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Importance: The Affordable Care Act (ACA) expanded Medicaid and Marketplace insurance to nonelderly adults in 2014, but whether these policies improved outcomes later in life is unknown., Objective: To examine whether exposure to ACA expansions during middle age (50-64 years) was associated with changes in health, utilization, and spending after these adults entered Medicare at 65 years of age., Design, Setting, and Participants: This serial analysis of the Health and Retirement Study cohort linked to Medicare enrollment and claims data from January 1, 2010, to December 31, 2018. Adults aged 65 to 68 years entering Medicare after the ACA (exposed to ACA expansions during middle age) were compared with adults entering Medicare before the ACA (4452 person-years). Interrupted time series analyses were used to assess overall changes associated with exposure to ACA expansions and difference-in-differences analyses to isolate changes associated with Medicaid expansion among low-income adults (incomes ≤400% of the federal poverty level for any ACA coverage and ≤138% for Medicaid expansion coverage). Data were analyzed from March 1, 2023, to May 1, 2024., Exposures: ACA coverage expansion overall in 2014 and Medicaid expansion as of 2018., Main Outcomes and Measures: Health (self-reported overall, activities of daily living [ADL], instrumental ADL, and depressive symptoms), utilization (outpatient visits, emergency department visits, and hospital admission), and costs (self-reported out-of-pocket and Medicare costs)., Results: Among the analytic sample of 2782 participants (mean age, 66.4 [95% CI, 66.3-66.5] years), a weighted 59.1% (95% CI, 55.3%-62.7%) were female. In interrupted time series analyses, reductions across cohorts were found in use of chronic disease medications (-5.0 [95% CI, -9.8 to -0.3] percentage points), hospitalizations per year (-0.2 [95% CI, -0.4 to -0.03]), and out-of-pocket costs (-$417 [95% CI, -$694 to -$139]) but no significant changes across cohorts in health status, outpatient or emergency visits, or Medicare costs. In difference-in-differences analyses relative to nonexpansion states, greater reductions were found in the number of ADL limitations (-0.4 [95% CI, -0.8 to -0.02]) and lesser reductions in out-of-pocket costs ($900 [95% CI, $275-$1526]) in Medicaid expansion states but otherwise similar changes in other outcomes., Conclusions and Relevance: This study found modest evidence of reductions in out-of-pocket costs and improvements in health among adults entering Medicare after the ACA. Insurance coverage and financial assistance should be preserved and enhanced to improve health and health care access among vulnerable older adults.

Objective: To evaluate inter-hospital variation in 90-day total episode spending for sepsis, estimate the relative contributions of each component of spending, and identify drivers of spending across the distribution of episode spending on sepsis care., Data Sources/study Setting: Medicare fee-for-service claims for beneficiaries (n=324,694) discharged from acute care hospitals for sepsis, defined by MS-DRG, between October 2014 and September 2018., Research Design: Multiple linear regression with hospital-level fixed effects was used to identify average hospital differences in 90-day episode spending. Separate multiple linear regression and quantile regression models were used to evaluate drivers of spending across the episode spending distribution., Results: The mean total episode spending among hospitals in the most expensive quartile was $30,500 compared with $23,150 for the least expensive hospitals ( P <0.001). Postacute care spending among the most expensive hospitals was almost double that of least expensive hospitals ($7,045 vs. $3,742), accounting for 51% of the total difference in episode spending between the most expensive and least expensive hospitals. Female patients, patients with more comorbidities, urban hospitals, and BPCI-A-participating hospitals were associated with significantly increased episode spending, with the effect increasing at the right tail of the spending distribution., Conclusion: Inter-hospital variation in 90-day episode spending on sepsis care is driven primarily by differences in post-acute care spending., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine how patients' location of death relates to health care utilization and spending for surviving spouses., Data Sources/study Setting: Health and Retirement Study (HRS) 2000-2012 linked to the Dartmouth Atlas and Medicare claims data., Study Design: This was an observational study. We matched bereaved spouses whose spouses died in a hospital to those whose spouses died outside the hospital using propensity scores based on decedent and spouse demographic and clinical characteristics, care preferences, and regional practice patterns., Data Collection/extraction Methods: We identified 1,348 HRS decedents with surviving spouses. We linked HRS data from each dyad with Medicare claims and regional characteristics., Principal Findings: In multivariable models, bereaved spouses of decedents who died in the hospital had $3,106 higher Medicare spending 12 months postdeath (p = .04) compared to those whose spouses died outside a hospital. Those surviving spouses were also significantly more likely to have an ED visit (OR = 1.5; p < .01) and hospital admission (OR = 1.4; p = .02) in the year after their spouse's in-hospital death. Increased Medicare spending for surviving spouses persisted through the 24-month period postdeath ($5,310; p = .02)., Conclusions: Bereaved spouses of decedents who died in the hospital had significantly greater Medicare spending and health care utilization themselves after their spouses' death., (© Health Research and Educational Trust.)

