BACKGROUND: The Surveillance, Epidemiology and End Results (SEER)-Medicare-linked database combines clinical information from population-based cancer registries with claims information from the Medicare program. The use of this database to study cancer screening, treatment, outcomes, and costs has grown in recent years. RESEARCH DESIGN: This paper provides an overview of the SEER-Medicare files for investigators interested in using these data for epidemiologic and health services research. The overview includes a description of the linkage of SEER and Medicare data and the files included as part of SEER-Medicare. The paper also describes the types of research projects that have been undertaken using the SEER-Medicare data. The overview concludes with a comparison of selected characteristics of elderly persons residing in the SEER areas to the US total aged. RESULTS: The paper identifies a number of potential uses of the SEER-Medicare data. The comparison of the elderly population in SEER areas to the US total shows that in the SEER areas there are a lower percentage of white persons and individuals living in poverty, and a higher percentage of urban-dwellers than the US total. Elderly persons in the SEER regions also have higher rates of HMO enrollment and lower rates of cancer mortality. CONCLUSIONS: The SEER-Medicare data are a unique resource that can be used for a variety of health services research projects. Although there are some differences between the elderly residing in the SEER areas and the US total, the SEER-Medicare data offer a large population-based cohort that can be used to longitudinally track care for persons over the course of cancer diagnosis, treatment, and follow-up.
This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees. We explain the model's principles, elements, organization, calibration, and performance. Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondary payer subpopulations are discussed.
National projections of future joint arthroplasties are useful for understanding the changing burden of surgery and related outcomes on the health system. The aim of this study is to update the literature by producing Medicare projections for primary total joint arthroplasty (TJA) procedures until 2040 and 2060. Methods: The present study used data from the Centers for Medicare & Medicaid Services (CMS) Medicare/Medicaid Part B National Summary and combined procedure counts with use of Current Procedural Terminology (CPT) codes to identify whether the procedure was a primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedure. In 2019, the annual volume of primary TKA was 480,958 and that of primary THA was 262,369. These values formed a baseline from which we generated point forecasts for 2020-2060 and 95% forecast intervals (FIs). Results: Between 2000 and 2019, the estimated annual volume of THA increased by 177% and that of TKA increased by 156% on average. Regression analysis projected an annual growth rate of 5.2% for THA and 4.44% for TKA. Based on these yearly projected increases, an estimated increase of 28.84% and 24.28% is expected for each 5-year period after 2020 for THA and TKA, respectively. By 2040, the number of THAs is projected to be 719,364 (95% FI, 624,766 to 828,286) and the number of TKA is projected to be 1,222,988 (95% FI, 988,714 to 1,512,772). By 2060, the number of THAs is projected to be 1,982,099 (95% FI, 1,624,215 to 2,418,839) and the number of TKAs is projected to be 2,917,959 (95% FI, 2,160,951 to 3,940,156). In 2019, Medicare data showed that THA constituted approximately 35% of TJA procedures performed. Conclusions: Based on 2019 total volume counts, our model forecasts an increase in THA procedures of 176% by 2040 and 659% by 2060. The estimated increase for TKA is projected to be 139% by 2040 and 469% by 2060. An accurate projection of future primary TJA procedure demands is important in order to understand future health-care utilization and surgeon demand. This finding is only applicable to a Medicare population and demands further analysis to see if this extends to other population groups. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
BACKGROUND: Reducing rates of rehospitalization has attracted attention from policymakers as a way to improve quality of care and reduce costs. However, we have limited information on the frequency and patterns of rehospitalization in the United States to aid in planning the necessary changes. METHODS: We analyzed Medicare claims data from 2003-2004 to describe the patterns of rehospitalization and the relation of rehospitalization to demographic characteristics of the patients and to characteristics of the hospitals. RESULTS: Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% [corrected] of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. In the case of 50.2% [corrected] of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician's office between the time of discharge and rehospitalization. Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition. We estimate that about 10% of rehospitalizations were likely to have been planned. The average stay of rehospitalized patients was 0.6 day longer than that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously. We estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion. CONCLUSIONS: Rehospitalizations among Medicare beneficiaries are prevalent and costly.
