Publications by authors named "Partha Deb"

43 Publications

The impact of the State Innovation Models Initiative on population health.

Econ Hum Biol 2021 May 5;42:101013. Epub 2021 May 5.

Visiting Nurse Service of New York, 220 East 42 Street, Floor 7, New York, NY 10017, United States.

In this paper, we examine the effects of the State Innovation Models Initiative (SIM) on population-level health status. SIM provided $250 million to six states in 2013 for broad delivery system reforms. We use data from the Behavioral Risk Factor Surveillance System for the years 2010-2016. Our sample is restricted to individuals ages 45 and older residing in 6 SIM and 15 control states. Treatment effects in a difference-in-difference design are estimated using a latent factor model for multiple indicators of health status. In addition to estimates for the primary sample, we obtain estimates for six subsamples based on strata of age, education, income, race and urban/rural status. We find that individuals in states that implemented SIM show significant improvements in health status. The effects of SIM are greater among older, Medicare eligible individuals, including those living in rural areas. The State Innovation Models Initiative, which provided financial incentives for states to implement health care delivery system reforms, led to population-level improvements in health status.
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http://dx.doi.org/10.1016/j.ehb.2021.101013DOI Listing
May 2021

Radiation Without Endocrine Therapy in Older Women With Stage I Estrogen-Receptor-Positive Breast Cancer Is Not Associated With a Higher Risk of Second Breast Cancer Events.

Int J Radiat Oncol Biol Phys 2021 May 8. Epub 2021 May 8.

Department of Population Health, NYU School of Medicine, New York, New York.

Purpose: The omission of radiation therapy (RT) in older women with stage 1 estrogen-receptor-positive (ER+) breast cancer receiving endocrine therapy (ET) is an acceptable strategy based on randomized trial data. Less is known about the omission of ET with or without RT.

Methods And Materials: We analyzed surveillance, epidemiology, and end results (SEER)-Medicare data for 13,321 women age 66 years or older with stage I ER+ breast cancer from 2007 to 2012 who underwent breast-conserving surgery. Patients were classified into 4 groups: (1) ET + RT (reference); (2) ET alone; (3) RT alone; and (4) neither RT nor ET (NT). Second breast cancer events (SBCEs) were captured using the Chubak high-specificity algorithm. We used χ tests for descriptive statistics, multivariable multinomial logistic regression to estimate relative risk of undergoing a treatment, and multivariable, propensity-weighted competing-risks survival regression to estimate standardized hazard ratio (SHR) of SBCE. We set significance at P ≤ .01.

Results: Most women underwent both treatments, with 44% undergoing ET + RT, 41% RT alone, 6.6% ET alone, and 8.6% NT, but practice patterns varied over time. From 2007 to 2012, RT decreased from 49% to 30%, whereas ET alone and ET + RT increased (ET alone, 5.4%-9.6%; ET + RT, 38%-51%). Compared with patients age 66 to 69 years, patients age 80 to 85 years were more likely to receive NT (odds ratio [OR], 8.9), RT (OR, 1.9), or ET (OR, 8.8) versus ET + RT (P < .01). Three percent of subjects had an SBCE (2.2% ET + RT, 3.0% RT alone, 3.2% ET alone, 7.0% NT). Relative to ET + RT, NT and ET alone were associated with higher SBCE (NT: SHR, 3.7, P < .001; ET alone: SHR, 2.2, P = .008), whereas RT was not associated with a higher SBCE (SHR 1.21; P = .137). Clinical factors associated with higher SBCE were HER2 positivity and pT1c (SHR, 1.7; P = .006).

Conclusions: Treatment with RT alone in older women with stage I ER+ disease is decreasing. RT alone is not associated with an increased risk for SBCE. By contrast, NT and ET are both associated with higher SBCE in multivariable analysis with propensity weighting. Further study of the omission of endocrine therapy in this patient population is warranted.
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http://dx.doi.org/10.1016/j.ijrobp.2021.04.030DOI Listing
May 2021

Nursing facilities, food manufacturing plants and COVID-19 cases and deaths.

Econ Lett 2021 Apr 25;201:109800. Epub 2021 Feb 25.

University of Michigan, School of Public Health, Department of Health Management and Policy, 1415 Washington Heights, Ann Arbor, MI 48109, USA.

News outlets pointed to meatpacking plants and nursing homes as viral hotspots during the first wave of the COVID-19 pandemic in the US. In contrast to news reports, we find that retirement communities and assisted living facilities were associated with fewer cases and deaths and that skilled nursing facilities were associated with fewer cases. We find that meatpacking plants were associated with more cases and deaths as were bakeries. In contrast dairy plants were associated with fewer cases and deaths. Proactive implementation of policy measures in nursing homes and retirement facilities were beneficial. Analogous guidance was lacking for food manufacturing establishments, potentially exacerbating the spread of the virus.
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http://dx.doi.org/10.1016/j.econlet.2021.109800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906540PMC
April 2021

Risk Factors for Long-term Mortality and Patterns of End-of-Life Care Among Medicare Sepsis Survivors Discharged to Home Health Care.

JAMA Netw Open 2020 02 5;3(2):e200038. Epub 2020 Feb 5.

Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Importance: Despite a growing recognition of the increased mortality risk among sepsis survivors, little is known about the patterns of end-of-life care among this population.

Objective: To describe patterns of end-of-life care among a national sample of sepsis survivors and identify factors associated with long-term mortality risk and hospice use.

Design, Setting, And Participants: This cohort study assessed sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care using national Medicare administrative, claims, and home health assessment data from 2013 to 2014. The initial and final primary analyses were conducted in July 2017 and from July to August 2019, respectively.

Exposures: Sepsis hospital discharge and 1 or more home health assessments within 1 week.

Main Outcomes And Measures: Outcomes were 1-year mortality among all sepsis survivors and hospitalization in the last 30 days of life, death in an acute care hospital, and hospice use among decedents. Multivariate logistic regression was used to identify factors associated with 1-year mortality and hospice use.

