@article {8514, title = {Neuroimaging overuse is more common in Medicare compared with the VA.}, journal = {Neurology}, volume = {87}, year = {2016}, month = {2016 Aug 23}, pages = {792-8}, abstract = {
OBJECTIVE: To inform initiatives to reduce overuse, we compared neuroimaging appropriateness in a large Medicare cohort with a Department of Veterans Affairs (VA) cohort.
METHODS: Separate retrospective cohorts were established in Medicare and in VA for headache and neuropathy from 2004 to 2011. The Medicare cohorts included all patients enrolled in the Health and Retirement Study (HRS) with linked Medicare claims (HRS-Medicare; n = 1,244 for headache and 998 for neuropathy). The VA cohorts included all patients receiving services in the VA (n = 93,755 for headache and 183,642 for neuropathy). Inclusion criteria were age over 65 years and an outpatient visit for incident neuropathy or a primary headache. Neuroimaging use was measured with Current Procedural Terminology codes and potential overuse was defined using published criteria for use with administrative data. Increasingly specific appropriateness criteria excluded nontarget conditions for which neuroimaging may be appropriate.
RESULTS: For both peripheral neuropathy and headache, potentially inappropriate imaging was more common in HRS-Medicare compared with the VA. Forty-nine percentage of all headache patients received neuroimaging in HRS-Medicare compared with 22.1\% in the VA (p < 0.001) and differences persist when analyzing more specific definitions of overuse. A total of 23.7\% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9.0\% in the VA (p < 0.001), and the difference persisted after excluding nontarget conditions.
CONCLUSIONS: Overuse of neuroimaging is likely less common in the VA than in a Medicare population. Better understanding the reasons for the more selective use of neuroimaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing.
}, keywords = {Aged, Aged, 80 and over, Cohort Studies, Female, Headache Disorders, Primary, Humans, Male, Medicare, Neuroimaging, Peripheral Nervous System Diseases, United States, United States Department of Veterans Affairs, Unnecessary Procedures}, issn = {1526-632X}, doi = {10.1212/WNL.0000000000002963}, url = {http://www.ncbi.nlm.nih.gov/pubmed/27402889}, author = {James F. Burke and Eve A Kerr and Ryan J McCammon and Holleman, Rob and Kenneth M. Langa and Brian C. Callaghan} } @article {8660, title = {Factors associated with cognitive evaluations in the United States.}, journal = {Neurology}, volume = {84}, year = {2015}, month = {2015 Jan 06}, pages = {64-71}, abstract = {OBJECTIVE: We aimed to explore factors associated with clinical evaluations for cognitive impairment among older residents of the United States.
METHODS: Two hundred ninety-seven of 845 subjects in the Aging, Demographics, and Memory Study (ADAMS), a nationally representative community-based cohort study, met criteria for dementia after a detailed in-person study examination. Informants for these subjects reported whether or not they had ever received a clinical cognitive evaluation outside of the context of ADAMS. Among subjects with dementia, we evaluated demographic, socioeconomic, and clinical factors associated with an informant-reported clinical cognitive evaluation using bivariate analyses and multivariable logistic regression.
RESULTS: Of the 297 participants with dementia in ADAMS, 55.2\% (representing about 1.8 million elderly Americans in 2002) reported no history of a clinical cognitive evaluation by a physician. In a multivariable logistic regression model (n = 297) controlling for demographics, physical function measures, and dementia severity, marital status (odds ratio for currently married: 2.63 [95\% confidence interval: 1.10-6.35]) was the only significant independent predictor of receiving a clinical cognitive evaluation among subjects with study-confirmed dementia.
CONCLUSIONS: Many elderly individuals with dementia do not receive clinical cognitive evaluations. The likelihood of receiving a clinical cognitive evaluation in elderly individuals with dementia associates with certain patient-specific factors, particularly severity of cognitive impairment and current marital status.
