Publications by authors named "Jose F Figueroa"

66 Publications

Racial and Ethnic Disparities in Heart and Cerebrovascular Disease Deaths During the COVID-19 Pandemic in the United States.

Circulation 2021 May 18. Epub 2021 May 18.

Cardiovascular Division, Washington University School of Medicine, Saint Louis, MO.

Cardiovascular deaths increased during the early phase of the COVID-19 pandemic in the United States. However, it is unclear whether racial/ethnic minorities have experienced a disproportionate rise in heart disease and cerebrovascular disease deaths. We used the National Center for Health Statistics to identify heart disease and cerebrovascular disease deaths for non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic individuals from March-August 2020 (pandemic period), as well as for the corresponding months in 2019 (historical control). We determined the age- and sex-standardized deaths per million by race/ethnicity for each year. We then fit a modified Poisson model with robust standard errors to compare change in deaths by race/ethnicity for each condition in 2020 vs. 2019. There were a total of 339,076 heart disease and 76,767 cerebrovascular disease deaths from March through August 2020, compared to 321,218 and 72,190 deaths during the same months in 2019. Heart disease deaths increased during the pandemic in 2020, compared with the corresponding period in 2019, for non-Hispanic White (age-sex standardized deaths per million, 1234.2 vs. 1208.7; risk ratio for death [RR] 1.02, 95% CI 1.02-1.03), non-Hispanic Black (1783.7 vs. 1503.8; RR 1.19, 1.17-1.20), non-Hispanic Asian (685.7 vs. 577.4; RR 1.19, 1.15-1.22), and Hispanic (968.5 vs. 820.4, RR 1.18, 1.16-1.20) populations. Cerebrovascular disease deaths also increased for non-Hispanic White (268.7 vs. 258.2; RR 1.04, 95% CI 1.03-1.05), non-Hispanic Black (430.7 vs. 379.7; RR 1.13, 95% CI 1.10-1.17), non-Hispanic Asian (236.5 vs. 207.4; RR 1.15, 1.09-1.21), and Hispanic (264.4 vs. 235.9; RR 1.12, 1.08-1.16) populations. For both heart disease and cerebrovascular disease deaths, each racial and ethnic minority group experienced a larger relative increase in deaths than the non-Hispanic White population (interaction term, p<0.001). During the COVID-19 pandemic in the US, Black, Hispanic, and Asian populations experienced a disproportionate rise in deaths due to heart disease and cerebrovascular disease, suggesting that racial/ethnic minorities have been most impacted by the indirect effects of the pandemic. Public health and policy strategies are needed to mitigate the short- and long-term adverse effects of the pandemic on the cardiovascular health of minority populations.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.121.054378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191372PMC
May 2021

Reforms to the Radiation Oncology Model: Prioritizing Health Equity.

Int J Radiat Oncol Biol Phys 2021 Jun;110(2):328-330

Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts. Electronic address:

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http://dx.doi.org/10.1016/j.ijrobp.2021.01.029DOI Listing
June 2021

Association Between Industry Marketing Payments and Prescriptions for PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) Inhibitors in the United States.

Circ Cardiovasc Qual Outcomes 2021 May 10;14(5):e007521. Epub 2021 May 10.

Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.S., D.S.K.).

Background: Marketing payments from the pharmaceutical industry to physicians have come under scrutiny due to their potential to influence clinical decision-making. Two proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) were approved by the US Food and Drug Administration in 2015 for reducing low-density lipoprotein cholesterol in high-risk patients, but their initial uptake was limited due to their high-cost and stringent prior authorization requirements. We sought to investigate the association between industry marketing and early adoption of PCSK9i among US physicians.

Methods: We used nationwide databases of primary care physicians, cardiologists, and endocrinologists treating Medicare beneficiaries to examine the association between PCSK9i-related marketing payments in 2016 and the number of filled PCSK9i prescriptions in 2017, after adjusting for physician characteristics. In subgroup analyses, we stratified our analyses by physician specialty and prior experience with prescribing PCSK9i.

Results: Among 209 840 physicians included in this analysis, 49 341 (24%) physicians received 292 941 PCSK9i-related marketing payments in 2016. The total value of these payments was $19 million, with a median payment of $61 per physician (interquartile range, $25-$132). Most payments (95%) were for meals, with a median of $14 per meal. The receipt of PCSK9i-related payments in 2016 was associated with increased PCSK9i prescription in 2017 (adjusted risk ratio, 3.18 [95% CI, 2.95-3.42]). This association was larger among primary care physicians (adjusted risk ratio, 6.67 [95% CI, 5.87-7.57]) than cardiologists (adjusted risk ratio, 2.00 [95% CI, 1.84-2.16]) and endocrinologists (adjusted risk ratio, 4.06 [95% CI, 2.95-5.59]). The association was observed across all types of payments.

Conclusions: At a time when few physicians had experience with prescribing PCSK9i under strict prior authorization requirements, industry marketing payments to physicians for PCSK9i, predominantly in the form of meals, were associated with increased PCSK9i prescription in the subsequent year.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007521DOI Listing
May 2021

Comparison of General Surgical Practice Size and Setting in 2017 vs 2013 in the US.

