Introduction: The coronavirus 2019 pandemic disrupted medical care delivery for cerebrovascular disease. Little is known about the long-term changes in healthcare utilization and mortality among people who suffered cerebrovascular events. Methods: We used 2018-2022 data to identify all Medicare fee-for-service and Medicare Advantage beneficiaries with a diagnosis code for an acute cerebrovascular event (stroke, transient ischemic attack, hemorrhage). We used Poisson-lognormal regression models with an offset term (beneficiary years) to model incident rate ratios (IRR) for late COVID (2021-2022) versus pre-COVID (2018-2019) for outpatient visits, emergency department (ED) visits, hospitalizations, and mortality in the year following the index event, adjusting for age, sex, and race. We examined patterns overall and by rurality (urban, micropolitan, rural) and quartile (q) of social vulnerability index. Results: We identified 7,071,072 and 7,065,171 unique beneficiaries in the pre-COVID and late-COVID periods, respectively, with an acute cerebrovascular event. Our cohort was predominantly non-Hispanic white (73%), female (54%), and urban (83%). Compared to pre-COVID, outpatient care utilization in the year following the acute event was higher in 2021-2022 (IRR = 1.14, 95% confidence interval [CI]: 1.13-1.14), while ED visits (IRR = 0.92, 95% CI: 0.91-0.92) and inpatient hospitalizations (IRR = 0.94, 95% CI: 0.94-0.95) were lower. Mortality was higher during the late-COVID versus pre-COVID period (IRR = 1.24, 95% CI: 1.23-1.25). The mortality differences were similar across rural strata but higher in more socially disadvantaged areas (IRR 1.20, 1.22, 1.24, 1.27 for q1 [reference], p interaction = q2 = 0.12, q3 = 0.01, and q4 < 0.001). Conclusions: Medicare beneficiaries who sustained acute cerebrovascular events had marked differences over the subsequent year in healthcare utilization patterns and increased mortality in the late-COVID period compared with their utilization and outcomes pre-COVID. The differences in mortality were the most pronounced for beneficiaries in socially disadvantaged areas.

Importance:During early months of the COVID-19 pandemic, presentations for acute myocardial infarction (AMI) declined significantly, and outcomes worsened. However, the full extent and long-term sequelae of changes in AMI epidemiology during the pandemic remain uncertain, as does whether these patterns differed by rurality. Objective:To describe the epidemiology of AMI-related hospitalizations, interventions, and outcomes among Medicare beneficiaries throughout the COVID-19 pandemic, focusing on differences in urban and rural populations. Design, Setting, and Participants:This retrospective cohort study included all Medicare fee-for-service beneficiaries with AMI between January 1, 2018, and December 31, 2023, in the analysis. Data were analyzed from March 19 to July 9, 2025. Exposures:Time period (prepandemic [January 1, 2018, to December 31, 2019], pandemic [January 1, 2020, to December 31, 2021], and postpandemic [January 1, 2022, to December 31, 2023]) and beneficiary-level rurality. Main Outcomes and Measures:The primary outcome was in-hospital death, defined as death within 1 day of discharge from the index episode of AMI. Secondary outcomes included death within 90 days of the index admission date and postdischarge outcomes. AMI episodes were defined as any emergency department (ED), observational, or inpatient stay with a primary ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) diagnosis or a primary cardiogenic shock and secondary STEMI or NSTEMI diagnosis. Generalized estimating equations clustering on hospitals were used to compare pandemic and postpandemic outcomes with the prepandemic period, adjusting for beneficiary characteristics. Results:A total of 1 152 851 AMI episodes among 1 032 212 beneficiaries were identified between 2018 and 2023, of which 75.6% were NSTEMI. Most AMI episodes were among male (57.6%) beneficiaries aged 65 to 80 years (56.8%). The unadjusted quarterly incidence of AMI decreased from 17.2 to 13.0 episodes per million beneficiary days at risk (quarter 1 of 2018 to quarter 4 of 2023). In-hospital (adjusted odds ratio [AOR], 1.09; 95% CI, 1.07-1.11]) and 90-day mortality (AOR, 1.10; 95% CI, 1.09-1.12) increased during the pandemic and then returned to baseline or lower (AORs, 0.99 [95% CI, 0.97-1.01] and 0.96 [95% CI, 0.95-0.98], respectively). After the pandemic, beneficiaries were less likely to discharge to a skilled nursing facility (AOR, 0.67; 95% CI, 0.66-0.68), utilize the ED (adjusted incidence rate ratio [AIRR], 0.93; 95% CI, 0.92-0.94), or experience readmission (AIRR, 0.90; 95% CI, 0.90-0.92) within 90 days of their index episode of AMI. Patterns were largely similar by rurality. Conclusions and Relevance:In this retrospective cohort study of fee-for-service Medicare beneficiaries, the incidence of AMI decreased during and after the pandemic. Beneficiaries experienced greater in-hospital and 90-day mortality during the pandemic. After the pandemic, in-hospital and 90-day mortality returned to baseline among micropolitan and rural beneficiaries and was lower than baseline among urban beneficiaries.

