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Objective: To propose and evaluate a novel approach for measuring hospital-level disparities according to the effect of a continuous, polysocial risk factor on those outcomes. Study Setting: Our cohort consisted of Medicare Fee-for-Service (FFS) patients 65 years and older admitted to acute care hospitals for one of six common conditions or procedures. Medicare administrative claims data for six hospital readmission measures including hospitalizations from July 2015 to June 2018 were used. Study Design: We adapted existing methodologies that were developed to report hospital-level disparities using dichotomous social risk factors (SRFs). The existing methods report disparities within and across hospitals; we developed and tested modified approaches for both methods using the Agency for Healthcare Research and Quality Socioeconomic Status Index. We applied the adapted methodologies to six 30-day hospital readmission measures included in the Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program measures. We compared the within- and across-hospital results for each to those obtained from using the original methods and dichotomizing the AHRQ SES Index into 'low' and 'high' scores. Data Collection: We used Medicare FFS administrative claims data linked to U.S. Census data. Principal Findings: For all six readmission measures we find that, when compared with the existing methods, the methods for continuous SRFs provide disparity results for more facilities though across a narrower range of values. Measures of disparity based on this approach are moderately to highly correlated with those based on a dichotomous version of the same risk factor, while reflecting a fuller spectrum of risk. This approach represents an opportunity for detection of provider-level results that more closely align with underlying social risk. Conclusion: We have demonstrated the feasibility and utility of estimating hospital disparities of care using a continuous, polysocial risk factor. This approach expands the potential for reporting hospital-level disparities while better accounting for the multifactorial nature of social risk on hospital outcomes. KEYWORDS determinants of health, patient outcomes, quality of care, social determinants of health What is known on this topic * Prior work on measuring disparities in hospital outcomes has relied on binary classification of patients' social risk factors, an approach that ignores the continuum and multifactorial nature of social risk. * Continuous risk scores, whether individual factors or multidimensional risk scores, have potential to improve the utility of hospital-level disparity measurement and support more robust quality improvement efforts. What this study adds * This report demonstrates the feasibility of measuring hospital-level disparities using a continuous multidimensional social index in a framework that aligns with methods already adopted for measuring disparities using dichotomous factors. * This approach potentially increases the range of measurable social risk by capturing small differences across a spectrum of patient risk. * Measuring disparities using a continuous social risk factor may also identify inequities among patients who are not at high risk., 1 | INTRODUCTION Disparities of care related to social risk have received increasing attention in recent years, especially in the context of measuring hospital performance on quality measures. Pay-for-performance programs [...]

Objective: To describe physicians' variation in de-adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence. Data Sources: We analyzed 2007-2015 claims data from OptumLabs[R] Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data. Study Design: We modeled f ibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty. Data Extraction: We identified patient-year-quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients' diabetes care based on evaluation and management visits and prescriptions of glucose-lowering drugs. Principal Findings: Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, -0.18 to -0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, -0.06 to -0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians' characteristics did not explain their variation (pseudo [R.sup.2] = 0.000). Conclusion: On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de-adoption settings. KEYWORDS diabetes mellitus, fibric acids, hydroxymethylglutaryl-CoA reductase inhibitors, longitudinal studies, physicians, Type 2, 1 | INTRODUCTION AND BACKGROUND While there is a substantial body of literature on the adoption of innovative treatments, the concept of 'de-adoption,' or the ending of practices as new [...]

