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Mechanical Ventilation and Survival in Patients With Advanced Dementia in Medicare Advantage

      Abstract

      Context

      Medicare Advantage (MA) cares for an increasing proportion of traditional Medicare (TM) patients although, the association of MA on low-value care among hospitalized patients is uncertain.

      Objectives

      We sought to determine whether invasive mechanical ventilation (IMV) use or mortality differs among hospitalized patients with advanced dementia (AD) enrolled in MA vs. TM and the influence of hospital MA concentration.

      Methods

      Retrospective cohort of hospitalized Medicare patients from 2016 to 2017 who were ≥66 years old with AD (n=147,153) and had a hospitalization with an assessment completed during a nursing home stay ≤120 days prior to that hospitalization indicating AD and severe cognitive/functional impairment. MA enrollment was ascertained at hospitalization; IMV use and 30- and 365-day mortality were determined via Medicare data. Multivariable logistic regression models clustered by hospital were used.

      Results

      Among hospitalized Medicare patients with AD, 27,253 (19%) were enrolled in MA, mean age was 84 (95% CI: 83.9–84.0) and 92,736 (63%) were female. Enrollment in MA was associated with increased IMV use (Adjusted Odds Ratio(AOR)=1.11, 95% CI: 1.04–1.18), 30- (Adjusted Hazard Ratio(AHR)=1.09, 95% CI: 1.05–1.12) and 365-day mortality (AHR=1.12, 95% CI: 1.08–1.16) compared to TM. Use of IMV was not different based on concentration of MA at the hospital level.

      Conclusion

      MA may reduce hospitalizations, however, once hospitalized, patients with AD enrolled in MA experience higher rates of IMV use and worse 30- and 365-day mortality compared to TM patients. Higher hospital concentration of MA did not reduce use of IMV. MA may not offer significant benefits in reducing low-value care among patients hospitalized with serious illness, questioning the benefits of this care model.

      Key Words

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      References

        • Sullivan DR
        • Kim H
        • Gozalo PL
        • Bunker J
        • Teno JM.
        Trends in noninvasive and invasive mechanical ventilation among medicare beneficiaries at the end of life.
        JAMA Intern Med. 2021; 181: 93-102https://doi.org/10.1001/jamainternmed.2020.5640
        • Shrank WH
        • Rogstad TL
        • Parekh N.
        Waste in the US health care system: estimated costs and potential for savings.
        JAMA. 2019; https://doi.org/10.1001/jama.2019.13978
        • Teno JM
        • Gozalo P
        • Trivedi AN
        • et al.
        Site of death, place of care, and health care transitions among US Medicare beneficiaries, 2000-2015.
        JAMA. 2018; 320: 264-271https://doi.org/10.1001/jama.2018.8981
        • Halpern NA
        • Pastores SM.
        Critical care medicine beds, use, occupancy, and costs in the United States: a methodological review.
        Crit Care Med. 2015; 43: 2452-2459https://doi.org/10.1097/CCM.0000000000001227
        • Wunsch H
        • Linde-Zwirble WT
        • Angus DC
        • et al.
        The epidemiology of mechanical ventilation use in the United States.
        Crit Care Med. 2010; 38: 1947-1953https://doi.org/10.1097/CCM.0b013e3181ef4460
        • Teno JM
        • Gozalo P
        • Khandelwal N
        • et al.
        Association of increasing use of mechanical ventilation among nursing home residents with advanced dementia and intensive care unit beds.
        JAMA Intern Med. 2016; 176: 1809-1816https://doi.org/10.1001/jamainternmed.2016.5964
      1. Lohr KN Medicare: A strategy for quality assurance: Volume 1. 1990 (PMID 25144047)
        https://pubmed.ncbi.nlm.nih.gov/25144047/
        Date accessed: March 4, 2021
        • Murray LA
        • Eppig FJ.
        Insurance trends for the Medicare population, 1991-1999.
        Health Care Financ Rev. 2002; 23: 9-15
        • Huskamp HA
        • Buntin MB
        • Wang V
        • Newhouse JP.
        Providing care at the end of life: do Medicare rules impede good care?.
        Health Aff (Millwood). 2001; 20: 204-211https://doi.org/10.1377/hlthaff.20.3.204
        • Buntin MB
        • Huskamp H.
        What is known about the economics of end-of-life care for Medicare beneficiaries?.
        Gerontologist. 2002; 42 (Spec No 3): 40-48https://doi.org/10.1093/geront/42.suppl_3.40
        • McGuire TG
        • Newhouse JP
        • Sinaiko AD.
        An economic history of Medicare part C.
        Milbank Q. 2011; 89: 289-332https://doi.org/10.1111/j.1468-0009.2011.00629.x
        • Park S
        • Figueroa JF
        • Fishman P
        • Coe NB.
        Primary care utilization and expenditures in traditional Medicare and Medicare advantage, 2007-2016.
        J Gen Intern Med. 2020; 35: 2480-2481https://doi.org/10.1007/s11606-020-05826-x
        • Landon BE
        • Zaslavsky AM
        • Bernard SL
        • Cioffi MJ
        • Cleary PD.
        Comparison of performance of traditional Medicare vs Medicare managed care.
        JAMA. 2004; 291: 1744-1752https://doi.org/10.1001/jama.291.14.1744
        • Nicholas LH.
        Better quality of care or healthier patients? Hospital utilization by Medicare advantage and fee-for-service enrollees.
        Forum Health Econ Policy. 2013; 16: 137-161https://doi.org/10.1515/fhep-2012-0037
        • Stevenson DG
        • Ayanian JZ
        • Zaslavsky AM
        • Newhouse JP
        • Landon BE.
        Service use at the end-of-life in Medicare advantage versus traditional Medicare.
        Med Care. 2013; 51: 931-937https://doi.org/10.1097/MLR.0b013e3182a50278
        • Curto V
        • Einav L
        • Finkelstein A
        • Levin J
        • Bhattacharya J.
        Health care spending and utilization in public and private Medicare.
        Am Econ J Appl Econ. 2019; 11: 302-332https://doi.org/10.1257/app.20170295
        • Parashuram S
        • Kim S
        • Dowd B.
        Inappropriate utilization in fee-for-service Medicare and Medicare advantage plans.
        Am J Med Qual. 2018; 33: 58-64https://doi.org/10.1177/1062860617702240
        • Park S
        • White L
        • Fishman P
        • Larson EB
        • Coe NB.
        Health care utilization, care satisfaction, and health status for Medicare advantage and traditional Medicare beneficiaries with and without Alzheimer disease and related dementias.
        JAMA Netw Open. 2020; 3e201809https://doi.org/10.1001/jamanetworkopen.2020.1809
      2. Terry KM, David. Medicare advantage for all? Not so fast. Health Affairs Blog blog. 2021.