Results: Among 87 581 sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care, 49 323 (56.3%) were aged 75 years or older, 69 499 (79.4%) were non-Hispanic white, and 48 472 (55.3%) were female. Among the total survivors, 24 423 (27.9%) people died within 1 year of discharge, with a median (interquartile range) survival time of 119 (51-220) days. Among these decedents, 16 684 (68.2%) were hospitalized in the last 30 days of life, 6560 (26.8%) died in an acute care hospital, and 12 573 (51.4%) were enrolled in hospice, with 5729 (45.6%) using hospice for 7 or fewer days. Several factors were associated with 1-year mortality, including a cancer diagnosis (odds ratio [OR], 3.66; 95% CI, 3.50-3.83; P < .001), multiple dependencies of activities of daily living or instrumental activities of daily living (OR, 2.80; 95% CI, 2.57-3.05; P < .001), and an overall poor health status (OR, 2.21; 95% CI, 2.01-2.44; P < .001) documented on home health assessment. Among the decedents, cancer was associated with hospice use (OR, 2.25; 95% CI, 2.11-2.41; P < .001), patients aged 85 years or older (OR, 1.49; 95% CI, 1.37-1.61; P < .001), and living in an assisted living setting (OR, 1.93; 95% CI, 1.69-2.19; P < .001).

Conclusions And Relevance: The findings of this study suggest that death within 1 year after sepsis discharge may be common among Medicare beneficiaries discharged to home health care. Although 1 in 2 decedents used hospice, aggressive care near the end of life and late hospice referral were common. Readily identifiable risk factors suggest opportunities to target efforts to improve palliative and end-of-life care among high-risk sepsis survivors.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.0038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137683PMC
February 2020

Till death do us part: the effect of marital status on health care utilization and costs at end-of-life. A register study on all colorectal cancer decedents in Norway between 2009 and 2013.

BMC Health Serv Res 2020 Feb 13;20(1):115. Epub 2020 Feb 13.

Institute of Health and Society, University of Oslo, Oslo, Norway.

Background: Economic analyses of end-of-life care often focus on single aspects of care in selected cohorts leading to limited knowledge on the total level of care required to patients at their end-of-life. We aim at describing the living situation and full range of health care provided to patients at their end-of-life, including how informal care affects formal health care provision, using the case of colorectal cancer.

Methods: All colorectal cancer decedents between 2009 and 2013 in Norway (n = 7695) were linked to six national registers. The registers included information on decedents' living situation (days at home, in short- or long-term institution or in the hospital), their total health care utilization and costs in the secondary, primary and home- and community-based care setting. The effect of informal care was assessed through marital status (never married, currently married, or previously married) using regression analyses (negative binominal, two-part models and generalized linear models), controlling for age, gender, comorbidities, education, income, time since diagnosis and year of death.

Results: The average patient spent four months at home, while he or she spent 27 days in long-term institutions, 16 days in short-term institutions, and 21 days in the hospital. Of the total costs (~NOK 400,000), 58, 3 and 39% were from secondary carers (hospitals), primary carers (general practitioners and emergency rooms) and home- and community-based carers (home care and nursing homes), respectively. Compared to the never married, married patients spent 30 more days at home and utilized less home- and community-based care, but more health care services at the secondary and primary health care level. Their total healthcare costs were significantly lower (-NOK 65,621) than the never married. We found similar, but weaker, patterns for those who had been married previously.

Conclusion: End-of-life care is primarily provided in the secondary and home-and community-based care level, and informal caregivers have a substantial influence on formal end-of-life care provision. Excluding aspects of care such as home and community-based care or informal care in economic analyses of end-of-life care provides a biased picture of the total resources required, and might lead to inefficient resource allocations.
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http://dx.doi.org/10.1186/s12913-019-4794-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7020544PMC
February 2020

Does Early Follow-Up Improve the Outcomes of Sepsis Survivors Discharged to Home Health Care?

Med Care 2019 08;57(8):633-640

Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY.

Background: There is little evidence to guide the care of over a million sepsis survivors following hospital discharge despite high rates of hospital readmission.

Objective: We examined whether early home health nursing (first visit within 2 days of hospital discharge and at least 1 additional visit in the first posthospital week) and early physician follow-up (an outpatient visit in the first posthospital week) reduce 30-day readmissions among Medicare sepsis survivors.

Design: A pragmatic, comparative effectiveness analysis of Medicare data from 2013 to 2014 using nonlinear instrumental variable analysis.

Subjects: Medicare beneficiaries in the 50 states and District of Columbia discharged alive after a sepsis hospitalization and received home health care.

Measures: The outcomes, protocol parameters, and control variables were from Medicare administrative and claim files and the home health Outcome and Assessment Information Set (OASIS). The primary outcome was 30-day all-cause hospital readmission.

Results: Our sample consisted of 170,571 mostly non-Hispanic white (82.3%), female (57.5%), older adults (mean age, 76 y) with severe sepsis (86.9%) and a multitude of comorbid conditions and functional limitations. Among them, 44.7% received only the nursing protocol, 11.0% only the medical doctor protocol, 28.1% both protocols, and 16.2% neither. Although neither protocol by itself had a statistically significant effect on readmission, both together reduced the probability of 30-day all-cause readmission by 7 percentage points (P=0.006; 95% confidence interval=2, 12).

Conclusions: Our findings suggest that, together, early postdischarge care by home health and medical providers can reduce hospital readmissions for sepsis survivors.
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http://dx.doi.org/10.1097/MLR.0000000000001152DOI Listing
August 2019

Heterogeneity in long term health outcomes of migrants within Italy.

J Health Econ 2019 01 2;63:19-33. Epub 2018 Nov 2.

CEIS, University of Rome Tor Vergata, Italy.

