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BACKGROUND: Post-acute care (PAC) is available for older adults who need additional services after hospitalization for acute cardiac events. With the aging population and an increase in the prevalence of cardiac disease, it is important to determine current PAC use for cardiac patients to assist health care workers to meet the needs of older cardiac patients. The purpose of this study was to determine the current PAC use and factors associated with PAC use for older adults following hospitalization for a cardiac event that includes coronary artery bypass graft and valve surgeries, myocardial infarction (MI), percutaneous coronary intervention (PCI), and heart failure (HF). METHODS AND RESULTS: A cross-sectional design and the 2003 Medicare part A database were used for this study. The sample (n = 1493521) consisted of patients 65 years and older discharged after their first cardiac event. Multinomial logistic regression was used to examine factors associated with PAC use. Overall, PAC use was 55% for cardiac valve surgery, 50% for MI, 45% for HF, 44% for coronary artery bypass graft, and 5% for PCI. Medical patients use more skilled nursing facility care, and surgical patients use more home health care. Only 0.1% to 3.4% of the cardiac patients use intermediate rehabilitation facilities. Compared with those who do not use PAC, those who use home health care and skilled nursing facility care are older and female, have a longer hospital length of stay, and have more comorbidity. Asians, Hispanics, and Native Americans were less likely to use PAC after hospitalization for an MI or HF. CONCLUSIONS: The current rate of PAC use indicates that almost half of nondisabled Medicare patients discharged from the hospital following a cardiac event use one of these services. Health care professionals can increase PAC use for Asians, Hispanics, and Native Americans by including culturally targeted communication. Optimizing recovery for cardiac patients who use PAC may require focused cardiac rehabilitation strategies. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study investigated the effect of alcohol-related disease on hip fracture and mortality. METHODS: A retrospective cohort design was used. The study cohort consisted of hospitalized Medicare beneficiaries with alcohol-related disease (n = 150,119) and randomly matched controls without alcohol-related disease (n = 726,218) identified through the 1988-1989 inpatient claims file. Incidence rates of hip fracture and mortality were examined. RESULTS: During the study period, 20,620 patients developed hip fracture, with 6973 cases among patients with alcohol-related disease and 13,647 cases among patients without alcohol-related disease. After adjustment for potential confounders, patients with alcohol-related disease had a 2.6-fold increased risk of hip fracture relative to patients without alcohol-related disease (95% confidence interval = 2.5, 2.6). Patients with alcohol-related disease had a higher risk of mortality at 1 year after hip fracture. CONCLUSIONS: Alcohol-related disease increases the risk of hip fracture significantly and reduces long-term survival. The present results suggest that patients hospitalized for alcohol-related disease should be targeted for hip fracture prevention programs. [ABSTRACT FROM AUTHOR]

Background: Similar to trends observed nationwide, the rates of cesarean deliveries declined in Ohio during the late 1980s and the early 1990s. This study examined the trends in cesarean deliveries in Ohio from 1989 through 1996, in the presence or absence of indications, and in relation to the use of obstetric procedures. Methods:Birth certificate data for all singleton, liveborn infants in Ohio (n =1,204,859) were used to analyze temporal trends in cesarean sections. Results:The rates of primary and repeat cesarean deliveries declined, respectively, from 15.7 to 12.4 percent and from 83 to 63.3 percent during the 8-year study period. Significant declines in repeat cesarean deliveries were observed both in the presence and absence of documented medical conditions that could present a potential indication for the procedure. The rates of repeat cesareans remained comparable among women with and without documented indications for cesarean section (64% and 61%, respectively). In addition, 45 and 30 percent of repeat cesareans in 1989 and 1996, respectively, were performed in the absence of any documented indications, or on an elective basis. The declines in cesarean delivery rates during the 8-year study period occurred simultaneously with an increase in the use of electronic fetal monitoring, induction, and stimulation of labor. Conclusions:The findings suggest that a sizable proportion of repeat cesarean deliveries in 1996 may be unnecessary, even though a marked decline in the procedure has occurred between 1989 and 1996. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study determined race-, age- and sex-specific trends in 30-day pulmonary embolism mortality rates. METHODS: Medicare beneficiaries with a primary or secondary discharge diagnosis of pulmonary embolism from 1984 to 1991 (n = 391,991) were examined. RESULTS: For a primary diagnosis of pulmonary embolism, mortality rates declined by 15.2% and 16.0%, respectively, for White male patients 65 to 74 years old and 75 years or older. There was a corresponding decline in mortality rates for White women. For a secondary diagnosis of pulmonary embolism, mortality rates declined by 14.7% and 9.8%, respectively, for White male patients 65 to 74 years old and 75 years or older. CONCLUSIONS: The White mortality rate declines revealed in this study did not translate, in all cases, to Black patient groups. [ABSTRACT FROM AUTHOR]