}, keywords = {Aged, Aged, 80 and over, Cognition Disorders, Cohort Studies, Dementia, Female, Humans, Logistic Models, Male, Marital Status, Multivariate Analysis, Neuropsychological tests, Severity of Illness Index, United States}, issn = {1526-632X}, doi = {10.1212/WNL.0000000000001096}, url = {http://www.neurology.org/cgi/doi/10.1212/WNL.0000000000001096}, author = {Vikas Kotagal and Kenneth M. Langa and Brenda L Plassman and Gwenith G Fisher and Bruno J Giordani and Robert B Wallace and James F. Burke and David C Steffens and Mohammed U Kabeto and Roger L. Albin and Norman L Foster} } @article {8332, title = {Longitudinal patient-oriented outcomes in neuropathy: Importance of early detection and falls.}, journal = {Neurology}, volume = {85}, year = {2015}, month = {2015 Jul 07}, pages = {71-9}, publisher = {85}, abstract = {OBJECTIVE: To evaluate longitudinal patient-oriented outcomes in peripheral neuropathy over a 14-year time period including time before and after diagnosis.
METHODS: The 1996-2007 Health and Retirement Study (HRS)-Medicare Claims linked database identified incident peripheral neuropathy cases (ICD-9 codes) in patients >=65 years. Using detailed demographic information from the HRS and Medicare claims, a propensity score method identified a matched control group without neuropathy. Patient-oriented outcomes, with an emphasis on self-reported falls, pain, and self-rated health (HRS interview), were determined before and after neuropathy diagnosis. Generalized estimating equations were used to assess differences in longitudinal outcomes between cases and controls.
RESULTS: We identified 953 peripheral neuropathy cases and 953 propensity-matched controls. The mean (SD) age was 77.4 (6.7) years for cases, 76.9 (6.6) years for controls, and 42.1\% had diabetes. Differences were detected in falls 3.0 years before neuropathy diagnosis (case vs control; 32\% vs 25\%, p = 0.008), 5.0 years for pain (36\% vs 27\%, p = 0.002), and 5.0 years for good to excellent self-rated health (61\% vs 74\%, p < 0.0001). Over time, the proportion of fallers increased more rapidly in neuropathy cases compared to controls (p = 0.002), but no differences in pain (p = 0.08) or self-rated health (p = 0.9) were observed.
CONCLUSIONS: In older persons, differences in falls, pain, and self-rated health can be detected 3-5 years prior to peripheral neuropathy diagnosis, but only falls deteriorates more rapidly over time in neuropathy cases compared to controls. Interventions to improve early peripheral neuropathy detection are needed, and future clinical trials should incorporate falls as a key patient-oriented outcome.
}, keywords = {Accidental Falls, Aged, Aged, 80 and over, Early Diagnosis, Female, Humans, International Classification of Diseases, Longitudinal Studies, Male, Medicare, Patient-Centered Care, Peripheral Nervous System Diseases, Treatment Outcome, United States}, issn = {1526-632X}, doi = {10.1212/WNL.0000000000001714}, author = {Brian C. Callaghan and Kevin Kerber and Kenneth M. Langa and Banerjee, Mousumi and Rodgers, Ann and Ryan J McCammon and James F. Burke and Eva L Feldman} } @article {8930, title = {Expenditures in the elderly with peripheral neuropathy: Where should we focus cost-control efforts?}, journal = {Neurology. Clinical Practice}, volume = {3}, year = {2013}, month = {2013 Oct}, pages = {421-430}, abstract = {To optimize care in the evaluation of peripheral neuropathy, we sought to define which tests drive expenditures and the role of the provider type. We investigated test utilization and expenditures by provider type in those with incident neuropathy in a nationally representative elderly, Medicare population. Multivariable logistic regression was used to determine predictors of MRI and electrodiagnostic utilization. MRIs of the neuroaxis and electrodiagnostic tests accounted for 88\% of total expenditures. Mean and aggregate diagnostic expenditures were higher in those who saw a neurologist. Patients who saw a neurologist were more likely to receive an MRI and an electrodiagnostic test. MRIs and electrodiagnostic tests are the main contributors to expenditures in the evaluation of peripheral neuropathy, and should be the focus of future efficiency efforts.
}, keywords = {Medical Expenses, Medicare/Medicaid/Health Insurance, Older Adults, Peripheral Neuropathy}, issn = {2163-0402}, doi = {10.1212/CPJ.0b013e3182a78fb1}, author = {Brian C. Callaghan and James F. Burke and Rodgers, Ann and Ryan J McCammon and Kenneth M. Langa and Eva L Feldman and Kevin Kerber} }