This article examines the long term physical and mental health effects of internal migration focusing on a relatively unique migration experience concentrated over a short period between 1950 and 1970 from the South to the North of Italy. We find a positive and statistically significant association between migration, its timing and physical health for migrant females, which we show are likely to represent rural females in both the early and the late cohort. We find less defined evidence of migration-health association for mental health. We link our findings to the economic transition and labor market transformation that Italy witnessed in that era. Male migrants were likely to be positively selected to migration, but harsh working conditions were likely to downplay this differential. On the contrary, women migrants, by and large, would not engage in the formal labor market avoiding the ill effects of working environments, at the same time benefiting from better living conditions and health care in the destination regions.
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http://dx.doi.org/10.1016/j.jhealeco.2018.10.002DOI Listing
January 2019

Isolated Involvement of Penis in Fournier's Gangrene: A Rare Possibility.

J Coll Physicians Surg Pak 2018 Feb;28(2):164-165

Department of Urology, R. G. Kar Medical College and Hospital, Kolkata, India.

skin and subcutaneous tissue. Penis may be secondarily affected in some cases; however, primary isolated involvement of penis is rare. A 48-year male smoker presented with pain and blackish discoloration of the distal part of penis for the last 4 days which developed following rupture of a papulo-vesicular lesion over the prepuce of penis. It rapidly progressed to involve half of the skin of the penis. The patient was hospitalized and broad spectrum antibiotics were administered parenterally. Emergency wound debridement and urinary diversion by suprapubic cystostomy was done. After repeated wound debridement and dressings, the wound healed. Our case was unusual as the penis was the sole site of affection, which is very unusual and only few such cases are reported in the literature.
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http://dx.doi.org/10.29271/jcpsp.2018.02.164DOI Listing
February 2018

Modeling Health Care Expenditures and Use.

Annu Rev Public Health 2018 04 12;39:489-505. Epub 2018 Jan 12.

Departments of Health Management and Policy and Economics, University of Michigan, Ann Arbor, Michigan 48109, USA; and National Bureau of Economic Research; email:

Health care expenditures and use are challenging to model because these dependent variables typically have distributions that are skewed with a large mass at zero. In this article, we describe estimation and interpretation of the effects of a natural experiment using two classes of nonlinear statistical models: one for health care expenditures and the other for counts of health care use. We extend prior analyses to test the effect of the ACA's young adult expansion on three different outcomes: total health care expenditures, office-based visits, and emergency department visits. Modeling the outcomes with a two-part or hurdle model, instead of a single-equation model, reveals that the ACA policy increased the number of office-based visits but decreased emergency department visits and overall spending.
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http://dx.doi.org/10.1146/annurev-publhealth-040617-013517DOI Listing
April 2018

Seminoma in Undescended Testis Presenting as Metastatic Enlarged Cervical Lymph Nodes.

J Coll Physicians Surg Pak 2017 Nov;27(11):736-737

Department of Urology, RG Kar Medical College and Hospital, Kolkata, India.

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http://dx.doi.org/2759DOI Listing
November 2017

Encouraging Medicare Advantage Enrollees to Switch to Higher Quality Plans: Assessing the Effectiveness of a "Nudge" Letter.

MDM Policy Pract 2017 Jan-Jun;2(1):2381468317707206. Epub 2017 May 5.

CVS Health, Cumberland, Rhode Island (BLH, WHS).

There are considerable quality differences across private Medicare Advantage insurance plans, so it is important that beneficiaries make informed choices. During open enrollment for the 2013 coverage year, the Centers for Medicare & Medicaid Services sent letters to beneficiaries enrolled in low-quality Medicare Advantage plans (i.e., plans rated less than 3 stars for at least 3 consecutive years by Medicare) explaining the stars and encouraging them to reexamine their choices. To understand the effectiveness of these low-cost, behavioral "nudge" letters, we used a beneficiary-level national retrospective cohort and performed multivariate regression analysis of plan selection during the 2013 open enrollment period among those enrolled in plans rated less than 3 stars. Our analysis controls for beneficiary demographic characteristics, health and health care spending risks, the availability of alternative higher rated plan options in their local market, and historical disenrollment rates from the plans. We compared the behaviors of those beneficiaries who received the nudge letters with those who enrolled in similar poorly rated plans but did not receive such letters. We found that beneficiaries who received the nudge letter were almost twice as likely (28.0% [95% confidence interval = 27.7%, 28.2%] vs. 15.3% [95% confidence interval = 15.1%, 15.5%]) to switch to a higher rated plan compared with those who did not receive the letter. White beneficiaries, healthier beneficiaries, and those residing in areas with more high-performing plan choices were more likely to switch plans in response to the nudge. Our findings highlight both the importance and efficacy of providing timely and actionable information to beneficiaries about quality in the insurance marketplace to facilitate informed and value-based coverage decisions.
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http://dx.doi.org/10.1177/2381468317707206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6124927PMC
May 2017

Can a brief period of double J stenting improve the outcome of extracorporeal shock wave lithotripsy for renal calculi sized 1 to 2 cm?

Investig Clin Urol 2017 03 15;58(2):103-108. Epub 2017 Feb 15.

Department of Urology, R G Kar Medical College and Hospital, Kolkata, India.

Purpose: Extracorporeal shock wave lithotripsy (ESWL) is an established modality for renal calculi. Its role for large stones is being questioned. A novel model of temporary double J (DJ) stenting followed by ESWL was devised and outcomes were assessed.

Materials And Methods: The study included 95 patients with renal calculi sized 1 to 2 cm. Patients were randomized into 3 groups. Group 1 received ESWL only, whereas group 2 underwent stenting followed by ESWL. In group 3, a distinct model was applied in which the stent was kept for 1 week and then removed, followed by ESWL. Procedural details, analgesic requirements, and outcome were analyzed.