BACKGROUND: The health implications of regional differences in Medicare spending are unknown. OBJECTIVE: To determine whether regions with higher Medicare spending provide better care. DESIGN: Cohort study. SETTING: National study of Medicare beneficiaries. PATIENTS: Patients hospitalized between 1993 and 1995 for hip fracture (n = 614,503), colorectal cancer (n = 195,429), or acute myocardial infarction (n = 159,393) and a representative sample (n = 18,190) drawn from the Medicare Current Beneficiary Survey (1992-1995). EXPOSURE MEASUREMENT: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306). OUTCOME MEASUREMENTS: Content of care (for example, frequency and type of services received), quality of care (for example, use of aspirin after acute myocardial infarction, influenza immunization), and access to care (for example, having a usual source of care). RESULTS: Average baseline health status of cohort members was similar across regions of differing spending levels, but patients in higher-spending regions received approximately 60% more care. The increased utilization was explained by more frequent physician visits, especially in the inpatient setting (rate ratios in the highest vs. the lowest quintile of hospital referral regions were 2.13 [95% CI, 2.12 to 2.14] for inpatient visits and 2.36 [CI, 2.33 to 2.39] for new inpatient consultations), more frequent tests and minor (but not major) procedures, and increased use of specialists and hospitals (rate ratio in the highest vs. the lowest quintile was 1.52 [CI, 1.50 to 1.54] for inpatient days and 1.55 [CI, 1.50 to 1.60] for intensive care unit days). Quality of care in higher-spending regions was no better on most measures and was worse for several preventive care measures. Access to care in higher-spending regions was also no better or worse. CONCLUSIONS: Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist-oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions.
BACKGROUND: Studies have shown that long-term exposure to air pollution increases mortality. However, evidence is limited for air-pollution levels below the most recent National Ambient Air Quality Standards. Previous studies involved predominantly urban populations and did not have the statistical power to estimate the health effects in underrepresented groups. METHODS: and 10 parts per billion (ppb) for ozone using a two-pollutant Cox proportional-hazards model that controlled for demographic characteristics, Medicaid eligibility, and area-level covariates. RESULTS: , the risk of death among men, blacks, and people with Medicaid eligibility was higher than that in the rest of the population. CONCLUSIONS: and ozone at concentrations below current national standards. This effect was most pronounced among self-identified racial minorities and people with low income. (Supported by the Health Effects Institute and others.).
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Importance: Studies have found differences in practice patterns between male and female physicians, with female physicians more likely to adhere to clinical guidelines and evidence-based practice. However, whether patient outcomes differ between male and female physicians is largely unknown. Objective: To determine whether mortality and readmission rates differ between patients treated by male or female physicians. Design, Setting, and Participants: We analyzed a 20% random sample of Medicare fee-for-service beneficiaries 65 years or older hospitalized with a medical condition and treated by general internists from January 1, 2011, to December 31, 2014. We examined the association between physician sex and 30-day mortality and readmission rates, adjusted for patient and physician characteristics and hospital fixed effects (effectively comparing female and male physicians within the same hospital). As a sensitivity analysis, we examined only physicians focusing on hospital care (hospitalists), among whom patients are plausibly quasi-randomized to physicians based on the physician's specific work schedules. We also investigated whether differences in patient outcomes varied by specific condition or by underlying severity of illness. Main Outcomes and Measures: Patients' 30-day mortality and readmission rates. Results: A total of 1 583 028 hospitalizations were used for analyses of 30-day mortality (mean [SD] patient age, 80.2 [8.5] years; 621 412 men and 961 616 women) and 1 540 797 were used for analyses of readmission (mean [SD] patient age, 80.1 [8.5] years; 602 115 men and 938 682 women). Patients treated by female physicians had lower 30-day mortality (adjusted mortality, 11.07% vs 11.49%; adjusted risk difference, -0.43%; 95% CI, -0.57% to -0.28%; P < .001; number needed to treat to prevent 1 death, 233) and lower 30-day readmissions (adjusted readmissions, 15.02% vs 15.57%; adjusted risk difference, -0.55%; 95% CI, -0.71% to -0.39%; P < .001; number needed to treat to prevent 1 readmission, 182) than patients cared for by male physicians, after accounting for potential confounders. Our findings were unaffected when restricting analyses to patients treated by hospitalists. Differences persisted across 8 common medical conditions and across patients' severity of illness. Conclusions and Relevance: Elderly hospitalized patients treated by female internists have lower mortality and readmissions compared with those cared for by male internists. These findings suggest that the differences in practice patterns between male and female physicians, as suggested in previous studies, may have important clinical implications for patient outcomes.