JAMA Netw Open 2021 Apr 1;4(4):e216848. Epub 2021 Apr 1.

Department of Health Policy and Management, Harvard Chan School of Public Health, Boston, Massachusetts.

Importance: As health care delivery markets have changed and new payment models have emerged, physicians in many specialties have consolidated their practices, but whether this consolidation has occurred in surgical practices is unknown.

Objective: To examine changes in the size of surgical practices, market-level factors associated with this consolidation, and how place of service for surgical care delivery varies by practice size.

Design, Setting, And Participants: A cross-sectional study of Medicare Data on Provider Practice and Specialty from January 1 to December 31, 2013, compared with January 1 to December 31, 2017, was conducted on all general surgeon practices caring for patients enrolled in Medicare in the US. Data analysis was performed from November 4, 2019, to January 9, 2020.

Exposures: Practice sizes in 2013 and 2017 were compared relative to hospital market concentration measured by the Herfindahl-Hirschman Index in the hospital referral region.

Main Outcomes And Measures: The primary outcome was the change in size of surgical practices over the study period. Secondary outcomes included change in surgical practice market concentration and the place of service for provision of surgical care stratified by surgical practice size.

Results: From 2013 to 2017, the number of surgical practices in the US decreased from 10 432 to 8451. The proportion of surgeons decreased in practices with 1 (from 26.2% to 17.4%), 2 (from 8.3% to 6.6%), and 3 to 5 (from 18.0% to 16.5%) surgeons, and the proportion of surgeons in practices with 6 or more surgeons increased (from 47.6% to 59.5%). Hospital concentration was associated with an increase in the size of the surgical practice. Each 10% increase in the hospital market concentration was associated with an increase of 0.204 surgeons (95% CI, 0.020-0.388 surgeons; P = .03) per practice from 2013 to 2017. Similarly, a 10% increase in the hospital-level HHI was associated with an increase in the surgical practice HHI of 0.023 (95% CI, 0.013-0.033; P < .001). Large surgical practices increased their share of Medicare services provided from 36.5% in 2013 to 45.6% in 2017. Large practices (31.3% inpatient in 2013 to 33.1% in 2017) were much more likely than small practices (19.0% inpatient in 2013 to 17.7% in 2017) to be based in hospital settings and this gap widened over time.

Conclusions And Relevance: Surgeons have increasingly joined larger practices over time, and there has been a significant decrease in solo, small, and midsize surgical practices. The consolidation of surgeons into larger practices appears to be associated with hospital market concentration in the same market. Although overall care appears to be more hospital based for larger practices, the association between the consolidation of surgical practices and patient access and outcomes should be studied.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.6848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082320PMC
April 2021

Value of Discharging Heart Failure Patients Home-Reply.

JAMA Cardiol 2021 Mar 24. Epub 2021 Mar 24.

Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri.

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http://dx.doi.org/10.1001/jamacardio.2021.0324DOI Listing
March 2021

Disparities in Surgical Readmissions and Use of Observation Status in Hip and Knee Replacements: A Retrospective Cohort Study.

Ann Surg 2021 Jul;274(1):e90-e91

Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1097/SLA.0000000000004806DOI Listing
July 2021

Rural-Urban Disparities In All-Cause Mortality Among Low-Income Medicare Beneficiaries, 2004-17.

Health Aff (Millwood) 2021 02;40(2):289-296

Rishi K. Wadhera is an assistant professor of medicine at Harvard Medical School and an investigator at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center.

There is growing concern about the health of older US adults who live in rural areas, but little is known about how mortality has changed over time for low-income Medicare beneficiaries residing in rural areas compared with their urban counterparts. We evaluated whether all-cause mortality rates changed for rural and urban low-income Medicare beneficiaries dually enrolled in Medicaid, and we studied disparities between these groups. The study cohort included 11,737,006 unique dually enrolled Medicare beneficiaries. Between 2004 and 2017 all-cause mortality declined from 96.6 to 92.7 per 1,000 rural beneficiaries (relative percentage change: -4.0 percent). Among urban beneficiaries, declines in mortality were more pronounced (from 86.9 to 72.8 per 1,000 beneficiaries, a relative percentage change of -16.2 percent). The gap in mortality between rural and urban beneficiaries increased over time. Rural mortality rates were highest in East North Central states and increased modestly in West North Central states during the study period. Public health and policy efforts are urgently needed to improve the health of low-income older adults living in rural areas.
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http://dx.doi.org/10.1377/hlthaff.2020.00420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168613PMC
February 2021

Comparison of deep learning with traditional models to predict preventable acute care use and spending among heart failure patients.