Objectives: To compare the accuracy of and factors affecting the accuracy of self-reported fall-related injuries (SFRIs) with those of administratively obtained FRIs (AFRIs)., Design: Retrospective observational study SETTING: United States PARTICIPANTS: Fee-for-service Medicare beneficiaries aged 65 and older (N=47,215)., Measurements: We used 24-month self-report recall data from 2000-2012 Health and Retirement Study data to identify SFRIs and linked inpatient, outpatient, and ambulatory Medicare data to identify AFRIs. Sensitivity and specificity were assessed, with AFRIs defined using the University of California at Los Angeles/RAND algorithm as the criterion standard. Logistic regression models were used to identify sociodemographic and health predictors of sensitivity., Results: Overall sensitivity and specificity were 28% and 92%. Sensitivity was greater for the oldest adults (38%), women (34%), those with more functional limitations (47%), and those with a prior fall (38%). In adjusted results, several participant factors (being female, being white, poor functional status, depression, prior falls) were modestly associated with better sensitivity and specificity. Injury severity (requiring hospital care) most substantively improved SFRI sensitivity (73%)., Conclusion: An overwhelming 72% of individuals who received Medicare-reimbursed health care for FRIs failed to report a fall injury when asked. Future efforts to address underreporting in primary care of nonwhite and healthier older adults are critical to improve preventive efforts. Redesigned questions-for example, that address stigma of attributing injury to falling-may improve sensitivity., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives: Explore the relationship between behavioral and psychological symptoms of dementia (BPSD; specifically, delusions, hallucinations, and agitation/aggression) and associated caregiver distress with emergency department (ED) utilization, inpatient hospitalization, and expenditures for direct medical care., Design/setting/participants: Retrospective cross-sectional cohort of participants with dementia (N = 332) and informants from the Aging, Demographics, and Memory Study, a nationally representative survey of U.S. adults >70 years old., Measurements: BPSD of interest and associated informant distress (trichotomized as none/low/high) were assessed using the Neuropsychiatric Inventory (NPI). Outcomes were determined from one year of Medicare claims and examined according to presence of BPSD and associated informant distress, adjusting for participant demographics, dementia severity, and comorbidity., Results: Fifty-eight (15%) participants with dementia had clinically significant delusions, hallucinations, or agitation/aggression. ED visits, inpatient admissions, and costs were not significantly higher among the group with significant BPSD. In fully adjusted models, a high level of informant distress was associated with all outcomes: ED visit incident rate ratio (IRR) 3.03 (95% CI: 1.98-4.63; p < 0.001), hospitalization IRR 2.78 (95% CI: 1.73-4.46; p < 0.001), and relative cost ratio 2.00 (95% CI: 1.12-3.59; p = 0.02)., Conclusions: A high level of informant distress related to participant BPSD, rather than the symptoms themselves, was associated with increased healthcare utilization and costs. Effectively identifying, educating, and supporting distressed caregivers may help reduce excess healthcare utilization for the growing number of older adults with dementia., (Copyright © 2017 American Association for Geriatric Psychiatry. All rights reserved.)

Background: Obesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use and Medicare expenditures is unknown., Objective: To describe the associations between body mass index (BMI) and hospice use and Medicare expenditures in the last 6 months of life., Design: Retrospective cohort., Setting: The HRS (Health and Retirement Study)., Participants: 5677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012., Measurements: Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death. Body mass index was modeled as a continuous variable with a quadratic functional form., Results: For decedents with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3% (95% CI, 36.5% to 40.2%), hospice duration was 42.8 days (CI, 42.3 to 43.2 days), probability of in-home death was 61.3% (CI, 59.4% to 63.2%), and total Medicare expenditures were $42 803 (CI, $41 085 to $44 521). When BMI increased to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (CI, -9.3 to -4.0 percentage points), hospice duration decreased by 3.8 days (CI, -4.4 to -3.1 days), probability of in-home death decreased by 3.2 percentage points (CI, -6.0 to -0.4 percentage points), and total Medicare expenditures increased by $3471 (CI, $955 to $5988). For morbidly obese decedents (BMI ≥40 kg/m2), the predicted probability of hospice enrollment decreased by 15.2 percentage points (CI, -19.6 to -10.9 percentage points), hospice duration decreased by 4.3 days (CI, -5.7 to -2.9 days), and in-home death decreased by 6.3 percentage points (CI, -11.2 to -1.5 percentage points) versus decedents with BMI of 20 kg/m2., Limitation: Baseline data were self-reported, and the interval between reported BMI and time of death varied., Conclusion: Among community-dwelling decedents in the HRS, increasing obesity was associated with reduced hospice use and in-home death and higher Medicare expenditures in the last 6 months of life., Primary Funding Source: Robert Wood Johnson Foundation Clinical Scholars Program.

Objective: To inform initiatives to reduce overuse, we compared neuroimaging appropriateness in a large Medicare cohort with a Department of Veterans Affairs (VA) cohort., Methods: Separate retrospective cohorts were established in Medicare and in VA for headache and neuropathy from 2004 to 2011. The Medicare cohorts included all patients enrolled in the Health and Retirement Study (HRS) with linked Medicare claims (HRS-Medicare; n = 1,244 for headache and 998 for neuropathy). The VA cohorts included all patients receiving services in the VA (n = 93,755 for headache and 183,642 for neuropathy). Inclusion criteria were age over 65 years and an outpatient visit for incident neuropathy or a primary headache. Neuroimaging use was measured with Current Procedural Terminology codes and potential overuse was defined using published criteria for use with administrative data. Increasingly specific appropriateness criteria excluded nontarget conditions for which neuroimaging may be appropriate., Results: For both peripheral neuropathy and headache, potentially inappropriate imaging was more common in HRS-Medicare compared with the VA. Forty-nine percentage of all headache patients received neuroimaging in HRS-Medicare compared with 22.1% in the VA (p < 0.001) and differences persist when analyzing more specific definitions of overuse. A total of 23.7% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9.0% in the VA (p < 0.001), and the difference persisted after excluding nontarget conditions., Conclusions: Overuse of neuroimaging is likely less common in the VA than in a Medicare population. Better understanding the reasons for the more selective use of neuroimaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing., (© 2016 American Academy of Neurology.)