This cross-sectional study examines the association of Chronic Condition Special Needs Plans vs conventional Medicare Advantage plans with quality of care and outcomes after hospitalization in patients with heart failure.

This cross-sectional study examines the use of long-acting injectable antiretroviral therapy among Medicare beneficiaries with HIV and characterizes the differences between people receiving oral antiretroviral therapy vs long-acting injectable antiretroviral therapy.

Importance:As the population of older people with HIV (PWH) in the US is growing, costs to Medicare are expected to rise substantially. Objectives:To project the number of Medicare beneficiaries aged 65 years or older receiving care for HIV in the US from 2026 to 2035 and the budget impact on Medicare. Design, Setting, and Participants:This economic evaluation used the Cardiovascular, HIV, Aging, Hearing Loss, Mental Health, and Dementia (CHARMED) simulation model to project the number of Medicare beneficiaries aged 65 years or older receiving care for HIV and associated costs from 2026 to 2035. The model was populated with age- and sex-stratified clinical data and costs derived from 2023 traditional Medicare claims and accounted for enrollment in Medicare Advantage, as well as health care inflation. Data analysis was conducted from September 2023 to May 2026. Main Outcomes and Measures:Number of Medicare beneficiaries aged 65 years or older receiving care for HIV and undiscounted costs to Medicare from 2026 to 2035. Results:The simulated cohort was informed by 111 600 PWH enrolled in Medicare at the start of 2026 (mean [SD] age, 70.9 [5.0] years; 77% male). The analysis found that 121 890 PWH would be enrolled in Medicare and in care by the end of 2026, including 60 390 PWH aged 65 to 69 years, 36 340 aged 70 to 74 years, 17 200 aged 75 to 79 years, and 7970 aged 80 years or older. By the end of 2035, this number would increase to 193 560, with increases in each age category (65-69 years: 70 490; 70-74 years: 62 820; 75-79 years: 38 290; 80 years and older: 21 960). Annual costs to Medicare for PWH aged 65 years or older and receiving care for HIV would increase from $10.9 billion by the end of 2026 to $27.3 billion by the end of 2035. Cumulative costs over 10 years were projected to be $187.2 billion, with 63% of cumulative costs due to antiretroviral therapy (ART). If ART costs are reduced by 60%, Medicare would save $70.3 billion over the next decade; projected savings due to the Inflation Reduction Act and generic ART would be $19.4 billion, accounting for the timing of onset and estimated reductions. Based on uncertainties in the number of Medicare beneficiaries and costs of care, sensitivity analyses found that cumulative costs would range from $103.3 billion to $267.5 billion over the next decade. Conclusions and Relevance:In this economic evaluation using microsimulation modeling, the number of Medicare beneficiaries aged 65 years or older receiving care for HIV was projected to increase substantially over the next decade, resulting in $187.2 billion in 10-year cumulative costs to Medicare. Reducing ART costs by 60% could lead to 38% lower overall Medicare spending for older Medicare beneficiaries with HIV.