OBJECTIVES: This study analyzed whether inadequate functional health literacy is an independent risk factor for hospital admission. METHODS: We studied a prospective cohort of 3260 Medicare managed care enrollees. RESULTS: Of the participants, 29.5% were hospitalized. The crude relative risk (RR) of hospitalization was higher for individuals with inadequate literacy (n = 800; RR = 1.43; 95% confidence interval [CI] = 1.24, 1.65) and marginal literacy (n = 366; RR = 1.33; 95% CI = 1.09, 1.61) than for those with adequate literacy (n = 2094). In multivariate analysis, the adjusted relative risk of hospital admission was 1.29 (95% CI = 1.07, 1.55) for individuals with inadequate literacy and 1.21 (95% CI = 0.97, 1.50) for those with marginal literacy. CONCLUSIONS: Inadequate literacy was an independent risk factor for hospital admission among elderly managed care enrollees.
IMPORTANCE: A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care. OBJECTIVE: To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270,202), 2005 (n = 291,819), or 2009 (n = 286,282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. MAIN OUTCOME MEASURES: Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life). RESULTS: Our random 20% sample included 848,303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%). CONCLUSION AND RELEVANCE: Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.
CONTEXT: Total knee arthroplasty (TKA) is one of the most common and costly surgical procedures performed in the United States. OBJECTIVE: To examine longitudinal trends in volume, utilization, and outcomes for primary and revision TKA between 1991 and 2010 in the US Medicare population. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort of 3,271,851 patients (aged ≥65 years) who underwent primary TKA and 318 563 who underwent revision TKA identified in Medicare Part A data files. MAIN OUTCOME MEASURES: We examined changes in primary and revision TKA volume, per capita utilization, hospital length of stay (LOS), readmission rates, and adverse outcomes. RESULTS: Between 1991 and 2010 annual primary TKA volume increased 161.5% from 93,230 to 243,802 while per capita utilization increased 99.2% (from 31.2 procedures per 10,000 Medicare enrollees in 1991 to 62.1 procedures per 10,000 in 2010). Revision TKA volume increased 105.9% from 9650 to 19,871 while per capita utilization increased 59.4% (from 3.2 procedures per 10,000 Medicare enrollees in 1991 to 5.1 procedures per 10,000 in 2010). For primary TKA, LOS decreased from 7.9 days (95% CI, 7.8-7.9) in 1991-1994 to 3.5 days (95% CI, 3.5-3.5) in 2007-2010 (P < .001). For primary TKA, rates of adverse outcomes resulting in readmission remained stable between 1991-2010, but rates of all-cause 30-day readmission increased from 4.2% (95% CI, 4.1%-4.2%) to 5.0% (95% CI, 4.9%-5.0%) (P < .001). For revision TKA, the decrease in hospital LOS was accompanied by an increase in all-cause 30-day readmission from 6.1% (95% CI, 5.9%-6.4%) to 8.9% (95% CI, 8.7%-9.2%) (P < .001) and an increase in readmission for wound infection from 1.4% (95% CI, 1.3%-1.5%) to 3.0% (95% CI, 2.9%-3.1%) (P < .001). CONCLUSIONS: Increases in TKA volume have been driven by both increases in the number of Medicare enrollees and in per capita utilization. We also observed decreases in hospital LOS that were accompanied by increases in hospital readmission rates.