Objective: To evaluate longitudinal patient-oriented outcomes in peripheral neuropathy over a 14-year time period including time before and after diagnosis., Methods: The 1996-2007 Health and Retirement Study (HRS)-Medicare Claims linked database identified incident peripheral neuropathy cases (ICD-9 codes) in patients ≥65 years. Using detailed demographic information from the HRS and Medicare claims, a propensity score method identified a matched control group without neuropathy. Patient-oriented outcomes, with an emphasis on self-reported falls, pain, and self-rated health (HRS interview), were determined before and after neuropathy diagnosis. Generalized estimating equations were used to assess differences in longitudinal outcomes between cases and controls., Results: We identified 953 peripheral neuropathy cases and 953 propensity-matched controls. The mean (SD) age was 77.4 (6.7) years for cases, 76.9 (6.6) years for controls, and 42.1% had diabetes. Differences were detected in falls 3.0 years before neuropathy diagnosis (case vs control; 32% vs 25%, p = 0.008), 5.0 years for pain (36% vs 27%, p = 0.002), and 5.0 years for good to excellent self-rated health (61% vs 74%, p < 0.0001). Over time, the proportion of fallers increased more rapidly in neuropathy cases compared to controls (p = 0.002), but no differences in pain (p = 0.08) or self-rated health (p = 0.9) were observed., Conclusions: In older persons, differences in falls, pain, and self-rated health can be detected 3-5 years prior to peripheral neuropathy diagnosis, but only falls deteriorates more rapidly over time in neuropathy cases compared to controls. Interventions to improve early peripheral neuropathy detection are needed, and future clinical trials should incorporate falls as a key patient-oriented outcome., (© 2015 American Academy of Neurology.)

Objectives: Although critical care physicians view obesity as an independent poor prognostic marker, growing evidence suggests that obesity is, instead, associated with improved mortality following ICU admission. However, this prior empirical work may be biased by preferential admission of obese patients to ICUs, and little is known about other patient-centered outcomes following critical illness. We sought to determine whether 1-year mortality, healthcare utilization, and functional outcomes following a severe sepsis hospitalization differ by body mass index., Design: Observational cohort study., Setting: U.S. hospitals., Patients: We analyzed 1,404 severe sepsis hospitalizations (1999-2005) among Medicare beneficiaries enrolled in the nationally representative Health and Retirement Study, of which 597 (42.5%) were normal weight, 473 (33.7%) were overweight, and 334 (23.8%) were obese or severely obese, as assessed at their survey prior to acute illness. Underweight patients were excluded a priori., Interventions: None., Measurements and Main Results: Using Medicare claims, we identified severe sepsis hospitalizations and measured inpatient healthcare facility use and calculated total and itemized Medicare spending in the year following hospital discharge. Using the National Death Index, we determined mortality. We ascertained pre- and postmorbid functional status from survey data. Patients with greater body mass indexes experienced lower 1-year mortality compared with nonobese patients, and there was a dose-response relationship such that obese (odds ratio = 0.59; 95% CI, 0.39-0.88) and severely obese patients (odds ratio = 0.46; 95% CI, 0.26-0.80) had the lowest mortality. Total days in a healthcare facility and Medicare expenditures were greater for obese patients (p < 0.01 for both comparisons), but average daily utilization (p = 0.44) and Medicare spending were similar (p = 0.65) among normal, overweight, and obese survivors. Total function limitations following severe sepsis did not differ by body mass index category (p = 0.64)., Conclusions: Obesity is associated with improved mortality among severe sepsis patients. Due to longer survival, obese sepsis survivors use more healthcare and result in higher Medicare spending in the year following hospitalization. Median daily healthcare utilization was similar across body mass index categories.