Sci Rep 2021 Jan 13;11(1):1164. Epub 2021 Jan 13.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Recent health reforms have created incentives for cardiologists and accountable care organizations to participate in value-based care models for heart failure (HF). Accurate risk stratification of HF patients is critical to efficiently deploy interventions aimed at reducing preventable utilization. The goal of this paper was to compare deep learning approaches with traditional logistic regression (LR) to predict preventable utilization among HF patients. We conducted a prognostic study using data on 93,260 HF patients continuously enrolled for 2-years in a large U.S. commercial insurer to develop and validate prediction models for three outcomes of interest: preventable hospitalizations, preventable emergency department (ED) visits, and preventable costs. Patients were split into training, validation, and testing samples. Outcomes were modeled using traditional and enhanced LR and compared to gradient boosting model and deep learning models using sequential and non-sequential inputs. Evaluation metrics included precision (positive predictive value) at k, cost capture, and Area Under the Receiver operating characteristic (AUROC). Deep learning models consistently outperformed LR for all three outcomes with respect to the chosen evaluation metrics. Precision at 1% for preventable hospitalizations was 43% for deep learning compared to 30% for enhanced LR. Precision at 1% for preventable ED visits was 39% for deep learning compared to 33% for enhanced LR. For preventable cost, cost capture at 1% was 30% for sequential deep learning, compared to 18% for enhanced LR. The highest AUROCs for deep learning were 0.778, 0.681 and 0.727, respectively. These results offer a promising approach to identify patients for targeted interventions.
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http://dx.doi.org/10.1038/s41598-020-80856-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7806727PMC
January 2021

Accountable Care Organizations during Covid-19: Routine care for older adults with multiple chronic conditions.

Healthc (Amst) 2021 Mar 14;9(1):100511. Epub 2020 Dec 14.

Harvard T.H. Chan School of Public Health, Department of Health Policy & Management, Boston, MA, USA; Brigham and Women's Hospital, Department of Medicine, Division of General Internal Medicine, Harvard Medical School, Boston, MA, USA. Electronic address:

The COVID-19 pandemic threatens the health and well-being of older adults with multiple chronic conditions. To date, limited information exists about how Accountable Care Organizations (ACOs) are adapting to manage these patients. We surveyed 78 Medicare ACOs about their concerns for these patients during the pandemic and strategies they are employing to address them. ACOs expressed major concerns about disruptions to necessary care for this population, including the accessibility of social services and long-term care services. While certain strategies like virtual primary and specialty care visits were being used by nearly all ACOs, other services such as virtual social services, home medication delivery, and remote lab monitoring were far less commonly accessible. ACOs expressed that support for telehealth services, investment in remote monitoring capabilities, and funding for new, targeted care innovation initiatives would help them better care for vulnerable patients during this pandemic.
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http://dx.doi.org/10.1016/j.hjdsi.2020.100511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832775PMC
March 2021

Association of race, ethnicity, and community-level factors with COVID-19 cases and deaths across U.S. counties.

Healthc (Amst) 2021 Mar 21;9(1):100495. Epub 2020 Nov 21.

Harvard T.H. Chan School of Public Health, Department of Health Policy & Management, Boston, MA, USA; Harvard Global Health Institute, Harvard University, Cambridge, MA, USA.

The United States currently has one of the highest numbers of cumulative COVID-19 cases globally, and Latino and Black communities have been disproportionately affected. Understanding the community-level factors that contribute to disparities in COVID-19 case and death rates is critical to developing public health and policy strategies. We performed a cross-sectional analysis of U.S. counties and found that a 10% point increase in the Black population was associated with 324.7 additional COVID-19 cases per 100,000 population and 14.5 additional COVID-19 deaths per 100,000. In addition, we found that a 10% point increase in the Latino population was associated with 293.5 additional COVID-19 cases per 100,000 and 7.6 additional COVID-19 deaths per 100,000. Independent predictors of higher COVID-19 case rates included average household size, the share of individuals with less than a high school diploma, and the percentage of foreign-born non-citizens. In addition, average household size, the share of individuals with less than a high school diploma, and the proportion of workers that commute using public transportation independently predicted higher COVID-19 death rates within a community. After adjustment for these variables, the association between the Latino population and COVID-19 cases and deaths was attenuated while the association between the Black population and COVID-19 cases and deaths largely persisted. Policy efforts must seek to address the drivers identified in this study in order to mitigate disparities in COVID-19 cases and deaths across minority communities.
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http://dx.doi.org/10.1016/j.hjdsi.2020.100495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680060PMC
March 2021

Changes in Racial Disparities in Mortality After Cancer Surgery in the US, 2007-2016.

JAMA Netw Open 2020 12 1;3(12):e2027415. Epub 2020 Dec 1.

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

Importance: Racial disparities are well documented in cancer care. Overall, in the US, Black patients historically have higher rates of mortality after surgery than White patients. However, it is unknown whether racial disparities in mortality after cancer surgery have changed over time.

Objective: To examine whether and how disparities in mortality after cancer surgery have changed over 10 years for Black and White patients overall and for 9 specific cancers.

Design, Setting, And Participants: In this cross-sectional study, national Medicare data were used to examine the 10-year (January 1, 2007, to November 30, 2016) changes in postoperative mortality rates in Black and White patients. Data analysis was performed from August 6 to December 31, 2019. Participants included fee-for-service beneficiaries enrolled in Medicare Part A who had a major surgical resection for 9 common types of cancer surgery: colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, or prostate cancer.

Exposures: Cancer surgery among Black and White patients.

Main Outcomes And Measures: Risk-adjusted 30-day, all-cause, postoperative mortality overall and for 9 specific types of cancer surgery.