This paper provides an empirical analysis of how the U.S. Social Security and Medicare insurance system affect the labor supply of older males in the presence of incomplete markets for loans, annuities, and insurance. We estimate a detailed dynamic programming (DP) model of the joint labor supply and Social Security acceptance decision, focusing on a sample of males in the low to middle income brackets whose only pension is Social Security. The DP model delivers a rich set of predictions about the dynamics of retirement behavior, and comparisons of actual vs. predicted behavior show that the DP model is able to account for wide variety of phenomena observed in the data, including the pronounced peaks in the distribution of retirement ages at 62 and 65 (the ages of early and normal eligibility for Social Security benefits, respectively). We identify a significant fraction of health insurance constrained individuals who have no form of retiree insurance other than Medicare, and who can only obtain fairly priced private insurance via their employer's group plan. The combination of significant individual risk aversion and a long tailed (Pareto) distribution of care expenditures implies that there is a significant security value for these individuals to remain employed until they are eligible for Medicare coverage at age 65. Overall, our model suggests that a number of heretofore puzzling aspects of retirement behavior can be viewed as artifacts of particular details of the Social Security rules, whose incentive effects are especially strong for lower income individuals and those who do not have access to fairly priced loans, annuities, and insurance.
CONTEXT: Elderly patients may have limited ability to read and comprehend medical information pertinent to their health. OBJECTIVE: To determine the prevalence of low functional health literacy among community-dwelling Medicare enrollees in a national managed care organization. DESIGN: Cross-sectional survey. SETTING: Four Prudential HealthCare plans (Cleveland, Ohio; Houston, Tex; south Florida; Tampa, Fla). PARTICIPANTS: A total of 3260 new Medicare enrollees aged 65 years or older were interviewed in person between June and December 1997 (853 in Cleveland, 498 in Houston, 975 in south Florida, 934 in Tampa); 2956 spoke English and 304 spoke Spanish as their native language. MAIN OUTCOME MEASURE; Functional health literacy as measured by the Short Test of Functional Health Literacy in Adults. RESULTS: Overall, 33.9% of English-speaking and 53.9% of Spanish-speaking respondents had inadequate or marginal health literacy. The prevalence of inadequate or marginal functional health literacy among English speakers ranged from 26.8% to 44.0%. In multivariate analysis, study location, race/language, age, years of school completed, occupation, and cognitive impairment were significantly associated with inadequate or marginal literacy. Reading ability declined dramatically with age, even after adjusting for years of school completed and cognitive impairment. The adjusted odds ratio for having inadequate or marginal health literacy was 8.62 (95% confidence interval, 5.55-13.38) for enrollees aged 85 years or older compared with individuals aged 65 to 69 years. CONCLUSIONS: Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. Low health literacy may impair elderly patients' understanding of health messages and limit their ability to care for their medical problems.
BACKGROUND: Cardiac rehabilitation (CR) is effective in prolonging survival and reducing disability in patients with coronary heart disease. However, national use patterns and predictors of CR use have not been evaluated thoroughly. METHODS AND RESULTS: Using Medicare claims, we analyzed outpatient (phase II) CR use after hospitalizations for acute myocardial infarctions or coronary artery bypass graft surgery in 267,427 fee-for-service beneficiaries aged > or = 65 years who survived for at least 30 days after hospital discharge. We used multivariable analyses to identify predictors of CR use and to quantify geographic variations in its use. We obtained unadjusted, adjusted-smoothed, and standardized rates of CR use by state. Overall, CR was used in 13.9% of patients hospitalized for acute myocardial infarction and 31.0% of patients who underwent coronary artery bypass graft surgery. Older individuals, women, nonwhites, and patients with comorbidities (including congestive heart failure, previous stroke, diabetes mellitus, or cancer) were significantly less likely to receive CR. Coronary artery bypass graft surgery during the index hospitalization, higher median household income, higher level of education, and shorter distance to the nearest CR facility were important predictors of higher CR use. Adjusted CR use varied 9-fold among states, ranging from 6.6% in Idaho to 53.5% in Nebraska. The highest CR use rates were clustered in the north central states of the United States. CONCLUSIONS: CR use is relatively low among Medicare beneficiaries despite convincing evidence of its benefits and recommendations for its use by professional organizations. Use is higher after coronary artery bypass graft surgery than with acute myocardial infarctions not treated with revascularization procedures and varies dramatically by state and region of the United States.