Results: Eighty-eight patients (male, 47; female, 41) were available for analysis. The patients' mean age was 37.9±10.9 years. Stone profile was similar among groups. Group 3 received fewer shocks (mean, 3,155) than did group 1 (mean, 3,859; p=0.05) or group 2 (mean, 3,872; p=0.04). The fragmentation rate was similar in group 3 (96.7%) and groups 1 (81.5%, p=0.12) and 2 (87.1%, p=0.16). Overall clearance in group 3 was significantly improved (83.3%) compared with that in groups 1 (63.0%, p=0.02) and 2 (64.5%, p=0.02) and was maintained even in lower pole stones. The percentage successful outcome in groups 1, 2, and 3 was 66.7%, 64.5%, and 83.3%, respectively (p=0.21). The analgesic requirement in group 2 was higher than in the other groups (p=0.00). Group 2 patients also had more grade IIIa (2/3) and IIIB (1/2) complications.

Conclusions: Stenting adversely affects stone clearance and also makes the later course uncomfortable. Our model of brief stenting followed by ESWL provided better clearance, comfort, and a modest improvement in outcome with fewer sittings and steinstrasse in selected patients with large renal calculi.
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http://dx.doi.org/10.4111/icu.2017.58.2.103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5330380PMC
March 2017

Reducing Readmissions among Heart Failure Patients Discharged to Home Health Care: Effectiveness of Early and Intensive Nursing Services and Early Physician Follow-Up.

Health Serv Res 2017 08 28;52(4):1445-1472. Epub 2016 Jul 28.

Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.

Objective: To compare the effectiveness of two "treatments"-early, intensive home health nursing and physician follow-up within a week-versus less intense and later postacute care in reducing readmissions among heart failure (HF) patients discharged to home health care.

Data Sources: National Medicare administrative, claims, and patient assessment data.

Study Design: Patients with a full week of potential exposure to the treatments were followed for 30 days to determine exposure status, 30-day all-cause hospital readmission, other health care use, and mortality. An extension of instrumental variables methods for nonlinear statistical models corrects for nonrandom selection of patients into treatment categories. Our instruments are the index hospital's rate of early aftercare for non-HF patients and hospital discharge day of the week.

Data Extraction Methods: All hospitalizations for a HF principal diagnosis with discharge to home health care between July 2009 and June 2010 were identified from source files.

Principal Findings: Neither treatment by itself has a statistically significant effect on hospital readmission. In combination, however, they reduce the probability of readmission by roughly 8 percentage points (p < .001; confidence interval = -12.3, -4.1). Results are robust to changes in implementation of the nonlinear IV estimator, sample, outcome measure, and length of follow-up.

Conclusions: Our results call for closer coordination between home health and medical providers in the clinical management of HF patients immediately after hospital discharge.
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http://dx.doi.org/10.1111/1475-6773.12537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5517672PMC
August 2017

Secondary Surgery Versus Chemotherapy for Recurrent Ovarian Cancer.

Am J Clin Oncol 2018 05;41(5):458-464

Department of Economics, Hunter College, NY.

Objective: The best course of treatment for recurrent ovarian cancer is uncertain. We sought to determine whether secondary cytoreductive surgery for first recurrence of ovarian cancer improves overall survival compared with other treatments.

Materials And Methods: We assessed survival using Surveillance, Epidemiology and End Results-Medicare data for advanced stage ovarian cancer cases diagnosed from January 1, 1997 to December 31, 2007 with survival data through 2010 using multinomial propensity weighted finite mixture survival regression models to distinguish true from misclassified recurrences. Of 35,995 women ages 66 years and older with ovarian cancer, 3439 underwent optimal primary debulking surgery with 6 cycles of chemotherapy; 2038 experienced a remission.

Results: One thousand six hundred thirty-five of 2038 (80%) women received treatment for recurrence of whom 72% were treated with chemotherapy only, 16% with surgery and chemotherapy and 12% received hospice care. Median survival of women treated with chemotherapy alone, surgery and chemotherapy, or hospice care was 4.1, 5.4, and 2.2 years, respectively (P<0.001). Of those receiving no secondary treatments, 75% were likely true nonrecurrences with median survival of 15.9 years and 25% misclassified with 2.4 years survival. Survival among women with recurrence was greater for those treated with surgery and chemotherapy compared with chemotherapy alone (hazard ratio=1.67; 95% confidence interval, 1.13-2.47). Women who were older with more comorbidities and high-grade cancer had worse survival.

Conclusions: Secondary surgery with chemotherapy to treat recurrent ovarian cancer increases survival by 1.3 years compared with chemotherapy alone and pending ongoing randomized trial results, may be considered a standard of care.
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http://dx.doi.org/10.1097/COC.0000000000000310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5665721PMC
May 2018

Increased observation services in Medicare beneficiaries with chest pain.

Am J Emerg Med 2016 Jan 7;34(1):16-9. Epub 2015 Sep 7.

CVS Caremark, Birmingham, AL.

Introduction: We examined trends in the use of observation services and the relationship between index service type (observation services, emergency department [ED] visits, inpatient stays) and both clinical outcomes and Medicare payments.

Methods: We created a yearly cohort panel of Medicare beneficiaries with chest pain. We evaluate the relationships between index service type and 30-day clinical outcomes using a multinomial logit model and between index service type and Medicare payments using generalized linear models.

Results: In 2009, 24% of patients with chest pain received observation services; this rose to 29% in 2011. Conversely, 20% were treated as hospital inpatients in 2009; this fell to 16% in 2011. In the adjusted analysis, the risk of 30-day return to the hospital was 7% less (95% confidence interval, 5%-8%) for those receiving observation services as compared with inpatients. Average Medicare payments ranged from $3032 for beneficiaries initially treated in the ED to $3885 for those initially treated in observation to $6545 for those initially treated as inpatients.

Discussion: Patients treated in observation are less likely than those treated in the ED or as inpatients to have an adverse event within 30 days. Adjusted Medicare payments, including the index stay and the subsequent 30 days, were substantially less for those treated in observation as compared with those treated as inpatients, but more than for those treated and released from the ED. Higher rates of observation service use do not appear to be negatively affecting patient outcomes and may lower costs relative to inpatient treatment.
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http://dx.doi.org/10.1016/j.ajem.2015.08.049DOI Listing
January 2016

Did the 2009 American Recovery and Reinvestment Act affect dietary intake of low-income individuals?