Objectives: To examine whether out-of-pocket expenditures (OOPEs) exhibit the same geographic variation as Medicare claims, given wide variation in the costs of U.S. health care, but no information on how that translates into OOPEs or financial burden for older Americans., Design: Retrospective cohort study., Setting: Data from the Health and Retirement Study linked to Medicare claims., Participants: A nationally representative cohort of 4,657 noninstitutionalized, community-dwelling, fee-for-service elderly Medicare beneficiaries interviewed in 2006 and 2008., Measurements: The primary predictor was per capita Medicare spending quintile according to hospital referral region. The primary outcome was a self-reported, validated measure of annual OOPEs excluding premiums., Results: Mean and median adjusted per capita Medicare payments were $5,916 and $2,635, respectively; mean and median adjusted OOPEs were $1,525 and $779, respectively. Adjusted median Medicare payments were $3,474 in the highest cost quintile and $1,942 in the lowest cost quintile (ratio 1.79, P < .001 for difference). In contrast, adjusted median OOPEs were not higher in the highest than in the lowest Medicare cost quintile ($795 vs $764 for a Q5:Q1 ratio of 1.04, P = .42). The Q5:Q1 ratio was 1.48 for adjusted mean Medicare payments and 1.04 for adjusted mean OOPEs (both P < .001)., Conclusion: Medicare payments vary widely between high- and low-cost regions, but OOPEs do not., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Background: Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing., Methods: We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. The 1996-2007 Health and Retirement Study Medicare claims-linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using International Classification of Diseases, Ninth Revision, codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods., Results: Of the 12, 673 patients, 1031 (8.1%) received a new International Classification of Diseases, Ninth Revision, diagnosis of neuropathy and met the study inclusion criteria. Of the 15 tests considered, a median of 4 (interquartile range, 2-5) tests were performed, with more than 400 patterns of testing. Magnetic resonance imaging of the brain or spine was ordered in 23.2% of patients, whereas a glucose tolerance test was rarely obtained (1.0%). Mean Medicare expenditures were significantly higher in the diagnostic period than in the baseline period ($14,362 vs $8067, P < .001)., Conclusions: Patients diagnosed as having peripheral neuropathy typically undergo many tests, but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield magnetic resonance imaging, whereas few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.

Unlabelled: Prevalence of cirrhosis among older adults is expected to increase; therefore, we studied the health status, functional disability, and need for supportive care in a large national sample of individuals with cirrhosis. A prospective cohort of individuals with cirrhosis was identified within the longitudinal, nationally representative Health and Retirement Study. Cirrhosis cases were identified in linked Medicare data via ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes and compared to an age-matched cohort without cirrhosis. Two primary outcome domains were assessed: (1) patients' health status (perceived health status, comorbidities, health care utilization, and functional disability as determined by activities of daily living and instrumental activities of daily living), and (2) informal caregiving (hours of caregiving provided by a primary informal caregiver and associated cost). Adjusted negative binomial regression was used to assess the association between cirrhosis and functional disability. A total of 317 individuals with cirrhosis and 951 age-matched comparators were identified. Relative to the comparison group, individuals with cirrhosis had worse self-reported health status, more comorbidities, and used significantly more health care services (hospitalizations, nursing home stays, physician visits; P < 0.001 for all bivariable comparisons). They also had greater functional disability (P < 0.001 for activities of daily living and instrumental activities of daily living), despite adjustment for covariates such as comorbidities and health care utilization. Individuals with cirrhosis received more than twice the number of informal caregiving hours per week (P < 0.001), at an annual cost of US $4700 per person., Conclusion: Older Americans with cirrhosis have high rates of disability, health care utilization, and need for informal caregiving. Improved care coordination and caregiver support is necessary to optimize management of this frail population., (Copyright © 2011 American Association for the Study of Liver Diseases.)

Context: It is unclear if advance directives (living wills) are associated with end-of-life expenditures and treatments., Objective: To examine regional variation in the associations between treatment-limiting advance directive use, end-of-life Medicare expenditures, and use of palliative and intensive treatments., Design, Setting, and Patients: Prospectively collected survey data from the Health and Retirement Study for 3302 Medicare beneficiaries who died between 1998 and 2007 linked to Medicare claims and the National Death Index. Multivariable regression models examined associations between advance directives, end-of-life Medicare expenditures, and treatments by level of Medicare spending in the decedent's hospital referral region., Main Outcome Measures: Medicare expenditures, life-sustaining treatments, hospice care, and in-hospital death over the last 6 months of life., Results: Advance directives specifying limits in care were associated with lower spending in hospital referral regions with high average levels of end-of-life expenditures (-$5585 per decedent; 95% CI, -$10,903 to -$267), but there was no difference in spending in hospital referral regions with low or medium levels of end-of-life expenditures. Directives were associated with lower adjusted probabilities of in-hospital death in high- and medium-spending regions (-9.8%; 95% CI, -16% to -3% in high-spending regions; -5.3%; 95% CI, -10% to -0.4% in medium-spending regions). Advance directives were associated with higher adjusted probabilities of hospice use in high- and medium-spending regions (17%; 95% CI, 11% to 23% in high-spending regions, 11%; 95% CI, 6% to 16% in medium-spending regions), but not in low-spending regions., Conclusion: Advance directives specifying limitations in end-of-life care were associated with significantly lower levels of Medicare spending, lower likelihood of in-hospital death, and higher use of hospice care in regions characterized by higher levels of end-of-life spending.

This paper assesses the effect of payment caps for Medicare home health care on the use of informal care by older adults with functional limitations. We find that individuals exposed to more restrictive payment caps offset reductions in Medicare home health care with increased informal care, although we only observe this effect for lower-income individuals. This suggests that home care payment restrictions may have increased the caregiving burden on some low-income families, but that many higher-income families were able to either forgo the care or finance it privately. Home care payment policies should recognize these effects, balancing costs of the program with the desire to protect families from the burdens associated with providing informal home care.

Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We compared Medicare claims from 1993-2005 to clinical dementia assessments carried out in 2001-2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110% increase in costs for those with dementia as compared to a 68% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia.