        • Khandker RK
        • Black CM
        • Xie L
        • et al.
        Analysis of episodes of care in Medicare beneficiaries newly diagnosed with Alzheimer's Disease.
        J Am Geriatr Soc. 2018; 66: 864-870https://doi.org/10.1111/jgs.15281
        • LaMantia MA
        • Scheunemann LP
        • Viera AJ
        • Busby-Whitehead J
        • Hanson LC.
        Interventions to improve transitional care between nursing homes and hospitals: a systematic review.
        J Am Geriatr Soc. 2010; 58: 777-782https://doi.org/10.1111/j.1532-5415.2010.02776.x
        • Hebert LE
        • Scherr PA
        • Bienias JL
        • Bennett DA
        • Evans DA.
        Alzheimer disease in the US population: prevalence estimates using the 2000 census.
        Arch Neurol. 2003; 60: 1119-1122https://doi.org/10.1001/archneur.60.8.1119
        • Thomas KS
        • Dosa D
        • Wysocki A
        • Mor V.
        The minimum data set 3.0 cognitive function scale.
        Med Care. 2017; 55: e68-e72https://doi.org/10.1097/MLR.0000000000000334
      3. Identifying medicare managed care beneficiaries from the master beneficiary summary or denominator files (ResDAC) (2017).

        • Huckfeldt PJ
        • Escarce JJ
        • Rabideau B
        • Karaca-Mandic P
        • Sood N.
        Less intense postacute care, better outcomes for enrollees in Medicare advantage than those in fee-for-service.
        Health Aff (Millwood). 2017; 36: 91-100https://doi.org/10.1377/hlthaff.2016.1027
        • de Miguel-Diez J
        • Jimenez-Garcia R
        • Hernandez-Barrera V
        • et al.
        National trends in hospital admissions for asthma exacerbations among pediatric and young adult population in Spain (2002-2010).
        Respir Med. 2014; 108: 983-991https://doi.org/10.1016/j.rmed.2014.04.008
        • Stefan MS
        • Priya A
        • Pekow PS
        • et al.
        The comparative effectiveness of noninvasive and invasive ventilation in patients with pneumonia.
        J Crit Care. 2018; 43: 190-196https://doi.org/10.1016/j.jcrc.2017.05.023
        • Valley TS
        • Walkey AJ
        • Lindenauer PK
        • Wiener RS
        • Cooke CR.
        Association between noninvasive ventilation and mortality among older patients with pneumonia.
        Crit Care Med. 2017; 45: e246-e254https://doi.org/10.1097/CCM.0000000000002076
        • Wunsch H
        • Kramer A
        • Gershengorn HB.
        Validation of intensive care and mechanical ventilation codes in Medicare data.
        Crit Care Med. 2017; 45: e711-e714https://doi.org/10.1097/CCM.0000000000002316
        • Mehta AB
        • Douglas IS
        • Walkey AJ.
        Evidence-based utilization of noninvasive ventilation and patient outcomes.
        Ann Am Thorac Soc. 2017; 14: 1667-1673https://doi.org/10.1513/AnnalsATS.201703-208OC
        • Gozalo P
        • Teno JM
        • Mitchell SL
        • et al.
        End-of-life transitions among nursing home residents with cognitive issues.
        N Engl J Med. 2011; 365: 1212-1221https://doi.org/10.1056/NEJMsa1100347
      4. Dying in America: improving quality and honoring individual preferences near the end of life. 2015.