Results: A total of 870 929 cancer operations were performed during the 10-year study period. In the baseline year, a total of 103 446 patients had cancer operations (96 210 White patients and 7236 Black patients). Black patients were slightly younger (mean [SD] age, 73.0 [6.4] vs 74.5 [6.8] years), and there were fewer Black vs White men (3986 [55.1%] vs 55 527 [57.7%]). Overall national mortality rates following cancer surgery were lower for both Black (-0.12%; 95% CI, -0.17% to -0.06% per year) and White (-0.14%; 95% CI, -0.16% to -0.13% per year) patients. These reductions were predominantly attributable to within-hospital mortality improvements (Black patients: 0.10% annually; 95% CI, -0.15% to -0.05%; P < .001; White patients: 0.13%; 95% CI, -0.14% to -0.11%; P < .001) vs between-hospital mortality improvements. Across the 9 different cancer surgery procedures, there was no significant difference in mortality changes between Black and White patients during the period under study (eg, prostate cancer: 0.35; 95% CI, 0.02-0.68; lung cancer: 0.61; 95% CI, -0.21 to 1.44).

Conclusions And Relevance: These findings offer mixed news for policy makers regarding possible reductions in racial disparities following cancer surgery. Although postoperative cancer surgery mortality rates improved for both Black and White patients, there did not appear to be any narrowing of the mortality gap between Black and White patients overall or across individual cancer surgery procedures.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.27415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716190PMC
December 2020

Polysocial Risk Scores for Assessing Social Determinants of Health-Reply.

JAMA 2020 10;324(16):1681-1682

Harvard T. H. Chan School of Public Health, Cambridge, Massachusetts.

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http://dx.doi.org/10.1001/jama.2020.15702DOI Listing
October 2020

Association of Clinician Health System Affiliation With Outpatient Performance Ratings in the Medicare Merit-based Incentive Payment System.

JAMA 2020 09;324(10):984-992

Cardiovascular Division, School of Medicine, Washington University in St Louis, St Louis, Missouri.

Importance: Integration of physician practices into health systems composed of hospitals and multispecialty practices is increasing in the era of value-based payment. It is unknown how clinicians who affiliate with such health systems perform under the new mandatory Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS) relative to their peers.

Objective: To assess the relationship between the health system affiliations of clinicians and their performance scores and value-based reimbursement under the 2019 MIPS.

Design, Setting, And Participants: Publicly reported data on 636 552 clinicians working at outpatient clinics across the US were used to assess the association of the affiliation status of clinicians within the 609 health systems with their 2019 final MIPS performance score and value-based reimbursement (both based on clinician performance in 2017), adjusting for clinician, patient, and practice area characteristics.

Exposures: Health system affiliation vs no affiliation.

Main Outcomes And Measures: The primary outcome was final MIPS performance score (range, 0-100; higher scores intended to represent better performance). The secondary outcome was MIPS payment adjustment, including negative (penalty) payment adjustment, positive payment adjustment, and bonus payment adjustment.

Results: The final sample included 636 552 clinicians (41% female, 83% physicians, 50% in primary care, 17% in rural areas), including 48.6% who were affiliated with a health system. Compared with unaffiliated clinicians, system-affiliated clinicians were significantly more likely to be female (46% vs 37%), primary care physicians (36% vs 30%), and classified as safety net clinicians (12% vs 10%) and significantly less likely to be specialists (44% vs 55%) (P < .001 for each). The mean final MIPS performance score for system-affiliated clinicians was 79.0 vs 60.3 for unaffiliated clinicians (absolute mean difference, 18.7 [95% CI, 18.5 to 18.8]). The percentage receiving a negative (penalty) payment adjustment was 2.8% for system-affiliated clinicians vs 13.7% for unaffiliated clinicians (absolute difference, -10.9% [95% CI, -11.0% to -10.7%]), 97.1% vs 82.6%, respectively, for those receiving a positive payment adjustment (absolute difference, 14.5% [95% CI, 14.3% to 14.6%]), and 73.9% vs 55.1% for those receiving a bonus payment adjustment (absolute difference, 18.9% [95% CI, 18.6% to 19.1%]).

Conclusions And Relevance: Clinician affiliation with a health system was associated with significantly better 2019 MIPS performance scores. Whether this represents differences in quality of care or other factors requires additional research.
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http://dx.doi.org/10.1001/jama.2020.13136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489823PMC
September 2020

Quality of Care and Outcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized With Heart Failure.

JAMA Cardiol 2020 Dec;5(12):1349-1357

Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.

Importance: Medicare Advantage (MA), a private insurance plan option, now covers one-third of all Medicare beneficiaries. Although patients with cardiovascular disease enrolled in MA have been reported to receive higher quality of care in the ambulatory setting than patients enrolled in fee-for-service (FFS) Medicare, it is unclear whether MA is associated with higher quality in patients hospitalized with heart failure, or alternatively, if incentives to reduce utilization under MA plans may be associated with worse care.

Objective: To determine whether there are differences in quality of care received and in-hospital outcomes among patients enrolled in MA vs FFS Medicare.

Design, Setting, And Participants: Observational, retrospective cohort study of patients hospitalized with heart failure in hospitals participating in the Get With the Guidelines-Heart Failure registry.

Exposures: Medicare Advantage enrollment.