Objectives: To examine different clinically relevant eligibility criteria sets to determine how they differ in numbers and characteristics of individuals served., Design: Cross-sectional analysis of the 2000 wave of the Health and Retirement Study (HRS), a nationally representative longitudinal health interview survey of adults aged 50 and older., Setting: Population-based cohort of community-dwelling older adults, subset of an ongoing longitudinal health interview survey., Participants: Adults aged 65 and older who were respondents in the 2000 wave of the HRS (n=10,640, representing approximately 33.6 million Medicare beneficiaries)., Measurements: Three clinical criteria sets were examined that included different combinations of medical conditions, cognitive impairment, and activity of daily living/instrumental activity of daily living (ADL/IADL) dependency., Results: A small portion of Medicare beneficiaries (1.3-5.8%) would be eligible for care coordination, depending on the criteria set chosen. A criteria set recently proposed by Congress (at least four severe complex medical conditions and one ADL or IADL dependency) would apply to 427,000 adults aged 65 and older in the United States. Criteria emphasizing cognitive impairment would serve an older population., Conclusion: Several criteria sets for a Medicare care-coordination benefit are clinically reasonable, but different definitions of eligibility would serve different numbers and population groups of older adults.

Background: Non‐Hispanic Black individuals may be less likely to receive a diagnosis of dementia compared to non‐Hispanic White individuals. These findings raise important questions regarding which factors may explain this observed association and any differences in the time to which disparities emerge following dementia onset. Methods: We conducted a retrospective cohort study using survey data from the 1995 to 2016 Health and Retirement Study linked with Medicare fee‐for‐service claims. Using the Hurd algorithm (a regression‐based approach), we identified dementia onset among older adult respondents (age ≥65 years) from the Telephone Interview for Cognitive Status and proxy respondents. We determined date from dementia onset to diagnosis using Medicare data up to 3 years following onset using a list of established diagnosis codes. Cox Proportional Hazards modeling was used to examine the association between an individual's reported race and likelihood of diagnosis after accounting for sociodemographic characteristics, income, education, functional status, and healthcare use. Results: We identified 3435 older adults who experienced a new onset of dementia. Among them, 30.1% received a diagnosis within 36 months of onset. In unadjusted analyses, the difference in cumulative proportion diagnosed by race continued to increase across time following onset, p‐value <0.001. 23.8% of non‐Hispanic Black versus 31.4% of non‐Hispanic White participants were diagnosed within 36 months of dementia onset, Hazard Ratio = 0.73 (95% CI: 0.61, 0.88). The association persisted after adjustment for functional status and healthcare use; however, these factors had less of an impact on the strength of the association than income and level of education. Conclusion: Lower diagnosis rates of dementia among non‐Hispanic Black individuals persists after adjustment for sociodemographic characteristics, functional status, and healthcare use. Further understanding of barriers to diagnosis that may be related to social determinants of health is needed to improve dementia‐related outcomes among non‐Hispanic Black Americans. [ABSTRACT FROM AUTHOR]

Background: Using billing data generated through health care delivery to identify individuals with dementia has become important in research. To inform tradeoffs between approaches, we tested the validity of different Medicare claims-based algorithms.Methods: We included 5 784 Medicare-enrolled, Health and Retirement Study participants aged older than 65 years in 2012 clinically assessed for cognitive status over multiple waves and determined performance characteristics of different claims-based algorithms.Results: Positive predictive value (PPV) of claims ranged from 53.8% to 70.3% and was highest using a revised algorithm and 1 year of observation. The tradeoff of greater PPV was lower sensitivity; sensitivity could be maximized using 3 years of observation. All algorithms had low sensitivity (31.3%-56.8%) and high specificity (92.3%-98.0%). Algorithm test performance varied by participant characteristics, including age and race.Conclusion: Revised algorithms for dementia diagnosis using Medicare administrative data have reasonable accuracy for research purposes, but investigators should be cognizant of the tradeoffs in accuracy among the approaches they consider. [ABSTRACT FROM AUTHOR]

Marital status is recognized as an important social determinant of health, income, and social support, but is rarely available in administrative data. We assessed the feasibility of using exact address data and zip code history to identify cohabiting couples using the 2018 Medicare Vital Status file and ZIP codes in the 2011–2014 Master Beneficiary Summary Files. Medicare beneficiaries meeting our algorithm displayed characteristics consistent with assortative mating and resembled known married couples in the Health and Retirement Study linked to Medicare claims. Address information represents a promising strategy for identifying cohabiting couples in administrative data including healthcare claims and other data types. [ABSTRACT FROM AUTHOR]