There is an urgent need for scalable strategies for treatment of overweight and obesity that can be implemented in clinical settings. To implement and evaluate an online weight management program in a large, diverse population of patients. Clinical implementation project in primary care and specialty clinics. Eligible patients were ≥ 20 years old, spoke English or Spanish, and had a body mass index (BMI) of ≥ 30 kg/m2 or a BMI of 25–29.9 kg/m2 plus ≥ 1 cardiovascular risk factor or obesity-related condition. Enrolled patients were encouraged to register for a 12-month digital health program called RestoreHealth, which included an online program/app and coaching. We examined recruitment and enrollment in the program, as well as engagement, absolute and percent weight change, and predictors of weight change during the first six months. Subgroup analyses were conducted by use of anti-obesity medications. A total of 5056 patients enrolled between November 2022 and October 2023, and 4511 (89.2

Importance:Urgent care (UC) centers have proliferated rapidly, yet research on how utilization has changed among older adults is limited. Objectives:To examine UC utilization among older adults and assess whether utilization rates varied by beneficiary sociodemographic and community characteristics. Design, Setting, and Participants:This cross-sectional study used data from a 20% national sample of fee-for-service Medicare beneficiaries aged 65 years or older using UC centers from January 1, 2012, to December 31, 2019. Statistical analysis was performed from May 1, 2021, to November 24, 2025. Main Outcome and Measures:Among Medicare beneficiaries aged 65 years or older, unadjusted UC visits were calculated by year from 2012 to 2019 overall and stratified by demographic characteristics, frailty, community rurality, Social Deprivation Index (SDI), and physician supply. Adjusted incidence rate ratios (IRRs) were calculated for UC visits in 2018 and 2019 using negative binomial models. Trends in the distribution of UC visits among the most frequent clinician specialty categories (primary care, emergency medicine, and advanced practice practitioners [APPs]) were examined using linear models. Results:There were 3 516 816 UC visits among 9 514 946 beneficiaries (mean [SD] age across visits, 75.2 [7.5] years; 63.4% women). UC visits increased from 47.7 to 117.2 per 1000 from 2012 to 2019 (9.0 [95% CI, 9.0-9.1] visits per 1000 per year). The growth in UC utilization was slowest for beneficiaries aged 85 years or older (4.0 [95% CI, 3.8-4.1] visits per 1000 per year), Medicaid-eligible beneficiaries (4.0 [95% CI, 3.9-4.2] visits per 1000 per year), those residing in communities that were rural (5.0 [95% CI, 4.8-5.2] visits per 1000 per year), thow who were disadvantaged (6.8 [95% CI, 6.0-7.6] visits per 1000 per year), and those with fewer physicians (7.2 [95% CI, 5.5-8.8] visits per 1000 per year). In 2018 and 2019, beneficiaries residing in rural communities had 45% lower adjusted UC utilization compared with urban communities (IRR, 0.55 [95% CI, 0.54-0.55]) and those residing in zip codes in the SDI fourth quartile had 23% lower adjusted UC utilization (IRR, 0.77 [95% CI, 0.77-0.78]) compared with those in the most advantaged quartile. The percentage of beneficiaries managed by APPs increased from 21.0% in 2012 to 50.8% in 2019. Conclusions and Relevance:In this cross-sectional analysis, UC utilization increased markedly among older adults, with a disproportionate concentration in urban, less-disadvantaged communities. The distribution of clinician training and specialty also changed, with APPs delivering care for more than half of UC visits among older adults in 2019. These findings highlight the evolving patterns of acute care delivery for this growing population and the need for additional evidence on how these trends are associated with patient-centered outcomes and the efficiency of care.