BACKGROUND: Congestive heart failure is the most common discharge diagnosis for Medicare beneficiaries. While several single-center studies have suggested that these patients are particularly vulnerable to readmission, no recent study, to our knowledge, has reported the readmission rates for a large number of elderly patients with congestive heart failure across a diverse spectrum of hospitals. OBJECTIVES: To define the readmission rate for elderly patients discharged after an episode of congestive heart failure. To determine the spectrum of diagnoses that are responsible for readmissions among patients with congestive heart failure. To identify patient and hospital characteristics associated with a higher likelihood of readmission. METHODS: This observational study, using Medicare administrative files, evaluated readmission and death among all survivors of a hospitalization in Connecticut for congestive heart failure from fiscal year 1991 through fiscal year 1994. RESULTS: There were 17448 survivors of a hospitalization for congestive heart failure during the study period. In the 6 months following the index admission, 7596 patients (44%) were readmitted to a hospital at least once. Congestive heart failure was the most frequent reason for readmission among study patients, accounting for 18% of all readmissions. In the multivariable analysis, significant predictors of readmission included male sex (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.05-1.20), at least 1 prior admission within 6 months of the index admission (OR, 1.64; 95% CI, 1.53-1.77), Deyo comorbidity score of more than 1 (OR, 1.56; 95% CI, 1.45-1.68), and length of stay in the index hospitalization of more than 7 days (OR, 1.32; 95% CI, 1.24-1.41). While age was not a significant predictor of readmission, it became significant in a model with the combined outcome of readmission or death as the dependent variable. CONCLUSION: Readmission after a hospitalization for congestive heart failure is common among Medicare beneficiaries, with almost half of the patients readmitted within 6 months. This striking rate of readmission in a common diagnosis demands efforts to further clarify the determinants of readmission and develop strategies to prevent this adverse outcome.
BACKGROUND: There are wide disparities between blacks and whites in the use of many Medicare services. We studied the effects of race and income on mortality and use of services. METHODS: We linked 1990 census data on median income according to ZIP Code with 1993 Medicare administrative data for 26.3 million beneficiaries 65 years of age or older (24.2 million whites and 2.1 million blacks). We calculated age-adjusted mortality rates and age- and sex-adjusted rates of various diagnoses and procedures according to race and income and computed black:white ratios. The 1993 Medicare Current Beneficiary Survey was used to validate the results and determine rates of immunization against influenza. RESULTS: For mortality, the black:white ratios were 1.19 for men and 1.16 for women (P<0.001 for both). For hospital discharges, the ratio was 1.14 (P<0.001), and for visits to physicians for ambulatory care it was 0.89 (P<0.001). For every 100 women, there were 26.0 mammograms among whites and 17.1 mammograms among blacks. As compared with mammography rates in the respective most affluent group, rates in the least affluent group were 33 percent lower among whites and 22 percent lower among blacks. The black:white rate ratio was 2.45 for bilateral orchiectomy and 3.64 for amputations of all or part of the lower limb (P<0.001 for both). For every 1000 beneficiaries, there were 515 influenza immunizations among whites and 313 among blacks. As compared with immunization rates in the respective most affluent group, rates in the least affluent group were 26 percent lower among whites and 39 percent lower among blacks. Adjusting the mortality and utilization rates for differences in income generally reduced the racial differences, but the effect was relatively small. CONCLUSIONS: Race and income have substantial effects on mortality and use of services among Medicare beneficiaries. Providing health insurance is not enough to ensure that the program is used effectively and equitably by all beneficiaries.
The objective of this study is to investigate whether hospitals known to be good places to practice nursing have lower Medicare mortality than hospitals that are otherwise similar with respect to a variety of non-nursing organizational characteristics. Research to date on determinants of hospital mortality has not focused on the organization of nursing. We capitalize on the existence of a set of studies of 39 hospitals that, for reasons other than patient outcomes, have been singled out as hospitals known for good nursing care. We match these "magnet" hospitals with 195 control hospitals, selected from all nonmagnet U.S. hospitals with over 100 Medicare discharges, using a multivariate matched sampling procedure that controls for hospital characteristics. Medicare mortality rates of magnet versus control hospitals are compared using variance components models, which pool information on the five matches per magnet hospital, and adjust for differences in patient composition as measured by predicted mortality. The magnet hospitals' observed mortality rates are 7.7% lower (9 fewer deaths per 1,000 Medicare discharges) than the matched control hospitals (P = .011). After adjusting for differences in predicted mortality, the magnet hospitals have a 4.6% lower mortality rate (P = .026 [95% confidence interval 0.9 to 9.4 fewer deaths per 1,000]). The same factors that lead hospitals to be identified as effective from the standpoint of the organization of nursing care are associated with lower mortality among Medicare patients.