Background: Older adults with mild cognitive impairment (MCI) should receive evidence-based treatments when indicated. Providers and patients may overestimate the risk of dementia in patients with MCI leading to potential under-treatment. However, the association between pre-existing MCI and receipt of evidence-based treatments is uncertain.Objective: To compare receipt of treatments for acute myocardial infarction (AMI) between older adults with pre-existing MCI and cognitively normal patients.Design: Prospective study using data from the nationally representative Health and Retirement Study, Medicare, and American Hospital Association.Participants: Six hundred nine adults aged 65 or older hospitalized for AMI between 2000 and 2011 and followed through 2012 with pre-existing MCI (defined as modified Telephone Interview for Cognitive Status score of 7-11) and normal cognition (score of 12-27).Main Measures: Receipt of cardiac catheterization and coronary revascularization within 30 days and cardiac rehabilitation within 1 year of AMI hospitalization.Key Results: Among the survivors of AMI, 19.2% had pre-existing MCI (55.6% were women and 44.4% were male, with a mean [SD] age of 82.3 [7.5] years), and 80.8% had normal cognition (45.7% were women and 54.3% were male, with a mean age of 77.1 [7.1] years). Survivors of AMI with pre-existing MCI were significantly less likely than those with normal cognition to receive cardiac catheterization (50% vs 77%; P < 0.001), coronary revascularization (29% vs 63%; P < 0.001), and cardiac rehabilitation (9% vs 22%; P = 0.001) after AMI. After adjusting for patient and hospital factors, pre-existing MCI remained associated with lower use of cardiac catheterization (adjusted hazard ratio (aHR), 0.65; 95% CI, 0.48-0.89; P = 0.007) and coronary revascularization (aHR, 0.55; 95% CI, 0.37-0.81; P = .003), but not cardiac rehabilitation (aHR, 1.01; 95% CI, 0.49-2.07; P = 0.98).Conclusions: Pre-existing MCI is associated with lower use of cardiac catheterization and coronary revascularization but not cardiac rehabilitation after AMI. [ABSTRACT FROM AUTHOR]

This pharmacoepidemiology study uses Medicare data to estimate US prescription fills for antidepressants, anxiolytics, antipsychotics, opioids, and antiepileptics among community-dwelling older adults with dementia in 2014-2015, and identifies the most commonly prescribed medications. [ABSTRACT FROM AUTHOR]

Rationale: Sepsis is a leading cause of death and disability whose heterogeneity is often cited as a key impediment to translational progress.Objectives: To test the hypothesis that there are consequential and significant differences in sepsis outcomes that result from differences in a patient's clinical course leading up to sepsis hospitalization.Methods: We conducted an observational cohort study of U.S. Health and Retirement Study (HRS) participants in Medicare (1998-2012) and U.S. Department of Veterans Affairs beneficiaries (2009). Using latent profile analysis, we identified patient subtypes based on trajectory of presepsis healthcare facility use. Subtypes were identified in the derivation cohort (1,512 sepsis hospitalizations among earlier HRS participants), then validated them in two additional cohorts (1,992 sepsis hospitalizations among later HRS participants; 32,525 sepsis hospitalizations among U.S. Department of Veterans Affairs beneficiaries). We measured the association between presepsis path and 90-day mortality using chi-square tests and multivariable logistic regression.Results: We identified three subtypes: low use of inpatient healthcare facilities, comprising 84% of the derivation cohort; rising use, 12%; and high use, 4%. The shape and distribution of presepsis trajectories were similar in all three cohorts. In the derivation cohort, 90-day mortality differed by presepsis trajectory as follows: 38% (low use), 63% (rising use), and 48% (high use) (P < 0.001). This association persisted in the validation cohorts (P < 0.001 for each). The rising use class remained an independent predictor of mortality after adjustment for potential confounders, including detailed physiologic data.Conclusions: In national cohorts of patients with sepsis, we have shown that several distinct paths into sepsis exist. These paths, identified by trajectories of presepsis healthcare use, are predictive of 90-day mortality. [ABSTRACT FROM AUTHOR]

Background: Prior work suggests that obesity may confer a survival advantage among persons with cardiovascular disease (CVD). This obesity “paradox” is frequently studied in the context of prevalent disease, a stage in the disease process when confounding from illness-related weight loss and selective survival are especially problematic. Our objective was to examine the association of obesity with mortality among persons with incident CVD, where biases are potentially reduced, and to compare these findings with those based on prevalent disease. Methods: We used data from the Health and Retirement Study, an ongoing, nationally representative longitudinal survey of U.S. adults age 50 years and older initiated in 1992 and linked to Medicare claims. Cox proportional hazard models were used to estimate the association between weight status and mortality among persons with specific CVD diagnoses. CVD diagnoses were established by self-reported survey data as well as Medicare claims. Prevalent disease models used concurrent weight status, and incident disease models used pre-diagnosis weight status. Results: We examined myocardial infarction, congestive heart failure, stroke, and ischemic heart disease. A strong and significant obesity paradox was consistently observed in prevalent disease models (hazard of death 18–36% lower for obese class I relative to normal weight), replicating prior findings. However, in incident disease models of the same conditions in the same dataset, there was no evidence of this survival benefit. Findings from models using survey- vs. claims-based diagnoses were largely consistent. Conclusion: We observed an obesity paradox in prevalent CVD, replicating prior findings in a population-based sample with longer-term follow-up. In incident CVD, however, we did not find evidence of a survival advantage for obesity. Our findings do not offer support for reevaluating clinical and public health guidelines in pursuit of a potential obesity paradox. [ABSTRACT FROM AUTHOR]

