A medicare benefit expansion: inpatient clinical and economic outcomes in deep brain stimulation for Parkinson's Disease
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Background: The Centers for Medicare and Medicaid Services, (CMS) implements National Coverage Decisions (NCD) to expand access or eliminate regional reimbursement differences. Policymakers may estimate clinical and economic consequences through short term pilots or demonstration projects. Objective: Examined whether short term outcomes mirror longer term outcomes for a CMS NCD for Deep Brain Stimulation (DBS) in Parkinson's Disease (PD). Methods: This observational study examined the inpatient clinical and economic outcomes associated with a CMS NCD for DBS in PD using Health Care Utilization Project (HCUP) retrospective data from 1999 through 2007. The Healthcare Utilization Project (HCUP) data, is supported by CMS. HCUP is the largest collection of all-payer, uniform, state-based inpatient surgery administrative data and covers the years of interest. Short-term cross-sectional analysis examined 12 months pre NCD (January 1, 1999 to March 31, 2003); and 12 months post NCD (April 1, 2003 to March 30, 2004). Long-term, cross-sectional analysis examined the three years, three months prior to the the short term pre period (January 1, 1999 to March 31, 2002); and the three years, nine months after the short term post period (April 1 2004 to December 31, 2007). Results: A patient who had DBS surgery in the 12 months post NCD is more likely to be discharged to long or short term care rather than home (OR 3.671, p=0.0249); is associated with longer lengths of stay (0.2888, p=0.0001); and is positively associated with the log of total charges (0.19985, p=0.0240). A patient who has DBS surgery more than 12 months post NCD compared surgery more than 12 months pre NCD, was less likely to have complications (OR 0.376, 0.0004) , was associated with a shorter length of stay (-0.2857, p=0.0093), and is positively associated with the log of total charges (0.33875, p<0.001). Conclusions: These results suggest that after the benefit expansion, outcomes worsened in the short term, and improved in the long term. Policymakers may benefit from a longer term view when forecasting before--or interpreting outcomes after--a benefit design change. Differences in populations served may cause temporary or long term shifts in health outcomes and resource utilization.
Table of Contents
Introduction and problem statement -- Literature review -- Methods and hypotheses -- Results -- Hierarchical specification -- Discussion and implication -- Conclusions -- Appendix A. Data dictionary -- Appendix B. Complications - long run without physician variable -- Appendix C. Complications - long run with physician influence -- Appendix D. Non death disposition - long run full sample -- Appendix E. Non death disposition - long run with physician influence -- Appendix F. Length of stay - long run without physician influence -- Appendix G. Length of stay - long run with physican influence -- Appendix H. Log total charges - long run full sample -- Appendix L. Log total charges - long run subsample -- Appendix J. Complications -- short run full sample hierarchical logistic multivariate model -- Appendix K. Complications - short run subsample hierarchical logistic multivariate model -- Appendix L. Non death disposition - short run full sample hierarchical logistic multivariate model -- Appendix M. Non death disposition - short run subsample hierarchical logistic multivariate model -- Appendix N. Length of stay - short run full sample hierarchical negative binomial multivariate model -- Appendix O. Length of stay - short run subsample hierarchical negative binomial multivariate -- Appendix P. Log total charges - short run full sample hierarchical ordinary least squares multivariate model -- Appendix Q. Log total charges - short run subsample hierarchical ordinary least squares multivariate model