Importance:Many health systems are integrating care delivery and financing by operating their own Medicare Advantage (MA) plans. Although these hospital-operated MA plans may improve care coordination and efficiency, their implications for care utilization and patient outcomes remain unclear. Objective:To assess whether enrollment in hospital-operated MA plans is associated with differences in care utilization or health outcomes after major inpatient admissions. Design, Setting, and Participants:This cross-sectional study used 2022 national Medicare data to compare 90-day care utilization and clinical outcomes after major inpatient admissions occurring between January 1, 2022, and September 30, 2022, among MA beneficiaries enrolled in hospital-operated MA plans vs other MA plans. Analyses adjusted for patient characteristics and county fixed effects, with inverse probability weighting to address potential patient selection. Data were analyzed from April 2025 to June 2026. Exposure:Enrollment in hospital-operated MA plans. Main Outcomes and Measures:Primary outcomes included rates of subsequent all-cause inpatient admissions, emergency department visits, observational stays, skilled nursing facility use, inpatient rehabilitation or long-term acute care use, length of subsequent inpatient and skilled nursing facility stays, mortality, and number of healthy days at home, all measured within 90 days of discharge. The secondary outcome was total episode spending, including spending during both the index admission and in the 90 days after discharge. Results:The sample included 2278 MA plans offered in 2022, 332 (14.6%) of which were identified as hospital-operated MA plans. Across these plans, 468 441 major inpatient episodes related to 1 of 10 high-volume, high-cost medical or surgical conditions were identified, 75 662 (16.2%) of which were covered by hospital-operated MA plans. Compared with beneficiaries in other MA plans, hospital-operated MA plan enrollees were older, more often male and Hispanic, less likely to be non-Hispanic Black, and less likely to be dually eligible for Medicaid. After adjustment, hospital-operated MA plan enrollment was associated with lower rates of skilled nursing facility use (15.4% vs 18.3%; adjusted difference, -2.9 [95% CI, -3.2 to -2.6] percentage points [pp]) and observational stays (10.2% vs 11.6%; adjusted difference, -1.3 [95% CI, -1.6 to -1.1] pp) and higher rates of inpatient rehabilitation and/or long-term acute care services use (1.8% vs 1.0%; adjusted difference, 0.8 [95% CI, 0.8 to 0.9] pp) and readmissions (26.9% vs 25.0%; adjusted difference, 1.8 [95% CI, 1.5 to 2.1] pp), with no significant differences in emergency department visits. Despite these shifts in care utilization, hospital-operated MA plan enrollees experienced more healthy days at home (71.75 vs 71.52 days; adjusted difference, 0.23 [95% CI, 0.06 to 0.44] days) and no significant differences in mortality. Overall, hospital-operated MA plan enrollment was associated with lower episode spending ($24 072 vs $24 244; adjusted difference, -$172 [95% CI, -$291 to -$53]), with patterns broadly consistent across medical conditions and surgical procedures. Conclusions and Relevance:In this cross-sectional study of major inpatient episodes among MA beneficiaries, hospital-operated MA plan enrollment was associated with distinct post-acute care utilization patterns, lower episode spending, and no evidence of worse clinical outcomes. These findings suggest that vertical integration between health systems and health plans may be associated with more efficient and coordinated care delivery.

Importance:There were well-documented changes in health care use during the COVID-19 pandemic. Little is known about whether there were any associated decreases in claims-based comorbidity ascertainment that might have relevance to health services and policy research. Objective:To quantify differences in claims-based comorbidity assessment in Medicare beneficiaries pre- vs post-COVID-19. Design, Setting, and Participants:This cross-sectional study analyzed data from the 30 Chronic Conditions Warehouse 1- or 2-year lookback claims algorithms to ascertain each comorbidity with exact date ranges for all fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries. Data were analyzed from April 2025 to April 2026. Exposures:The first quarter (Q1) of 2019 and 2022 were evaluated as pre- and post-COVID-19, respectively. Main Outcomes and Measures:The main outcomes were comorbidities per beneficiary and association between each comorbidity and mortality in 2019 vs 2022. The changes in prevalence of each comorbidity between 2019 and 2022 were analyzed and fit models within disjoint population subgroups were combined via multilevel meta-analysis models to determine whether each comorbidity's association with mortality changed over time. Results:This study included 59 514 042 beneficiaries in 2019 (32 351 732 females [54.4%]; 50 814 834 aged 65 years or older [85.4%]) and 63 202 599 beneficiaries in 2022 (34 377 560 females [54.4%]; 55 197 435 aged 65 years or older [87.3%]). The mean number of coded comorbidities per beneficiary decreased from 3.85 to 3.62 for FFS and 4.54 to 4.39 for MA (-0.15) between 2019 and 2022. In FFS, 19 comorbidities (63.3%) decreased, 2 (6.7%) were unchanged, and 9 (30%) increased. In MA, 14 comorbidities (46.7%) decreased, 7 (23.3%) were unchanged, and 9 (30%) increased. In multivariable analyses pooled across FFS and MA, 11 comorbidities (36.7%) were more positively associated with mortality, and 4 (13.3%) were more negatively associated with mortality in Q1 2022 than in Q1 2019. Conclusions and Relevance:Coded levels of many comorbidities in Medicare were lower postpandemic than prepandemic, and the association of these codes with mortality changed. This suggests that across the COVID-19 pandemic comorbidity capture was affected by utilization changes, and the association between comorbidities and mortality changed as a result. Analyses that include immediately pre- or post-COVID-19 data and condition inferences on membership in utilization-based disease groups, or use claims-based risk adjustment, may be subject to bias.