Main Outcomes And Measures: In-hospital mortality, discharge disposition, length of stay, and 4 heart failure achievement measures.

Results: Of 262 626 patients hospitalized with heart failure, 93 549 (35.6%) were enrolled in MA and 169 077 (64.4%) in FFS Medicare. The median (interquartile range) age was 78 (70-85) years for patients enrolled in MA and 78 (69-86) years for patients enrolled in FFS Medicare. Standard mean differences in age, sex, prevalence of comorbidities, or objective measures on admission, including vital signs and laboratory values, were less than 10%. After adjustment, there were no statistically significant differences in receipt of evidence-based β-blockers when indicated; angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, or angiotensin receptor-neprilysin inhibitors at discharge; measurement of left ventricular function; and postdischarge appointments by Medicare insurance type. Patients enrolled in MA, however, had higher odds of being discharged directly home (adjusted odds ratio [AOR], 1.16; 95% CI, 1.13-1.19; P < .001) relative to patients enrolled in FFS Medicare and lower odds of being discharged within 4 days (AOR, 0.97; 95% CI, 0.93-1.00; P = .04). There was no significant difference in in-hospital mortality between patients with MA and patients with FFS Medicare (AOR, 0.98; 95% CI, 0.92-1.03; P = .42).

Conclusions And Relevance: Among patients hospitalized with heart failure, no observable benefit was noted in quality of care or in-hospital mortality between those enrolled in MA vs FFS Medicare, except lower use of post-acute care facilities. As MA continues to grow, it will be important to ensure that participating private plans provide an added value to the patients they cover to justify the higher administrative costs compared with traditional FFS Medicare.
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http://dx.doi.org/10.1001/jamacardio.2020.3638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489427PMC
December 2020

Accountable Care Organizations Are Associated with Savings Among Medicare Beneficiaries with Frailty.

J Gen Intern Med 2020 Aug 31. Epub 2020 Aug 31.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

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http://dx.doi.org/10.1007/s11606-020-06166-6DOI Listing
August 2020

Community-Level Factors Associated With Racial And Ethnic Disparities In COVID-19 Rates In Massachusetts.

Health Aff (Millwood) 2020 11 27;39(11):1984-1992. Epub 2020 Aug 27.

Benjamin D. Sommers is the Huntley Quelch Professor of Health Care Economics in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and a professor of medicine at Brigham and Women's Hospital and Harvard Medical School, all in Boston, Massachusetts.

Massachusetts has one of the highest cumulative incidence rates of coronavirus disease 2019 (COVID-19) cases in the US. Understanding which specific demographic, economic, and occupational factors have contributed to disparities in COVID-19 incidence rates across the state is critical to informing public health strategies. We performed a cross-sectional study of 351 Massachusetts cities and towns from January 1 to May 6, 2020, and found that a 10-percentage-point increase in the Black non-Latino population was associated with an increase of 312.3 COVID-19 cases per 100,000 population, whereas a 10-percentage-point increase in the Latino population was associated with an increase of 258.2 cases per 100,000. Independent predictors of higher COVID-19 rates included the proportion of foreign-born noncitizens living in a community, mean household size, and share of food service workers. After adjustment for these variables, the association between the Latino population and COVID-19 rates was attenuated. In contrast, the association between the Black population and COVID-19 rates persisted but may be explained by other systemic inequities. Public health and policy efforts that improve care for foreign-born noncitizens, address crowded housing, and protect food service workers may help mitigate the spread of COVID-19 among minority communities.
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http://dx.doi.org/10.1377/hlthaff.2020.01040DOI Listing
November 2020

Association of Medicare Advantage Penetration With Per Capita Spending, Emergency Department Visits, and Readmission Rates Among Fee-for-Service Medicare Beneficiaries With High Comorbidity Burden.

Med Care Res Rev 2020 Aug 26:1077558720952582. Epub 2020 Aug 26.

University of Pennsylvania, Philadelphia, PA, USA.

Rapid growth of Medicare Advantage (MA) plans has the potential to change clinical practice for both MA and fee-for-service (FFS) beneficiaries, particularly for high-need, high-cost beneficiaries with multiple chronic conditions or a costly single condition. We assessed whether MA growth from 2010 to 2017 spilled over to county-level per capita spending, emergency department visits, and readmission rates among FFS beneficiaries, and how much this varied by the comorbidity burden of the beneficiary. We also examined whether the association between MA growth and per capita spending in FFS varied in beneficiaries with specific chronic conditions. MA growth was associated with decreased FFS spending and emergency department visits only among beneficiaries with six or more chronic conditions. MA growth was associated with decreased FFS spending among beneficiaries with 11 of the 20 chronic conditions. This suggests that MA growth may drive improvements in efficiency of health care delivery for high-need, high-cost beneficiaries.
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http://dx.doi.org/10.1177/1077558720952582DOI Listing
August 2020

Consolidation Among Cardiologists Across U.S. Practices Over Time.

J Am Coll Cardiol 2020 08;76(5):590-593

Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri; Washington University Institute for Public Health, Center for Health Economics and Policy, St. Louis, Missouri. Electronic address: https://twitter.com/kejoynt.