Background: Estrogen and hormone replacement therapies to reduce Alzheimer's disease (AD) have yielded conflicting results. However, this study proposes that the well-characterized increase in serum gonadotropins following menopause or andropause are accountable for the increased risk of developing AD among the elderly population., Objective: To determine the role of gonadotropins in the development of AD and investigate gonadotropin-releasing hormone (GnRH) agonist therapy as a potential preventative and/or disease-modifying approach to AD management., Methods: Male Medicare beneficiaries aged 67 to 75 and hospitalized with prostate cancer (n = 115,789) were compared to three control groups: men of the same demographics undergoing a cholecystectomy (n = 97,267), herniorrhaphy (n = 68,778), or transurethral prostatectomy (n = 267,691). A proportion of the patients hospitalized with prostate cancer were assumed to have low concentrations of serum gonadotropins and sex steroids as a result of GnRH agonist therapy, while those in the control groups were assumed to have elevated gonadotropin but lowered sex steroid levels that are associated with andropause in this age group., Results: The rates of development of select diagnoses of dementia, including AD, over a twelve-year follow-up period following surgery. When compared to control patients, men hospitalized with prostate cancer have a protection against dementia after twelve years of follow-up, with relative risks ranging from 0.48 to 0.83., Conclusion: Patients with prostate cancer are treated with the GnRH analogue leuprolide acetate, our data suggest that leuprolide acetate may be therapeutic for AD via its downregulation of serum gonadotropins.

Background: Delayed chemotherapy is associated with inferior survival in stage III colon and stage II/III rectal cancer patients, but similar studies have not been performed in stage II colon cancer patients. We investigate the association between delayed and incomplete chemotherapy, and the association of delayed chemotherapy with survival in stage II colon cancer patients., Patients and Methods: Patients (age ≥ 66) diagnosed as stage II colon cancer and received chemotherapy from 1992 to 2005 were identified from the linked SEER-Medicare database. The association between delayed and incomplete chemotherapy was assessed using unconditional and conditional logistic regressions. Survival outcomes were assessed using stratified Cox regression based on propensity score matched samples., Results: 4,209 stage II colon cancer patients were included, of whom 73.0% had chemotherapy initiated timely (≤ 2 months after surgery), 14.7% had chemotherapy initiated with moderate delay (2-3 months), and 12.3% had delayed chemotherapy (≥ 3 months). Delayed chemotherapy was associated with not completing chemotherapy (adjusted odds ratio (OR): 1.33 (95% confidence interval: 1.11, 1.59) for moderately delayed group, adjusted OR: 2.60 (2.09, 3.24) for delayed group). Delayed chemotherapy was associated with worse survival outcomes (hazard ratio (HR): 1.75 (1.29, 2.37) for overall survival; HR: 4.23 (2.19, 8.20) for cancer-specific survival)., Conclusion: Although the benefit of chemotherapy is unclear in stage II colon cancer patients, delay in initiation of chemotherapy is associated with an incomplete chemotherapy course and poorer survival, especially cancer-specific survival. Causal inference in the association between delayed initiation of chemotherapy and inferior survival requires further investigation.

Objective: To estimate the effect of assisted reproductive technology (ART) on major malformation (MM) rate in ART offspring independent of the effect of subfertility on MM., Design: Meta-analysis., Methods: This meta-analysis is based on our previously published meta-analysis of observational studies evaluating the relationship between ART treatment and MM rates, as well as recent research by Zhu et al. to estimate the impact of subfertility alone on MM in subfertile couples conceiving spontaneously., Results: The overall odds ratio for MM in our original meta-analysis, in which all studies used apparently inappropriate control groups of "normal" populations, was 1.29 (95% CI 1.01-1.67). Here we attempted to estimate the risk of subfertility and used this estimate to perform an adjusted meta-analysis. Zhu et al. found that about 40% of the odds of MM was due to subfertility. When we took Zhu's finding into account, the adjusted odds ratio in the meta-analysis was 1.01 (95% CI 0.82-1.23)., Conclusions: Our study suggests ART does not increase the risk of MM as much as previously reported. More research is needed to quantify the underlying risk of subfertility and separate it from the risk associated with ART. Physicians who counsel subfertile couples should recognize that previous studies of MM rates in ART patients probably overestimated the risk.

Purpose: To investigate the association of overall and disease-specific survival with the five standard treatment modalities for prostate cancer (CaP): radical prostatectomy (RP), brachytherapy (BT), external beam radiotherapy, androgen deprivation therapy, and no treatment (NT) within 6 months after CaP diagnosis., Methods and Materials: The study population included 10,179 men aged 65 years and older with incident CaP diagnosed between 1999 and 2001. Using the linked Ohio Cancer Incidence Surveillance System, Medicare, and death certificate files, overall and disease-specific survival through 2005 among the five clinically accepted therapies were analyzed., Results: Disease-specific survival rates were 92.3% and 23.9% for patients with localized vs. distant disease at 7 years, respectively. Controlling for age, race, comorbidities, stage, and Gleason score, results from the Cox multiple regression models indicated that the risk of CaP-specific death was significantly reduced in patients receiving RP or BT, compared with NT. For localized disease, compared with NT, in the monotherapy cohort, RP and BT were associated with reduced hazard ratios (HR) of 0.25 and 0.45 (95% confidence intervals 0.13-0.48 and 0.23-0.87, respectively), whereas in the combination therapy cohort, HR were 0.40 (0.17-0.94) and 0.46 (0.27-0.80), respectively., Conclusions: The present population-based study indicates that RP and BT are associated with improved survival outcomes. Further studies are warranted to improve clinical determinates in the selection of appropriate management of CaP and to improve predictive modeling for which patient subsets may benefit most from definitive therapy vs. conservative management and/or observation.