Cancer is associated with biological aging and functional decline; however, few studies have simultaneously examined objective changes in physical function and biological aging in older adults who develop cancer. We therefore compared functional and accelerated aging in generally healthy adults with and without incident invasive cancer, using data from DO-HEALTH, a three-year, randomized controlled trial including 2152 participants (mean age: 74.9 years, 61.1% women), free of major health conditions. Functional aging was assessed by the Short Physical Performance Battery, handgrip strength, gait speed, and five-times sit-to-stand test (STS). Biological aging was measured in a subsample (n = 777) using Horvath, Hannum, GrimAge and PhenoAge clocks, and DunedinPACE. Participants with incident cancer showed a greater decline in STS (Δ adjusted means [AM]: 0.64 s [95% CI 0.06, 1.22]) and grip strength (ΔAM -1.77 kPa [-3.51, -0.03]). Furthermore, baseline biological aging was accelerated between 3.52 and 6.77 months, measured by Horvath, Hannum, and PhenoAge clocks. Findings support the geroscience hypothesis linking greater phenotypic functional decline to accelerated biological aging in older adults with incident cancer. The data for this observational analysis stem from the DO-HEALTH clinical trial, which was prospectively registered (clinicaltrials.gov; NCT01745263; registered on December 10, 2012).

This cross-sectional study evaluates whether reclassification of homelessness-related Medicare codes is associated with changes in inpatient documentation of homelessness and other health-related social needs.

Background The COVID-19 pandemic led to disruptions in cardiovascular care in mid-2020, but less is known about how patterns of care and clinical outcomes changed for older adults with cardiovascular (CV) risk factors and/or established cardiovascular disease (CVD) in the later stages of the pandemic. Objectives This study sought to identify changes in utilization of health care services and all-cause mortality among Medicare beneficiaries with CV risk factors or CVD in the “late pandemic” (January 2021 to December 2022) overall and across subgroups based on rurality and social vulnerability index. Methods The study included all Medicare fee-for-service and Medicare Advantage beneficiaries with CV risk factors (hypertension, diabetes mellitus, hyperlipidemia) or CVD (coronary heart disease, heart failure, atrial fibrillation, stroke) from January 2018 to December 2022. A Poisson-lognormal regression model was fitted to compare the adjusted incidence rate ratio (aIRR) of acute care visits, outpatient visits, and all-cause mortality during the late pandemic (January 2021 to July 2022) compared with the prepandemic period (January 2018 to December 2019). Results There were 51,355,577 beneficiaries in the prepandemic period and 55,214,638 in the late pandemic period with CV risk factors or CVD. Hospital visit rates were lower in the late pandemic period compared with the prepandemic period (aIRR: 0.918; 95% CI: 0.915-0.922), and declines were evident among rural and urban beneficiaries, as well as across all levels of social vulnerability and in both fee-for-service and Medicare Advantage. In contrast, use of outpatient visits was higher during the late pandemic period (aIRR: 1.141; 95% CI: 1.134-1.149); these increases were on average higher among urban communities and Medicare Advantage beneficiaries. Mortality was higher during the late pandemic period (aIRR: 1.248; 95% CI: 1.240-1.257), and surges in mortality among this population tracked with national COVID-19 mortality. Beneficiaries in the most socially vulnerable communities (aIRR: 1.116; 95% CI: 1.106-1.124) and those covered by Medicare Advantage (aIRR: 1.342; 95% CI: 1.329-1.356]) experienced the greatest increase. Conclusions In the later stages of the COVID-19 pandemic, among Medicare beneficiaries with CV risk factors or established CVD, hospitalizations were lower than before the pandemic, outpatient care was used more frequently, and mortality was significantly elevated across risk groups and geographies, with the greatest increases seen in vulnerable communities and those covered by Medicare Advantage.