BACKGROUND: Randomized trials have shown reductions in perioperative mortality and morbidity with endovascular repair of abdominal aortic aneurysm, as compared with open surgical repair. Longer-term survival rates, however, were similar for the two procedures. There are currently no long-term, population-based data from the comparison of these strategies. METHODS: We studied perioperative rates of death and complications, long-term survival, rupture, and reinterventions after open as compared with endovascular repair of abdominal aortic aneurysm in propensity-score-matched cohorts of Medicare beneficiaries undergoing repair during the 2001-2004 period, with follow-up until 2005. RESULTS: There were 22,830 matched patients undergoing open repair of abdominal aortic aneurysm in each cohort. The average age of the patients was 76 years, and approximately 20% were women. Perioperative mortality was lower after endovascular repair than after open repair (1.2% vs. 4.8%, P<0.001), and the reduction in mortality increased with age (2.1% difference for those 67 to 69 years old vs. 8.5% for those 85 years or older, P<0.001). Late survival was similar in the two cohorts, although the survival curves did not converge until after 3 years. By 4 years, rupture was more likely in the endovascular-repair cohort than in the open-repair cohort (1.8% vs. 0.5%, P<0.001), as was reintervention related to abdominal aortic aneurysm (9.0% vs. 1.7%, P<0.001), although most reinterventions were minor. In contrast, by 4 years, surgery for laparotomy-related complications was more likely among patients who had undergone open repair (9.7%, vs. 4.1% among those who had undergone endovascular repair; P<0.001), as was hospitalization without surgery for bowel obstruction or abdominal-wall hernia (14.2% vs. 8.1%, P<0.001). CONCLUSIONS: As compared with open repair, endovascular repair of abdominal aortic aneurysm is associated with lower short-term rates of death and complications. The survival advantage is more durable among older patients. Late reinterventions related to abdominal aortic aneurysm are more common after endovascular repair but are balanced by an increase in laparotomy-related reinterventions and hospitalizations after open surgery.
BACKGROUND: Pneumonia accounts for more than 600 000 Medicare hospitalizations yearly. Guidelines have recommended antibiotic treatment within 8 hours of arrival at the hospital. METHODS: We performed a retrospective study using medical records from a national random sample of 18 209 Medicare patients older than 65 years who were hospitalized with community-acquired pneumonia from July 1998 through March 1999. Outcomes were severity-adjusted mortality, readmission within 30 days of discharge, and length of stay (LOS). RESULTS: Among 13 771 (75.6%) patients who had not received outpatient antibiotic agents, antibiotic administration within 4 hours of arrival at the hospital was associated with reduced in-hospital mortality (6.8% vs 7.4%; adjusted odds ratio [AOR], 0.85; 95% confidence interval [CI], 0.74-0.98), mortality within 30 days of admission (11.6% vs 12.7%; AOR, 0.85; 95% CI, 0.76-0.95), and LOS exceeding the 5-day median (42.1% vs 45.1%; AOR, 0.90; 95% CI, 0.83-0.96). Mean LOS was 0.4 days shorter with antibiotic administration within 4 hours than with later administration. Timing was not associated with readmission. Antibiotic administration within 4 hours of arrival was documented for 60.9% of all patients and for more than 50% of patients regardless of hospital characteristics. CONCLUSIONS: Antibiotic administration within 4 hours of arrival was associated with decreased mortality and LOS among a random sample of older inpatients with community-acquired pneumonia who had not received antibiotics as outpatients. Administration within 4 hours can prevent deaths in the Medicare population, offers cost savings for hospitals, and is feasible for most inpatients.