Econ Hum Biol 2015 Dec 29;19:170-83. Epub 2015 Aug 29.

National Center for Health Statistics, United States. Electronic address:

This paper examines the relationship between increased Supplemental Nutritional Assistance Program (SNAP) benefits following the 2009 American Recovery and Reinvestment Act (ARRA) and the diet quality of individuals from SNAP-eligible compared to ineligible (those with somewhat higher income) households using data from the 2007-2010 National Health and Nutrition Examination Survey. The ARRA increased SNAP monthly benefits by 13.6% of the maximum allotment for a given household size, equivalent to an increase of $24 to $144 for one-to-eight person households respectively. In the full sample, we find that these increases in SNAP benefits are not associated with changes in nutrient intake and diet quality. However, among those with no more than a high school education, higher SNAP benefits are associated with a 46% increase in the mean caloric share from sugar-sweetened beverages (SSBs) and a decrease in overall diet quality especially for those at the lower end of the diet quality distribution, amounting to a 9% decline at the 25th percentile.
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http://dx.doi.org/10.1016/j.ehb.2015.08.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362314PMC
December 2015

The Roles of Cost and Quality Information in Medicare Advantage Plan Enrollment Decisions: an Observational Study.

J Gen Intern Med 2016 Feb 18;31(2):234-241. Epub 2015 Aug 18.

Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA.

Background: To facilitate informed decision-making in the Medicare Advantage marketplace, the Centers for Medicare & Medicaid Services publishes plan information on the Medicare Plan Finder website, including costs, benefits, and star ratings reflecting quality. Little is known about how beneficiaries weigh costs versus quality in enrollment decisions.

Objective: We aimed to assess associations between publicly reported Medicare Advantage plan attributes (i.e., costs, quality, and benefits) and brand market share and beneficiaries' enrollment decisions.

Design, Setting, Participants: We performed a nationwide, beneficiary-level cross-sectional analysis of 847,069 beneficiaries enrolling in Medicare Advantage for the first time in 2011.

Main Measures: Matching beneficiaries with their plan choice sets, we used conditional logistic regression to estimate associations between plan attributes and enrollment to assess the proportion of enrollment variation explained by plan attributes and willingness to pay for quality.

Key Results: Relative to the total variation explained by the model, the variation in plan choice explained by premiums (25.7 %) and out-of-pocket costs (11.6 %) together explained nearly three times as much as quality ratings (13.6 %), but brand market share explained the most variation (35.3 %). Further, while beneficiaries were willing to pay more in total annual combined premiums and out-of-pocket costs for higher-rated plans (from $4,154.93 for 2.5-star plans to $5,698.66 for 5-star plans), increases in willingness to pay diminished at higher ratings, from $549.27 (95 %CI: $541.10, $557.44) for a rating increase from 2.5 to 3 stars to $68.22 (95 %CI: $61.44, $75.01) for an increase from 4.5 to 5 stars. Willingness to pay varied among subgroups: beneficiaries aged 64-65 years were more willing to pay for higher-rated plans, while black and rural beneficiaries were less willing to pay for higher-rated plans.

Conclusions: While beneficiaries prefer higher-quality and lower-cost Medicare Advantage plans, marginal utility for quality diminishes at higher star ratings, and their decisions are strongly associated with plans' brand market share.
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http://dx.doi.org/10.1007/s11606-015-3467-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4720649PMC
February 2016

Variation in chest pain emergency department admission rates and acute myocardial infarction and death within 30 days in the Medicare population.

Acad Emerg Med 2015 Aug 23;22(8):955-64. Epub 2015 Jul 23.

Department of Emergency Medicine, The George Washington University, Washington, DC.

Objectives: The objective was to assess the relationship between emergency department (ED) admission rates for Medicare beneficiaries with chest pain and outcomes, specifically 30-day rates of acute myocardial infarction (AMI) and mortality.

Methods: Using a 20% random sample of Medicare beneficiaries in 2009, 158,295 beneficiaries with a primary diagnosis of chest pain at the conclusion of their ED visits were selected to assess outcomes based on the decision to hospitalize or discharge home. The proportions of these patients admitted to inpatient or observation status at 2,219 U.S. hospitals were calculated, adjusting for differences in patient and hospital characteristics. Both bivariate analysis and multivariable logistic regression were used to estimate the effect of the adjusted admission rates (designed to be a measure of care intensity) on patient outcomes. Other covariates in the multivariable model included patient demographics, medical conditions, and hospital utilization in the 30 days prior to the ED visits. Results from the bivariate and multivariable analyses were compared for consistency.

Results: The adjusted Medicare admission rate for ED patients with chest pain averaged 63% for the middle quintile of the patient sample and ranged from 38% to 81% in the lowest and highest quintiles. The multivariable model yielded estimates of 3.6 fewer cases of AMI (95% confidence interval [CI] = 1.5 to 5.1 cases) and 2.8 fewer deaths (95% CI = 0.6 to 4.1 deaths) per 1,000 chest pain patients associated with an admission rate of 81% versus 38%. The estimates from the bivariate analysis were of similar magnitude.

Conclusions: Considerable variation exists across U.S. hospitals in ED admission rates for Medicare patients with chest pain. Hospitals that approach admissions more conservatively (i.e., higher admission rates) in this population have lower rates of AMI and mortality.
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http://dx.doi.org/10.1111/acem.12728DOI Listing
August 2015

Vascular Targeting of a Gold Nanoparticle to Breast Cancer Metastasis.

J Pharm Sci 2015 Aug 2;104(8):2600-10. Epub 2015 Jun 2.

Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio.