Objective: To determine mammography utilization rates for randomly selected white and black women in the USA., Study Design: This was an observational study using data from 1988 to 2000. Data were extracted from the Behavioral Risk Factor Surveillance System, an annual self-report telephone survey conducted nationally by the Centers for Disease Control and Prevention., Methods: The main outcome measure was the mammography utilization rates of women ages 18-40 years responding to 'Have you ever had a mammogram?'. In total, 354097 women were included in this study [310336 (87.6%) white women and 43761 (12.4%) black women]., Results: In women ages 18-33, black women showed consistently higher mammography utilization rates than white women. Utilization rates among women ages 18-23 years were 20.0% and 11.0% for black and white women, respectively. Among women ages 24-29 years, rates were 22.2% and 11.5% for black and white women, respectively. For women ages 30-33 years, rates were 25.7% and 18.1% for black and white women, respectively. Utilization rates were similar in black and white women over 33 years of age., Conclusions: This study found that young black women were receiving more mammography screening than young white women between 1988-2000. This may be due to the increased risk of fibroid masses in young black women.

Purpose: To estimate the risk of major malformations in IVF and ICSI infants., Methods: Forty-four studies published in English since 1990 where the major malformation rate for IVF or ICSI cases was compared to an appropriate control group were reviewed. Nineteen studies met all selection criteria. In addition, a quality score was developed to assess each study based on sample size, timing of diagnosis, appropriateness of control group and other factors., Results: In 19 studies, the major malformation rates ranged from 0-9.5% for IVF; 1.1-9.7 for ICSI; and 0-6.9% in the control groups. When ICSI was compared to IVF, and multiple births compared to singleton, there were no statistically significant differences. When data from 16 studies involving 28,524 IVF infants and 2,520,988 spontaneously conceived controls and 7 studies involving 7234 ICSI infants and 978,078 controls were pooled, we found an overall odds ratio for the 19 studies of 1.29 (95% CI 1.01-1.67)., Conclusions: The overall odds ratio of 1.29 was statistically significant at the 5% level. These results may be useful for counseling ART patients and properly designing the consent forms used for ART procedures. It is not clear whether this risk is due to the procedures used in ART. We found that some of these studies have design flaws. All of them lacked an appropriate control group, i.e. infertile patients conceiving spontaneously. These flaws may create biases that would in almost all instances increase the risk of major malformations in the study group. Further research with better designed studies will likely result in a better estimate of the risk of major malformations associated with IVF and ICSI.

Background: The completeness of Medicare claims for identifying patients with melanoma for purposes of conducting population-based studies of melanoma is unknown., Methods: Using a linked Surveillance, Epidemiology, and End Result (SEER) tumor registry-Medicare database, the sensitivity of Medicare claims for identifying 5372 patients age > or =65 years diagnosed with invasive melanoma between 1992 and 1996 was determined. Sensitivity was calculated as the proportion of incident cases of melanoma reported by SEER that was also captured by Medicare claim diagnostic codes., Results: The overall sensitivity of combined Part A and Part B Medicare for incident cases of melanoma was 90.1%. Part B Medicare and Part A Medicare alone had 89.5% and 16.5% sensitivity respectively. Sensitivity was lower for patients with unrecorded Breslow depth and for patients with unstaged or distant stage melanoma., Conclusions: Medicare Part B claims have a high sensitivity for detecting melanoma incidence; Medicare Part A has low sensitivity. This sharply contrasts with published studies of other cancers, for whom Part A rather than Part B Medicare captures the predominant portion of incident cases. Medicare Part B or combined Part A and Part B administrative data is a potentially valuable resource for population-based melanoma research in the elderly. Further research characterizing the specificity and predictive value of Medicare data is needed to assess the potential implications of false positive melanoma diagnostic codes.

Little is known about variation in surveillance practices following the diagnosis of invasive melanoma. The objective of this study was to characterize geographic, patient, and tumor variation in the use of follow-up surveillance testing in patients with local or regional stage melanoma. A cohort of Medicare beneficiaries > or =65 y diagnosed with invasive melanoma during 1992 to 1996 living in a Surveillance, Epidemiology, and End Results registry area was studied. Outpatient and inpatient Medicare claims 3 mo following diagnosis were examined for up to 2 y for surveillance procedures of interest. Use of chest X-ray, chest computed tomography scan, abdominal and/or pelvic computed tomography scan, abdominal ultrasound, head computed tomography scan, head magnetic resonance imaging, laboratory testing, and skin examinations were compared between patient groups and geographic regions. A total of 3389 patients were identified for the analysis. Surveillance testing was relatively common, ranging from 13% for abdominal ultrasound to 80% for laboratory testing. Follow-up skin examinations were performed in 70% to 90% of patients. The use of most surveillance procedures was associated (p<0.01) with younger age, male gender, regional stage tumors, and geographical area, with up to 2-fold differences observed. In contrast, there was much less variability in the receipt of skin examinations. Further studies are needed to determine the etiology and impact of such disparities, and the influence of surveillance procedures on morbidity and mortality.