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http://dx.doi.org/10.1016/j.jacc.2020.04.081DOI Listing
August 2020

Hospital Readmission and Emergency Department Revisits of Homeless Patients Treated at Homeless-Serving Hospitals in the USA: Observational Study.

J Gen Intern Med 2020 09 14;35(9):2560-2568. Epub 2020 Jul 14.

Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.

Background: As the U.S. homeless population grows, so has the challenge of providing effective care to homeless individuals. Understanding hospitals that achieve better outcomes after hospital discharge for homeless patients has important implications for making our health system more sustainable and equitable.

Objective: To determine whether homeless patients experience higher rates of readmissions and emergency department (ED) visits after hospital discharge than non-homeless patients, and whether the homeless patients exhibit lower rates of readmissions and ED visits after hospital discharge when they were admitted to hospitals experienced with the treatment of the homeless patients ("homeless-serving" hospitals-defined as hospitals in the top decile of the proportion of homeless patients).

Design: A population-based longitudinal study, using the data including all hospital admissions and ED visits in FL, MA, MD, and NY in 2014.

Participants: Participants were 3,527,383 patients (median age [IQR]: 63 [49-77] years; 1,876,466 [53%] women; 134,755 [4%] homeless patients) discharged from 474 hospitals.

Main Measures: Risk-adjusted rates of 30-day all-cause readmissions and ED visits after hospital discharge.

Key Results: After adjusting for potential confounders, homeless patients had higher rates of readmissions (adjusted rate, 27.3% vs. 17.5%; adjusted odds ratio [aOR], 1.93; 95% CI, 1.69-2.21; p < 0.001) and ED visits after hospital discharge (37.1% vs. 23.6%; aOR, 1.98; 95% CI, 1.74-2.25; p < 0.001) compared with non-homeless patients. Homeless patients treated at homeless-serving hospitals exhibited lower rates of readmissions (23.9% vs. 33.4%; p < 0.001) and ED visits (31.4% vs. 45.4%; p < 0.001) after hospital discharge than homeless patients treated at non-homeless-serving hospitals.

Conclusions: Homeless patients were more likely to be readmitted or return to ED within 30 days after hospital discharge, especially when they were treated at hospitals that treat a small proportion of homeless patients. These findings suggest that homeless patients may receive better discharge planning and care coordination when treated at hospitals experienced with caring for homeless people.
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http://dx.doi.org/10.1007/s11606-020-06029-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459070PMC
September 2020

Avoidable Hospitalizations And Observation Stays: Shifts In Racial Disparities.

Health Aff (Millwood) 2020 06;39(6):1065-1071

Ashish K. Jha is the director of the Harvard Global Health Institute and is dean of global strategy and the K. T. Li Professor of Global Health, Harvard T. H. Chan School of Public Health.

Racial disparities in hospitalization rates for ambulatory care-sensitive conditions are concerning and may signal differential access to high-quality ambulatory care. Whether racial disparities are improving as a result of better ambulatory care versus artificially narrowing because of increased use of observation status is unclear. Using Medicare data for 2011-15, we sought to determine whether black-white disparities in avoidable hospitalizations were improving and evaluated the degree to which changes in observations for ambulatory care-sensitive conditions may be contributing to changes in these gaps. We found that while the racial gap in avoidable hospitalizations due to such conditions has decreased, that seems to be explained by a concomitant increase in the gap of avoidable observation stays. This suggests that changes from inpatient admissions to observation status seem to be driving the reduction in racial disparities in avoidable hospitalizations, rather than changes in the ambulatory setting.
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http://dx.doi.org/10.1377/hlthaff.2019.01019DOI Listing
June 2020

Primary Care Utilization and Expenditures in Traditional Medicare and Medicare Advantage, 2007-2016.

J Gen Intern Med 2020 08 6;35(8):2480-2481. Epub 2020 May 6.

Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1007/s11606-020-05826-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7403260PMC
August 2020

A PATH TO RESUME AESTHETIC CARE EXECUTIVE SUMMARY OF PROJECT AesCert™ GUIDANCE SUPPLEMENT: PRACTICAL CONSIDERATIONS FOR AESTHETIC MEDICINE PROFESSIONALS SUPPORTING CLINIC PREPAREDNESS IN RESPONSE TO THE SARS-CoV-2 OUTBREAK.

Facial Plast Surg Aesthet Med 2020 May 2. Epub 2020 May 2.

Harvard Medical School, 1811, Medicine, Boston, Massachusetts, United States;