Importance:In 2023, the Centers for Medicare & Medicaid Services terminated dual-eligible special needs plan look-alikes-Medicare Advantage plans with beneficiary panels composed of more than 80% dual-eligible individuals but lacking Medicaid integration. Understanding whether this policy promoted dual-eligible enrollment in integrated care plans, particularly those attaining high-level integration, is critical. Objective:To describe dual-eligible enrollment transitions after the look-alike plan termination and evaluate whether the policy was associated with increased enrollment in highly integrated plans. Design, Setting, and Participants:This repeated cross-sectional study analyzed US Medicare administrative data from January 2017 to January 2023. Samples were limited to full-benefit dual-eligible beneficiaries. Main Outcomes and Measures:First, a beneficiary-level analysis was conducted on 2023 enrollment patterns among full-benefit dual-eligible individuals whose 2022 plans were terminated, including factors associated with enrollment in highly integrated plans in 2023. Next, a county-year-level difference-in-differences design was used to compare changes in full-benefit dual-eligible enrollment before (2017-2022) and after (2023) the termination policy between counties with vs without terminated look-alike plans. A difference-in-differences design was used to evaluate whether the look-alike termination policy was associated with the proportion of full-benefit dual-eligible individuals enrolled in highly integrated care plans. Results:Between 2017 and 2022, 482 of 2576 counties had full-benefit dual-eligible individuals enrolled in look-alike plans for at least 1 year. Of the 170 399 full-benefit dual-eligible individuals enrolled in look-alike plans in 2022 (58.9% female; 20.6% Asian, 44.8% Hispanic, 11.3% non-Hispanic Black, 21.4% non-Hispanic White, and 2% other) and remained dual-eligible in 2023, only 5.4% transitioned to highly integrated plans, while 55.6% moved to nonintegrated plans. Dual-eligible individuals transitioning to highly integrated plans were more likely to be older (65-74 years: adjusted difference, 3.4 percentage points [pp]; 95% CI, 2.8-4.1 pp; 75-84 years: adjusted difference, 4.1 pp; 95% CI, 3.3-4.8 pp; ≥85 years: adjusted difference, 5.0 pp; 95% CI, 4.0-5.9 pp), female (adjusted difference: 0.6 pp; 95% CI, 0.2-0.9 pp), without disabilities (adjusted difference, -0.7 pp; 95% CI, -1.2 to -0.2 pp), and less likely to be Asian (adjusted difference, -5.0 pp; 95% CI, -5.6 to -4.4 pp) or Black (adjusted difference, -0.9 pp; 95% CI, -1.6 to -0.2 pp). The termination policy was not associated with a significant differential increase in enrollment into highly integrated plans in counties with look-alike plans compared with those without (0.6 pp; 95% CI, -0.4 to 1.6 pp). However, there was a 2.6-pp differential increase (95% CI, 0.01-5.1 pp) in enrollment into plans offering some integration, primarily driven by enrollment growth in plans with lower levels of integration. Enrollment also increased in conventional Medicare Advantage plans with fewer than 80% of dual-eligible enrollees (2.6 pp; 95% CI, 0.7-4.5 pp) after the termination policy. Conclusions and Relevance:In this study, the termination of look-alike plans was insufficient to significantly shift dual-eligible individuals toward highly integrated plans. Complementary strategies are necessary to ensure that dual-eligible individuals enroll into highly integrated care models that may improve outcomes.

BACKGROUND:The ICEBERG tool was initially validated in two small pilot studies to address the lack of a comprehensive geriatric screening tool in emergency settings. The present study builds on the second pilot study and extends it to a larger, multicenter sample. METHODS:We report results from a large ICEBERG tool validation study across three emergency rooms (ERs) including 1664 patients aged 70 years and older. The tool targets 9 domains and is administered by ER physicians or specialized nurses. To assess criterion validity-the extent to which ICEBERG scores are associated with relevant clinical outcomes-we compared patients who scored below versus above the median (<10; ≥10) ICEBERG score for six key clinical outcomes: length of stay in acute care, nursing care in minutes, one-on-one nursing care, in-hospital mortality, discharge to nursing home, and readmission within 30 days. Negative binomial regression was used for the outcomes length of stay and nursing care in minutes. Logistic regression was used for the other outcomes. All analyses were adjusted for age and sex. RESULTS:Patients with ICEBERG scores of 10 or higher had significantly longer stays in acute care (8.9 vs 6.6 days), required more nursing care (56.4 vs 32.8 h), had higher odds of one-on-one nursing care (Odds Ratio, OR = 2.85), in-hospital mortality (OR = 1.89), discharge to a nursing home (OR = 3.20), or being readmitted within 30 days (OR = 1.81). CONCLUSIONS:Based on our findings, the ICEBERG tool identifies older patients with a geriatric risk profile at ERs on all key clinical outcomes tested.