Background: The use of Medicaid data to study cancer-related outcomes would be highly desirable. However, the accuracy of Medicaid claims data in the identification of incident cases of breast cancer is unknown., Objectives: (1) To estimate the sensitivity of Medicaid claims data for case ascertainment of breast cancer, and (2) to determine the positive predictive value (PPV) of diagnostic and procedure codes retrieved from Medicaid claims, using the Ohio Cancer Incidence Surveillance System (OCISS) as the gold standard., Methods: The study used the linked OCISS and Medicaid enrollment files, 1997-1998 (n = 1,648). The claims search yielded 2,635 incident cases, of which 1,132 were also identified through the OCISS-Medicaid files. Sensitivity and PPV of Medicaid data were calculated in subgroups of the population., Results: The overall sensitivity was 68.7 percent, but varied greatly across the subgroups of the population. It was lower among women enrolled in Medicaid only for part of the study year than those enrolled in Medicaid for 12 months of the study year (56.7 percent and 78.0 percent respectively, p < 0.0001), and lower among those who are dual Medicare-Medicaid eligible compared to those not participating in the Medicare program (63.1 percent and 78.6 percent respectively, p < 0.0001). The overall PPV was 43.0 percent, increasing up to 86.6 percent in the presence of procedure codes indicating the presence of mastectomy and lumpectomy, in addition to that of breast cancer diagnosis., Conclusions: The sensitivity of Medicaid claims for case ascertainment of breast cancer is somewhat low, but improves considerably when accounting for women enrolled in Medicaid for the entire duration of the study year. The PPV is poor due to a high rate of false positives. The higher PPV obtained in the presence of procedure codes, in addition to diagnosis codes, will help researchers to correctly identify incident cases of breast cancer using Medicaid claims data.

We examined the effects of nitrogen dioxide (NO(2)), ozone (O(3)), particulate matter of <10 microm aerodynamic diameter (PM(10)), and sulfur dioxide (SO(2)) on asthmatics ages 5-34 years enrolled in Medicaid in Cincinnati, Cleveland, and Columbus, OH (N=5416). Our study period was for the summer months, June-August, from July 1, 1991 to June 30, 1996. We preformed Poisson regression analyses for the number of daily emergency department (ED) visits for asthma in each city and on the aggregate data controlling for time trends and minimum temperature. We found a 12% increased likelihood of an asthma ED visit per 50 microg/m(3) increase in PM(10) in Cleveland [95% confidence interval (CI)=0-27%] and a 35% increase per 50 microg/m(3) increase in SO(2) in Cincinnati (95% CI=9-21%). When data were analyzed for all three cities combined, the risk of an ED visit increased for all pollutant increases and specifically by 12% (95% CI=1-23%) per 50 microg/m(3) increase in SO(2). Attributable risk estimates show a five times greater impact on Cleveland over Cincinnati or Columbus. Between 1991 and 1996, air pollutants in Cincinnati, Cleveland, and Columbus increased ED visits for asthmatics enrolled in Medicaid.

Background: Barrett esophagus, a consequence of chronic gastroesophageal reflux disease, is a premalignant condition for adenocarcinoma of the esophagus and, possibly, the gastric cardia. However, the actual use and clinical impact of upper gastrointestinal endoscopy in screening and surveillance for Barrett esophagus are unknown., Methods: A cohort included 1633 patients with adenocarcinoma (777 esophagus, 856 cardia) who were 70 years or older. They were diagnosed between 1993 and 1996 and were identified from the Surveillance, Epidemiology and End Results program registry. All claims for upper endoscopy and a diagnosis of Barrett esophagus from 1991 through 1 year before diagnosis were identified from linked Medicare files., Results: One or more upper endoscopies before diagnosis were performed in 9.7% of patients (13.0% esophagus, 6.8% cardia) and a diagnosis of Barrett esophagus was present in only 3.7% of patients. A shift toward earlier stage at diagnosis was observed in patients with previous endoscopy or Barrett diagnosis. For example, 62% of patients with esophageal and 49% of patients with cardia tumors who underwent previous endoscopy presented with in situ or local stage carcinoma, compared with 35% and 27% of other patients, respectively. Receipt of endoscopy was also associated with a reduced risk of death for esophageal adenocarcinoma (relative hazard 0.73, 95% confidence interval 0.57-0.93; P = 0.01), but not for adenocarcinoma of the cardia., Conclusions: Receipt of upper endoscopy at least 1 year before diagnosis of adenocarcinoma, which may reflect prediagnosis screening, was associated with an earlier tumor stage and improved survival. These data support the role of endoscopic screening and surveillance for Barrett esophagus and highlight the underdiagnosis of populations at risk., (Copyright 2002 American Cancer Society.DOI 10.1002/cncr.10646)