The vast majority of breast cancer deaths are due to metastatic disease. Although deep tissue targeting of nanoparticles is suitable for some primary tumors, vascular targeting may be a more attractive strategy for micrometastasis. This study combined a vascular targeting strategy with the enhanced targeting capabilities of a nanoparticle to evaluate the ability of a gold nanoparticle (AuNP) to specifically target the early spread of metastatic disease. As a ligand for the vascular targeting strategy, we utilized a peptide targeting alpha(v) beta(3) integrin, which is functionally linked to the development of micrometastases at a distal site. By employing a straightforward radiolabeling method to incorporate Technetium-99m into the AuNPs, we used the high sensitivity of radionuclide imaging to monitor the longitudinal accumulation of the nanoparticles in metastatic sites. Animal and histological studies showed that vascular targeting of the nanoparticle facilitated highly accurate targeting of micrometastasis in the 4T1 mouse model of breast cancer metastasis using radionuclide imaging and a low dose of the nanoparticle. Because of the efficient targeting scheme, 14% of the injected AuNP deposited at metastatic sites in the lungs within 60 min after injection, indicating that the vascular bed of metastasis is a viable target site for nanoparticles.
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http://dx.doi.org/10.1002/jps.24518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504827PMC
August 2015

Spatiotemporal mapping of matrix remodelling and evidence of in situ elastogenesis in experimental abdominal aortic aneurysms.

J Tissue Eng Regen Med 2017 01 6;11(1):231-245. Epub 2014 May 6.

Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA.

Spatiotemporal changes in the extracellular matrix (ECM) were studied within abdominal aortic aneurysms (AAAs) generated in rats via elastase infusion. At 7, 14 and 21 days post-induction, AAA tissues were divided into proximal, mid- and distal regions, based on their location relative to the renal arteries and the region of maximal aortic diameter. Wall thicknesses differed significantly between the AAA spatial regions, initially increasing due to positive matrix remodelling and then decreasing due to wall thinning and compaction of matrix as the disease progressed. Histological images analysed using custom segmentation tools indicated significant differences in ECM composition and structure vs healthy tissue, and in the extent and nature of matrix remodelling between the AAA spatial regions. Histology and immunofluorescence (IF) labelling provided evidence of neointimal AAA remodelling, characterized by presence of elastin-containing fibres. This remodelling was effected by smooth muscle α-actin-positive neointimal cells, which transmission electron microscopy (TEM) showed to differ morphologically from medial SMCs. TEM of the neointima further showed the presence of elongated deposits of amorphous elastin and the presence of nascent, but not mature, elastic fibres. These structures appeared to be deficient in at least one microfibrillar component, fibrillin-1, which is critical to mature elastic fibre assembly. The substantial production of elastin and elastic fibre-like structures that we observed in the AAA neointima, which was not observed elsewhere within AAA tissues, provides a unique opportunity to capitalize on this autoregenerative phenomenon and direct it from the standpoint of matrix organization towards restoring healthy aortic matrix structure, mechanics and function. Copyright © 2014 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/term.1905DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4440859PMC
January 2017

Cost-offsets of prescription drug expenditures: data analysis via a copula-based bivariate dynamic hurdle model.

Health Econ 2014 Oct 19;23(10):1242-59. Epub 2013 Aug 19.

Department of Economics, Hunter College and the Graduate Center, CUNY, and NBER, USA.

In this paper, we estimate a copula-based bivariate dynamic hurdle model of prescription drug and nondrug expenditures to test the cost-offset hypothesis, which posits that increased expenditures on prescription drugs are offset by reductions in other nondrug expenditures. We apply the proposed methodology to data from the Medical Expenditure Panel Survey, which have the following features: (i) the observed bivariate outcomes are a mixture of zeros and continuously measured positives; (ii) both the zero and positive outcomes show state dependence and inter-temporal interdependence; and (iii) the zeros and the positives display contemporaneous association. The point mass at zero is accommodated using a hurdle or a two-part approach. The copula-based approach to generating joint distributions is appealing because the contemporaneous association involves asymmetric dependence. The paper studies samples categorized by four health conditions: arthritis, diabetes, heart disease, and mental illness. There is evidence of greater than dollar-for-dollar cost-offsets of expenditures on prescribed drugs for relatively low levels of spending on drugs and less than dollar-for-dollar cost-offsets at higher levels of drug expenditures.
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http://dx.doi.org/10.1002/hec.2982DOI Listing
October 2014

Nanoparticles for localized delivery of hyaluronan oligomers towards regenerative repair of elastic matrix.

Acta Biomater 2013 Dec 2;9(12):9292-302. Epub 2013 Aug 2.

Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Biomedical Engineering, The Cleveland Clinic, 9500 Euclid Avenue, ND 20, Cleveland, OH 44195, USA.

Abdominal aortic aneurysms (AAAs) are rupture-prone progressive dilations of the infrarenal aorta due to a loss of elastic matrix that lead to weakening of the aortic wall. Therapies to coax biomimetic regenerative repair of the elastic matrix by resident, diseased vascular cells may thus be useful to slow, arrest or regress AAA growth. Hyaluronan oligomers (HA-o) have been shown to induce elastic matrix synthesis by healthy and aneurysmal rat aortic smooth muscle cells (SMCs) in vitro but only via exogenous dosing, which potentially has side-effects and limitations to in vivo delivery towards therapy. In this paper, we describe the development of HA-o loaded poly(lactide-co-glycolide) nanoparticles (NPs) for targeted, controlled and sustained delivery of HA-o towards the elastogenic induction of aneurysmal rat aortic SMCs. These NPs were able to deliver HA-o over an extended period (>30 days) at previously determined elastogenic doses (0.2-20 μg ml(-1)). HA-o released from the NPs led to dose-dependent increases in elastic matrix synthesis, and the recruitment and activity of lysyl oxidase, the enzyme which cross-links elastin precursor molecules into mature fibers/matrix. Therefore, we were able to successfully develop a nanoparticle-based system for controlled and sustained HA-o delivery for the in vitro elastogenic induction of aneurysmal rat aortic smooth muscle cells.
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http://dx.doi.org/10.1016/j.actbio.2013.07.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4024830PMC
December 2013

Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay.

Health Aff (Millwood) 2013 Mar;32(3):552-61

Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, USA.

