TY - JOUR T1 - Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department JF - JAMA Internal Medicine Y1 - 2023 A1 - Smulowitz, Peter B. A1 - Weinreb, Gabe A1 - McWilliams, J. Michael A1 - O’Malley, A. James A1 - Landon, Bruce E. AB - The role of patient-level factors that are unrelated to the specific clinical condition leading to an emergency department (ED) visit, such as functional status, cognitive status, social supports, and geriatric syndromes, in admission decisions is not well understood, partly because these data are not available in administrative databases.To determine the extent to which patient-level factors are associated with rates of hospital admission from the ED.This cohort study analyzed survey data collected from participants (or their proxies, such as family members) enrolled in the Health and Retirement Study (HRS) from January 1, 2000, to December 31, 2018. These HRS data were linked to Medicare fee-for-service claims data from January 1, 1999, to December 31, 2018. Information on functional status, cognitive status, social supports, and geriatric syndromes was obtained from the HRS data, whereas ED visits, subsequent hospital admission or ED discharge, and other claims-derived comorbidities and sociodemographic characteristics were obtained from Medicare data. Data were analyzed from September 2021 to April 2023.The primary outcome measure was hospital admission after an ED visit. A baseline logistic regression model was estimated, with a binary indicator of admission as the dependent variable of interest. For each primary variable of interest derived from the HRS data, the model was reestimated, including the HRS variable of interest as an independent variable. For each of these models, the odds ratio (OR) and average marginal effect (AME) of changing the value of the variable of interest were calculated.A total of 42 392 ED visits by 11 783 unique patients were included. At the time of the ED visit, patients had a mean (SD) age of 77.4 (9.6) years, and visits were predominantly for female (25 719 visits [60.7\%]) and White (32 148 visits [75.8\%]) individuals. The overall percentage of patients admitted was 42.5\%. After controlling for ED diagnosis and demographic characteristics, functional status, cognition status, and social supports all were associated with the likelihood of admission. For instance, difficulty performing 5 activities of daily living was associated with an 8.5–percentage point (OR, 1.47; 95\% CI, 1.29-1.66) AME increase in the likelihood of admission. Having dementia was associated with an AME increase in the likelihood of admission of 4.6 percentage points (OR, 1.23; 95\% CI, 1.14-1.33). Living with a spouse was associated with an AME decrease in the likelihood of admission of 3.9 percentage points (OR, 0.84; 95\% CI, 0.79-0.89), and having children living within 10 miles was associated with an AME decrease in the likelihood of admission of 5.0 percentage points (OR, 0.80; 95\% CI, 0.71-0.89). Other common geriatric syndromes, including trouble falling asleep, waking early, trouble with vision, glaucoma or cataract, use of hearing aids or trouble with hearing, falls in past 2 years, incontinence, depression, and polypharmacy, were not meaningfully associated with the likelihood of admission.Results of this cohort study suggest that the key patient-level characteristics, including social supports, cognitive status, and functional status, were associated with the decision to admit older patients to the hospital from the ED. These factors are critical to consider when devising strategies to reduce low-value admissions among older adult patients from the ED. ER - TY - JOUR T1 - Estimated Annual Spending on Aducanumab in the US Medicare Program JF - JAMA Health Forum Y1 - 2022 A1 - Mafi, John N. A1 - Leng, Mei A1 - Arbanas, Julia Cave A1 - Tseng, Chi-Hong A1 - Damberg, Cheryl L. A1 - Catherine A Sarkisian A1 - Landon, Bruce E. KW - aducanumab KW - annual spending KW - Medicare AB - The US Food and Drug Administration’s June 2021 decision to approve aducanumab for treatment for Alzheimer dementia raised concerns that a drug with uncertain benefit and high cost could, in aggregate, threaten Medicare's solvency. In response to these concerns, Biogen recently announced a 50% annual drug price reduction from $56 000 to $28 200 per patient. Preliminary US spending estimates either used extrapolated Alzheimer dementia prevalence data from 2012 or did not explicitly quantify ancillary costs, such as additional diagnostic imaging to monitor the amyloid-associated imaging abnormalities (ARIAs) that occur in 41% of treated patients, and did not incorporate the recently announced price reduction.1-3 We estimated upper bound and lower bound annualized Medicare costs for administering aducanumab to beneficiaries with the approved indications of mild cognitive impairment (MCI) or mild dementia, focusing on the degree to which associated ancillary health services affect spending.1 VL - 3 SN - 2689-0186 IS - 1 ER - TY - JOUR T1 - Complex Medicare Advantage Choices May Overwhelm Seniors—Especially Those With Impaired Decision Making JF - Health Affairs Y1 - 2011 A1 - J. Michael McWilliams A1 - Afendulis, Christopher C. A1 - McGuire, Thomas G. A1 - Landon, Bruce E. KW - Decision making KW - Medicare KW - Medicare claims data AB - The proliferation of Medicare Advantage plans has given Medicare enrollees more choices, but these could be overwhelming for some, especially for those with impaired decision-making capabilities. We analyzed national survey data and linked Medicare enrollment data for the period 2004–07 to examine the effects on enrollment of expanded choices and benefits in the Medicare Advantage program. The availability of more plan options was associated with increased enrollment in Medicare Advantage when elderly Medicare beneficiaries chose from a limited number of plans—for example, fewer than fifteen plans. Enrollment was unchanged or decreased in Medicare Advantage when beneficiaries chose from larger numbers of plans—for example, fifteen to thirty, or more than thirty. Elderly adults with low cognitive function were less responsive to the generosity of available benefits than those with high cognitive function when choosing between traditional Medicare and Medicare Advantage. Simplifying choices in Medicare Advantage could improve beneficiaries’ enrollment decisions, strengthen value-based competition among plans, and extend the benefits of choice to seniors with impaired cognition. It could also lower their out-of-pocket costs. VL - 30 IS - 9 ER - TY - JOUR T1 - Conducting High-Value Secondary Dataset Analysis: An Introductory Guide and Resources JF - Journal of General Internal Medicine Y1 - 2011 A1 - John Z. Ayanian A1 - Kenneth E Covinsky A1 - Landon, Bruce E. A1 - Ellen P McCarthy A1 - Wee, Christina C. A1 - Michael A Steinman KW - Datasets KW - Meta-analyses KW - Survey Methodology AB - Secondary analyses of large datasets provide a mechanism for researchers to address high impact questions that would otherwise be prohibitively expensive and time-consuming to study. This paper presents a guide to assist investigators interested in conducting secondary data analysis, including advice on the process of successful secondary data analysis as well as a brief summary of high-value datasets and online resources for researchers, including the SGIM dataset compendium (www.sgim.org/go/datasets). The same basic research principles that apply to primary data analysis apply to secondary data analysis, including the development of a clear and clinically relevant research question, study sample, appropriate measures, and a thoughtful analytic approach. A real-world case description illustrates key steps: (1) define your research topic and question; (2) select a dataset; (3) get to know your dataset; and (4) structure your analysis and presentation of findings in a way that is clinically meaningful. Secondary dataset analysis is a well-established methodology. Secondary analysis is particularly valuable for junior investigators, who have limited time and resources to demonstrate expertise and productivity. VL - 26 IS - 8 ER -