A recent, nationwide study of 54 million births reported increasing trends toward more prenatal resource utilization from 1981 to 1995, when other indicators have shown worsening trends in birth outcomes. The Adequacy of Prenatal Care Utilization (APNCU) Index was used to measure resource utilization, but the Index appears to be biased because women grouped in the intensive category have the highest rates of low birth weight (LBW). The objective of this paper is to provide a systematic examination of the Index and to uncover biases that may preclude its use in analyzing the association between resource utilization and birth outcomes. This is a cross-sectional study including all singleton live births in 1993 through 1996 (n = 591,403) in Ohio. Birth certificate data are used to derive the Index, which categorizes women as follows: Adequate Plus (A+), Adequate, Intermediate, and Inadequate. The Index is based on the ratio of observed to expected (O/E) number of prenatal visits. The expected number of visits is based on the American College of Obstetricians and Gynecologists (ACOG) recommendations. The Index also considers the month of initiation of prenatal care. The outcome measures are low birth weight (LBW) and small-for-gestational age (SGA). The LBW rate is 11.8% in the (A+) category, compared to 9.4% in the Inadequate category, and 3.3% and 3.5% in each of the Intermediate and Adequate categories, respectively. Preterm births are disproportionately represented in the (A+) category: 61.2% of births prior to 37 weeks are (A+), whereas only 18.9% of term births are (A+). This apparent bias results from the fact that the ACOG schedule of prenatal visits allocates nearly one third of the total visits to the last 4-5 weeks of gestation. A shorter gestational age implies fewer number of expected visits, a smaller denominator in the O/E ratio, and O/E ratios exceeding 100% by large margins. In fact, the observed number of visits exceeds the expected number of visits by only one or two in 40.1% of all births grouped in the (A+) category. Consequently, the Index yields misleading results indicating that women grouped in the (A+) category (or O/E ratios > 110%) are most likely to deliver LBW infants. Contrary to the results obtained through the APNCU Index, our gestational age-specific analysis showed that increasing number of prenatal visits is associated with improved birth outcomes. We recommend that the use of the APNCU Index to study the association between prenatal resource utilization and LBW be discontinued.

Background: National-level population-based data about breast carcinoma incidence and its association with screening mammography are currently not available., Methods: Inpatient, hospital outpatient and physician/supplier Medicare claims were used to identify incident cases of breast carcinoma in women > or = 65 years from 1996 to 1997 and calculate county-level incidence rates. The 1994-1995 claims data were used to determine county-level rates of mammography, and determine the correlation with incidence., Results: The median 2-year incidence rate for women > or = 65 was 979/100,000, and substantial variation in incidence between counties was observed. (i.e. 25th percentile 789/100,000, 75th percentile 1186/100,000). Two-year county-level mammography rates also varied among counties (i.e. 25th percentile 30.5%, 75th percentile 40.9%) and were higher in white women than in black women (median 36.8 and 26.3%, respectively). Counties with higher rates of mammography also had higher age-adjusted incidence rates., Conclusions: Medicare claims may provide an alternative source of population-based data, particularly for areas in which registry data are not readily available, or are of limited scope. The data highlight the geographic variation in incidence and screening rates that may be useful for targeted interventions, and also suggest that mammography remains in a growth phase.

Background: To the authors' knowledge, national-level population-based data regarding prostate carcinoma incidence and detection currently are not available. The availability of such data could identify those regions with a disproportionately high cancer incidence as well as the population-level association between prostate carcinoma detection and incidence., Methods: Inpatient, hospital outpatient, and physician/supplier Medicare claims from 1997 were used to identify incident cases of prostate carcinoma in men age > or = 65 years and to calculate state and county-level incidence rates. The 1991 and 1997 claims data were used to determine small area rates of prostate-specific antigen (PSA) testing and prostate biopsy and to determine their correlation with incidence., Results: The calculated incidence rates for 1997 were 890 per 100,000 and 1196 per 100,000, respectively, in white males and African-American males and varied substantially between counties (i.e., 25--75th percentile, 676--1124 per 100,000). Rates of PSA and prostate biopsy increased markedly from 1991 to 1997 in both white men (1580 per 100,000 to 24,286 per 100,000) and African-American men (1277 per 100,000 to 15,190 per 100,000), and considerable variation in detection between counties was observed. Counties that had higher rates of prostate biopsy also had higher age-adjusted incidence rates, and county-level PSA testing was found to be associated with incidence in African-American patients, but not in white patients., Conclusions: Medicare claims may provide an alternative source of population-based data, particularly for areas in which registry data are not readily available or are of limited scope. In addition, claims provide otherwise unavailable national data concerning cancer detection., (Copyright 2001 American Cancer Society.)

The objective of this study was to characterize elderly trauma hospitalizations nationwide. Elderly Medicare beneficiaries hospitalized in 1989, with trauma as a primary or secondary diagnosis, were studied cross-sectionally. Descriptive analyses and primary mortality rates among different levels of trauma center designation were provided. Estimated relative risks, chi-square tests of association, and multivariate logistic regression were performed. There were 577,193 geriatric trauma patients admitted to 5227 short-stay U.S. hospitals. Level one trauma centers constituted less than 4% of hospitals, but admitted 7.5% of patients, including disproportionate numbers of blacks, males, and patients with more severe primary injury diagnoses. Risk of inpatient death increased with age, male gender, black race, and severity of injury. Level one trauma center patients displayed a 1.49 greater risk for inpatient death even after controlling for confounding variables in a multivariate model. This population-based study provides a detailed national picture of the elderly trauma hospitalization experience, contrasting profiles and outcomes between hospitals with and without designated trauma centers. Although demonstrating higher inpatient mortality rates, Level one trauma centers admit a decidedly different patient population than other hospitals, which is disproportionately younger, black and male and includes the most severely injured geriatric patients. Additional confounding factors should be explored.

Using a Medicare-based retrospective cohort study, the stroke risk in patients with atrial flutter (RR = 1.41) was determined to be greater than that in a control group (RR = 1.00) but less than that in an atrial fibrillation group (RR = 1.64). Furthermore, patients with atrial flutter who subsequently had an episode of atrial fibrillation had a higher risk of stroke (RR = 1.56) than patients with atrial flutter who never had a subsequent episode of atrial fibrillation (RR = 1.11).