Objective: To examine variation in trajectories of abandoning conventionally fractionated whole-breast irradiation (CF-WBI) for adjuvant breast radiotherapy among physician peer groups and the associated cost implications. Data Sources: Medicare claims data were obtained from the Chronic Conditions Data Warehouse for fee-for-service beneficiaries with breast cancer in 2011-2014. Study Design: We used social network methods to identify peer groups of physicians that shared patients. For each physician peer group in each time period (T1 = 20112012 and T2 = 2013-2014), we calculated a risk-adjusted rate of CF-WBI use among eligible women, after adjusting for patient clinical characteristics. We applied a latent class growth analysis to these risk-adjusted rates to identify distinct trajectories of CF-WBI use among physician peer groups. We further estimated potential savings to the Medicare program by accelerating abandonment of CF-WBI in T2 using a simulation model. Data Collection/Extraction Methods: Use of conventionally fractionated whole-breast irradiation was determined from Medicare claims among women [greater than or equal to] 66 years of age who underwent adjuvant radiotherapy after breast conserving surgery. Principal Findings: Among 215 physician peer groups caring for 16 988 patients, there were four distinct trajectories of abandoning CF-WBI: (a) persistent high use (mean risk-adjusted utilization rate: T1 = 94.3%, T2 = 90.6%); (b) decreased high use (T1 = 81.3%, T2 = 65.3%); (c) decreased medium use (T1 = 60.1%, T2 = 44.0%); and (d) decreased low use (T1 = 31.6%, T2 = 23.6%). Peer groups with a smaller proportion of patients treated at free-standing radiation facilities and a larger proportion of physicians that were surgeons tended to follow trajectories with lower use of CFWBI. If all physician peer groups had practice patterns in T2 similar to those in the 'decreased low use' trajectory, the Medicare program could save $83.3 million (95% confidence interval: $58.5 million-$112.2 million). Conclusions: Physician peer groups had distinct trajectories of abandoning CF-WBI. Physician composition and setting of radiotherapy were associated with the different trajectories. Distinct practice patterns across the trajectories had important cost implications. KEYWORDS abandonment, breast cancer, conventionally fractionated, hypofractionated, physician peer group, radiotherapy, trajectory, 1 INTRODUCTION Research has shown that hypofractionated whole-breast irradiation (HF-WBI) is as effective as conventionally fractionated whole-breast irradiation (CF-WBI) in reducing the risk of recurrence and mortality following breast conserving [...]

Objective: To propose and evaluate a metric for quantifying hospital-specific disparities in health outcomes that can be used by patients and hospitals. Data Sources/Study Setting: Inpatient admissions for Medicare patients with acute myocardial infarction, heart failure, or pneumonia to all non-federal, short-term, acute care hospitals during 2012-2015. Study Design: Building on the current Centers for Medicare and Medicaid Services methodology for calculating risk-standardized readmission rates, we developed models that include a hospital-specific random coefficient for either patient dual eligibility status or African American race. These coefficients quantify the difference in risk-standardized outcomes by dual eligibility and race at a given hospital after accounting for the hospital's patient case mix and proportion of dual eligible or African American patients. We demonstrate this approach and report variation and performance in hospital-specific disparities. Principal Findings: Dual eligibility and African American race were associated with higher readmission rates within hospitals for all three conditions. However, this disparity effect varied substantially across hospitals. Conclusion: Our models isolate a hospital-specific disparity effect and demonstrate variation in quality of care for different groups of patients across conditions and hospitals. Illuminating within-hospital disparities can incentivize hospitals to reduce inequities in health care quality. KEYWORDS disparities, dual eligibility, quality measurement, race, 1 | INTRODUCTION Over the last decade, the Centers for Medicare and Medicaid Services (CMS) has promoted the use of quality measures in accountability programs with the goal of improving [...]

Objective: To develop an empiric approach for evaluating the performance of physician peer groups based on patient-sharing in administrative claims data. Data Sources: Surveillance, Epidemiology and End Results-Medicare linked dataset. Study Design: Applying social network theory, we constructed physician peer groups for patients with breast cancer. Under different assumptions of key parameter values--minimum patient volume for physician inclusion and minimum number of patients shared between physicians for a connection--we compared agreement in group membership between split samples during 2004-2006 (T1) (reliability) and agreement in group membership between Tl and 2007-2009 (T2) (stability). We also compared the results with those derived from randomly generated groups and to hospital affiliation-based groups. Principal Findings: The sample included 142 098 patients treated by 43 174 physicians in Tl and 136 680 patients treated by 51 515 physicians in T2. We identified parameter values that resulted in a median peer group reliability of 85.2 percent (Interquartile range (IQR) [0 percent, 96.2 percent]) and median stability of 73.7 percent (IQR [0 percent, 91.0 percent]). In contrast, stability of randomly assigned peer groups was 6.2 percent (IQR [0 percent, 21.0 percent]). Median overlap of empirical groups with hospital groups was 32.2 percent (IQR [12.1 percent, 59.2 percent]). Conclusions: It is feasible to construct physician peer groups that are reliable, stable, and distinct from both randomly generated and hospital-based groups. KEYWORDS methods, patient-sharing, physician networks, 1 | INTRODUCTION Social network analysis has been increasingly used to examine patterns of health care delivery and outcomes. (1-7) In this context, pairs of physicians who provide care to [...]