This Project AesCert™ Guidance Supplement ("Guidance Supplement") was developed in partnership with a multi-disciplinary panel of board-certified physician and doctoral experts in the fields of Infectious Disease, Immunology, Public Health Policy, Dermatology, Facial Plastic Surgery and Plastic Surgery. The Guidance Supplement is intended to provide aesthetic medicine physicians and their staffs with a practical guide to safety considerations to support clinic preparedness for patients seeking non-surgical aesthetic treatments and procedures following the return-to-work phase of the COVID-19 pandemic, once such activity is permitted by applicable law. Many federal, state and local governmental authorities, public health agencies and professional medical societies have promulgated COVID-19 orders and advisories applicable to health care practitioners. The Guidance Supplement is intended to provide aesthetic physicians and their staffs with an additional set of practical considerations for delivering aesthetic care safely and generally conducting business responsibly in the new world of COVID-19. Aesthetic providers will face new and unique challenges as government stay-at-home orders and related commercial limitations are eased, and the U.S. economy reopens and healthcare systems transition from providing only urgent and other essential treatment to resuming routine care and elective procedures and services. The medical aesthetic specialties will therefore wish to resume practice in order to ensure high quality, expert care is available, and importantly to help promote patients' positive self-image and sense of well-being following a lengthy and stressful period of quarantine. In a number of areas, this Guidance Supplement exceeds traditional aesthetic office safety precautions, recognizing reduced tolerance in an elective treatment environment for any risk associated with COVID-19's highly variable presentation and unpredictable course. The disease has placed a disturbing number of young, otherwise healthy patients in extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits and other suddenly life-threatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. Accordingly, the Guidance Supplement seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers. While the Guidance Supplement cannot foreclose the risk of infection, nor serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain non-surgical procedures typically performed in aesthetic medical settings. It is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual healthcare professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public health conditions.
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http://dx.doi.org/10.1089/abc.2020.0239DOI Listing
May 2020

Association between industry payments for opioid products and physicians' prescription of opioids: observational study with propensity-score matching.

J Epidemiol Community Health 2020 08 29;74(8):647-654. Epub 2020 Apr 29.

Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA

Background: Industry marketing to physicians for opioids has received substantial attention as it can potentially influence physicians' prescription of opioids. However, robust evidence demonstrating a causal link between industry payments for opioids and physicians' prescription practice for opioids is lacking.

Methods: Using the national databases of physicians treating Medicare beneficiaries, we examined the association between physicians' receipt of opioid-related industry payments in 2016 and (1) the number of opioids prescribed and (2) the annual expenditures for the opioid products by those physicians in 2017, using propensity-score matching in a 1:1 ratio adjusting for the physician characteristics (sex, years in practice, medical school attended, specialty), the number of opioid prescriptions in 2016, and physicians' financial relationships with industry in 2015. We compared matched pairs of physicians using the estimated effect and paired t-test.

Results: Among 43 778 physicians included after propensity-score matching, physicians who received opioid-related industry payments in 2016 prescribed more opioids (153.8 vs 129.7; adjusted difference (95% CI), 24.1 (19.1 to 29.1)) and accounted for more spending due to opioids ($10 476 vs $6983; adjusted difference (95% CI), $3493 (2854 to 4134)) in 2017, compared with physicians who did not receive payments. The association was larger among primary care physicians than surgeons or specialists. The dose-response analysis revealed that even a small amount of industry payments was sufficient to effectively affect physicians' prescription practice of opioids.

Conclusions: Opioid-related industry payments to physicians in the prior year were associated with a higher number of opioid prescriptions and expenditures for opioid products in the subsequent year.
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http://dx.doi.org/10.1136/jech-2020-214021DOI Listing
August 2020

Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs.

JAMA 2020 Jun;323(21):2192-2195

Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2020.7197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191469PMC
June 2020

Quality Measure Development and Associated Spending by the Centers for Medicare & Medicaid Services.

JAMA 2020 04;323(16):1614-1616

Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2020.1816DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189223PMC
April 2020

Addressing Social Determinants of Health: Time for a Polysocial Risk Score.

JAMA 2020 Apr;323(16):1553-1554

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2020.2436DOI Listing
April 2020

Association of Mental Health Disorders With Health Care Spending in the Medicare Population.

JAMA Netw Open 2020 03 2;3(3):e201210. Epub 2020 Mar 2.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: The degree to which the presence of mental health disorders is associated with additional medical spending on non-mental health conditions is largely unknown.

Objective: To determine the proportion and degree of total spending directly associated with mental health conditions vs spending on other non-mental health conditions.

Design, Setting, And Participants: This retrospective cohort study of 4 358 975 fee-for-service Medicare beneficiaries in the US in 2015 compared spending and health care utilization among Medicare patients with serious mental illness (SMI; defined as bipolar disease, schizophrenia or related psychotic disorders, and major depressive disorder), patients with other common mental health disorders (defined as anxiety disorders, personality disorders, and posttraumatic stress disorder), and patients with no known mental health disorders. Data analysis was conducted from February to October 2019.

Exposure: Diagnosis of an SMI or other common mental health disorder.

Main Outcomes And Measures: Risk-adjusted, standardized spending and health care utilization. Multivariable linear regression models were used to adjust for patient characteristics, including demographic characteristics and other medical comorbidities, using hospital referral region fixed effects.