Objective: To examine changes over time in the cesarean section rates for fee-for-service (FFS) beneficiaries versus enrollees of managed care programs (MCPs) in the Ohio Medicaid population., Study Design: Cross-sectional study using linked Ohio birth certificates and Medicaid files., Patients and Methods: Study patients were Medicaid-enrolled residents of urban counties who had singleton, live births from 1992 through 1997 (n = 86,459). Changes in primary and repeat cesarean section rates were analyzed in the FFS and MCP groups. The test of homogeneity of odds ratios was used to measure the statistical difference between unadjusted odds ratios. Logistic regression analysis was conducted to adjust for risk factors., Results: From 1992 to 1997, the difference in the rates of primary and repeat cesarean sections between FFS and MCP patients decreased. The unadjusted odds ratio (OR) increased from 0.66 to 0.81 (P = .06) for primary cesarean sections and from 0.67 to 1.04 (P = .03) for repeat cesarean sections; this indicated that the likelihood of undergoing a cesarean section increased over time for MCP enrollees compared with FFS beneficiaries. The results of the multivariate analysis indicated that the interaction term of payment source by year was not significant for primary cesarean sections (adjusted OR = 0.93; 95% confidence interval = 0.83, 1.04), but was highly significant for repeat cesarean sections (adjusted OR = 0.53; 95% confidence interval = 0.44, 0.64)., Conclusion: We observed a reduction in the difference between the rates of both primary and repeat cesarean sections in FFS and MCP patients over time. The reduction was not statistically significant for primary cesarean sections. For repeat cesarean sections, however, we observed a convergence of the rates for FFS and MCP patients.

Background: Endoscopic examinations of the colon are often recommended for surveillance following colorectal cancer resection. The actual use and outcome of this testing are not known., Methods: Five thousand seven hundred sixteen patients 65 years of age or older with local or regional stage colorectal cancer diagnosed in 1991 were identified through the Surveillance Epidemiology and End Results registry. All inpatient and outpatient Medicare claims from 6 months after diagnosis through the end of 1994 were examined to determine use of endoscopic procedures., Results: One or more colonoscopies were performed in 51%, with an average of 2.9 procedures performed among those tested; sigmoidoscopy was performed in 17%. The rate of colonoscopy was highest during the initial 18 months. Polypectomy was performed in 21% of all patients, and subsequent primary colorectal tumors were diagnosed in 1.3%. Factors associated with colonoscopy and sigmoidoscopy use included younger age, survival through follow-up, and geographic region; sigmoidoscopy was also more common in relation to rectal cancers., Conclusions: There is variability in the use of endoscopic procedures following potentially curative resection for colorectal cancer, with patient-related factors and local practice patterns accounting for the variation. Further studies are needed to elicit the reasons for lack of follow-up and adherence to practice guidelines.

Background: Although health claims data are increasingly used in evaluating variations in patterns of cancer care and outcomes, little is known about the comparability of these data with tumor registry information., Objectives: To evaluate the agreement between Medicare claims and tumor registry data in measuring patterns of diagnostic and therapeutic procedures for older cancer patients., Research Design: Analysis of a database linking Surveillance, Epidemiology and End Results (SEER) registry data and Medicare claims in patients aged > or =65 years with cancer., Subjects: 361,255 Medicare patients with invasive breast, colorectal, endometrial, lung, pancreatic, and prostate cancer diagnosed between 1984 and 1993., Measures: Concordance of SEER files with corresponding Medicare claims., Results: Medicare claims generally identified patients who underwent resection and radical surgery according to SEER (ie, concordance > or =85%-90%) but less likely biopsy or local excision (ie, concordance < or =50%). In some instances, claims also categorized patients as having more invasive surgery than was listed in SEER and also provided incremental information about the use of surgical treatment after 4 months. SEER files and, to a lesser degree, Medicare claims identified radiation therapy not included in the other data source, and Medicare files also captured a significant number of patients with codes for chemotherapy., Conclusions: Medicare files may be appropriate for studies of patterns of use of surgical treatment, but not for diagnostic procedures. The potential benefit of Medicare claims in identifying delayed surgical intervention and chemotherapy deserves further study.

Objectives: To examine the association between hospital type and mortality and length of stay using hospitalized Medicare beneficiaries for a 10-year period., Methods: The retrospective cohort study included 16.9 million hospitalized Medicare beneficiaries > or = 65 years of age admitted for 10 common medical conditions and 10 common surgical procedures from 1984 to 1993. A total of 5,127 acute-care hospitals in the United States were grouped into 6 mutually exclusive hospital types based on teaching status and financial structure (for-profit [FP], not-for-profit [NFP], osteopathic [OSTEO], public [PUB], teaching not-for-profit [TNFP], and teaching public [TPUB]) as reported in the 1988 American Hospital Association database. Logistic and linear regression methods were used to examine risk-adjusted 30-day and 6-month mortality and length of stay., Results: During the 10-year study period, 10.6 million patients were admitted with 1 of the 10 selected medical conditions, and 6.3 million patients were hospitalized for 1 of the 10 selected surgical procedures. Patients at TNFP hospitals had significantly lower risk-adjusted 30-day mortality rates than patients at other hospital types when all diagnoses or procedures were combined (combined diagnoses: RR(TNFP) = 1.00 [reference], RR(TPUB) = 1.40, RR(OSTEO) = 1.14, RR(PUB) = 1.07, RR(FP) = 1.03, RR(NFP) = 1.02; combined procedures: RR(TNFP) = 1.00 [reference], RR(OSTEO) = 1.36, RR(TPUB) = 1.30, RR(PUB) = 1.16, RR(FP) = 1.13, RR(NFP) = 1.08). The results were mostly consistent when diagnoses and procedures were examined separately. After adjustment for patient characteristics, patients at other hospital types had 10% to 20% shorter lengths of stay (LOS) than patients at TNFP hospitals for most diagnoses and procedures studied., Conclusion: As measured by the risk-adjusted 30-day mortality, TNFP hospitals had an overall better performance than other hospital types. However, patients at TNFP hospitals had relatively longer LOS than patients at other hospital types, perhaps reflecting the medical education and research activities found at teaching institutions. Future research should examine the empirical evidence to help elucidate the adequate LOS for a given condition or procedure while maintaining the quality of care.

