Background: Statins have questionable benefits among older adults with life-limiting illness. Statin use is widespread among U.S. older adults, but little is known about use in nursing homes. This dissertation was designed to identify the prevalence and predictors of statin pharmacotherapy use and discontinuation in U.S. nursing homes. Methods: Data sources (2011-2016) included: Minimum Data Set 3.0, Medicare administrative claims data, Provider of Service files, and Dartmouth Atlas files. Analyses included: descriptive statistics, multilevel modeling, and proportional change in cluster variations with adjustments to reduce confounding and model misspecification. Results: Approximately 36% of older adults admitted to U.S. nursing homes between 2015 – 2016 were actively using statins at the time of admission. Among long-stay residents with life-limiting illness, 34% were on statins at one time (2016; aged 65-75 years: 44%, >75 years: 31%). Statin use varied significantly by hospital referral regions, with most variation in the >75 age group. Limiting the sample to statin users, 20% discontinued statins within 30 days of nursing home admission. While discontinuation was positively associated with severity of life-limiting condition, the majority of residents remained on statins 30 days post-admission, including those with a < 6-month prognosis. Conclusion: Statin use is pervasive across US nursing homes and persists with life-limiting illness. Geographic variation appeared to coincide with clinical uncertainty, especially among adults >75 with few national guidelines. More needs to be done to prioritize statin deprescribing in nursing homes with research that identifies ways to facilitate improved patient-provider awareness and engagement in the discontinuation process.

The objectives for this study were to develop a continuity of care scale, to assess the mean level of continuity of care, to assess association between demographic variables and clinical variables with continuity of care, and to assess association between continuity of care and medication adherence among Medicare beneficiaries. A retrospective cohort study was conducted to achieve the objectives using data from the 2015 to 2017 Medicare Current Beneficiaries Survey (MCBS). To be included in the sample, beneficiaries had to have a hyperlipidemia diagnosis, be continuously enrolled in Medicare Part D for six months from start of medication adherence, be continuously enrolled in Medicare Part A and Part B in the preceding year, and had to have at least two prescription claims for hyperlipidemia medications. Beneficiaries were excluded if they had a proxy responder, had an Alzheimer’s disease or dementia diagnosis, were enrolled in Medicare due to end-stage renal disease or disability, or were residing in a long-term care facility. Among 2,120 beneficiaries that met sample selection criteria, 57 percent were aged 75 years or older, 57 percent were female, and 87 percent were White. An overall continuity of care scale was developed using MCBS items that asked respondents about their care experience. Exploratory factor analysis was used to determine subscales of continuity of care using a randomly selected 60 percent of the sample, which yielded three subscales of continuity of care: relational continuity (Factor 1), informational continuity (Factor 2), and management continuity (Factor 3). Confirmatory factor analysis conducted using the remaining 40 percent of the sample validated factor structure of the continuity of care scale. The mean level of overall continuity of care among Medicare beneficiaries was 3.26 out of 4. Medication adherence was assessed using proportion of days (PDC) covered for anti-hyperlipidemia medications. Beneficiaries with a PDC of 80 percent or more were considered medication adherent. Approximately, 81 percent of beneficiaries were adherent to prescribed hyperlipidemia medications. Association between demographic variables and clinical variables with overall continuity of care was assessed using multivariable logistic regression based on purposeful selection of variables method. Older age, low perceived health status, and lower number of prescribed medications were associated with low overall continuity of care. Race and marital status were found to have interaction effect on overall continuity of care. Among non-white beneficiaries, married beneficiaries reported higher overall continuity of care than not-married beneficiaries. Among married beneficiaries, whites reported lower overall 12 continuity of care than non-whites. Association between overall continuity of care and medication adherence was assessed using multivariable logistic regression with purposeful selection of variables method. There was no association found between overall continuity of care and medication adherence.

The purpose of this project was to design a chronic care plan using the chronic care management (CCM) framework to improve health services at lower healthcare costs. The practice-focused question explored whether the operationalization of the CCM model would impact progress toward the management of chronic illness for the target population of Medicare beneficiaries with 2 or more chronic illnesses in an urban acute care agency located in the western United States. The middle-range theory, logic rational plan model, Lewin’s change theory, and the CCM’s coordination care and collaborative care concepts were used to guide the project. Data were collected from nursing databases and government agencies. Nurses were significant to the CCM reform by supporting the elements for proactive care. Nurse practitioners can bill using the CCM codes, and clinical nurses can performed patient sensitive care. The social changes were patients with chronic illnesses realized a better quality of life at lower health costs.

No description available.

Managed care plans purport to improve the health of their members with chronic diseases. How has the growing adoption of Medicare Advantage (MA), the managed care program for Medicare beneficiaries, affected the progression of chronic disease? The literature is rich with articles focusing on managed care organizations' impacts on quality of care, access, patient satisfaction, and costs. However, few studies have analyzed these impacts with respect to market penetration of Medicare managed care. The objective of this research has been to analyze the relationships between the market penetration of MA plans and the progression of chronic diseases among Medicare beneficiaries. The Chronic Disease Severity Index scale (CDSI) was constructed to represent beneficiaries' overall chronic disease states for survey or claims-based data, when more direct clinical measures of disease progression are not available. Using the CDSI on the MEPS survey dataset from AHRQ, we sought to assess the impacts of MA market penetration and other covariates on the overall chronic disease state of Medicare beneficiaries from 2004 through 2008. Though the model explains much of the variation in CDSI change, the author expected the multilevel model would show that MA penetration explains a significant level of variation in CDSI change. However, this hypothesis was not substantiated, and the findings suggest that unmeasured factors may be contributing to additional unexplained heterogeneity. Policymakers should explore opportunities to refine the current MA program. The MA program costs the federal government more than the Traditional Fee-for-Service Medicare program, and there is no definitive evidence that outcomes differ. Within both programs, there is opportunity to experiment with different models of payment, healthcare service delivery and care coordination. The Patient Protection and Affordable Care Act (ACA) contains provisions for innovative demonstration projects in delivery and payment. The effectiveness of these ACA initiatives must be monitored, both for impacts on health outcomes and for economic effects. This research can inform future approaches to outcomes assessment using the CDSI, and multilevel modeling methodologies similar to those employed here. Firms offering MA health plans would be prudent to proactively demonstrate their value to beneficiaries and taxpayers. They should explore means of better monitoring and reporting the longitudinal outcomes of their enrolled beneficiaries. Demonstrating that they can bring value in terms of improved health outcomes will help insure their long-term survival, both in the marketplace and in the political arena. / Graduation date: 2012