Objectives To measure the association between spousal depression, general health, fatigue and sleep, and future care recipient healthcare expenditures and emergency department ( ED) use. Design Prospective cohort study. Setting Health and Retirement Study. Participants Home-dwelling spousal dyads in which one individual (care recipient) was aged 65 and older and had one or more activity of daily living or instrumental activity of daily living disabilities and was enrolled in Medicare Part B (N = 3,101). Exposure Caregiver sleep (Jenkins Sleep Scale), depressive symptoms (Center for Epidemiologic Studies Depression-8 Scale), and self-reported general health measures. Measurements Primary outcome was care recipient Medicare expenditures. Secondary outcome was care recipient ED use. Follow-up was 6 months. Results Caregiver depressive symptoms score and six of 17 caregiver well-being measures were prospectively associated with higher care recipient expenditures after minimal adjustment ( P < .05). Higher care recipient expenditures remained significantly associated with caregiver fatigue (cost increase, $1,937, 95% confidence interval ( CI) = $770-3,105) and caregiver sadness (cost increase, $1,323, 95% CI = $228-2,419) after full adjustment. Four of 17 caregiver well-being measures, including severe fatigue, were significantly associated with care recipient ED use after minimal adjustment ( P < .05). Greater odds of care recipient ED use remained significantly associated with caregiver fatigue (odds ratio ( OR) = 1.24, 95% CI = 1.01-1.52) and caregiver fair to poor health ( OR = 1.23, 95% CI = 1.04-1.45) after full adjustment. Caregiver total sleep score was not associated with care recipient outcomes. Conclusion Poor caregiver well-being, particularly severe fatigue, is independently and prospectively associated with higher care recipient Medicare expenditures and ED use. [ABSTRACT FROM AUTHOR]

Objectives To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life ( EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life. Design Retrospective cohort study. Setting Health and Retirement Study ( HRS). Participants Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105). Measurements Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected. Results The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models. Conclusion Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences. [ABSTRACT FROM AUTHOR]

Objectives To determine the prevalence of cognitive impairment in older adults with heart failure ( HF). Design Cross-sectional analysis of the 2004 wave of the nationally representative Health and Retirement Study linked to 2002 to 2004 Medicare administrative claims. Setting United States, community. Participants Six thousand one hundred eighty-nine individuals aged 67 and older. Measurements An algorithm was developed using a combination of self- and proxy report of a heart problem and the presence of one or more Medicare claims in administrative files using standard HF diagnostic codes. On the basis of the algorithm, three categories were created to characterize the likelihood of a HF diagnosis: high or moderate probability of HF, low probability of HF, and no HF. Cognitive function was assessed using a screening measure of cognitive function or according to proxy rating. Age-adjusted prevalence estimates of cognitive impairment were calculated for the three groups. Results The prevalence of cognitive impairment consistent with dementia in older adults with HF was 15%, and the prevalence of mild cognitive impairment was 24%. The odds of dementia in those with HF were significantly higher, even after adjustment for age, education level, net worth, and prior stroke (odds ratio = 1.52, 95% confidence interval = 1.14-2.02). Conclusion Cognitive impairment is common in older adults with HF and is independently associated with risk of dementia. A cognitive assessment should be routinely incorporated into HF-focused models of care. [ABSTRACT FROM AUTHOR]

The article presents a study that examines the agreement between Medicare administrative and Health and Retirement Study (HRS) survey data and identify predictors linked with self-report of heart failure (HF), using a valid Medicare claims algorithm as the reference standard. It is concluded that self-report of HF is an insensitive method for accurately determining HF cases, especially in those with less-severe disease and who are non-white.

Ophthalmologic abnormalities have been described in patients with dementia, but the extent to which poor vision and treatment for visual disorders affect cognitive decline is not well defined. Linked data from the Health and Retirement Study and Medicare files (1992–2005) were used to follow the experiences of 625 elderly US study participants with normal cognition at baseline. The outcome was a diagnosis of dementia, cognitively impaired but no dementia, or normal cognition. Poor vision was associated with development of dementia (P = 0.0048); individuals with very good or excellent vision at baseline had a 63% reduced risk of dementia (95% confidence interval (CI): 20, 82) over a mean follow-up period of 8.5 years. Participants with poorer vision who did not visit an ophthalmologist had a 9.5-fold increased risk of Alzheimer disease (95% CI: 2.3, 39.5) and a 5-fold increased risk of cognitively impaired but no dementia (95% CI: 1.6, 15.9). Poorer vision without a previous eye procedure increased the risk of Alzheimer disease 5-fold (95% CI: 1.5, 18.8). For Americans aged 90 years or older, 77.9% who maintained normal cognition had received at least one previous eye procedure compared with 51.7% of those with Alzheimer disease. Untreated poor vision is associated with cognitive decline, particularly Alzheimer disease. [ABSTRACT FROM PUBLISHER]