Background: To the authors' knowledge, physician attitudes and reported practices regarding colorectal carcinoma screening have not been studied in areas of highest risk for cancer death., Methods: Medicare claims were used to calculate colorectal carcinoma 2-year case-fatality rates for counties with >100 incident cases of colorectal carcinoma between 1991-1993. All 2682 practicing primary care physicians in 20 counties with the lowest case-fatality rates (mean of 29.9%) and 19 counties with the highest case-fatality rates (mean of 47.8%) were surveyed regarding their screening procedures and attitudes., Results: Among the 972 respondents (36.1%), the reported use of fecal occult blood testing (FOBT) and flexible sigmoidoscopy was similar in the low and high case-fatality counties. However, physicians who practiced in the high case-fatality counties were less likely to be trained in and to perform sigmoidoscopy themselves (37.0% vs. 45.6%; P<0.01). Moreover, practitioners in the high case-fatality counties were more likely than the other physicians to consider or plan enhanced FOBT and sigmoidoscopic screening in the near future. FOBT and sigmoidoscopy screening rates at the county level were associated negatively with cancer incidence rates, case-fatality rates, and metastatic disease rates, suggesting a potentially protective effect., Conclusions: Geographically targeted interventions are a potentially cost-effective strategy for focusing additional screening services on the highest risk populations. The primary care clinicians in these high risk areas are logical partners for these interventions by virtue of their high degree of readiness to change their current screening practices., (Copyright 1999 American Cancer Society.)

Although the association between malignancy and thromboembolic disease is well established, the relative risk of developing initial and recurrent deep vein thrombosis (DVT) or pulmonary embolism (PE) among patients with malignancy versus those without malignancy has not been clearly defined. The Medicare Provider Analysis and Review Record (MEDPAR) database was used for this analysis. Patients hospitalized during 1988-1990 with DVT/PE alone, DVT/PE and malignancy, malignancy alone, or 1 of several nonmalignant diseases (other than DVT/PE) were studied. The association of malignancy and nonmalignant disease with an initial episode of DVT/PE, recurrent DVT/PE, and mortality were analyzed. The percentage of patients with DVT/PE at the initial hospitalization was higher for those with malignancy compared with those with nonmalignant disease (0.6% versus 0.57%, p = 0.001). The probability of readmission within 183 days of initial hospitalization with recurrent thromboembolic disease was 0.22 for patients with prior DVT/PE and malignancy compared with 0.065 for patients with prior DVT/PE and no malignancy (p = 0.001). Among those patients with DVT/PE and malignant disease, the probability of death within 183 days of initial hospitalization was 0.94 versus 0.29 among those with DVT/PE and no malignancy (p = 0.001). The relative risk of DVT/PE among patients with specific types of malignancy is described. This study demonstrates that patients with concurrent DVT/PE and malignancy have a more than threefold higher risk of recurrent thromboembolic disease and death (from and cause) than patients with DVT/PE without malignancy. An alternative management strategy may be indicated for such patients.

Background: There are a paucity of data supporting the routine use of follow-up testing to detect recurrent disease after potentially curative initial surgery in patients with nonmetastatic colorectal carcinoma., Methods: Using the population-based Surveillance, Epidemiology, and End Results (SEER) registry, all patients age > or =65 years with local or regional colorectal carcinoma who were diagnosed in 1991, underwent surgical resection, and survived at least 6 months after diagnosis were identified. All inpatient, hospital outpatient, and physician/supplier Medicare claims from 6 months after diagnosis through 1994 were examined for follow-up procedures of interest. Procedure use during follow-up was compared across patient groups using both bivariate and multivariate analyses., Results: A total of 5716 patients were identified, with 1.3% found to have developed subsequent primary tumors of the colon or rectum, and 74% surviving through 1994. One or more procedures of interest were performed in 88% of patients; the most commonly performed tests were liver enzymes, chest X-rays, colonoscopy, and computed tomography scans. Lower rates of testing generally were observed with older age groups, patients with fewer comorbidities, and patients who did not survive through the follow-up period. Among all procedures studied, there also was significant variation in the rates of testing across the 9 SEER areas, varying from 1.5-fold to 3.6-fold. The geographic variation persisted in multivariate models adjusting for potentially confounding factors., Conclusions: The current study found significant variability in the use of follow-up procedures, with the most striking differences apparent across geographic regions. Further studies are needed to determine the underlying reasons for the disparities, as well as the impact of surveillance on patient outcomes.

