing our findings, our outlook is to gain greater insight into the utilisation of healthcare by different population groups and in different contexts. Abstract word count: 202 words

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Measuring Underuse of Necessary Care Among Elderly Medicare Beneficiaries Using Inpatient and Outpatient Claims

Cited by 151 publications

References 32 publications

A Longitudinal Evaluation of Persons With Disabilities: Does a Longitudinal Definition Help Define Who Receives Necessary Care?

A Longitudinal Evaluation of Persons With Disabilities: Does a Longitudinal Definition Help Define Who Receives Necessary Care?

Preventable Hospitalization Among Elderly Medicare Beneficiaries With Type 2 Diabetes

The moral career of poor patients in free clinics

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