Despite its demonstrated potential to both improve quality of care and lower costs, the Medicare hospice benefit has been seen as producing savings only for patients enrolled 53-105 days before death. Using data from the Health and Retirement Study, 2002-08, and individual Medicare claims, and overcoming limitations of previous work, we found $2,561 in savings to Medicare for each patient enrolled in hospice 53-105 days before death, compared to a matched, nonhospice control. Even higher savings were seen, however, with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1-7, 8-14, and 15-30 days prior to death, respectively. Within all periods examined, hospice patients also had significantly lower rates of hospital service use and in-hospital death than matched controls. Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit.
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http://dx.doi.org/10.1377/hlthaff.2012.0851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3655535PMC
March 2013

Association between Medicare Advantage plan star ratings and enrollment.

JAMA 2013 Jan;309(3):267-74

Centers for Medicare & Medicaid Services, Center for Medicare & Medicaid Innovation, Rapid-Cycle Evaluation Group, Baltimore, MD 21244, USA.

Importance: The US Centers for Medicare & Medicaid Services publishes star ratings reflecting Medicare Advantage plan quality to inform enrollment decisions.

Objective: To assess the association between publicly reported Medicare Advantage plan quality ratings and enrollment.

Design, Setting, And Participants: Cross-sectional study of 2011 Medicare Advantage enrollments among 952,352 first-time enrollees and 322,699 enrollees switching plans.

Main Outcome Measure: Association between star ratings and enrollment was modeled using conditional logit regression, controlling for beneficiary and plan characteristics.

Results: Among the 952,352 included first-time enrollees, a 1-star higher rating was associated with a 9.5 (95% CI, 9.3-9.6) percentage-point increase in likelihood to enroll. The highest rating available to a beneficiary was associated with a 1.9 (95% CI, 1.8-2.1) percentage-point increase in likelihood to enroll. Among the 322,699 enrollees switching plans, a 1-star higher rating was associated with a 4.4 (95% CI, 4.2-4.7) percentage-point increase in likelihood to enroll. A rating at least as high as a beneficiary's prior plan was associated with a 6.3 (95% CI, 6.0-6.6) percentage-point increase in likelihood to enroll. Star ratings were less strongly associated with enrollment for black, rural, low-income, and the youngest beneficiaries.

Conclusion And Relevance: Medicare's 5-star rating program for Medicare Advantage is associated with beneficiaries' enrollment decisions.
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http://dx.doi.org/10.1001/jama.2012.173925DOI Listing
January 2013

Choosing models for health care cost analyses: issues of nonlinearity and endogeneity.

Health Serv Res 2012 Dec 23;47(6):2377-97. Epub 2012 Apr 23.

GRECC/REAP, James J. Peters VA Medical Center, Bronx, NY 10468, USA.

Objective: To compare methods of analyzing endogenous treatment effect models for nonlinear outcomes and illustrate the impact of model specification on estimates of treatment effects such as health care costs.

Data Sources: Secondary data on cost and utilization for inpatients hospitalized in five Veterans Affairs acute care facilities in 2005-2006.

Study Design: We compare results from analyses with full information maximum simulated likelihood (FIMSL); control function (CF) approaches employing different types and functional forms for the residuals, including the special case of two-stage residual inclusion; and two-stage least squares (2SLS). As an example, we examine the effect of an inpatient palliative care (PC) consultation on direct costs of care per day.

Data Collection/extraction Methods: We analyzed data for 3,389 inpatients with one or more life-limiting diseases.

Principal Findings: The distribution of average treatment effects on the treated and local average treatment effects of a PC consultation depended on model specification. CF and FIMSL estimates were more similar to each other than to 2SLS estimates. CF estimates were sensitive to choice and functional form of residual.

Conclusions: When modeling cost or other nonlinear data with endogeneity, one should be aware of the impact of model specification and treatment effect choice on results.
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http://dx.doi.org/10.1111/j.1475-6773.2012.01414.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3523380PMC
December 2012

Understanding heterogeneity in price elasticities in the demand for alcohol for older individuals.

Health Econ 2013 Jan 12;22(1):89-105. Epub 2011 Dec 12.

University of Iowa, Health Management and Policy, Iowa City, Iowa, USA.

This paper estimates the price elasticity of demand for alcohol using Health and Retirement Study data. To account for unobserved heterogeneity in price responsiveness, we use finite mixture models. We recover two latent groups, one is significantly responsive to price, but the other is unresponsive. The group with greater responsiveness is disadvantaged in multiple domains, including health, financial resources, education and perhaps even planning abilities. These results have policy implications. The unresponsive group drinks more heavily, suggesting that a higher tax would fail to curb the negative alcohol-related externalities. In contrast, the more disadvantaged group is more responsive to price, thus suffering greater deadweight loss, yet this group consumes fewer drinks per day and might be less likely to impose negative externalities.
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http://dx.doi.org/10.1002/hec.1817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641566PMC
January 2013

Elastogenic inductability of smooth muscle cells from a rat model of late stage abdominal aortic aneurysms.

Tissue Eng Part A 2011 Jul 9;17(13-14):1699-711. Epub 2011 May 9.

Clinical Center, National Institutes of Health, Bethesda, Maryland, USA.