Results: Of 4 358 975 Medicare beneficiaries, 987 379 (22.7%) had an SMI, 326 991 (7.5%) had another common mental health disorder, and 3 044 587 (69.8%) had no known mental illness. Compared with patients with no known mental illness, patients with an SMI were younger (mean [SD] age, 72.3 [11.6] years vs 67.4 [15.7] years; P < .001) and more likely to have dual eligibility (633 274 [20.8%] vs 434 447 [44.0%]; P < .001). Patients with an SMI incurred more mean (SE) spending on mental health services than those with other common mental health disorders or no known mental illness ($2024 [3.9] vs $343 [6.2] vs $189 [2.1], respectively; P < .001). Patients with an SMI also had substantially higher mean (SE) spending on medical services for physical conditions than those with other common mental health disorders or no known mental illness ($17 651 [23.6] vs $15 253 [38.2] vs $12 883 [12.8], respectively; P < .001), reflecting $4768 (95% CI, $4713-$4823; 37% increase) more in costs for patients with an SMI and $2370 (95% CI, $2290-$2449; 18.4% increase) more in costs for patients with other common mental health disorders. Among Medicare beneficiaries, $2 686 016 110 of $64 326 262 104 total Medicare spending (4.2%) went to mental health services and an additional $5 482 791 747 (8.5%) went to additional medical spending associated with mental illness, representing a total of 12.7% of spending associated with mental health disorders.

Conclusions And Relevance: In this study, having a mental health disorder was associated with spending substantially more on other medical conditions. These findings quantify the extent of additional spending in the Medicare fee-for-service population associated with a diagnosis of a mental health disorder.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.1210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082719PMC
March 2020

Mortality and Hospitalizations for Dually Enrolled and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older, 2004 to 2017.

JAMA 2020 03;323(10):961-969

Center for Health Economics and Policy, Institute for Public Health and Cardiovascular Division, School of Medicine, Washington University in St Louis, St Louis, Missouri.

Importance: Medicare beneficiaries who are also enrolled in Medicaid (dually enrolled beneficiaries) have drawn the attention of policy makers because they comprise the poorest subset of the Medicare population; however, it is unclear how their outcomes have changed over time compared with those only enrolled in Medicare (nondually enrolled beneficiaries).

Objective: To evaluate annual changes in all-cause mortality, hospitalization rates, and hospitalization-related mortality among dually enrolled beneficiaries and nondually enrolled beneficiaries.

Design, Setting, And Participants: Serial cross-sectional study of Medicare fee-for-service beneficiaries aged 65 years or older between January 2004 and December 2017. The final date of follow-up was September 30, 2018.

Exposures: Dual vs nondual enrollment status.

Main Outcomes And Measures: Annual all-cause mortality rates; all-cause hospitalization rates; and in-hospital, 30-day, 1-year hospitalization-related mortality rates.

Results: There were 71 017 608 unique Medicare beneficiaries aged 65 years or older (mean age, 75.6 [SD, 9.2] years; 54.9% female) enrolled in Medicare for at least 1 month from 2004 through 2017. Of these beneficiaries, 11 697 900 (16.5%) were dually enrolled in Medicare and Medicaid for at least 1 month. After adjusting for age, sex, and race, annual all-cause mortality rates declined from 8.5% (95% CI, 8.45%-8.56%) in 2004 to 8.1% (95% CI, 8.05%-8.13%) in 2017 among dually enrolled beneficiaries and from 4.1% (95% CI, 4.08%-4.13%) in 2004 to 3.8% (95% CI, 3.76%-3.79%) in 2017 among nondually enrolled beneficiaries. The difference in annual all-cause mortality between dually and nondually enrolled beneficiaries increased between 2004 (adjusted odds ratio, 2.09 [95% CI, 2.08-2.10]) and 2017 (adjusted odds ratio, 2.22 [95% CI, 2.21-2.23]) (P < .001 for interaction between dual enrollment status and time). All-cause hospitalizations per 100 000 beneficiary-years declined from 49 888 in 2004 to 41 121 in 2017 among dually enrolled beneficiaries (P < .001) and from 29 000 in 2004 to 22 601 in 2017 among nondually enrolled beneficiaries (P < .001); however, the difference between these groups widened between 2004 (adjusted risk ratio, 1.72 [95% CI, 1.71-1.73]) and 2017 (adjusted risk ratio, 1.83 [95% CI, 1.82-1.83]) (P < .001 for interaction). Among hospitalized beneficiaries, the risk-adjusted 30-day mortality rates declined from 10.3% (95% CI, 10.22%-10.33%) in 2004 to 10.1% (95% CI, 10.02%-10.20%) in 2017 among dually enrolled beneficiaries and from 8.5% (95% CI, 8.50%-8.56%) in 2004 to 8.1% (95% CI, 8.06%-8.13%) in 2017 among nondually enrolled beneficiaries. In contrast, 1-year mortality increased among hospitalized beneficiaries from 23.1% (95% CI, 23.05%-23.20%) in 2004 to 26.7% (95% CI, 26.58%-26.84%) in 2017 among dually enrolled beneficiaries and from 18.1% (95% CI, 18.11%-18.17%) in 2004 to 20.3% (95% CI, 20.21%-20.31%) in 2017 among nondually enrolled beneficiaries. The difference in hospitalization-related outcomes between dually and nondually enrolled beneficiaries persisted during the study period.

Conclusions And Relevance: Among Medicare fee-for-service beneficiaries aged 65 years or older, dually enrolled beneficiaries had higher annual all-cause mortality, all-cause hospitalizations, and hospitalization-related mortality compared with nondually enrolled beneficiaries. Between 2004 and 2017, these differences did not decrease.
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http://dx.doi.org/10.1001/jama.2020.1021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064881PMC
March 2020