OBJECTIVE:To assess the clinical effectiveness of a pilot multifaceted intervention to prevent persistent opioid use among patients undergoing orthopedic and spine surgery. DESIGN:Pre-post pilot study. SETTING:Two hospitals (academic medical center and affiliated community hospital) in a single healthcare system. Preintervention period was July 1, 2021 to June 1, 2022; post-intervention period was June 2, 2022 to February 28, 2023. PATIENTS:A total of 171 inpatient orthopedic and neurosurgical spine patients. INTERVENTION:Multifaceted persistent Opioid use Prevention Program (MOPP), including standardized order sets, pharmacist-led discharge counseling, a virtual post-discharge visit, and a mobile app for tracking pain, function, and opioid use for up to 180 days after hospital discharge. MAIN OUTCOME MEASURES:Persistent opioid use within 180 days post-discharge. RESULTS:Outcome assessors were blinded. Of 115 patients in the intervention group, 91 (79 percent) received at least one component of MOPP. Persistent opioid use was observed in 10.9 percent of usual care patients and 4.5 percent in intervention patients (weighted difference -6.4 percent, 95 percent confidence interval [CI] -21 percent, +8.2, p = 0.37). In subgroup analyses, the intervention demonstrated a significant reduction in persistent opioid use among nonopioid-naive patients (weighted difference -40 percent, 95 percent CI -76 percent, -4.2 percent), with evidence of effect modification by opioid-naive status (p value for interaction term 0.005). CONCLUSIONS:This pilot study demonstrated a nonsignificant overall effect on the primary outcome, with significant effects on nonopioid-naive patients. Further research with a larger trial is needed to validate these findings.

Introduction Obesity is an increasing chronic medical condition facing the veteran population. Glucagon-like peptide 1 receptor agonists (GLP-1s) have emerged as an optimal treatment for obesity- and related-medical disorders. As the Veterans Health Administration (VHA) continues to expand community-based care purchased under the MISSION Act, it is unknown whether veterans receiving community-based primary care experience comparable access to GLP-1 prescriptions.Methods In this national analysis of VHA data, we assessed differences in GLP-1 prescribing among veterans with overweight or obesity in VHA direct care compared with community care.Results Veterans with 3 or more primary care visits receiving VHA-direct primary care had 1.2 percentage points (pp) higher adjusted probability of GLP-1 prescriptions (20% higher odds) than veterans receiving mostly community primary care. Black and Asian veterans had 1.8-pp and 2.2-pp lower probabilities of GLP-1 prescriptions (26% and 34% lower odds, respectively) compared with White counterparts across both settings.Conclusion Researchers and policymakers should continue to monitor whether differences in care between the direct and community settings contribute to disparities in GLP-1 access.

BACKGROUND:During the COVID-19 pandemic, the Centers for Medicare and Medicaid Services created a waiver to reimburse telemedicine services. It is important to understand factors that facilitate incorporation of telemedicine into ongoing cardiovascular practice. METHODS:This was a retrospective cohort study of telemedicine and office visits delivered by cardiologists between January 1, 2022, and December 31, 2023, for Medicare beneficiaries. We calculated the adjusted incidence rate ratio (aIRR) of telemedicine visits, representing the proportion of a physician's visits delivered by telemedicine, to identify factors associated with telemedicine use. RESULTS:There were 23 334 physicians in our cohort; they were predominantly men (84.8%) and affiliated with a hospital (93.5%), and the majority were general cardiologists (66.1%). During 2022 and 2023, 3.4% of visits were delivered by telemedicine. In a regression model adjusted for beneficiary and provider characteristics, several physician-level factors were associated with increased telemedicine: female sex (aIRR, 1.48 [95% CI, 1.41-1.57]), electrophysiology specialty (aIRR, 1.57 [95% CI, 1.47-1.67] compared with general cardiology), and caring for a high proportion of beneficiaries living in areas of social vulnerability (quartile 3 aIRR, 1.22 [95% CI, 1.12-1.32]; quartile 4 aIRR, 1.27 [95% CI, 1.16-1.39]). Caring for more beneficiaries residing in a rural area (aIRR, 0.71 [95% CI, 0.66-0.76]) or the South (aIRR, 0.61 [95% CI, 0.55-0.66]) and for beneficiaries aged >85 years (aIRR, 0.77 [95% CI, 0.73-0.81] were associated with lower use of telemedicine). CONCLUSIONS:Telemedicine is used relatively sparsely among cardiologists. Physician factors, including sex; specialty; and the vulnerability, rurality, and age of beneficiary panels, impact the degree to which telemedicine is a major part of clinical practice.