Background: Although Medicare claims data have been used to identify cases of cancer in older Americans, there are few data about their relative sensitivity., Objectives: To investigate the sensitivity of diagnostic and procedural coding for case ascertainment of breast, colorectal, endometrial, lung, pancreatic, and prostate cancer., Subjects: Three hundred and eighty nine thousand and two hundred and thirty-six patients diagnosed with cancer between 1984 and 1993 resided in one of nine Surveillance Epidemiology and End Results (SEER) areas., Measures: The sensitivity of inpatient and Part B diagnostic and cancer-specific procedural codes for case finding were compared with SEER., Results: The sensitivity of inpatient and inpatient plus Part B claims for the corresponding cancer diagnosis was 77.4% and 91.2%, respectively. The sensitivity of inpatient claims alone was highest for colorectal (86.1%) and endometrial (84.1%) cancer and lowest for prostate cancer (63.6%). However, when Part B claims were included, the sensitivity for diagnosis of breast cancer was greater than for other cancers (93.6%). Inpatient claim sensitivity was highest for earlier years of the study, and, because of more complete data and longer follow up, the highest sensitivity of combined inpatient and Part B claims was achieved in the late 1980s or early 1990s., Conclusions: Medicare claims provide reasonably high sensitivity for the detection of cancer in the elderly, especially if inpatient and Part B claims are combined. Because the study did not measure other dimensions of accuracy, such as specificity and predictive value, the potential costs of including false positive cases need to be assessed.

The main objective of the study is to present a method that estimates the proportion of unnecessary Cesarean sections (C-sections) using birth certificate data. This population-based cross-sectional study uses two major databases--Ohio birth certificates and Medicaid eligibility files--and includes singleton infants born during the period July 1991 through June 1993 (n = 262,013). A total of 57 variables indicative of adverse events, including maternal medical risk factors, complications of labor and delivery, and congenital anomalies that are available on the birth certificate, are examined to estimate the rate of unnecessary C-sections. The results obtained through this method indicate that nearly 40% of the repeat C-sections had no documented abnormalities on the birth certificate to justify a C-section. Because studies using medical records have yielded similar results, we believe that using birth certificate data may be a reliable method to measure and monitor the rate of unnecessary C-sections.

Objectives: The goal of this study was to provide estimates of race- and sex-specific survival rates over a 10-year period for a cohort of 49,752 Medicare patients admitted to the hospital in 1984 with a diagnosis of pulmonary embolism., Methods: Data were derived from Medicare Provider Analysis and Review Record inpatient claims files and the National Death Index file., Results: For a primary diagnosis of pulmonary embolism, median survival times among Black men and women were 2.5 years and 5.2 years, respectively; for White men and women, the median survival times were 4.3 years and 5.9 years, respectively. Median survival times for Black men and women and White men and women with a secondary diagnosis of pulmonary embolism were 0.4 years, 0.7 years, 0.8 years, and 1.4 years, respectively. Survival rates declined with advancing age., Conclusions: Overall, survival rates among Blacks were lower than those among Whites, and men had lower survival rates than women. These survival estimates provide new insights into outcomes following pulmonary embolism in hospitalized elderly people.

Background: Population-based cancer registries that can be used to compare cancer incidence and mortality across regions of the U.S. are currently lacking. The authors conducted this study to validate Medicare claims as a measure of county-level colorectal carcinoma incidence among older Americans. Variations found among counties are described in this article., Methods: A total of 183,174 hospitalized patients age 65 years in 1991-1993 with newly diagnosed colorectal carcinoma who resided in one of 480 large counties were identified in Medicare files. The county-level truncated age, race, and gender adjusted incidence rates for the population age 65 years, the proportion of patients with a code indicating distant metastases, and the 2-year case-fatality rates were determined. Corresponding rates from the SEER database were compared., Results: The median truncated adjusted 3-year incidence rate was 870 per 100,000 (Quartile 1-Quartile 3, 779-955), with almost twofold differences among counties even after the exclusion of outliers. The median proportion of patients with codes indicating distant metastases was 23.4% (range, 10.2-46.9%; Quartile 1-Quartile 3, 20.8-25.8), and the average 2-year case-fatality rate was 39.2% (range, 26.5-51.4%; Quartile 1-Quartile 3, 37.0-41.6). Medicare files tended to underestimate the truncated incidence rate according to SEER, but among counties the two sets of rates were closely correlated (r = 0.94, P < 0.0001)., Conclusions: Medicare files are a potential alternative source of national data for the study of colorectal carcinoma incidence among the elderly at the county level. The data also suggest significant variations among counties in colorectal carcinoma incidence, stage, and mortality that could be used in public health initiatives.

Objectives: This study determined race-, age- and sex-specific trends in 30-day pulmonary embolism mortality rates., Methods: Medicare beneficiaries with a primary or secondary discharge diagnosis of pulmonary embolism from 1984 to 1991 (n = 391,991) were examined., Results: For a primary diagnosis of pulmonary embolism, mortality rates declined by 15.2% and 16.0%, respectively, for White male patients 65 to 74 years old and 75 years or older. There was a corresponding decline in mortality rates for White women. For a secondary diagnosis of pulmonary embolism, mortality rates declined by 14.7% and 9.8%, respectively, for White male patients 65 to 74 years old and 75 years or older., Conclusions: The White mortality rate declines revealed in this study did not translate, in all cases, to Black patient groups.