Although abdominal aortic aneurysms (AAA) can be potentially stabilized by inhibiting inflammatory cell recruitment and their release of proteolytic enzymes, active AAA regression is not possible without regeneration of new elastic matrix structures. Unfortunately, postneonatal vascular smooth muscle cells (SMCs), healthy, and likely more so, diseased cells, poorly synthesize or remodel elastic fibers, impeding any effort directed at regenerative AAA treatment. Previously, we determined the eleastogenic benefits of oligomers (HA-o; 4-6 mers) of the glycosaminoglycan, hyaluronan (HA) and transforming growth factor-β1 (TGF-β1) to healthy SMCs. Since AAAs are often diagnosed only late in development when matrix disruption is severe, we now determine if elastogenic upregulation of SMCs from late-stage AAAs (>100% diameter increase) is possible. AAAs were induced by perfusion of rat infrarenal aortae with porcine pancreatic elastase. Elastic matrix degradation, vessel expansion (∼120%), inflammatory cell infiltration, and enhanced activity of matrix-metalloproteases (MMPs) 2 and 9 resulted, paralleling human AAAs. Aneurysmal SMCs (EaRASMCs) maintained a diseased phenotype in 2D cell culture and exhibited patterns of gene expression different from healthy rat aortic SMCs (RASMCs). Relative to passage-matched healthy RASMCs, unstimulated EaRASMCs produced far less tropoelastin and matrix elastin. Exogenous TGF-β and HA-o (termed "factors") significantly decreased EaRASMC proliferation and enhanced tropoelastin synthesis, though only at the highest provided dose combination (20 mg/mL of HA-o, 10 ng/mL of TGF-β); despite such enhancement, tropoelastin amounts were only ∼40% of amounts synthesized by healthy RASMC cultures. Differently, elastic matrix synthesis was enhanced beyond amounts synthesized by healthy RASMCs (112%), even at lower doses of factors (2 mg/mL of HA-o and 5 ng/mL of TGF-β). The factors also enhanced elastic fiber deposition over untreated EaRASMC cultures and restored several genes whose expression was altered in EaRASMC cultures back to levels expressed by healthy RASMCs. However, the activity of MMPs 2 and 9 generated by EaRASMC cultures was unaffected by the factors/factor dose. The study confirms that SMCs from advanced AAAs can be elastogenically induced, although much higher doses of elastogenic factors are required for induction relative to healthy SMCs. Also, the factors do not appear to inhibit MMP activity, vital to preserve existing elastic matrix structures that serve as nucleation sites for new elastic fiber deposition. Thus, to enhance net accumulation of newly regenerated elastic matrix, toward possibly regressing AAAs, codelivery of MMP inhibitors may be necessitated.
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http://dx.doi.org/10.1089/ten.TEA.2010.0526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3118732PMC
July 2011

The effect of job loss on overweight and drinking.

J Health Econ 2011 Mar 14;30(2):317-27. Epub 2011 Jan 14.

Hunter College and the Graduate Center, CUNY, USA.

This paper examines the impact of job loss due to business closings on body mass index (BMI) and alcohol consumption. We suggest that the ambiguous findings in the extant literature may be due in part to unobserved heterogeneity in response and in part due to an overly broad measure of job loss that is partially endogenous (e.g., layoffs). We improve upon this literature using: exogenously determined business closings, a sophisticated estimation approach (finite mixture models) to deal with complex heterogeneity, and national, longitudinal data from the Health and Retirement Study. For both alcohol consumption and BMI, we find evidence that individuals who are more likely to respond to job loss by increasing unhealthy behaviors are already in the problematic range for these behaviors before losing their jobs. These results suggest the health effects of job loss could be concentrated among "at risk" individuals and could lead to negative outcomes for the individuals, their families, and society at large.
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http://dx.doi.org/10.1016/j.jhealeco.2010.12.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086369PMC
March 2011

Medicare spending and outcomes after postacute care for stroke and hip fracture.

Med Care 2010 Sep;48(9):776-84

RAND Health, Arlington, VA, USA.

Background: Elderly patients who leave an acute care hospital after a stroke or a hip fracture may be discharged home, or undergo postacute rehabilitative care in an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Because 15% of Medicare expenditures are for these types of postacute care, it is important to understand their relative costs and the health outcomes they produce.

Objective: To assess Medicare payments for and outcomes of patients discharged from acute care to an IRF, a SNF, or home after an inpatient diagnosis of stroke or hip fracture between January 2002 and June 2003.

Research Design: This is an observational study based on Medicare administrative data. We adjust for observable differences in patient severity across postacute care sites, and we use instrumental variables estimation to account for unobserved patient selection.

Study Outcomes: Mortality, return to community residence, and total Medicare postacute payments by 120 days after acute care discharge.

Results: Relative to discharge home, IRFs improve health outcomes for hip fracture patients. SNFs reduce mortality for hip fracture patients, but increase rates of institutionalization for stroke patients. Both sites of care are far more expensive than discharge to home.

Conclusions: When there is a choice between IRF and SNF care for stroke and hip fracture patients, the marginal patient is better off going to an IRF for postacute care. However, given the marginal cost of an IRF stay compared with returning home, the gains to these patients should be considered in light of the additional costs.
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http://dx.doi.org/10.1097/MLR.0b013e3181e359dfDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3627731PMC
September 2010

Hospital-based palliative care consultation: effects on hospital cost.

J Palliat Med 2010 Aug;13(8):973-9

Health Services REAP/GRECC, James J. Peters VA Medical Center, Bronx, NY 10468, USA.

Context: Palliative care consultation teams in hospitals are becoming increasingly more common. Palliative care improves the quality of hospital care for patients with advanced disease. Less is known about its effects on hospital costs.

Objective: To evaluate the relationship between palliative care consultation and hospital costs in patients with advanced disease.

Design, Setting, And Patients: An observational study of 3321 veterans hospitalized with advanced disease between October 1, 2004 and September 30, 2006. The sample includes 606 (18%) veterans who received palliative care and 2715 (82%) who received usual hospital care. October 1, 2004 and September 30, 2006.

Main Outcome Measures: We studied the costs and intensive care unit (ICU) use of palliative versus usual care for patients in five Veterans Affairs hospitals over a 2-year period. We used an instrumental variable approach to control for unmeasured characteristics that affect both treatment and outcome.

Results: The average daily total direct hospital costs were $464 a day lower for the 606 patients receiving palliative compared to the 2715 receiving usual care (p < 0.001). Palliative care patients were 43.7 percentage points less likely to be admitted to ICU during the hospitalization than usual care patients (p < 0.001).

Comments: Palliative care for patients hospitalized with advanced disease results in lower costs of care and less utilization of intensive care compared to similar patients receiving usual care. Selection on unobserved characteristics plays an important role in the determination of costs of care.
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http://dx.doi.org/10.1089/jpm.2010.0038DOI Listing
August 2010