As more than 50% of Medicare beneficiaries are enrolled in Medicare Advantage (MA), understanding whether the treatment covered by MA vs traditional Medicare (TM) is comparable can aid in providing high-value care. As the majority of patients with cancer undergo radiotherapy, it is important to quantify TM and MA utilization in oncology. To analyze the primary type of radiotherapy technology used, treatment length, and estimated spending for MA patients with cancer undergoing radiotherapy compared with TM patients with cancer. This retrospective cross-sectional study used 2018 Medicare claims data for TM and MA patients aged 65 years or older who received radiotherapy for 1 of 15 cancer types. Analyses were performed between May 1 and December 28, 2024. Insurance type (MA vs TM), cancer type, age, dual-eligibility status, medical comorbidities, county, and radiotherapy center type. Primary type of radiotherapy technology used, treatment length, and estimated spending for 90-day radiotherapy episodes. Adjusted rates and odds ratios (ORs) were calculated to compare technology types and rate ratios (RRs) to compare treatment length and estimated spending between TM and MA episodes. Of 31 563 treatment episodes among 30 941 patients, 22 594 (71.58%) were covered by TM (mean [SD] age, 74.76 [6.57] years; 50.76% among males) and 8969 (28.42%) were covered by MA (mean [SD] age, 74.51 [6.24] years; 51.78% among males). For radiotherapy episodes in patients with MA, adjusted analyses revealed lower odds of proton therapy use (52 [0.58% (95% CI, 0.34%-0.82%)] vs 373 [1.65% (95% CI, 1.50%-1.80%)]; OR, 0.36 [95% CI, 0.27-0.48]) and stereotactic radiotherapy use (1235 [13.77% (95% CI, 13.13%-14.41%)] vs 3391 [15.01% (95% CI, 14.61%-15.41%)]; OR, 0.87 [95% CI, 0.81-0.95]), higher odds of 2- or 3-dimensional radiotherapy use (3962 [44.17% (95% CI, 43.39%-44.96%)] vs 9584 [42.43% (95% CI, 41.93%-42.92%)]; OR, 1.13 [95% CI, 1.06-1.21]), greater mean treatment length (21.38 [95% CI, 21.14-21.61] vs 19.48 [95% CI, 19.33-19.62] treatments; RR, 1.10 [95% CI, 1.08-1.11]), and higher estimated radiotherapy spending ($8677.56 [95% CI, $8566.58-$8788.54] vs $8393.20 [95% CI, $8323.34-$8463.05]; RR, 1.04 [95% CI, 1.02-1.06]) compared with episodes in patients with TM. In this cross-sectional study, MA patients with cancer undergoing radiotherapy had higher estimated spending and greater mean treatment length than those covered by TM. Despite lower utilization of more expensive advanced treatment modalities, MA was not associated with cost savings. Whether MA meets the value proposition for radiation oncology requires further investigation.

Medicare beneficiaries with cardiovascular disease are increasingly enrolling in Medicare Advantage and other managed care plans, raising concern for plan choice complexity and subsequent detrimental plan selection. In this repeated cross-sectional observational study, between 2016 and 2022, plan choice complexity for Medicare beneficiaries with cardiovascular disease has worsened substantially, especially for the medically complex and socially vulnerable beneficiaries dual-eligible for Medicare and Medicaid. These findings raise substantial concern for the health and well-being of Medicare beneficiaries given that plan choice complexity has previously been shown to negatively impact decision-making and outcomes for people with cardiovascular disease.