        • Sachs GA
        • Shega JW
        • Cox-Hayley D.
        Barriers to excellent end-of-life care for patients with dementia.
        J Gen Intern Med. 2004; 19: 1057-1063https://doi.org/10.1111/j.1525-1497.2004.30329.x
        • Mitchell SL
        • Kiely DK
        • Hamel MB.
        Dying with advanced dementia in the nursing home.
        Arch Intern Med. 2004; 164: 321-326https://doi.org/10.1001/archinte.164.3.321
        • Morrison RS
        • Siu AL.
        Mortality from pneumonia and hip fractures in patients with advanced dementia.
        JAMA. 2000; 284: 2447-2448
        • Cheng AC
        • Cheng KC
        • Chen CM
        • Hsing SC
        • Sung MY
        The outcome and predictors of failed extubation in intensive care patientsd the elderly is an important predictor.
        Int J Gerontol. 2011; 5: 206-211
        • Behrendt CE.
        Acute respiratory failure in the United States: incidence and 31-day survival.
        Chest. 2000; 118: 1100-1105https://doi.org/10.1378/chest.118.4.1100
        • Mitchell SL
        • Teno JM
        • Kiely DK
        • et al.
        The clinical course of advanced dementia.
        N Engl J Med. 2009; 361: 1529-1538https://doi.org/10.1056/NEJMoa0902234
        • Burwell SM.
        Setting value-based payment goals–HHS efforts to improve U.S. health care.
        N Engl J Med. 2015; 372: 897-899https://doi.org/10.1056/NEJMp1500445
        • Ginsburg PB.
        Fee-for-service will remain a feature of major payment reforms, requiring more changes in Medicare physician payment.
        Health Aff (Millwood). 2012; 31: 1977-1983https://doi.org/10.1377/hlthaff.2012.0350
        • Zuvekas SH
        • Cohen JW.
        Fee-for-service, while much maligned, remains the dominant payment method for physician visits.
        Health Aff (Millwood). 2016; 35: 411-414https://doi.org/10.1377/hlthaff.2015.1291
        • Teno JM
        • Keohane LM
        • Mitchell SL
        • et al.
        Dying with dementia in Medicare advantage, accountable care organizations, or traditional Medicare.
        J Am Geriatr Soc. 2021; https://doi.org/10.1111/jgs.17225
        • Duncan I
        • Ahmed T
        • Dove H
        • Maxwell TL.
        Medicare cost at end of life.
        Am J Hosp Palliat Care. 2019; 36: 705-710https://doi.org/10.1177/1049909119836204
        • Spettell CM
        • Rawlins WS
        • Krakauer R
        • et al.
        A comprehensive case management program to improve palliative care.
        J Palliat Med. 2009; 12: 827-832https://doi.org/10.1089/jpm.2009.0089
        • Callison K.
        Medicare managed care spillovers and treatment intensity.
        Health Econ. 2016; 25: 873-887https://doi.org/10.1002/hec.3191
        • Baicker K
        • Chernew ME
        • Robbins JA.
        The spillover effects of Medicare managed care: Medicare advantage and hospital utilization.
        J Health Econ. 2013; 32: 1289-1300https://doi.org/10.1016/j.jhealeco.2013.09.005
        • Baicker K
        • Robbins JA
        Medicare payments and system-level health-care use: the spillover effects of Medicare Managed Care.
        Am J Health Econ. 2015; 1: 399-431https://doi.org/10.1162/AJHE_a_00024
        • Jung HY
        • Li Q
        • Rahman M
        • Mor V.
        Medicare advantage enrollees' use of nursing homes: trends and nursing home characteristics.
        Am J Manag Care. 2018; 24: e249-e256
        • Meyers DJ
        • Trivedi AN
        • Mor V
        • Rahman M.
        Comparison of the quality of hospitals that admit Medicare advantage patients vs traditional Medicare patients.
        JAMA Netw Open. 2020; 3e1919310https://doi.org/10.1001/jamanetworkopen.2019.19310
        • Henke RM
        • Karaca Z
        • Gibson TB
        • et al.
        Medicare advantage penetration and hospital costs before and after the affordable care act.
        Med Care. 2018; 56: 321-328https://doi.org/10.1097/MLR.0000000000000885
        • Teno JM
        • Christian TJ
        • Gozalo P
        • Plotzke M.
        Proportion and patterns of hospice discharges in medicare advantage compared to medicare fee-for-service.
        J Palliat Med. 2018; 21: 302-306https://doi.org/10.1089/jpm.2017.0046