OBJECTIVES: To examine concerns that vulnerable populations, such as depressed or cognitively impaired beneficiaries would have challenges accessing Part D coverage. DESIGN: Logistic regression analysis was used to assess whether elderly Medicare beneficiaries with depression or cognitive impairment differentially planned to and actually signed up for Part D. SETTING: 2004 and 2006 data from the Health and Retirement Study (HRS) were used, including a subsample that completed the Prescription Drug Study (PDS) in 2005. PARTICIPANTS: Nine thousand five hundred ninety-three HRS respondents and 3,567 PDS respondents. MEASUREMENTS: The outcome variables of interest were planned and actual enrollment in Part D. The independent variables were depression and cognitive impairment status. The analyses were adjusted using clinical and demographic predictors including age, sex, race or ethnicity, educational attainment, net worth, marital status, health status, number of health conditions being treated with prescription medications, and presence of a caregiver. RESULTS: Although having depression or cognitive impairment was associated with a higher likelihood of planning to and actually signing up for Part D in unadjusted analyses, in adjusted analyses, having depression or cognitive impairment was not significantly associated with whether Medicare beneficiaries planned to enroll in or actually enrolled in Part D. CONCLUSION: Vulnerable Medicare beneficiaries with depression or cognitive impairment were able to access Part D benefits to the same extent as nonvulnerable beneficiaries. More research is needed to determine how well Part D meets the needs of these populations. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the extent to which elderly individuals use various skilled care facilities after coronary artery bypass grafting (CABG). DESIGN: Retrospective cohort study. SETTING: State of Michigan from 1997 to 1998. PARTICIPANTS: Residents aged 65 and older enrolled in Medicare who underwent CABG. MEASUREMENTS: Cumulative incidence of admission within 100 days of hospital discharge, relative risk (RR) of admission, readmission or extended stay at a skilled care facility, and length of stay in a skilled care facility. RESULTS: Fifty percent of patients aged 80 and older used a skilled care facility after CABG, with most requiring admission to a skilled nursing facility (SNF) or readmission to an acute-care hospital within 100 days after discharge. Patients aged 80 and older had a significantly higher risk of admission to a SNF (adjusted RR = 3.3, 95% confidence interval (CI) = 2.8-4.0) than did those aged 65 to 69, as did patients aged 75 to 79 (adjusted RR = 2.2, 95% CI = 1.8-2.6) and those aged 70 to 74 (adjusted RR= 1.5, 95% CI = 1.3-1.8). The length of time spent in skilled care facilities significantly increased with age (mean days = 13.3 for aged 65-69, 16.9 for 70-74, 19.6 for 75-79, and 22.9 for 80 and older; P<.001). CONCLUSION: Older patients are more likely to be admitted to a SNF, be readmitted to an acute-care hospital, and have longer institutional stays after CABG. When balancing the risks and benefits of CABG, physicians, patients, families, and policy-makers need to carefully consider the likelihood of follow-up institutional care in elderly patients. [ABSTRACT FROM AUTHOR]

Objective: There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx).Methods: We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated.Results: Of the 6370 respondents, 5382 (84%) reported No CA, 812 (13%) reported CA/No Tx, and 176 (3%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were 1210 dollars, 1450 dollars, and 1880 dollars, respectively (P < .01). Prescription medications (1120 dollars per year) and home care services (250 dollars) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27% of their yearly income on OOPE compared to only 5% of yearly income for high-income individuals with no cancer history (P < .01).Conclusions: Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer. [ABSTRACT FROM AUTHOR]

Objective The aim of this study is to determine if depression is independently associated with risk of hospitalization for pneumonia after adjusting for demographics, medical comorbidity, health-risk behaviors, baseline cognition and functional impairments. Methods This secondary analysis of prospectively collected data examined a population-based sample of 6704 Health and Retirement Study (HRS) (1998–2008) participants > 50 years old who consented to have their interviews linked to their Medicare claims and were without a dementia diagnosis. The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. ICD-9-CM diagnoses were used to identify hospitalizations for which the principal discharge diagnosis was for bacterial or viral pneumonia. The odds of hospitalization for pneumonia for participants with depression relative to those without depression were estimated using logistic regression models. Population attributable fractions were calculated to determine the extent that hospitalizations for pneumonia could be attributable to depression. Results After adjusting for demographic characteristics, clinical factors, and health-risk behaviors, depression was independently associated with increased odds of hospitalization for pneumonia (odds ratio [OR]: 1.28, 95% confidence interval [95%CI]: 1.08, 1.53). This association persisted after adjusting for baseline cognition and functional impairments (OR: 1.24, 95%CI: 1.03, 1.50). In this cohort, 6% (95%CI: 2%, 10%) of hospitalizations for pneumonia were potentially attributable to depression. Conclusion Depression is independently associated with increased odds of hospitalization for pneumonia. This study provides additional rationale for integrating mental health care into medical settings in order to improve outcomes for older adults. [ABSTRACT FROM AUTHOR]

The number of older adults with cognitive impairment is increasing, and such adults often require a surrogate to make decisions about health care. However, little is known about the aggressiveness of end-of-life care for these people, especially those who reside in the community. We found that cognitive impairment is common among older adults approaching the end of life, whether they live in the community or in a nursing home, and that nearly 30 percent of patients with severe dementia remained in the community until death. Among those patients, having an advance directive in the form of a living will was associated with significantly less aggressive care at the end of life, compared to similar patients without an advance directive--as measured by Medicare spending ($11,461 less per patient), likelihood of in-hospital death (17.9 percentage points lower), and use of the intensive care unit (9.4 percentage points lower). In contrast, advance directives were not associated with differences in care for people with normal cognition or mild dementia, whether they resided in the community or in a nursing home. Timely advance care planning after a diagnosis of cognitive impairment may be particularly important for older adults who reside in the community. [ABSTRACT FROM AUTHOR]